Sunday, December 17, 2006

Beyond Tipping the 1992 Food Pyramid: A social science critique of MyPyramid.gov - Tara Naylor

The release of the new food pyramid, MyPyramid, (http://www.mypyramid.gov/) in January 2005 was a step forward in the fight against obesity because it combines both healthy eating and exercise. The United States Department of Agriculture (USDA) describes MyPyramid as an interactive food guidance system. To this end, they have tipped the 1992 food pyramid onto its side, stripped away all pictures of foods, and added a stick figure climbing up stairs on the side of the pyramid. Internet users can log in to the MyPyramid website where they enter their age, gender, and activity level to create a personalized pyramid. They also get a personalized eating plan that outlines not only which foods to eat, but also the quantities of these foods in cups or ounces. The plan also encourages at least 30 minutes of exercise each day. This is a great improvement from the one-size fits all approach of the 1992 food pyramid that measured portions using the cryptic term of “servings”, and ignored the importance of exercise in maintaining a healthy weight

Even so, there are dissenters that feel the pyramid is still inadequate. An article on food pyramids published by Harvard School of Public Health says, “The bad news is that the new pyramid doesn’t convey enough information to help you make informed choices about your diet and long-term health.” (1) They go on to say that there is no distinction made between fat types (trans, saturated, unsaturated), the grain information can be misleading (make half your grains whole) and there are no specific foods that should be avoided in MyPyramid. The article goes on to promote other pyramids, including their own Healthy Eating Pyramid, which they claim is based on more current research and not influenced by lobbying efforts by the food industry.
For those without internet access, MyPyramid is little more than a picture of a stick figure climbing stairs on a pyramid that has colorful bands of various widths that taper at the top of the pyramid. Without the internet to decode the colorful bands, the food groups they represent and how much should be consumed remains a mystery. Many people who need this information do not have access to the internet. In the United States 71% of the population uses the Internet, but there is a socioeconomic divide. About 90% of the most affluent quarter of Americans use the internet compared with only 43% of the poorest quarter of Americans. (2) In an article titled Uncle Sam’s diet sensation: MyPyramid—an overview and commentary, Johnston says, “[MyPyramid.gov is] not likely to be accessed by the populations that need it most: the underprivileged.” (3) In a population studied from birth to 36 years of age, later onset of obesity was more common in the lower occupational groups and those with lower educational achievements. (4) A highly significant association was found between level of education (a primary measure of socioeconomic status) and risk factors for disease, with the lowest education level being at the highest risk for disease. (5)

Furthermore, even those who can get access to the internet may have a difficult time assimilating the information if they have a low literacy level. A study has shown that many health websites are written at a reading level that prohibits optimal access and interpretation by some low literacy adults. (6) In the United States, illiteracy and poor health status are independently associated, even after adjusting for confounding sociodemographic factors. (7) The Stanford Nutrition Action Program (SNAP) was developed as a dietary fat intervention specifically for low-literacy adults. (8) This program focused on goal-setting through classroom based teaching with an interactive learning style, and used only a few written materials. The curriculum included food tastings, demonstrations, interactive discussions and group activities to achieve the nutrition objectives. By tailoring the intervention to the needs of this low-literacy population, the SNAP curriculum was significantly more effective in achieving dietary changes than the general nutrition curriculum.

The USDA has added the slogan “Steps to a Healthier You” to the bottom of the food pyramid which makes the message more positive and indicates that these changes will not happen overnight. On the MyPyramid.gov website, the USDA says of their slogan, “It suggests that individuals can benefit from taking small steps to improve their diet and lifestyle each day.” The problem for most overweight Americans is that following the food pyramid is not a small step; it requires a concerted life change. While the superficial changes are headed in the right direction, the USDA is still missing the importance of the way people think about food, and how these factors influence what they ultimately decide to eat. Even people who are committed to eating healthy will have to seek out the MyPyramid website, answer the questions and then print out the personalized pyramid. Then they have translate the personalized serving recommendations for each food category into a grocery list and finally into meals.

There are successful interventions that use small steps that can be implemented more easily to gradually change the eating behavior of Americans. It has been shown that cutting out or burning as few as 100 calories each day through reduced food intake and increased physical activity, could prevent weight gain in many people. This can be accomplished by leaving behind the last few bites of each meal or walking for 15 minutes each day. (9)

For so long public health messages have focused on the negative effects of a poor diet (higher risks of heart disease and cancer) that people have become afraid of food. The diet message has reached saturation level in the minds of most Americans. At this point it makes more sense to shift to a more positive campaign that promotes the benefits of exercise. A stick figure walking up MyPyramid, and an anecdotal comment about 30 minutes of moderate to vigorous exercise does not encourage sedentary people to get started in an exercise routine. A specific exercise program that is quick and easy to fit into a busy schedule that people can just follow without thinking too much about it would increase their level of physical activity. The feeling of accomplishment encourages people to continue the exercise program and over time people would buy in to the concept of food as fuel for the body. Participants in a study of obese women in a nutrition-exercise program expressed concerns they had during the program; including child care, transportation to a safe place to walk/jog, alternatives during inclement weather, rewards for reaching milestones, etc. (10) We should keep these concerns in mind when developing an intervention to promote physical activity.

The USDA has failed to incorporate social and behavioral sciences in designing this intervention. All of the focus is on the individual in MyPyramid. Overeating can be considered an eating disorder, and it is an addiction on the individual level. In a study comparing Weight Watchers and Overeaters Anonymous from a developmental and sociological perspective, Weiner showed that both interventions are valuable as they are group/community based approaches. (11) A solid understanding of the psychology behind people’s eating habits and the community in which they live is critical to the development of a successful intervention to change someone’s diet. It is at the essence of the problem to contextualize the factors that are going through someone’s head when they are deciding what to eat.

The Diffusion of Innovations theory describes the pattern of how new behaviors are adopted by society. It provides a conceptual paradigm for understanding the process of diffusion and social change. There are early adopters that pioneer the change and then others seeing their success quickly follow suit. This more closely emulates the way the American public embraces fad diets, so it makes sense to use a similar theory as the basis for designing an intervention to promote healthy eating. Rogers proposed a five-stage model for the diffusion of innovations. (12) To make this model work, the innovation must first be communicated effectively so that people know that the innovation exists and how it works (its function). Once the message is communicated, people must be convinced of the value of the innovation through persuasion. The MyPyramid.gov campaign was not well publicized. In fact, not very many people are aware that the food pyramid has changed.

A public health intervention designed to implement small changes in portion size and a simple defined exercise program would be the innovation, and then strategic campaigns would promote early adopters within communities. These people would be social leaders that are popular, and they would then spread the message of healthy eating and exercise. Others, seeing the success of the early adopters, would try these small steps to reduce portion size and start exercising and this early majority would share their stories of success with friends and colleagues. Those who are skeptical, or from a lower socioeconomic status may take longer to receive the message. And there will always be some people (laggards) who will be resistant to implementing this intervention at all.

A successful example of an intervention that puts the Diffusion of Innovations theory into practice was described by Wiist and Flack. (13) They used a church-based program to educate a minority group about reducing cholesterol. Leaders of the church were asked to identify “natural helpers” in their community, and these people were trained to test cholesterol levels and provide structured education to those with high cholesterol levels. The church leaders were among the first to be screened, and encouraged the community to do so from the pulpit during sermons, through the church service bulletins, on the church bulletin boards, on local radio and in newspapers. This intervention was successful in lowering cholesterol levels because it was designed with social and behavior principles in mind. People who may not go to the doctor otherwise were screened and became informed of their cholesterol level. The intervention was done in the context of a community in which the members were comfortable, and people they trusted taught the education classes. The community aspect is very important, because this created a support network of people who were working together towards a similar goal.
America is experiencing an obesity crisis and the public health effort is going to need to take a more proactive and productive stance to improve the eating habits than MyPyramid.gov. This campaign is complicated, poorly communicated and unpersuasive, and it is not accessible to those without Internet access. In his critique of MyPyramid.gov, Johnston says, “…Obesity prevention programs structured only to educate and inform have generally been unsuccessful.” (3) To create a successful public health intervention for the obesity problem in America, we need to leverage social support networks in communities. We need to identify the people in these communities to whom others naturally turn for advice and build on these relationships to influence others to modify their health behavior. By focusing on their perceptions and understanding the barriers that keep them from eating healthy and being more active, public health interventions would be more successful. When interventions are geared to wants and needs of the population in which we want to affect change people will be more responsive and motivated to implement these changes in their own lives.

References:
Harvard School of Public Health. Food Pyramids. 2006 http://www.hsph.harvard.edu/nutritionsource/pyramids.html
Evans L. UCLA World Internet Project Finds Gaps between Rich and Poor, Young and Old, Men and Women. 2004. http://www.international.ucla.edu/article.asp?parentid=7488
Johnston, CS. Uncle Sam’s diet sensation: MyPyramid—an overview and commentary. 2005 MedGenMed 7:78.
Braddon FE, Rodgers B, Wadsworth ME, Davies JM. Onset of obesity in a 36 year birth cohort study. Br Med J (Clin Res Ed). 1986. 293: 299-303.
Winkleby MA, Fortmann SP, Barrett DC. Social class disparities in risk factors for disease: eight-year prevalence patterns by level of education. Prev Med. 1990. 19:1–12.
Birru MS, Monaco V, Charles L, Drew H, Njie V, Bierria T, Detlefsen, and Steinman RA. Internet Usage by Low-Literacy Adults Seeking Health Information: An Observational Analysis. J Med Internet Res. 2004. 6: e25.
Weiss BD, Hart G, McGee DL, D'Estelle S. Health status of illiterate adults: relation between literacy and health status among persons with low literacy skills. J Am Board Fam Pract. 1992. 5:257-64
Howard-Pitney B, Winkleby MA, Albright CL, Bruce B, Fortmann SP. The Stanford Nutrition Action Program: a dietary fat intervention for low-literacy adults. Am J Public Health. 1997. 87: 1971-1976
Hill JO, Wyatt HR, Reed GW, Peters JC. Obesity and the Environment: Where Do We Go from Here? Science 2003. 299:853 -855.
Lasco RA, Curry RH, Dickson VJ, Powers J, Menes S, and Merritt RK. Participation rates, weight loss, and blood pressure changes among obese women in a nutrition-exercise program. Public Health Rep. 1989; 104: 640–646.
Weiner S. The addiction of overeating: self-help groups as treatment models. J Clin Psychol. 1998 54:163-7.
Rogers E. Diffusion of Innovations. 1962.
Wiist WH, Flack JM. A church-based cholesterol education program. Public Health Rep. 1990. 105: 381-388.

110 Comments:

Blogger Michael Siegel said...

This is an excellent critique that demonstrates the difference between simply providing information and giving people the tools to be able to make their own healthy decisions. The pyramid itself, as you show, does not provide tools to people, especially given the literacy problems that you mention. Your critique is similar to Min's, which addresses the inadequacy of food nutrition labeling for much the same reasons. Both of you show that instead of worrying about fancy labeling, we need to figure out effective ways to give people the tools and power to be able to make their own healthy decisions.

5:06 PM  
Anonymous Anonymous said...

This is a great use of the Diffusion of Innovation to show how MyPyramid.gov may work for early adopters but not necessarily for everyone else. I wonder if there was a way to take advantage of these natural leaders to get them to reach others through community-based interventions just by giving them ideas?

5:20 PM  
Anonymous Anonymous said...

As I was reading through the first paragraph of your critique, when I came across the fact that the new pyramid and its benefits were mainly accessible via the internet I, too, thought, "well this could certainly be difficult for certain populations to access in order to effectively apply to their own lives." I definitely agree that this is a major flaw in this intervention. Also, I agree with the fact that the new pyramid was not well-publicized -- even being a student who is online often, I knew that the food pyramid had been updated but was unaware of the internet tool that was created at MyPyramid.gov. Good critique of the issue.

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