Friday, December 17, 2010

Improving the Efficacy of Calorie Labeling in Low Income Neighborhoods—Becky Zwickl

Obesity worries continue to garner an abundance of attention in the United States. The medical implications are staggering as “obesity has been deemed a public health epidemic, which carries with it high financial and psychological stakes” (1). Daily reports on the news and dire pronouncements from government officials have reached a frantic level. As a result of this growing problem, public health programs and campaigns that specifically target obesity are being developed, in the hopes that they will aid in curbing the epidemic.

The Affordable Care Act that passed in March 2010 includes several provisions for improving the overall health of people in the United States. Hidden among various insurance-based changes is an attempt to change basic eating habits; the hope is that preventive efforts will decrease the necessity of later obesity-related medical interventions. Restaurants will be required to post calorie counts, which should, according to many people, reduce overall calorie consumption considerably and thus cut back on obesity (2).

New York State had already begun posting calorie counts prior to the passage of the Health Reform Law. In 2009 the Governor of New York proposed legislation forcing restaurants to post specific calorie counts for food served on their menus, asserting that most diners are not aware of how many calories they consume in restaurants (3). The legislation later passed on July 19, 2008, providing a natural experiment on the efficacy of calorie posting (2).

Examining data from New York reveals a key problem with the well-intended legislation. While some research shows consumers reducing their overall calories when made aware of caloric content, other research stratifies the results more carefully by socioeconomic status (4). And, therein lies a large problem with calorie posting. In lower income areas, researchers found that the population pays little to no attention to calorie posting; in fact, one study showed that in some cases people actually ordered more calories in lower income neighborhoods after seeing the calorie postings (4). Interestingly, however, the participants in that case claimed to note the calorie contents and believed they were eating less than usual (5). Essentially, calorie posting had no positive effect in the very neighborhoods that most suffer from obesity. It is clear from this result that in order to establish an effective intervention to obesity, the campaign must specifically target low income neighborhoods and the psychosocial reasons behind the predicament.

Lower Education Levels Decrease Calorie Posting Efficacy

A significant obstacle to calorie posting’s efficacy is the education level of many in low income neighborhoods. The United State Census Bureau reports that only 1.8% of individuals subsisting at 50% of the federal poverty level have a bachelor’s degree (6). In contrast, 17.5% of the general United States population has obtained a bachelors degree. Considering the education level of a public health program target population is very important for a range of reasons. It may affect the biases, general knowledge or even tendencies of a population.

In order to examine how education level can affect calorie labeling it is integral to consider the basis of the intervention itself. Calorie posting, like many obesity interventions, is based on individual cognition models such as the Health Belief Model (HBM) and Theory of Reasoned Action. As models of individual decision making, they present specific reasons for the failure of calorie labeling as a result of lower education levels. Campaigners surmise that if people see the calories posted they will make a conscious effort to alter their eating habits (at least in terms of calories consumed). This is based on a general assumption that people know the number of calories they should eat in a day and are willing to adhere to this count if only they are aware of the content of their food. Various aspects of the HBM, however, can also be used to explain why calorie labeling is not effective in lower income neighborhoods.

The HBM first asserts that a person must perceive that they are susceptible to the health problem which, in this case, is obesity (7). It is very difficult to assess on a general level the perceived susceptibility of a population. However, it is clear from anecdotal evidence that most people know if they are in danger of obesity (or already obese) (5). The next step, however, is where calorie posting runs into problems.

After a person realizes they are susceptible to becoming obese, and the health problems associated with it, they then must perceive the threat as severe (7). Health hazards associated with obesity are often not of immediate concern. Rather, cardiovascular disease, high cholesterol and diabetes develop slowly and take many years to damage a person’s health. Thus, the perceived severity of consuming many calories is not high.

Additionally, the Health Belief Model relies on interventions having a high perceived benefit (7). The perceived benefits of eating a lower calorie food, however, are fairly low. There is no immediate benefit, and instant gratification is far more rewarding than the knowledge that if you cut back calories every day you may eventually lose some weight and be healthier overall. As a caveat, health knowledge varies greatly by income level. Studies examining black lower-income women found that the women tend to have lower breast and cervical cancer survival rates than the general population partially due to “late diagnosis and inadequate secondary prevention” (8). This in turn shows a general lower level of health knowledge among low income women who, as stated before, generally have a lower educational level. Thus, they may simply lack the basic health knowledge regarding obesity’s dangers. Or, they may not know that calorie cutting can prevent obesity in the first place.

The fifth aspect of Health Belief Model is cues to action (7). As stated before, lower income individuals tend to have lower education levels. Therefore they are less likely to have the cues to action of higher income individuals. For instance, people with lower incomes are less likely to have a primary care physician or a regular check up. A study in Western Europe showed that those with lower education levels also had a lower likelihood of visiting a physician; this held even when finances were not a concern (9). It is easy then to conclude that in the United States, where 16% of the population is uninsured and finances are a real barrier that physician visits are far less frequent among lower education and lower income people (10). As a result, they may not realize the extent of their eating habit problems; someone who never meets with a physician is unlikely to know that they have high cholesterol or blood pressure as there is no obvious physical indicator. If there is no authoritative person informing low income individuals of the dangers of high calorie diets, there is a severe lacking in cues to action.

The Theory of Reasoned Action (TRA) also reveals how lower education levels can interact with calorie labeling to reduce its efficacy. TRA, like HBM, relies on individual decision making, focusing on behavioral intention, attitude, and subjective norm (11). Behavioral intention in the TRA is made up of attitude and subjective norms. For instance, in order to have the intention of closely monitoring your caloric intake, you must first have positive attitudes towards altering your behavior (perhaps relating to HBM’s perceived susceptibility, since if you are more susceptible you are more likely to change your behavior). However, positive attitudes towards decreasing calorie consumption are unlikely to arise when the population is unaware that calorie overconsumption directly affects health. Once again, we see education is an obstacle to altering eating habits.

Hierarchy of Needs Deemphasizes Necessity of Healthy Eating

Another weak link in calorie labeling becomes obvious when considering the basic human hierarchy of needs. Interestingly, studies show that in certain restaurants, such as Starbucks, prominently displaying calorie counts has a fairly strong effect on decreasing the calories consumed, while that same trend is not apparent in other restaurants (12). There is a simple reason behind this; Starbucks tend to be located in well to do neighborhoods, and are generally frequented by middle to high income consumers who can afford a $4.00 coffee drink. For example, there is only one Starbucks located in the Bronx (13). Meanwhile, within a 4 block radius on the Upper East Side there are three store locations. There is a clear difference in income levels between these two areas of New York City, and these store locations reflect a larger percentage of disposable income. When people have disposable income they do not worry about spending a little more money for a higher quality product. This prioritizing can be easily explained by Maslow’s Hierarchy of Need Pyramid.

The first level of the pyramid is physiological needs (14). When someone does not have their basic physiological needs met, they are unable to progress to the upper levels of the pyramid. Many people in lower income neighborhoods may not have this basic need met, and they are therefore unable to move higher up the pyramid. In fact, according to a report by the US Department of Agriculture, 14.7% of US households were food insecure in 2009 (15). Food insecurity, by the USDA’s definition, can range from “reports of reduced quality, variety, or desirability of food” to “reduced food intake” and hunger. With such a statistics it is simple to see that many people do not have their basic physiological needs met. And, if someone does not have enough money to consistently afford food, or at least quality food, they will likely not worry about health. Health is a higher order concern partially because it does not have an immediate effect on the person. If someone is hungry, they will order food that satiates that hunger without considering the number of calories even if the information is clearly posted.

In some instances, basic physiological needs may not be a concern. However, safety, which is the second level on Maslow’s Hierarchy of Needs pyramid, may not be met in some cases (14). In the same manner that physiological needs distract from health, safety threats can detract from healthy behavior. If there are constant communal worries about safety, it preoccupies the mind and deflects attention away from such health concerns as calories.

Additionally, the fourth aspect of the Health Belief Model, perceived barriers, interplays closely with Maslow’s Hierarchy of Needs (7). Put quite simply, price matters more than quality when people are worried constantly about money. If a double cheeseburger costs less than a salad, and is also more substantial and filling, the person is likely to select the cheeseburger. In higher income neighborhoods calorie labeling can be effective in thwarting the initial desire to look at price first. However, when money is tight and food is inconsistently available there remains no incentive to consider calories or healthfulness.

Considering these factors leaves any public health campaign targeted at low income neighborhoods at a lower likelihood of succeeding. However, there are ways to tie health in with lower order concerns. This entails careful education and framing of how the health problem is presented, which is clearly not done in the case of calorie labeling. Simply labeling foods will be hard pressed to succeed in areas where hunger and danger are basic facts of life.

Group Dynamics Fail To Encourage Community Wide Change

Calorie labeling is often considered only on the individual level of the consumer making a conscious decision to decrease calories. However, in some ways deciding to cut calories is influenced by group dynamics. So, in order to alter cognitive processes in low income neighborhoods, a group focused approach could be widely successful.

In all neighborhoods as people begin to change their eating habits other people observe this change and may alter their behavior as well. The Law of the Few asserts that only a few people well-connected and social people are needed to spread an idea which, in this case, is decreasing calorie consumption (16). So, if a few socially adept people in a wealthy area begin noting calorie postings and reducing their caloric intake, this could have an overwhelming effect on group dynamics. However, this alteration in group dynamics is unlikely to occur when there are other social factors overwhelming a social paradigm shift, as is the case in low income neighborhoods.

Initially, some influential people must realize the significance of calorie posting, choose to decrease their calories, and directly or indirectly influence others to do the same (16). In more well-educated and wealthier areas people tend to have the knowledge that eating high calorie foods leads to heart disease, diabetes, and a slew of other health problems. So, they are more willing (and motivated) to alter their eating habits. If the correct people change their eating habits, paying attention to calorie postings will eventually reach a tipping point and become widespread.

In areas where the population is less well-educated, people may not see a direct link between eating a high calorie diet and subsequent health problems. Thus, calorie observation will never become a standard of ordering among the influential people in the area, and will fail to spread among the population.

This idea is also tied in with Social Cognitive Theory. Social cognitive theory posits that people observe the actions of others, and that observation influences later actions taken by both parties (17). In other words, there is a constant reciprocal passing of ideas and cognitions. It operates quite similarly to the Law of the Few in that it involves both a group dynamic and shifting ideas among group members.

However, there are some slight differences. For one, the Law of the Few involves specific people altering their eating habits and consciously noting calorie counts. However, Social Cognitive Theory does not specify which type of people within a population need to alter their behavior for it to spread. The underlying problem with both, though, is that there is no incentive for calorie posting to become an effective calorie control measure in low income neighborhoods. Group dynamics simply do not support the initial hook; there is no incentive for anyone to begin watching caloric intake when there are so many other stressors in their lives. Thus, both the Law of the Few and Social Cognitive Theory help to explain why calorie postings fail on a group level.

Altering Education, Perception of Needs and Group Dynamics

Interventions designed to address calorie posting efficacy must consider the various sociological components. As a result, the proposed intervention has several different components each of which is designed to handle a separate part of the problem. While these suggestions are specifically tailored to difficulties faced in lower income neighborhoods, they could also be used to improve the overall efficacy of calorie posting.

The first prong of the intervention directly involves the content of calorie postings. Since education levels and health knowledge are inconsistent in low income neighborhoods, some additional nutritional information may better persuade consumer to purchase healthy foods. Specifically, a simple solution is to post calorie counts as a percentage of the recommended daily value. The USDA recommends on average, for women age 31-50, consumption of 1800 calories. And, for men in the same age range, that recommendation is 2200 calories (18). So an easy way to educate consumers would be to post calories as a percentage of that daily recommended value. Now, obviously there are some problems with this. Calorie recommendations vary based on weight and activity level in addition to gender. However, this would provide a guideline that fairly accurately reflects how much a person should be consuming in a day.

The second section of the intervention addresses the hierarchy of need. To arrange a successful public health campaign in low income neighborhoods, a drive for health must be tied in with lower order concerns. In response to this, an admittedly arduous task may be necessary. One way of increasing healthy eating awareness is to increase the exposure to healthy foods. Public health programs need to examine issues of access to healthy food in order to create a situation where basic physiological hunger can be easily met by healthy, accessible foods (19). So, the number of restaurants and grocery stores offering healthy alternatives needs to increase. If this occurs, people will become more familiar with healthier, low calorie foods, and will thus be more likely to purchase them. Although this is an indirect way of approaching food choice, it should alter choices enough that people, at the very least, do not have negative associations with the healthier, lower calorie food choices.

Finally, the third part of the intervention targets the group dynamics that largely affect calorie posting’s effectiveness. In many ways children’s behavior is the most malleable. They are still learning about food choices, and their preferences can still be altered. Additionally, there is the added bonus that children are required to attend school; there, a rich opportunity exists to further food education which can then be passed on to adults in the community. Currently 31 million children in the United States received free or discounted lunches at school because of financial necessity (20). If healthier meals are provided, and calorie postings are prominently displayed and explained, children will become familiar with the components of healthy eating. And, as asserted by the Law of the Few, some of these children are bound to be influential members of society and will thus pass their knowledge on to the community as a whole (16).

Improve Health Education through Updating Calorie Postings

Educating the public in a consistent and specific manner is crucial. A recent study found that internal knowledge is a very important factor in determining healthy eating; this knowledge can be greatly increased by presenting calorie counts as a percentage of the total daily recommended value (21). Essentially, the study found that the only guarantee of healthy eating is a very high level of health knowledge. However, the authors note that it is possible to improve health education by considering the baseline health knowledge of the population (21). Merely posting calories assumes that consumers know how many calories they ought to be eating. Therefore, it would be much more effective to assume a lower baseline health knowledge and post calories as a percentage of the recommended daily value.

One interesting thing to note is that presenting calorie information as a percentage may actually lead to a phenomenon where consumers associate low calorie counts with a positive experience. When participants in a study were asked to predict calorie values and then were shown the true values, they positively perceived items on which they had overestimated the calorie counts (22). As a result, people tended to more often purchase items that were healthier than they initially thought. So, posting calories as a percentage will help with this health knowledge goal as well; people will have a better idea of how healthy (or low-calorie) the foods are and will hopefully make positive associations with the lower calorie foods.

Linking Health Behavior with Physiological Need

Maslow insists that moving up the hierarchy of needs pyramid is not possible without first meeting lower order concerns, and health does not fall on the bottom rung of the pyramid (14). However, tying health in with hunger is possible. First, it is important to ensure that hunger needs are met by guaranteeing access to food. Access to healthy, nutrient-filled food is often more expensive and less accessible than fatty, sugary food. In Minnesota, residents living in “food deserts”, areas without limited access to grocery stores, reported cost as a significant barrier to healthy eating (23). Another difficulty is that low income neighborhoods are served primarily by small grocery stores. One investigative study found that 64% of pre-determined healthy foods (including low fat dairy products, low fat meat and whole grains) could not be found in these small grocery stores (24). Thus, residents in lower income areas are not exposed to healthy food, which creates another related, but fixable, problem.

People respond strongly to familiarity. Children tend to form preferences for foods that their parents offer them; unfamiliar foods are associated with a lower level of trust and liking (25). These preferences permeate even adult food choices. So, if residents in a low income neighborhood do not have access to whole grains and low fat options they will not be familiar with those foods. And, as a result, when they see healthier, low calorie options on a menu, they will likely ignore the calorie counts simply because they are not used to consuming the healthier options. Calorie posting can thus not be effective unless at-home eating habits change.

Although it can be more expensive to purchase healthier options, there is some evidence that it is possible to acquire healthy options at a fairly low cost. Healthier foods can best be provided by supporting the small grocery stores that already exist and encouraging them to stock healthier foods (26). Perhaps subsidies should be provided to small grocery stores that are willing to stock healthier options if the initial cost is too high. This would increase the familiarity of residents in the local neighborhood and, hopefully, lead them to note calorie postings and lead overall healthier lives.

Spreading Healthy Eating Throughout Low Income Communities

Recently, Congress passed a bill that will allow schools to encourage healthier eating through the school lunch program (27). This effort targets many of the current issues with school lunches: improved access between local farmers and schools, improved nutrition, and improved access to the program for low income individuals (27). While this is clearly well on the way being an effective intervention, it does not entirely address the problems in low income neighborhoods as there are slightly different social dynamics at work.

Yes, increasing the access to healthy food will undoubtedly make children healthier. There is strong evidence of the influence of peers on children’s health behavior (28). In low income neighborhoods, where more children are likely to qualify for the National School Lunch Program, there are more peers eating the same types of health food. This should eventually lead to a community-level change in eating habit. But, without knowledge of why the food choices are healthier, or how calories relate obesity, children will not be able to knowledgeably bring healthy eating into their daily lives.

National School Lunch programs must work on providing health education integrated in with the program. Calorie postings need to be prominently displayed and information on the importance of noting calories ought to be taught. According to a study at Washington State University, it is fairly simple to educate elementary school science teachers in the basics of healthy eating (29). Healthy food choices combined with knowledge about choosing healthy, low calorie foods will create an environment in schools that encourages and promotes healthy living. And, as these children grow up and become leaders in their communities they will spread the message and continue to promote healthy food choices.

In conclusion, solving the inadequacies of calorie posting is not a simple task. The drives behind unhealthy eating are too intertwined with societal factors that require massive remodeling. However, considering education and changing societal attitudes are imperative. When combined with the more explanatory calorie postings, these methods will eventually alter the discrepancies in attitudes toward calorie postings.


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