Friday, December 17, 2010

Punishment Doesn’t Work: Why The San Francisco Board Of Supervisors Has Missed The Mark -Margaret Swift

The Happy Meal is an icon of American culture. If you can believe it, we still have our Return of the Jedi drinking glasses. The McDonald’s Happy Meal has been around for over 30 years, and Good Morning America celebrated the Happy Meal’s birth with this segment. NHANES data from 2007-2008 indicates that 16.9% of children from 2-19 are obese. As a dietitian I can understand why some advocacy groups are concerned, but are toys really to blame? I thought we were trying to get overweight children to play more?

On November 2, 2010 The San Francisco Board of Supervisors passed a ban on restaurant toy giveaways for kid’s meals that do not meet the nutritional standards for calories, sodium and fat. In the article “You Want a Toy with That?” published in the New York Times on November 3rd, 2010, the “decision was backed by some unhappy facts, including recent findings that nearly 30% of city fifth graders were overweight.” (1) Many members of the constituency are outraged, and even the mayor of San Francisco plans to veto the toy ban; although the board’s 8 to 3 vote will override him.

Obesity is a complex and overwhelming social problem, and it is no surprise that the government wants to do all that it can to decrease the incidence of obesity. Traditionally, California State government has been a leader in innovative health policy, but, like much of the U.S, their efforts have produced limited results. I predict that the toy regulation will be no different. In this paper I will present 3 arguments as to why this ban is an ineffective public health policy, and suggest alternatives to help change adolescent eating behaviors.


Obesity is defined as having a Body Mass Index (BMI) greater than 30. According the Center for Disease Control (CDC) website (2), there has been a dramatic increase in obesity in America over the past 20 years. Only Colorado and the District of Columbia reported an incidence of obesity less than 20%, and nine states (Alabama, Arkansas, Kentucky, Louisiana, Mississippi, Missouri, Oklahoma, Tennessee, and West Virginia) report obesity prevalence over 30%. Healthy People 2010 aimed to reduce the national prevalence of obesity to 15% by 2011, but unfortunately that goal will not be met. Among minority and low-income populations, obesity is running rampant. In a review of data from 2006-2008, 25.6% of non-Hispanic blacks, non-Hispanic whites, and Hispanics were obese. Non-Hispanic blacks had 51% greater prevalence of obesity, and Hispanics had 21% greater prevalence, when compared with non-Hispanic whites. (3) Below are two diagrams demonstrating the dramatic changes in obesity prevalence in the U.S. from 1987-2009.

Obesity contributes to a staggering number of health complications including Diabetes, Heart Disease, Arthritis, and some Cancers. Rhem et. al (4) estimate that obesity leads to excess medical costs of $295 per person per year, similar to the medical costs of alcohol or tobacco use (4). A number of parent groups, consumers, and industry executives oppose the regulation of competitive foods by the federal government. They argue that the onus of obesity regulation is not the responsibility of government, but is the responsibility of families and individuals. As a result of the reauthorization of the Child Nutrition Act in 2004, education programs who participate in the National School Lunch Program were required to establish wellness policies for nutrition and activity no later than the first day of the 2006-2007 school year. As a result, school administrations scrambled to put policies into place, and many policies were established on limited budgets, using ineffective strategies. Traditionally state agencies and school authorities have regulated food policies, but that is slowly changing. Of recent interest, is the progressive regulation of sugar-sweetened beverages (SSB) sales in schools. Coca-Cola predicted these regulations, and began to self-regulate the sale of their SSB in schools (which ensued its own set of problems), but in May 2006 Schweppes, Coca-Cola, and PepsiCO signed an agreement to curtail the sails of SSB in schools. On criticism of these regulations is that they do not include 100% fruit juice or sports drinks; two beverages equally to blame for excess calorie intake in children. While there are a number of additional criticisms of this phase out plan, we can assume that the trend toward the federal regulation of competitive foods will only continue. (5) At this point, it is the responsibility of public health professionals to oversee that regulations will be effective and create change.


The Health-Belief Model (HBM) proposes that health behavior is influenced by four individual perceptions of a condition: susceptibility, severity, benefits of action and barriers to action. The theory suggests that a moderate to extreme degree of perceived susceptibility, or severity, creates a negative life-space. As a result, this negative life-space motivates individuals to alleviate negative forces by changing behavior in order to create a more positive life-space. Action is influenced by perceived barriers and whether or not an individual believes a specific action will produce a positive result. This version of the HBM came under intense scrutiny, and was later modified to include self-efficacy and cues to action. The San Francisco Board of Supervisors assumes that the toy restriction will be the cue to action for parents and children to eat healthier low-fat foods and ultimately decrease the prevalence of obesity.

The HBM is widely used in the development and evaluation of weight loss programs. The model has been most effective in individual counseling, but its linear cause-and-effect framework is inappropriate at the group level. In this case, the HBM creates a number of assumptions imposed by the San Francisco Board of Supervisors. The board assumes that parents have similar levels of health literacy than they do. Minority populations often perform at lower levels of health literacy then, say, government officials. Health literacy is affected by communication skills, lay and professional knowledge of a condition, culture, demands of the health care system, situation and context (6). In San Francisco, they expect that parents of at-risk children are aware their child is overweight or obese, and understand that this condition leads to chronic disease. They also assume that people with low levels of health literacy can identify foods high in fat and calories, comprehend the concept that fat has more calories per gram that any other nutrient, and that excess calories contribute to weight gain. And finally, the board believes that the target population wants to do something about being overweight. The Board is betting on the fact the people who are obese know it, understand why, and want to do something about it. The board also assumes that the only reason kids order a Happy Meal is for the toy. The assumptions derived from the limited framework of the HBM create gaping holes in the boards presumed results of the toy ban.


This intervention was created to improve the health of children. In addition to the government, many schools have set out to eliminate the sale of SSB to help prevent childhood obesity. A prospective study in Maine set out to examine the impact of eliminating or reducing SSB in local high schools as an effective school nutrition and wellness policy. Schools were placed in either the experimental group (eliminating/reducing the availability of SSB) or in the control group (making no changes to the availability of SSB) for 1 school year. Students at those schools were then recruited and given pre and post food frequency questionnaires. Initial data demonstrated a dramatic decrease in the availability of SSB in intervention schools when compared to controls. However, upon review of the selected student’s pre and post food frequency questionnaires, there was no significant difference in overall consumption of SSB in either group. This study suggests that eliminating the availability of SSB in schools does not change health behavior (7). Ebbeling et al (8) report that adolescents obtain nearly 50% of their beverages from home, and energy consumption from SSB has increased among all age groups and all sources since 2001. The sources of SSB include vending machines, restaurants, fast food establishments, grocery stores and supermarkets. (4) Regulating only one of the sources of food is clearly not effective, and the finger cannot be pointed solely at fast food restaurants.

A number of studies (9) (10) (8) (11) suggest adolescent wellness interventions that include schools, parents, care givers, mentors, and communities are the most effective. Interventions must consider specific mediators and moderators of childhood behavior. Stice et al (10), report that many obesity prevention programs produce limited results in target populations as there is often less stigma and body dissatisfaction for certain ethnic and minority groups (especially black women). They claim that interventions are more effective for high-risk groups because they typically participate in a specialized program as opposed to a universal program. In the case of adolescent programs, they go on to say that direct, population specific, easy to follow, interactive, and short term interventions are the most effective.

Many healthy eating interventions aimed at adolescents ignore the educational and behavioral strategies kids need to make healthful choices. Healthy eating interventions must address the community of food sources. Psychological reactance theory suggests that if someone is told to do one thing they will often do the opposite. That is why it is important to consider the key mediators and moderators of adolescent behavior (4). The San Francisco toy ban only addresses one mediator of childhood behavior; therefore making it an ineffective behavioral health intervention.


Finally, consider where the toy ban intervention is taking place. In this case, the target population has already decided to eat at a fast-food restaurant. To change behavior you need to intervene before the behavior has occurred. Children and parents are bombarded by television advertisements that intervene at the right time and place. Food is the most frequently advertised product during children’s television viewing. In the study Advertised Foods on Children’s Television, researchers found that commercial advertisements account for approximately 16% of a child’s total viewing time. Commercials related to food (cereal, snacks, candy and restaurants) comprised 47.8% of all commercials, and a staggering 129.7% of foods advertised were high in sugar, fat, sodium (only 8.9% of foods were low in sugar, fat and salt). Food choices are significantly related to foods advertised on television, and are positively correlated with bad eating habits, unhealthy concepts about food, and incorrect knowledge about principals of nutrition. (12) Food advertisements are often associated with having fun as opposed to being nutritious or healthy. McDonalds has done an incredible job getting consumers to believe that if you eat McDonalds you’ll be happy, have friends, have fun, and be attractive. Advertising theory suggests that the bigger the claim the more effective the message. The McDonald’s claims are supported by images of smiling kids and adults, bright sunny colors, thin, attractive people having fun. This commercial[1] shows Olympic athletes eating McDonald’s. When was the last time you saw a McDonald’s packed with athletes? In a sense McDonald’s promises that their food is healthy and does not make you fat. This is propaganda, but as Dr. Siegel says, propaganda is a very effective group level model.


The aforementioned arguments suggest that the San Francisco Board of Supervisors toy ban will be ineffective as it is based upon the Health Belief Model, ignores the collective influences on adolescent behavior, and intervenes at the wrong place and time. As an alternative I would suggest implementing a program I have named Eat Healthy California. This program would address and involve the multiple mediators and moderators of childhood behavior. The programs campaigning efforts would invoke advertising theory to inform parents, schools, and local communities of the program goals and benefits. The Eat Healthy California brand will have a modern feel, designed to attract parents, while interesting children and teens. The program goals will be to empower children to make healthy eating choices through the involvement and influence of parents, schools and peers.

I would suggest Eat Healthy California partner with a company like NuVal: Nutrition Made Easy. NuVal is a healthy eating system that lets consumers see the nutritional value of the foods they are choosing at a glance. NuVal is a system that is already in place, but they are looking to expand to food vendors across the U.S. Each food in the NuVal system is assigned a score from 1-100; which indicates the overall nutritional value of that food. Eat Healthy California would use NuVal’s established food score system to create “point vouchers”. The idea is, that each student at a participating school would collect points for every food they or their family purchases, orders, or consumes. The school with the most points at the end of the school year receives a healthy food makeover. Each school will elect an Eat Healthy Officer who will oversee a group of Eat Healthy Advocates from each grade and or classroom. Advocates will help motivate their peers, collect points and tally points throughout the school year or semester. Points are uploaded on the schools personal Eat Healthy California web page. Interactive demonstrations and seminars will be conducted monthly at participating schools throughout the year to help parents and students meet their Eat Healthy goals and reinforce the program’s healthy eating message.


The broaden-and-build theory of positive emotions suggests that positive emotions broaden one’s ability to accept an array of behavioral options. Whereas, negative emotions tend narrow one’s ability to learn and change behavior. The author, Barbara Fredrickson claims that the cascade of reactions that occur as a result of the though-action response to emotion is difficult to overcome. Traditionally, positive emotion has been thought to be the product of well-being, but Fredrickson argues that positive emotions can produce well- being. By ‘broadening a person’s momentary thought-action repertoire positive emotion may loosen the hold that negative emotion has gained on that person’s mind and body by dismantling or undoing the preparations for a specific action’. (13) In essence, behavior patterns are hard to change, but one can start to loosen a behavior’s hold through a positive, fun, play-like experience. This model, as opposed to the negatively driven framework of the HBM, focuses on the nature of children to play and have fun. Eat Healthy California offers a fun, light hearted competition, and positive incentives aimed at changing adolescent behavior.


I mentioned earlier that, when planning an intervention, it is important to consider the mediators and moderators of adolescent behavior. International HIV Prevention programs have seen some success in South Africa and Ghana. This is primarily attributed to understanding the structure of African-American adolescent culture. In a study by Romer et. al (14) on mass media as an HIV prevention strategy, investigators conducted in-depth interviews with a range of youth representative of the dynamic youth culture of today. They went to great lengths to discover the mediators for African-American youth’s beliefs regarding safe-sex behaviors. As a result of their investigation, 3 counter-messages were created to help reshape adolescent beliefs and norms regarding sex, condom use, and HIV. Investigators used mass media and encourage face-to-face interventions to reinforce their tag line “Life is what you make it. Be safe. If you are sexually active there is only one way to protect yourself for sure…use a condom correctly every time.” (14) In another example, the Program-X intervention set out to improve adolescent activity levels and increase the intake and availability of fruits and vegetables (FV) at home. Unfortunately, the Program-X intervention produced insignificant results. Researchers hypothesized that the intervention would address many of the mediators of activity and nutritional behaviors, but these hypotheses were based upon false assumptions. For example, investigators proposed that gender would be a key moderator in predicting FV consumption and physical activity. However, results indicated that gender was only a moderator for physical activity, and FV consumption was similar in both groups, regardless of gender. In retrospect, investigators admit that their data measurements were not culturally specific, and that health literacy levels were not determined at baseline. As a result, the intervention produced insignificant, and in some cases, negative results. (9). Hilderbrand and Betts (11) point out three categories that influence adolescent FV consumption. The first is income and environment (moderators that are particularly problematic for low-income populations), the second is attitudes and beliefs (mediators related to FV consumption), and the third is social dimensions (moderators such as the mother’s role as the gatekeeper in purchasing, preparing, and serving food). Eat Healthy California addresses many of the key influences on child nutrition behavior by involving communities, partnering with parents & food suppliers, and engaging children in activities that support culturally specific media counter-messages.


Media is an effective model for desirable behavior. Social learning theory acts as an explanation for how people acquire new behaviors. Media uses social life as a frequent subject, and therefore can have a profound effect on creating and recreating social linkages or “habits” (15). Media is frequently accessed by minorities and therefore is a great way to engage youth in the Eat Healthy California program. Using a similar tactic to Romer et al.’s HIV prevention campaign, radio and TV advertisement will have a pop-culture feel (see attached print ad example), and integrate Hip/Hop music, and African American actors engaging in Eat Healthy activities. Advertisements will take on a positive story-like format. Andrew Steptoe & Ana Diez Roux (16), point out an emerging body of research suggesting that happiness is related to numerous aspects of wellbeing, and future health. Happiness is also related to social connectedness and greater ratings of social support. The Eat Healthy California web page will be an interactive social network for participants fostering social connectedness and support. Schools and students will be encouraged to share their experiences, tips, recipes, and success stories; while monitoring their schools progress. The toy ban isolates and punishes those who make the “wrong” decision. However, Eat Healthy California rewards and connects peers reaching for similar goals.

In conclusion, the toy ban posed by the San Francisco Board of Supervisors is significantly flawed. The ban uses an antiquated rigid framework that focuses on punishment as a means to change behavior. Adolescent behavior is largely influenced by their community, environment, peers, parents, and beliefs. Their rebellious nature ensures that, if they cannot relate to public health messages, they will not adopt the suggested behavior. Public Health professionals need to enlist the support of those that influence adolescents to create change. The San Francisco Board of Supervisors has missed the mark on the real issue related to childhood obesity, the food! They have clearly made an uninformed and uneducated decision imposing a regulation that places blames an object rather than the true cause of the epidemic. This creates and unclear confusing message, requiring conceptual advances in the health knowledge of the most at-risk populations. The boars has attacked an American icon create a narrow-minded defense response. The ban will have no effect on the prevalence of obesity in their community, and I wonder if it will only make it worse. However, they can be assured that when asked “Do you want fries with that?” they will stand up and shout “YES”.



1. McKinley, Jesse. Do You Want a Toy with That? New York Times. New York, 2010, Novemver 3, 2010.

2. Obesity and Overweight Trends for Professionals: Data and Statistics. Center for Disease Control and Prevention. [Online] September 1, 2010. [Cited: December 9, 2010.]

3. L Pan, MD, et al. Differences in Prevalence of Obesity Among Black, White, and Hispanic Adults: United States, 2006–2008. US Government Printing office, Region IV : Center for Disease Control and Prevention, 2009.

4. Demographic and Behavioral Factors Associated with Daily Sugar-sweetened Soda Consumption in New York City Adults. Rhem, Colin D., et al. s.l. : Journal of Urban Health, 2008 Vol. 85, No.3, p. 375-385.

5. The Interplay of Public Health Law and Industry Self-Regulation: The Case of Sugar-sweetened Beverage Sales in Schools. Mello, Michelle M., JD, PhD, MPhil, Pomeranz, Jennifer JD, MPH and Moran, Patricia, JD MPH. : American Journal of Public Health, 2008, Vol. 98, No. 4 p.595-604

6. Department of Health and Human Services. Quick Guide to Health Literacy: Fact Sheet. Office of Disease Prevention and Health Promotion. [Online] [Cited: December 8, 2010.]

7. Reduced Availability of Sugar-sweetened Beverages and Diet Soda Has a Limited Impact of Beverage Consumption Patterns in Maine High School Youth. Whately Blum, ScD, John E., et al.: Journal of Nutrition Education and Behavior, 2008,Vol. 40, p. 341-347.

8. Effects of Decreasing Sugar-Sweetened Beverage Consumption on Body Weight in AsolescentsL A Randomized, Controlled Pilot Study. Ebbeling, Cara B., et al. American Academy of Pediactrics, 2006, Pediatrics, Vol. 117, p. 673-680.

9. Exploring the Mechanisms of Physical Activity and Dietary Behavior Change in the Program X Intervention for Adolescents. Lubans, PhD, David R, et al. Journal of Adolescent Health, 2010, Vol. 47, p. 83-91.

10. Stice, Eric, Shaw, Healther and Marti, Nathan C. A Meta-Analytic Review of Obesity Prevention Programs for Children and Adolescents: The Skinny on Interventions that Work. Psychological Bulletin. September 2006, Vol. 132(5):667-691.

11. Assessment of Stage of Change, Decisional Balance, Self-efficacy, and Use of Processes of Change of Low-income Parents for Increasing Servings of Fruits and Vegetables to Preschool-aged Children. Hilderbrand, PhD, Deana A. and Nancy, PhD, RD, Betts M. Journal of Nutrition Education and Behavior, 2009, Vol. 41.p.110-119

12. Advertised Foods on Children's Television. Taras, MD, Howard L. and Gage, MD, Miriam. Arch Pediatr Adolesc Med., 1995, Vol. 149, p. 649-652.

13. The Broaden-and-Build Theroy of Positive Emotions. Fredrickson, Barbara L. Phil. Trans. R. Soc. Lond., 2004, Vol. 359,p. 1376-1377.

14. Mass Media as an HIV-prevention Strategy: Using Culturally-Sensative Messages to Reduce HIV-associated Sexual Behavior of at-risk African American Youth. Romer, PhD. D, et al. American Journal of Public Health, Vol. 99, 2150-2159.

15. DeFleur, Melvin L. and Ball-Rokeach, Sandra J. Theories of Mass Communication, Fifth Edition. White Plains, NY : Longman Inc. , 1989.

16. Steptoe, Andrew and Diez Roux, Anna V. Happiness, Health and Social Networks. British Medical Journal: Editorials . 2008, Vol. 338, a2781.

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