A Critique on the IOM's Approach to ‘meet the nutritional needs of children, foster healthy eating habits, and safeguard children's health’ – E.D.S
One Step in What Should Have Been a Multi-Step Solution: A Critique on the Institute of Medicine of the National Academies’ Approach to ‘meet the nutritional needs of children, foster healthy eating habits, and safeguard children's health’ – Erica (Dodd) Steiner
Nutrition is an important aspect of childhood development. Receiving ‘good’ or appropriate nutrition and engaging in healthy eating behaviors is one of the contributing factors to healthy growth, development, and energy levels in children (5). In addition, maintaining healthy eating behaviors can lead to a lower risk of adverse health effects that could develop and continue to persist throughout adulthood (5,6). Poor or undernutrition can result in delayed mental development and poor educational performance among children, as well as increased risk for adverse health effects such as osteoporosis, asthma, heart disease, stroke, high blood pressure, Type II diabetes, and obesity (2,3,5).
Recent evidence has identified a trend of increased obesity and a lack of nutritious intake among children and adolescents. Within the past 20 years, the prevalence of children who are overweight has doubled, and the prevalence of adolescents who are overweight has tripled (4, 5). Currently, children and adolescents are not receiving appropriate portions of nutrients as recommended by current U.S. dietary guidelines with more than 60% not receiving recommended fiber levels or complying with appropriate levels of saturated fats, and with 85% of females not receiving appropriate levels of calcium (1,5).
The problems and implications of poor nutrition and childhood obesity have been recognized and action is being taken to counteract the observed trends. The Institute of Medicine of the National Academies (IOM) is an organization that advises the government, private sector, and nation on ways to improve health (8). One of IOM’s goals is ‘to meet the nutritional needs of children, foster healthy eating habits, and safeguard children's health’ (10). IOM’s approach to meet these goals is to provide updated recommendations for nutrition standards based on new knowledge of nutrition to the National School Breakfast and Lunch programs, which are federally assisted meal programs to non-profit and public schools which help to provide low-cost/free nutritional meals (9,11,13). Nutrition standards for schools guided by the National School Breakfast and Lunch programs have not been updated for over a decade, and, as many students receive the majority of their meals at school, and in light of the rising trend in obesity and concerns regarding proper nutrition for children and adolescents, it is important to ensure that appropriate nutritious food is provided (10).
IOM’s main recommendation is to increase the amount of fruits and vegetables, ensure that half of breads/grains are whole grain, require that milk provided is fat-free or low-fat, set minimum and maximum caloric content, and decrease sodium levels (10). IOM also recommends that studies should be funded to evaluate implementation of recommendations, children acceptance of recommendations, children participation in school meals, and child health (10). Several companies that provide schools across the United States with food have agreed to comply with IOM’s recommendations and multiple schools and districts are adopting the recommended standards (12,14,15).
IOM’s approach of providing access to nutritious foods to address the problems of poor nutrition and obesity in children and adolescents is a necessary component for successful results. However, due to the lack of several key considerations, the approach will not be as successful as it could potentially be, and will ultimately fail in reaching IOM’s current set goal. While providing access to nutritious food, particularly at low-cost or free to children and adolescents from low-income or socio-economically disadvantaged households, is a key step in combating poor nutrition and the rising trend in obesity among children and adolescents, these efforts alone will not be sufficient to encourage healthy eating habits and increase child and adolescent health because they violate multiple social and behavioral theories/models that have been used to successfully initiate behavior changes. IOM’s approach should have included additional measures in conjunction with recommendations for the National School Breakfast and Lunch programs if their goal is to be achieved. IOM’s approach is only one step in what should have been a multi-step solution.
Recommendations do not Educate
IOM’s approach fails to educate children, adolescents, parents/caregivers, and even educators on the reasons why these particular foods are being recommended, the importance of eating nutritious meals, the benefits of health, and the implications of poor health. Before children or adolescents can understand why it is important to take action regarding healthy eating behaviors and before parents or caregivers can resolve to become engaged in ensuring their children partake in healthy eating behaviors, they need to know what healthy eating behaviors are, why healthy eating behaviors are important, and how to develop, act on, and maintain healthy eating behaviors. At least one study on an education curriculum intervention found that a comprehensive nutrition curriculum could be effective for improving health and reducing the risks of future diseases associated with poor health and obesity (16).
There are several social and behavioral models, such as the Health Belief Model and the Precaution Adoption Process Model, that emphasize the importance of having knowledge of a problem and the importance of being aware of the risks of a problem before behavior changing action can be taken.
The Precaution Adoption Process Model is based on five components: ‘unaware of the issue’, ‘unengaged by the issue’, ‘deciding about acting’, ‘deciding not to act’, ‘deciding to act’, ‘acting’, and ‘maintenance’ (17). The first component, ‘unaware of the issue’, holds that it is unlikely that a person’s behavior will change if the intended audience of the intervention is unaware that there is a problem with their current behavior, i.e. that behavior will not change in the face of ‘simple lack of knowledge or awareness’ (17). Similarly, if children, adolescents, and/or their parents are unaware of the problem of particular eating habits or the risks associated with obesity, they are unlikely to change any adverse eating habits to healthy eating habits.
The second component of the Precaution Adoption Process Model, ‘unengaged by the issue’, distinguishes between those who are unaware of a problem from those who are aware of a problem, but are not engaged to a degree that would result in addressing the problem (17). If children and adolescents are not aware of the risks, or are not engaged enough to consider addressing the problem and associated risks of poor nutrition and obesity, they will not take action to change their eating behavior/habits. Similarly, parents/caregivers will not take action to encourage their children to change poor eating behaviors or to adopt healthy- eating behaviors.
Without knowledge of the issue of poor nutrition and obesity, which is encompassed in the first two components of the Precaution Adoption Process Model, children and adolescents cannot move onto the subsequent components of the model which involve deciding about acting and, optimally, the decision to act, and then maintain healthy eating behaviors in order to improve health and reduce risks associated with poor nutrition and obesity.
The Health Belief Model is a health behavior model comprised of six components which include perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy (17). These components flow together and essentially maintain that a person will only engage in a behavior if they perceive that they are susceptible to the problem, they believe the problem is severe and has adverse consequences, they perceive the benefits of doing the behavior and that the behavior has positive consequences with regards to the problem, they do not perceive barriers or obstacles in engaging in the behavior, something occurs to motivate them to engage the behavior, and they believe they are capable and able to perform the behavior (17). If children and adolescents are not educated to the degree of their susceptibility to poor nutrition and obesity, the severe consequences of poor nutrition and obesity, and the great benefits of adopting healthy eating behaviors, they will not respond to the cue of accessible nutritious food and will not engage in incorporating healthy eating behaviors into their lifestyle. Similarly, if parents/caregivers of the children in question are not educated of the extent to which their children are susceptible to poor nutrition and obesity, do not recognize the risks and consequences of poor nutrition and obesity, and do not understand the benefits of healthy eating behaviors, they will not be affected by any cues, such as the availability of nutritious food through the National School Breakfast and Lunch programs, to action and will not believe that there is a need to encourage their children to adopt healthy eating behaviors.
The Health Belief Model and the Precaution Adoption Process Model indicate that if children, adolescents, and their parents/caregivers are not educated on what healthy eating behaviors are, why healthy eating behaviors are important, and how to develop, act on, and maintain healthy eating behaviors, IOM’s approach will not foster healthy eating habits or safeguard children's health.
Recommendations do not Consider Environment
IOM’s approach provides access to nutritious meals to children and adolescents while they are in school. However, IOM fails to recognize the environment of children’s and adolescent’s lives in full. IOM does not take into consideration that children may not have accessibility to nutritious food outside of school or that the environment that children and adolescents live in outside of school may not promote healthy eating behaviors.
Parents and caregivers are the traditional providers of home meals for children. If parents/caregivers do not exhibit good healthy eating behaviors, or encourage their children to adopt healthy eating behaviors, children and adolescents may not engage in healthy eating behaviors even when they are provided with accessibility to nutritious foods and therefore may not receive proper nutrition and may suffer consequences such as obesity. Studies indicate that ‘parents not only create food environments for children's early experiences with food and eating, but they also influence their children's eating by modeling their own eating behaviors, taste preferences, and food choices’ and that there is some evidence that ‘a child’s orientation to health is likely to be affected by role learning’, specifically the mother (18,22).
The Social Cognitive Theory takes into account how personal attributes, environment, and behavior interact (19). One of the constructs of the Social Cognitive Theory is Observational Learning/Modeling(19). The construct of Observational Learning/Modeling maintains that people will learn through observing the experience of others rather than through their own experience (19). In this case, children and adolescents are learning healthy eating behaviors, at least partly, from the parents or the adults that provide for them. By observing how their parents or caregivers engage in eating behaviors, children and adolescents learn to follow and adopt those eating behaviors. Therefore if parents and caregivers do not value and adopt healthy eating habits, it is unlikely that their children/adolescents will as well. This is an instance where ‘do as I say and not as I do’ is not realistic.
In addition, the Situated Learning Theory postulates that meaningful learning will only occur if the learning is done in the environment where it will be used (20). To be effective, behaviors should be learned in the context where they will be used in real life (20). Based on this theory, if children are not engaging in healthy eating behaviors with their caregivers at home, they will not emulate healthy eating behaviors elsewhere. Considering the reverse, school breakfast and lunch are not typical environments. So while nutritious options may be made available in the school environment and some children may even be forced to make nutritious selections at school, the school eating environment does not emulate real life. Therefore, children and adolescents may not follow healthy eating behaviors outside of school.
Children and adolescents learn from observing their parents and caregivers. Therefore, it is important to engage parents and caregivers in helping to set an example for children and adolescents on how to adopt health eating behaviors, to provide nutritious meals, to help children and adolescents understand the importance of healthy eating behaviors, and to help children and adolescents adopt and maintain healthy eating behaviors. Similarly, if children are not learning to engage in healthy eating habits at home in their family environments, they may not emulate healthy eating behaviors prescribed in the atypical environment of school.
The Social Cognitive Theory and Situated Learning Theory indicates that IOM’s current approach does not engage parents or caregivers, and therefore the recommendations to alter school meals will not succeed in attaining IOM’s current goal to ‘meet the nutritional needs of children, foster healthy eating habits, and safeguard children's health’ (10).
Recommendations do not Motivate Students to Act
IOM’s approach does not encourage children to take ownership of their nutritional needs, eating habits, or health. IOM’s approach merely provides access to nutritional food. There is no component in the recommendations that will motivate children to actively choose to eat nutritional foods, to adopt healthy eating habits, or to take action to improve their health as a conscious decision.
One study, that examined adolescent preference of school lunch items, found that when soy substitutes were offered in place of popular lunch options, such as chicken nuggets or burgers, students consumed the same amount of food regardless of whether the food contained soy or not (21). This indicates that children and adolescents are eating what is provided, but not thinking about what they eat. Studies have demonstrated children and adolescents do not increase fruit or vegetable consumption when only access to nutritious foods is provided and additional interventions are not employed (results were statistically significant) and that children prefer to eat foods that are high in fat, sugar, and calories, such as chicken nuggets, pizza, french fries, etc. (23,24).
With regards to nutritious intake, children and adolescents do not see immediate benefits. That is, children and adolescents are young and vital and, hopefully, active. They have not yet developed high blood pressure, hypercholesterolemia, heart disease, and other diseases associated with obesity and/or poor nutrition. Children and adolescents are also not likely to be concerned with the impact that their meals have on school performance. Why should a child or adolescent eat grilled chicken instead of chicken nuggets if the ‘reward’ is that they will be able to focus better when learning? This would not be enticing to a child or adolescent and would not motivate them to change their eating habits nor does the threat of adult diseases, where the idea of far off future consequences are hard to grasp, motivate children and adolescents to change their eating habits. To a child or adolescent, there is no motivation, reward, or incentive to change their eating habits. Especially when research has shown that children and adolescents successfully exhibit behavior change when rewards or incentives are offered or when competition is invoked (24).
One of the constructs of the Social Cognitive Theory is reinforcement, which maintains that behavior will increase or decrease based on the reinforcement offered (19). Research has shown that children and adolescents successfully exhibit behavior change when rewards or incentives are offered or when competition is invoked (24). Although access to nutritional foods is offered, there is no positive reinforcement for children and adolescents who consciously choose to eat nutritious foods that promote health. Therefore, there is no motivating factor for children and adolescents to make healthy eating choices or change eating behaviors. By neglecting to positively reinforce children and adolescents who engage in healthy eating behaviors, IOM is inadvertently bypassing a strong motivation that could be used great advantage to achieve the institution’s goal.
IOM’s approach does not motivate children and adolescents to consciously be aware of their eating habits or to take action in altering their eating habits. In the Health Belief Model, previously described, one of the components of the model is ‘cue to action’ which maintains that there is a factor or ‘cue’ that prompts action that results in behavior change (17). IOM’s current cue to action is providing access to nutritional foods. However, as studies have shown, this cue is not strong enough to motivate children and adolescents to take action and change eating behaviors. Without a cue strong enough to ‘jolt’ children and adolescents into action, children and adolescents will not actively change their eating behaviors, especially if the only intervention is accessibility to nutritious foods.
The Health Belief Model and Social Cognitive demonstrate that without a strong cue to action or an incentive to change eating behavior, IOM’s approach will not help to achieve their goal.
IOM’s goal to ‘meet the nutritional needs of children, foster healthy eating habits, and safeguard children's health’ will not be met by providing access to nutritional foods because this approach does not comply with components of the Health Belief Model and Precaution Adoption Process Model, the Observational Learning/Modeling and Reinforcement constructs of the Social Cognitive Theory, and Situated Learning Theory. The approach does not educate children/adolescents or parents/caregivers on the benefits of healthy eating behaviors and risk of poor nutrition/obesity; they do not consider contextual/environmental factors on children/adolescents’ eating behavior; and they do not motivate children/adolescents to consciously adopt healthy eating behaviors. A supplemental intervention is needed to address the concerns identified through the social and behavioral theories/models to address the problems of poor nutrition and obesity in children/adolescents.
Previous educational interventions for healthy eating behaviors that encourage parent involvement have been implemented successfully demonstrating significant improvements in nutrition knowledge and dietary habits (16). Therefore, it is reasonable to consider using an educational intervention as a supplement to IOM’s current approach. IOM’s approach should include a mandatory interactive educational intervention that utilizes the social and behavioral models that IOM’s current approach violates in addition to utilizing Herding Theory to address the identified deficiencies. The interactive educational intervention should be implemented as a class at a young age, such as first grade, as research has shown that behavior established in children have longer lasting effects that persist throughout life and healthy eating behavior is easier to develop in young children, and should be required through high school (24). The intervention should utilize the Health Belief Model and the Precaution Adoption Process Model by emphasizing the importance of eating nutritious meals, the benefits of health, the implications of poor health, and the need to develop healthy eating behaviors. The intervention should utilize the Observational Learning/Modeling construct of the Social Cognitive Theory and the Situated Learning Theory by changing children’s/adolescents’ environment and adjusting social norms through interactive methods with children/adolescents and parents/caregivers. The intervention should utilize the Health Belief Model and the Reinforcement construct of the Social Cognitive Theory by implementing incentives, rewards, and competition as a means to motivate children/adolescents to adopt healthy eating behaviors. An interactive educational class intervention such as this, in addition to accessibility of nutritious foods through IOM’s current approach instituted by the National School Breakfast and Lunch programs, could potentially have greater results and a much more long lasting effect on achieving IOM’s goal.
The first criticism of IOM’s approach is that the recommendations do not include educating children/adolescents or parents/caregivers on healthy eating behaviors.
In order to correct this deficiency, the interactive educational class intervention should literally provide education to children/adolescents on the importance of eating nutritious meals, the benefits of health, the implications of poor health, and the need to develop healthy eating behaviors. The information provided to children/adolescents should teach what healthy eating behaviors are, why healthy eating behaviors are important, the benefits of healthy eating behaviors, the consequences of poor eating behaviors, and how to develop, act on, and maintain healthy eating behaviors. The Precaution Adoption Process could be utilized in this way by educating children/adolescents so that they are aware of the problem of poor nutritious intake and its consequences so that they can move through the remaining components of the model, ‘deciding about acting’, ‘deciding not to act’, ‘deciding to act’, ‘acting’, and ‘maintenance’, and can therefore change their eating behaviors (17). Similarly, those children who are unengaged will be motivated through education and awareness to become engaged and will move through the remaining components of the Precaution Adoption Process Model previously listed.
The Health Belief Model can be utilized by providing children/adolescents with information on the problem of poor nutritious intake and its consequences so that they are aware of the problem, they are made aware of their susceptibility to the problem, they understand the severe/adverse effects of the problem, they understand the benefits of healthy eating behaviors, and they are taught to overcome barriers to implementing healthy eating behaviors. They can then respond to the cue to action of accessible nutritious food, overcome any doubts in self-efficacy (the ‘confidence in one’s ability to take action and overcome barriers’), and change their eating behaviors (17,19).
In addition, parents/caregivers should also be provided with information designed to educate on healthy eating behaviors, appropriate/nutritious foods, where to obtain reasonably priced healthy foods, and healthy recipes that utilize low cost foods so that they too can engage in changing their own eating behaviors by moving through the components of the Health Belief Model and Precaution Adoption Process Model and can play a key role in encouraging their children to change their eating behavior. As most of the children/adolescents participating in the National School Breakfast and Lunch programs are from socio-economically and/or financially disadvantaged families, it is important to ensure that parents/caregivers feel empowered to help their children achieve and maintain healthy eating behaviors, thereby fulfilling the self-efficacy component of the Health Belief Model (7). One study revealed that limited access to nutritious and affordable foods have a substantial impact on the ability and perceived ability of parents/caregivers to consistently provide nutritious meals for their family (25). By providing access to nutritious foods through the National School Breakfast and Lunch programs and through education, parents/caregivers can achieve self-efficacy and feel empowered to help their children achieve and maintain healthy eating behavior.
In addition, Herding Theory can be utilized to make the interactive educational class intervention more successful. Part of Herding Theory maintains that information is disseminated through other individuals that comprise a group and suggests that the behaviors/thoughts being conveyed should be incorporated by the individual because the information has been incorporated by the group regardless of the individual’s own private thoughts especially if an experienced or authoritative figure acts first (26,27,28).
By instituting an interactive educational class intervention, information can be disseminated to children/adolescents directly through an authoritative and experienced leader, the teacher/educator. By learning about healthy eating behaviors through school from a respected teacher, children/adolescents will adopt this information as a common behavior and therefore will incorporate the behavior as their own regardless of their own thoughts or preferences, just as indicated by Herding Theory.
Addressing Environment and Changing Social Norms
The second criticism of IOM’s approach is that the recommendations do not consider the environment in which children learn their eating behaviors and do not engage parents/caregivers to promote healthy eating behaviors or provide nutritious meals.
To address this deficiency, it is essential that the interactive educational class intervention engage parents/caregivers in changing the eating behaviors of children and adolescents as parents/caregivers help establish healthy eating habits, provide meal content, and act as role models by the behavior they exhibit (7). In addition, children’s/adolescents’ eating behaviors can be changed by their home environment from observing their parent’s/caregiver’s eating behaviors (22). Situated Learning Theory can be implemented through interactive homework assignments and projects, such as working with parents/caregivers to develop a weekly nutritious meal plan and implementing the meal plan one to two times per week to change children’s eating environment outside of school and change the social norms (socially accepted behavior that is considered normal) of eating behavior in which children are exposed to, thereby allowing children/adolescents to learn healthy eating behavior in their home environment in a ‘real-life’ context (17,20). Other interactive homework and projects should be utilized to continue parent/caregiver involvement in an active and positive way.
In addition, the Observational Learning/Modeling construct of the Social Cognitive Theory can be utilized by engaging parents/caregivers to change the home eating environment and to demonstrate healthy eating as a socially accepted normal and common behavior allowing children to adopt healthy eating behaviors by observing the behavior of others (19). Again, education (see previous section) and interactive homework assignments and projects should be utilized to engage parents/caregivers and to change the home eating environment of children so that they can learn healthy eating behaviors by observing their parents/caregivers in order to effectively implement the Observational Learning/Modeling construct of the Social Cognitive Theory.
Herding Theory can be utilized to make the intervention more successful. As Bikhchandani, Hirshleifer, and Welch stated in their article on information cascades and herding behavior, ‘information conveyed by actions may also be the most credible.’ Herding Theory holds that behavior can be adopted from an individual by observing others (26,28). By engaging parents/caregivers to change the home eating environment, Herding Theory can be utilized and children can adopt healthy eating behaviors by observing the actions of their family.
Addressing Motivation to Act
The third criticism of IOM’s approach fails to motivate children/adolescents to adopt healthy eating behavior. Studies have shown that providing access to nutritious foods alone does not motivate children/adolescents to adopt healthy eating behaviors (24). In addition, threats and consequences of adult diseases have little impact on children/adolescents.
Positive reinforcements, incentives, and competitions for rewards have proven effective in changing children’s eating behaviors (24). Therefore, the interactive educational class intervention should utilize the Reinforcement construct of the Social Cognitive Theory by incorporating incentives and competition as both part of in-class educational components and homework to motivate children/adolescents to adopt healthy eating behaviors. The incentives and competitions will also act as strong cue that will initiate action, thereby utilizing the Health Belief Model.
Again, Herding Theory can be utilized to make the intervention more successful. The second component of Herding Theory is ‘peer pressure’ which maintains that an individual will adopt a behavior or thought similar to that of the group because that individual cares what the group thinks about them (26). By initiating the use of incentives, rewards, and competitions among students, classes, and/or schools, children/adolescents will form groups which will reinforce each other by exerting peer pressure to follow healthy eating behavior to attain goals and ‘win’. Children/adolescents will adopt the healthy eating behavior in order to avoid wrath from the group (which would ensue if the group lost the reward or there was a perception that the group fell behind in the competition) and because the children/adolescents will care what their peers think about them and will want to conform in order to achieve the reward, incentive, or win the competition.
IOM’s current approach to provide nutritional foods through the National Breakfast and Lunch programs helps to provide access to nutritional foods. However, this alone will not reach IOM’s set goal. The components of the Health Belief Model, components of the Precaution Adoption Process Model, the Observational Learning/Modeling and Reinforcement constructs of the Social Cognitive Theory, and Situated Learning Theory have identified deficiencies in this approach to address the problems of poor nutrition and obesity in children and adolescents.
These social and behavioral models/theories should be utilized to recognize the importance of education, environment, and motivation to correct these deficiencies by providing education to children/adolescents and parents/caregivers, changing the environment in which children/adolescents learn eating behaviors, and motivating children/adolescents to change their eating behaviors. IOM’s current approach is just one step in what should have been a multi-step solution to ‘meet the nutritional needs of children, foster healthy eating habits, and safeguard children's health’ (10). However, this goal could still successfully be obtained if a mandatory interactive educational class intervention is implemented that utilizes the social behavioral theories/models identified above in addition to incorporating Herding Theory.
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