Sunday, December 17, 2006

Public Health’s Need to Reframe Nutrition from The Teenage Perspective: Switching from An Authoritative Voice to Empowering Adolescents – Asef Karim

Public Health’s authoritative counseling on nutrition

Public health practitioners generally present nutrition as a way to prevent disease. They contend that poor nutrition can cause life-threatening diseases such as hypertension, congestive heart failure, diabetes, osteoporosis, and cancer (4,7,16,17). Teenagers are told to eat healthy to avoid the long-term ramifications of poor nutritional choices. They are encouraged to act on the belief that the food they eat today will impact their distant future. Although this encouragement is well-intentioned and scientifically plausible, its tone is unappealing, if not condescending, to a teenager. It is unrealistic to expect a teenager to make a preventive health choice, the consequence of which may only be evident decades down the road, based on such authoritative counseling.

To be effective, public health needs to address nutrition from the teenage perspective and ask: In what manner does nutrition impact the immediate world of a youngster? Public health also needs to look beyond the individual teen and evaluate the broader social context within which teenage life exists in order to determine the underlying forces that direct the selection of a teenager’s individual nutritional health choices. Teens themselves should be the active public health advocates and messengers of good nutrition rather than just the passive recipients of school- or hospital-based expert nutritional intervention programs. Only with this shift in understanding, acceptance, and involvement will the public health message of “you are what you eat” be embraced by teenagers.

The public health campaign for nutrition is a list of recommendations that includes: “make healthy snacks available at home, encourage portion control, look for whole grains, fruits, vegetables, and calcium rich foods, eat a variety of ethnic foods, learn how to evaluate the nutrient density of a food item, and go to fast food web sites and evaluate nutritional contents” (2,5). Alongside this dietary ‘to-do’ list, there is a constant warning that poor nutritional choices lead to debilitating future disease states (17). Overall, public health paints an image of food and health that is boring, non-engaging, negative, and hopeless if one does not adhere to the warnings.

There are a variety of reasons why teenagers make poor nutritional choices. They learn food choices within their family setting. Children emulate their parents by imitating their behavior. Thus, parents who make unhealthy nutritional decisions pass their dietary habits and traits to their children. Parents also may not have time to make healthy snacks and lunches or be able to afford expensive fruits and vegetables for their children’s meals. Instead, parents provide teenagers with basic lunch money to buy food. As a result, teenagers have limited resources and no choice but to purchase whatever is available to eat at school. The organizational structure in schools also affects a youngster’s food choices. A recent study reveals: “If there are lengthy queues at the school lunch room, teens will opt to buy their lunch at local shops, choosing fast food outlets that have the shortest or fastest moving queues in order to eat quickly and resume other non-food activities” (18). As such, hanging out with friends or participating in other activities such as sports may take precedence to eating a meal.

Focusing on immediate versus future health risks

A necessary precondition to advocating proper nutrition to youth is to first identify the level at which teenagers relate to nutrition. Do they contemplate long-term consequences of food choices or do they make decisions based on the immediacy of their teenage reality? This concept of a decision-maker’s temporal preference in health behavior is important because it can determine the relative receptiveness of a targeted nutritional message to a teenager (3). Intertemporal models of behavior change explain that engagement in health behaviors is partly determined by time preferences (3,13). These models assume that people, especially young people, are impatient, and that an immediate health outcome is usually preferred to a delayed outcome (13,14). Because young people are rebellious, like to be independent, and tend to live for the moment, they discount future health problems and do not consider themselves at risk for chronic illnesses like heart disease, high blood pressure, or diabetes (13). Consequently, their frame of reference does not link the food they eat to their future health condition.

Encouraging good nutritional behavior as a method to prevent future chronic illness is impractical to youth because the benefits seem of little value compared to the immediate cost. Teenagers’ actions reflect the immediate day-to-day concerns of their reality: they go to school and study for exams to advance to the next grade, participate in team sports to gain bragging rights as the current champs, engage in extra-curricular clubs to form social networks, and work part-time to acquire pocket money to spend on entertainment with friends. The consequences of an adolescent’s nutritional choices need to be framed within this reality and be presented with attention to immediate “real world” effects, not distant future health risks.

An immediate problem teenagers can identify with is poor appearance. Linking food to oral disease as reflected in one’s appearance is an approach adolescents would understand. Dental disease from poor nutrition can result in bad breath, discolored teeth, holes in teeth, pain, bleeding gums, missing teeth, and the impaired ability to chew (1). The accompanying social effects may include shame, embarrassment, low self-esteem, and even social isolation (1). These immediate debilitating effects are more convincing to teenagers than is the future potential for chronic illness. Teenagers can understand and visualize how these compromised oral health conditions could impact their appearance and change their lives (6). As such, they would consider proper nutrition if they associated it with preventing these conditions.

Recognizing social norms-the need to belong and the attraction of fast food

Teenage life is complicated. Teens are confronted with adult expectations, organizational systems within schools, and peer pressure. It is important to recognize that there are many prevailing social and cultural norms that contribute to a teen’s dietary behavioral choice.

The pressure of belonging to a peer group may force a teen to make an unhealthy dietary choice. For example, if a child brings a healthy lunch to school, but his or her friends choose to go to a fast food restaurant for lunch, the child will probably neglect his homemade meal for a chance to be with friends. The importance of being accepted as a member of the peer group by contributing to the activities within that group may supersede individual nutritional desires simply to avoid the stigmatization of being the ‘outsider’ (18).

Outside of home and school, fast food institutions have made food fun, easy to buy, and cheap. The convenience of resorting to a fast food meal among friends is a comforting reward and substitute to the lack of a family sit-down dinner. Moreover, fast food is glamorized by celebrities. By endorsing certain beverages and foods, sports heroes and fashion icons convey a social message of acceptance and coolness if these products are consumed. The 1990’s Pepsi campaign featuring supermodel Cindy Crawford in a tight white t-shirt and blue jeans sipping on her Pepsi can conveys to young girls that by drinking Pepsi, they too, can belong to an elite group of ‘cool beautiful people’. The 2006 National Children’s Bureau (NCB) Report on food and drink advertising states that “children are drawn towards [food] products that are heavily branded and marketed, which tend to be of little nutritional value” (8). Media savvy and trend setting, teens readily accept and imitate the media messages of popular television and movie stars into their culture of being; they declare that they want to belong to this cultural phenomenon.

Corporate marketing techniques using celebrities have made fast food and beverages, despite their inherent unhealthy content of high fat and high sugar, extremely attractive products to adolescents (12). To counter this, the NCB Report recommends that “Government should introduce measures to stop manufacturers from using celebrities to endorse unhealthy food and drink” (8).

The same type of visceral attraction that fast food campaigns solicit to youngsters cannot be attributed to healthy food campaigns. For the most part, these campaigns, such as the “5 a day” campaign, are static and boring. The “5 a day” television Public Service Announcement (PSA) consists of an adult voice imparting the wisdom of good nutrition accompanied by the image of a young girl doing arts and crafts followed by images of “good foods” (15). This message is not dynamic and does not actually show the young girl relating to good foods. Youngsters who are rebellious, independent, and subject to peer pressure will not identify with this message. They will reject the message because it denies them autonomy and personal choice. Rather than talking about how important good food is, the PSA may be more persuasive if it simply showed a group of confident enthused youngsters eating and sharing good foods on the go. Such an image would explicitly convey that good foods are part of the peer social norm and experience. By choosing to eat such foods, teens could fulfill their internal desires of belonging to their peer group.

To further effect, the NCB Report states that, “Government and food manufacturers need to be more sophisticated in how they promote healthy food and drink to children. Techniques used to sell unhealthy food should be introduced to make healthy food fashionable and exciting-such as branding, celebrity endorsements, and [the use of] creative packaging” (8). Ultimately, a corporate savvy and creative approach is needed to show that good foods are cool and kids are ‘lovin it’.

Public health needs to understand the social reality of teenagers. The greater social context of ‘belonging’, as exemplified in the allegiance to the peer group and by the effect of celebrity marketing techniques, is important. It reveals powerful underlying forces that direct a teenager’s health choices.

Delivering an empowering positive message

Delivering the message of proper nutrition needs to come from the proper advocate. Food choice messages from health experts, nutrition counselors, and medical practitioners, though sound scientifically, may not reach the hearts of teens to effect change. Such messages, often serious in tone, critical in judgment, and which incite fear as the ultimate motivator, are ineffective.

Fear appeal messages have been used in public health campaigns to attempt behavior change (9,10,11,19). The basic premise is that a fear message makes a health threat seem so serious and likely to happen that the individual is “motivated to control the danger and consciously think about ways to remove or lessen the threat” (19). However, as Witte and Allen contend, if an individual doubts that the recommended response will work or that he or she is incapable of performing the response, he or she will focus on eliminating the fear through denial (e.g., “I can’t get high blood pressure or heart disease from eating this, it won’t happen to me”), defensive avoidance (e.g., “This is terrifying, I need to forget about it”), or reactance (e.g., “They are just trying to control me, I’m going to ignore them”) (19). Negative messages may not work because they focus on controlling inadequacies and fixing deficiencies, rather than focusing on the potential for positive growth and change.

Instead, adolescents will be more likely to accept a message if it comes from someone who appears to be in their peer group. They are more likely to relate to a contemporary and believe the messenger’s words and actions. For example, the “5 a day” PSA would be more effective if the young girl speaks about how much she enjoys fruits and vegetables or if she is shown going about her daily activities enjoying her good food. Such peer role modeling is inspirational. It motivates teens to act independently, create, and pursue like opportunities to be happy and healthy. Furthermore, teens gain a sense of ownership and are empowered to control their health. Role modeling creates an environment for self realization and change, rather than enforcing change from punishment.

The Future

To effect nutritional behavioral change amongst teenagers, public health specialists need to convey that good food is fun to eat and that it makes you feel and look good. These good food messages should come from happy, healthy young people. The public health approach to dietary recommendations should start by exploring a young teenager’s dietary pattern in the context of his or her world. Examination of the range of social and cultural influences on food and eating within family, school, and the outside environment should be considered. Social issues surrounding eating patterns such as the parental lack of time to make good lunches or dinners or the unavailability to commit to a structured family meal need to be addressed. Furthermore, the content, manner, and tone in which messages are conveyed to young people to empower them to make proper nutritional choices need to be re-evaluated.

It is simple; public health should emulate the corporate sector and invest time, money, and creative approaches to attract teenagers to ‘better’ nutrition products.

Works Referenced

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Anonymous Cindy Crawford said...

wuhooo! nice post here.. :)

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Blogger Radhika Ganesh said...

Good post on Public health..
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