Challenging Dogma - Fall 2009

Thursday, December 17, 2009

The Reworking of a Current Failing Nutritional Education Program - Lauren Wihbey

I. Introduction
Obesity in America is reaching epidemic proportions. Currently thirty-five percent of adults aged twenty to seventy-four are obese and six percent are extremely obese (1). The problem is much worse for both African Americans and Hispanics. As compared to whites, African Americans have fifty-one percent higher prevalence of obesity, and Hispanics have twenty-one percent higher obesity prevalence (2). Unfortunately, these statistics are not predicted to decline in the near future, but are only expected to increase over time. It is predicted that by next year, 2010, forty percent of all Americans are going to be obese, which is a five percent increase from 2008 (3). Those who are obese are also more like to suffer from many chronic diseases, like type two diabetes, cardiovascular disease and osteoarthritis (4). As a result, the economic consequences of obesity are just as costly as the health outcomes (4).
As a solution to this growing problem, the United States Department of Agriculture reformulated the Food Guide Pyramid of 1992 and introduced MyPyramid in 2005 through their Center for Nutrition Policy and Promotion. This center was established in 1994 to improve the nutrition and well-being of Americans and focuses on two primary objectives, which are advancing and promoting dietary guidance for all Americans, and conducting applied research and analyses in nutrition and consumer economics (5). The Center's core products to support its objectives are dietary guidelines for Americans, MyPyramid food guidance system, healthy eating index, U.S. food plans, nutrient content of the U.S. food supply, and expenditures on children by families (5).
MyPyramid is a food guidance system, as stated above, which translates nutritional recommendations into the kinds and amounts of food to eat each day (6). It is targeted to health professionals who are expected to teach and spread the information to the U. S. population (7). In turn, the health professionals are able to create a meal plan for each individual patient (7). The theory behind MyPyramid is that one size does not fit all because it offers personalized eating plans and interactive tools to help plan and assess food choices based on the dietary guidelines for Americans (7). The dietary guidelines for Americans are science-based advice on food and physical activity choices which describe a healthy diet as one which emphasizes fruits, vegetables, whole grains, fat-free or low-fat milk and milk products, lean meats like poultry, fish, beans, eggs, and nuts, and is low in saturated fats, trans fats, cholesterol, sodium, and added sugars (8). MyPyramid helps health professionals instruct individuals to use the dietary guidelines to make smart choices from every food group, find balance between food and physical activity, get the most nutrition out of calories, and stay within daily caloric needs (8).
In theory, MyPyramid is a good guide to better nutrition and healthy choices in order to prevent obesity. However, in practice, it is proving to be as ineffective as the older version, the Food Guide Pyramid (1, 2, 3, 4). MyPyramid still places too much emphasis on grains and milk and does not sufficiently emphasize the adverse effects of some types of fat (9). Unlike the Food Guide Pyramid’s graphic representation, which showed the proportions of various foods that should be consumed as layers of different sizes, MyPyramid conveys no information about nutrition (9). It is simply a figure climbing a rainbow-colored staircase (9). In response to this, this paper will critique MyPyramid based on its use of the Health Belief Model, violation of the Marketing and Advertising theories and use of Optimistic Bias in section two. Section three will provide an alternative intervention to the poor nutritional education that MyPyramid is providing by proving individual’s decisions are irrational, creating and marketing a new brand and image of MyPyramid and using the law of small numbers in order to combat an individual’s optimistic bias.

II. Critique of MyPyramid

A. Use of Health Belief Model
The Health Belief Model teaches that intention leads to a health behavior (10). This intention is motivated by the individual’s perceived susceptibility of disease, perceived severity of disease, perceived benefits of the behavior and perceived barriers to taking that behavior (10). This model teaches that each individual weighs the positives and negatives for each decision made and makes a rational choice of which action to then take. However, this is not how individuals make decisions. Individuals are completely irrational beings and act spontaneously (11). Also, individuals do not realize how easily they give into temptation (11). In other words, the Health Belief Model overemphasizes individual decisions and fails to address social and other environmental factors that can affect an individual’s actions (10).
MyPyramid uses the Health Belief Model as a mold for its guidelines. One of the main ideas the United States Department of Agriculture promotes about MyPyramid is that it can be tailored for each individual (7). However, it does not take into account any other factors that are involved when someone chooses what to eat when they are or are not hungry. Some of these other factors can be cultural, evolutionary, social and familial (12). For instance, a person could have recently eaten and may not be hungry, but if others around him or her are eating, that person is more likely to start eating (15). Individuals are actually more likely to eat with others than if they are alone (15, 16). Some believe that eating is a completly social activity and has very little to do with the individual’s level of hunger (15, 16). In addition, when someone is hungry, that person is in what is considered as a hot state and will be more likely to make irrational decisions and eat something not based on its nutritional value (14). That person will more likely decide to eat something based on how it tastes and how much it will cost (13). Therefore, individuals will make a decision solely based on their need at that time, which in this case is hunger (14). Also, these healthy foods that MyPyramid instructs individuals to eat are not always affordable, especially in certain neighborhoods where fresh fruits and vegetables are harder to find than in other neighborhoods. MyPyramid, then, needs to be revised to take into account for this irrationality.

B. MyPyramid’s Violation of the Marketing and Advertising Theory
In the marketing paradigm, advertisers create and package a product in order to fulfill the wants and needs of their target audience (17). They then create advertisements which appeal to more basic core human values like life, liberty, the pursuit of happiness, and fulfillment of the American dream (17). Other core values include sex appeal, power, status, independence, acceptance and control (18). As part of this paradigm, advertisements contain two elements. One is a promise, which the more outrageous it is, the more powerful it tends to be (18). The other is support for that promise with stories, images, symbols, or metaphors and music (18). However, a traditional public health marketing paradigm does the opposite. It tends to start with what they think people should want and create a product that appeals to the desire for health, which is not a core value of most individuals (17). This is exactly what MyPyramid is doing for their advertisements and marketing.
MyPyramid currently has a poster advertisement displayed in Washington, DC, which is a picture from the 1960s movie “The Jungle Book” and states “Eat Right. Be Active. Have Fun.” (20). At first glance, it is quite comical. In the poster, the boy is holding a bowl of bananas standing on one foot and the monkey is dancing with the bear while wearing ridiculous costumes (20). The promise of this advertisement is that eating right will lead to playing with monkeys and bears in a cartoon movie, not a healthy life as the statement tries to convey. The support is the picture, which is quite poor itself by not being the least bit relatable. When did reality become cartoons?
Besides these terrible poster advertisements, the United States Department of Agriculture is targeting the wrong audience. MyPyramid is meant for health professionals to teach their patients and other clients. In order for these patients to use MyPyramid, one must have internet access. The proper target audience should be those who need nutritional education the most and tend not to have access to the internet, which are the underprivileged (21). In 2000, only nineteen percent households with incomes below twenty-five thousand dollars had Internet access, compared with eighty percent in households with incomes of seventy-five thousand dollars or more (21). A non-internet, CD-ROM version of the diet plan will be available from the United States Department of Agriculture in the near future (21). However, it too will require computer access, minimizing its outreach impact and printed materials lack the customized features of MyPyramid offering little improvement over currently available educational materials (21).
Another important part of the traditional marketing paradigm is the product image and brand in order to help it sell (18). In contrast to traditional marketing brands, public health brands are a complex set of associations between an individual and a health behavior or set of behaviors that embody a lifestyle (19). For the MyPyramid campaign, the image is the pyramid and the brand is “Steps to a healthier you” (7). However, the new pyramid is not a very good image because it does not show any food or guidance. It is simply a pyramid with rainbow stripes with a figure next to it. Thus, the ambiguous, vertical stripes convey no useful information (22). The pyramid shape remains only to provide a slope for the stick figure to climb, which represent the steps in the brand (22). To market MyPyramid more effectively, the United States Department of Agriculture should first research what the consumer wants and then redefine, repackage, reposition, and reframe MyPyramid in such a way that it satisfies an existing demand among the target audience (17).

C. Use of the Optimistic Bias
Individuals tend to overestimate the risk of disease for others and underestimate their own risk for a disease (23). This is known as the optimistic bias. Individuals believe that something could certainly happen to their colleague or peer, but not themselves (23). They believe they are invincible to future poor outcomes (23). Therefore, individuals who falsely believe that their personal attributes exempt them from risk or that their present actions reduce their risks below those of other individuals may be inclined to engage in risky behaviors and to ignore precautions (23). Because of this optimistic bias, education about the risks for diseases and disease prevention is essentially not going to be effective. For example, smokers believe that one in two smokers will get lung cancer, when the actual statistic states only five to ten percent of smokers will develop lung cancer (24). The point here is not the low prevalence of lung cancer among smokers, but the belief of a high prevalence of lung cancer among smokers. One would assume that this belief would be enough for most smokers to immediately stop smoking. However, this is not the case because these same smokers, who believe there is a fifty percent chance of getting lung cancer, do not believe it will happen to them (24). They, of course, will not get lung cancer. Their friend will get lung cancer. Therefore, one must ask then why does the government put billions of dollars into educating the public about good nutrition habits to prevent obesity and other chronic diseases if the public does not believe they will become obese?
It is a belief of many public health professionals that if a person is educated about a disease, that person will no longer take part in behaviors that can cause that disease and only behave in ways that will prevent that disease (25). Clearly, this is not reality. For example, a study found that news coverage about the harmful effects of trans fat, combined with labeling information, may influence consumers' short-term purchases of foods high in trans fat, but is not enough to prompt shoppers to avoid these potentially artery-clogging purchases over the long term (26). Prevention programs for obesity that have emphasized education, communication, and information have also been proven to be generally ineffective (21). Many argue that health promotion strategies must go beyond education to achieve significant and lasting behavioral change to curb the current obesity epidemic (21). Information is not enough to change the way individuals think and behave (25). Everyone has very different experiences, stories and attitudes towards things and education cannot necessarily change those things (25). In order to counter this optimistic bias, public health professionals must stop overloading the public with information and make them believe they are not invincible to poor nutrition and obesity (25).

III. MyPlate – The New and Improved MyPyramid
Concerning statistics alone, MyPyramid is not as effective as the United States Department of Agriculture planned (1, 2, 3, 4). In fact, the obesity epidemic is worse now than it was when the older version of MyPyramid was in use (1, 2, 3, 4). The critiques previously stated give some insight as to why MyPyramid is not as effective as it should be. In addition, some other concerns may be reason for its ineffectiveness. For instance, the shape and display of the pyramid is not very easy to understand or to use for the average person (20, 21, 22). As MyPyramid is primarily a website to learn about healthy food choices, meal planning, and physical activity, it is not available to everyone because not everyone has internet access (21). More specifically, there needs to be a consideration for portion control and better food choices. With MyPyramid, an individual can still go to a fast food restaurant, get a meal, and still be within the dietary guidelines for Americans (20, 21, 22). This sends the wrong message to individuals. Eating a meal at a fast food restaurant is not as nutritious as a home cooked meal, for example. Nor is there much variety or balance in the meal, which is another problem with the current MyPyramid (20). There is no mention of balanced meals. MyPyramid only shows on its website how many servings of types of food an individual should consume daily (6, 7). Furthermore, there is an overemphasis of dairy product consumption, which does not take into account sex, age, or physical activity (27). Information on salt and alcohol intake is also lacking (27). Also, there is no focus on good or bad fats and carbohydrates (22). MyPyramid only shows that all fats are bad and all carbohydrates are good (6, 7). This is giving only part of the information, not all of it (22).
With this stated, a new intervention needs to be in place to replace MyPyramid. This new proposal will be called MyPlate, which will convey the same information as MyPyramid, but will be more user-friendly and available for everyone. It will also include the guidelines the current pyramid is lacking. The following sections will explain the steps needed to make the new intervention, MyPlate, more effective than MyPyramid.

A. Countering the Health Belief Model
The perceived benefits which MyPyramid teaches in order to choose nutritious food in daily servings and to get enough physical activity to outweigh the perceived barriers and lead to the intention of preventing obesity and other chronic diseases have proven to be ineffective (1, 2, 3, 4). With respect to diet, the nutritional value of foods actually plays a very small part in what individuals eat (15). For instance, they are unlikely to care if they are eating their five to nine servings of fruits and vegetables a day, especially if they can barely put food on the table (15). Furthermore, eating tends to be a social activity and individuals tend to eat whatever is available to them, especially when in a hot or hunger state (14, 15, 16). Therefore, MyPlate will stop using the Health Belief Model and provide education which will account for an individual’s complete lack of rationality when choosing what and what not to eat and getting enough exercise.
There are five aspects of irrational behavior that MyPlate will work into its teachings of eating a balanced, varied, and nutritious diet. The first aspect is a person’s expectation of a situation (11). For example, if a person expects to fail an exam, that person most likely will fail that exam. The second aspect is ownership, which is if a person owns something, that person will place a higher value on it (11). The third aspect is framing (11). If something is framed differently, a person’s attitude will most likely change about the thing being framed, whether positively or negatively (11). The fourth aspect is the lack of self-control (11). As stated, individuals underestimate how quickly they give into temptation (11). The fifth aspect is the importance of context and how much society overestimates character (11).
To use an individual’s irrationality to MyPlate’s advantage, its guidelines will include environmental and social factors. Without considering environmental factors, this intervention is not likely to curb the obesity epidemic (21). With respect to physical activity, experts believe that physical activity will increase only when physical movement becomes an unavoidable part of everyday life (21). Therefore, future urban-design strategies should encourage or even force physical movement by building parking lots at a specific distance from buildings or creating pedestrian paths from buildings to shopping areas (21). These strategies will also change the framing of physical activity and someone’s control over getting physical activity. If a person is forced to walk more, it will eventually become part of their daily routine. With an easy fix, the context has changed. With respect to diet, lasting dietary change, like increased fruit and vegetable consumption, will also require social and environmental modifications, such as lowering the cost of healthier foods, expanding product selection to include healthier alternatives, and nutrition labeling in restaurants (21). Nutrition labeling has started in some restaurants and in large cities, like New York City.

B. Marketing MyPlate Effectively
This intervention completely changed the brand and image of MyPyramid to make it more user-friendly and relatable. The new image is a plate portraying a balanced, varied and nutritious meal with a track around it with figures walking, running and biking. The brand will be a statement about how a healthy diet and physical activity can give control, a core value of most individuals, back to an individual. The target population will be the general adult population, emphasizing those who need the most help, which are the underprivileged. The website will still be available for those with internet access. However, more effort will be placed on getting this information to those without internet access. For example, brochures, pamphlets and meal and activity planning guides will be given out in areas where these groups go grocery shopping and live, as examples.
Changes in the advertising campaign will be much like those changes made to the TRUTH campaign in Florida (28). This campaign started with what was most important to the target audience and made an advertising campaign based on those values (28). The TRUTH campaign has, therefore, proved to be quite successful since it began (28). MyPlate will do the same. The United States Department of Agriculture will conduct community-based research to determine what is most important to their target audience, generally and how to make a healthy diet and physical activity easier to achieve, specifically. From this information, an advertising and marketing campaign will be used to more effectively reach the audience of MyPlate.

C. Countering Optimistic Bias with the Law of Small Numbers
The law of small numbers is a belief that consequently skews a judgment of the probability of events (30). For instance, a person is more likely to remember a poor experience over a good experience if they have seen it before. An example would be believing that one always waits in the long line at the grocery store. It is improbable that a person is always in the longest line, but that person is likely to only remember the times that that person is frustrated. This theory also skews individual’s perceptions of their risk of disease (30). For example, someone is more likely to remember his or her ninety-five year old aunt who smoked for seventy years and was never diagnosed with lung disease. This will skew the individual’s perception of the consequences of smoking and will cause him or her to not quit as readily if that person knew someone who did die of lung cancer after smoking for seventy years.
To counter the general population’s belief in their invincibility, MyPlate will stop overeducating the public about good food choices and physical activity and make them believe in their susceptibility of obesity and other chronic diseases. In order to establish this new belief, individuals will need to be shown stories of people like them telling them they can become obese and be diagnosed with diabetes or heart disease. This part of the intervention will be included in the marketing and advertising campaign for MyPlate. Commercials and ads will be placed in key places to reach the target populations. The stories must be relatable and show real people, but they must not be hysterical and over-emotional (30). The most important aspect of the story is that it must be real and honest (30). For these commercials and ads, the United States Department of Agriculture can use actors who look like individuals from the target population or use actual people from the target populations who suffer from obesity and other chronic diseases. These actors and real individuals can tell their stories and relate them back to how nutritious meals and physical activity could have changed their current state.

IV. Conclusions
Something must be done to make MyPyramid more effective to help curb the current obesity epidemic. MyPlate is an excellent start at helping individuals change the way they eat and increase their physical activity. MyPlate can be used with children as well as adult populations. For example, models of plates and food can be used in school settings to teach children proper balance, variety and nutrition. MyPlate can also be individualized based on an individual’s health needs. In all, MyPlate is taking the good aspects of MyPyramid and changing the bad ones to make nutritional and activity education more user-friendly and effective.

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