Monday, December 13, 2010

A New Machine With Old Parts- Charles J. Inglin

The United States of America has continued to be affected by the obesity epidemic despite the endless spending to reduce or possibly eliminate it. Up to this point, many efforts to solve the epidemic have been fruitless. Here in the state of Massachusetts the problem is no different; of the 5 million adults living in the state 37% are considered overweight and 22% are considered obese(1). Massachusetts became a funded state of the Center for Disease Control’s (CDC) Division of Nutrition, Physical Activity, and Obesity (DNPAO) in 2000, and despite this funding, the number of overweight and obese people has risen from 53% to 59%. This 6% rise continued despite the implementation of several programs by the state of Massachusetts to slow or stop the increase in the rate of obesity. Clearly there is a flaw in the creation and application, as the overweight and obesity rate continues to rise.
Reliance on 5-a-day
The programs that were implemented by the state of Massachusetts were based off of the social-ecological model. The social-ecological model is made of four levels which are individual, relationship, community, and societal. In this model, the goal is to target all four levels of interaction simultaneously, making it possible to sustain the prevention in theory (2). Massachusetts adopted this model from the CDC and established the Massachusetts Partnership for Healthy Weight. The Massachusetts state government took the model and made it into a five-tier model consisting of individual, interpersonal, organizational, community, and society. The first flaw in this intervention is the use of the 5-a-day program as a part of the plan to improve obesity in Massachusetts. Some of the strategies that involve the 5-a-day campaign as a base include; “strengthening communication and increase collaborative efforts between the statewide and regional coalitions/networks (e.g. 5-a-day regional coalitions), integrate 5-a-day education into existing community programs, and develop, implement, and maintain communications between communities and 5-a-day coalitions (3).” The 5-a-day campaign began back in 1991 and has yet to change the consumption of fruits and vegetables by the American people. The 5-a-day model is based off of three models: the Health Belief Model, Social Cognitive Theory, and the Transtheoretical Model. Two of these three models assume that human behavior is rational, meaning that the program relies heavily on spreading the word that fruits and vegetables are healthful and help fight diseases. Ingraining the belief that consuming more vegetables may reduce their risk of cancer and then they will proceed to increase their consumption. A similar trend is seen in the intervention Massachusetts has implemented. When looking at the several objectives in its plan it is notable that several objectives are geared towards educating individuals on what is good for them. The plan has objectives and strategies based on the 5-a-day program, under which the federal government spent 40.1 million dollars from 1993-1999 to cause a 0.6 increase in total amount of fruit and vegetable consumed per day by adults (4). The 5-a-day campaign was effective in spreading the word about the campaign, but not in pushing people to take the next step. This is clear in the evaluation of the program; the campaign managed to increase awareness and understanding of the recommendation by 18% and 19% respectively (4). Since the campaign is based on the Transtheoretical model it is expected that the people will act rationally with their new information, which puts them in the contemplation stage before they progress into the preparation and action stages. Clearly, based on the effectiveness of this campaign, this did not happen. Therefore, it does not benefit the Partnership program to rely on a campaign that proved to be ineffective.

What about ambivalence?
The Partnership intervention has taken some positive steps towards making it possible for people to exercise by establishing more bike paths and parks, but the problem of motivation is still an issue. People who are motivated will most likely take advantage of the areas that are created by the state, but people who are overweight or obese need an extra push. With the advancement in video games, computers, and television in this day in age, it is hard to get children and adolescents off the couch to play or exercise. This is demonstrated most obviously by the fact that the average child watches 3 to 4 hours of television a day (5). Consider this: if a child wakes up and goes to school until 2pm everyday and comes home and watches three hours of television, it is going to be dark by the time he or she finishes, leaving little time for the child to go outside and play. Although it is necessary to have these facilities in place, the mere creation of them will not create a drastic change in peoples’ lifestyles because it has no affect on their normal habits. Building more bike paths and bike racks has no direct affect on an adolescent or adult who comes home every day and sits on the couch and watches television. There is still a heavy assumption that educating the people on the benefits of being physically active and providing a place for them to exercise is going to automatically make healthier people.
The Partnership addresses this problem with the individual and interpersonal parts of the model and is based on the individual type models. The Partnership is still using the Health Belief Model and Transtheoretical model on this level which assumes behavior is rational (6). The theory assumes that the understanding of the severity of the diseases caused by obesity will prompt people to be motivated to exercise. The assumption is that they will be motivated to use the bike paths because they have been educated on the impact of obesity on their body. Although this seems to make sense in theory it is important to take a step back and look at a similar health risk: smoking. Currently in Massachusetts 13.5% of the population are smokers and 4.6% are occasional smokers (7). Despite the warning on the cigarette box and the continuous bombardment by the media about the harmful effects of smoking people, continue to smoke. People maintain their unhealthy habits despite the continuous education about the negative effects of the two. Therefore, it is time for a different approach to these problems to find the solutions.
Parents Versus Child
When looking at the Massachusetts Partnership for Healthy Weight, it is clear that many parts of the intervention will be implemented on the children via their parents. Some parts of the intervention will be through school which will be received somewhat more effectively because the children have less choice. In their home, on the other hand, where they are commanded to do things by their parent children will be less receptive. Since it is in an adolescent’s nature to rebel against their parents, it will be quite difficult to make them be more active. For instance, according to Silvia there is an increase in compliance when the giver and receiver of the message are similar (8). A parent and child may have similarities, but often a parent will threaten a child’s perceived freedom. A threat to freedom in psychological theory according to Clee and Wicklund is considered any pressure towards change (9). With the large changes being implemented this is likely to happen at some point. For example, when trying to convince the child to be more active, the parent restricts the child from watching television. Automatically the child will see this as a threat to their freedom, therefore, it will be difficult to cause a positive change in the child’s behavior, and ultimately lead to failure in getting the child to a healthy weight. Consequently, the main benefits of the program come from what happens within the school system. School only takes up half of the day, which gives the child plenty of time to be sedentary at home, as well as eat food that is unhealthy. If resistance should build, it could compromise the effectiveness of the intervention. Also, as a child reaches adolescence they gain more freedom, making it difficult to control the food they eat and their physical activity. This intervention is big on education and providing areas to be physically active but lacks certain programs that could be beneficial to keeping children and adults engaged.
Massachusetts Partnership for Healthy Weight as a Whole
Overall, the Partnership addresses many problems that will lead to an effective intervention, but based on the current rate of obesity in Massachusetts it has yet to be overly effective. The obesity rate continues to rise despite the implementation of state and federal programs within schools and communities. There is many good parts of the intervention that are in place that can ultimately be effective, yet the three flaws, 5-a-day, inadequate motivation, and a lack of parental intervention have prevented the programs’ success. So what are possible solutions to these flaws that may help the Partnership reach its goals?
Step outside the box
The 5-a-day campaign has been used since 1991 and has been unable to cause a significant change throughout the United States. If the Partnership expects to be successful, it is important that the intervention is solid in all areas. The new approach to push fruits and vegetables should be built similar to the “truth” campaign which has been proven to be effective. The “truth” campaign was launched in 1998 and by 2001 a study discovered that youth using tobacco in the last 30 days had been reduce by 7.4% in middle school and 4.8% in high school (10). Much better than the 0.6 fruit and vegetable increase per day created by the 5-a-day campaign over the several years it was run (4). The campaign for fruits and vegetables would have to be built with marketing that was built much like the “truth” marketing. Bringing in different populations and getting their opinion about fruits and vegetable would help to build the marketing campaign needed to attack the issue. For instance, the new baby carrots campaign, which uses the slogan “Eat’em like junk food,” has built an image for baby carrots that is similar to the junk foods kids eat daily (11). On top of this new found image, the campaign includes the introduction of the carrots into vending machines in schools making them more available for the students to eat. Unlike the 5-a-day campaign that is based on the Health Belief Model, Transtheoretical Model, and Social Cognitive theory, this campaign steps outside the box of normalcy. Its goals are not based on educating the students that baby carrots are good for them because this is already clear. Instead they are taking the effective marketing of the major junk food brands and using it for a healthy food. They are essentially making carrots seem fun to eat? This type of approach is formed from advertising theory and the idea of branding. In order for the Partnership to be effective, they need to apply a similar idea to their community that will engage the kids’ interest in fruits and vegetables. Branding is a way of communicating with the consumer and ultimately persuading them to purchase the product, or create some desired action (12). For example, when you think of Toyota the word “reliable” automatically pops into your head because that is the image they have developed for their automotive company. The baby carrots campaign has taken a stab at eliminating the old idea that vegetables are not a snack food for a vending machine and their healthy image. The campaign attempts to brand the baby carrots as junk food so children don’t think of them as a chore to eat, but a privilege.
My proposed approach to this part of the intervention would be a creation of a program that changes the view of fruits and vegetables to children within the school system. In the cafeteria, there would be the new baby carrots in their junk food packaging as an option for the kids to choose from as well as other fruit and vegetable dishes out of the norm. For example, a side in the middle school cafeteria could be things such as Gooey Peanut butter with tart Grannies, Bogus Broccoli with Dude Ranch dressing, and Zany Zucchini Baked Fries. These creative names would add fun to eating the vegetables and change the idea of suffering because they are eating vegetables. They are also in combination with something the kids may recognize as desirable. With the help of the teachers and lunch aides who could recommend the sides to the children it would be possible to spur interest in the children to at least try the sides. On top of this change in the cafeteria, the children would still be educated on the benefits of vegetables, but the 5-a-day idea would not be part of it. The idea of what actually constitutes 5 servings can be complicated, making it unlikely that the children will be able to grasp the concept. Instead of pushing 5-a-day, it would be more beneficial to give students educational materials on different ways to eat vegetables to make them tasty and fun. Some of these strategies would be having the kids sample different vegetable creations like the ones I named earlier to familiarize them with the idea that fruit and vegetables can taste good. Also, the old idea of not playing with your food should go out the window. It may be strange, but as kids, many people loved to bite the heads off of animal crackers and Goldfish. Consequently, if the kids were to make things out of fruits and vegetables such as dinosaur-shaped fruit and vegetable animals, it may motivate them to eat them. Overall, the goal would be to change the way children view vegetables and to create new creative programs to step away from the old 5-a-day model.
We Are All Competitors
The second flaw I had pointed out with the Partnership is the idea that people are lazy and need motivation to act. A good way to target this problem is to tap into human nature and create competition between people in order to motivate them to be active. Under Maslow’s theory of human motivation, this is clearly defined as an esteem need, which deals with one’s need to have self-respect, self-esteem and an overall positive outlook of themselves (13). These measurements of self can be satisfied through competition and can motivate people to compete. For example, some of the people who are idolized the most frequently are professional athletes within our society. These athletes have built their image of being great competitors, having great confidence, and people give them respect for this because there is an understanding of what it takes to achieve that level. Many people enjoy competition whether they are athletes or not. With a well-developed program that engages people to be physically active the Partnership could reach its goals. The people who compete in the pedometer competition will be gaining respect from others and hopefully self-esteem if they accomplish losing a little weight in the process. A study done at San Jose University actually found that 70% of the students who jogged regularly over 15 weeks valued themselves more after exercising (14).
On top of the Partnership expanding the area of the population it influences in Massachusetts, it would be beneficial to develop several competitions to motivate the residents. For example, each county can have a competition to see who can get the most steps in a month. The county can give out cheap pedometers that will keep step counts and packets to record the numbers. Along with the pedometers the competitors would receive educational materials with different effective diets and ways to calculate their energy needs. On top of the overall benefit the people would receive from walking, there would also be prizes for the top ten finishers in the competition, which will further motivate those who are on the fence about competing. Overall, this would provide motivation for the people throughout the state to go out and walk. Going back to Maslow’s theory of motivation, this type of competition can boost peoples’ self esteem by making them feel accomplished and accepted by the people around them. Ultimately, helping them work towards meeting their self esteem needs.
People Like People Like Themselves
The last major flaw in the Partnership is relying on the parents to cause change in certain aspects of their childrens’ lives such as a reduction in the amount of television they watch or even just getting them to be physically active. With the tendency for children to be rebellious in certain age groups, this can be a difficult task. Reflecting on the article by Silvia on Psychological Reactance theory, it is more likely for a receiver of a message to comply if the deliverer of the message has some similarity with the receiver (8). Using this concept, it is possible to develop a different approach to reducing the number of hours of television watched and amount of physical activity a child may get. The heart of the program would be run by mentors or peers. Reinforcing the idea of using a mentor or a peer is a study that was done on smoking prevention which used a control and a separate group with peer-led pressure resistance training. Telch et al discovered that there was a more variable and less powerful effect on students without pressure resistance training led by peers (15), demonstrating that with peer leadership certain interventions can have a stronger affect on the receivers. For example, if it is high school age kids it would make sense to have a freshman or sophomore in college to be their mentor because they would be considered peers. The mentor for the kids would meet a couple times a week to hang out and be active. To start the program it would be important to pick a variety of mentors with all different types of interests. Making it possible for a mentor to have similar interests to the kids they would be with, leading to better compliance with the activities. The mentor would be trained in some techniques of motivation so that it would be possible for them to get the kids moving. Their overall job would be to engage the kids in sports or some type of physical activity during the time they spent with their mentees. The same type of layout of this program could be used for middle school students, but their mentors would be coming from high school. Overall, this program would lead to the kids meeting older, accomplished individuals like themselves to look up to, which would inspire them to strive to be like their mentor.
If It’s Broke, Fix It
We have all heard the saying “if it ain’t broke don’t fix it” and although that is true it does not apply to Massachusetts’ approach to obesity. The overall plan that was put together for the Partnership has many solid components that pave the way for change, but thus far it has failed to do so.
1. Center for Disease Control and Prevention. Overweight and Obesity: Massachusetts.
2. Massachusetts Partnership for Healthy Weight. Health of Massachusetts: A Coordinated Response to Overweight and Obesity. Boston, Ma: Bureau of Family and Community Health.
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4. National Cancer Institute. 5 A Day Better Health Program Evaluation Report. Last updated March 1,2006, Accessed December 6, 2010.
5. American Academy of Child and Adolescent Psychiatry. Facts for Families: Children and Watching TV. Washington, DC: American Academy of Child and Adolescent Psychiatry.
6. Bethesada MD. Part 2: The Ecological Perspective: A Multilevel, Interactive Approach. Theory at a Glance: A guide for Health Promotion Practice. National Cancer Institute;2005:9-21
7. Massachusetts Department of Health. MassCHIP: Smoking Report for Massachusetts Total. Boston, MA: Massachusetts Department of Public Health.
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10. Hicks J. The Strategy Behind Florida’s “Truth” Campaign. Tobacco Control. 2001; 10: 3-5
11. Associated Press. Oh Snap! Baby Carrot Campaign Mimics Junk Food. New York, NY: CBS News Healthwatch.
12. Blistein J, Evans W, and Driscoll D. Chapter 1: Public Health branding: Recognition, promise, and Delivery of Healthy Lifestyles. Public Health Branding: Applying Marketing for Social Change. Oxford University Press, 2008; 3-24.
13. Maslow AH. A Theory of Human Motivation. Psychology Review. 1943:376-396.
14. Habib, Marlene (January 7, 1995). Regualr, moderate exercise can boost your self-esteem. Toronto Star.
15. Telch M, Miller L, Killen J, Cooke s, and Maccoby N. Social influences approach to smoking prevention: The effects of videotape delivery with and without same-age peer leader participation. Addictive Behavior. 1990; 15: 21-28.

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