Challenging Dogma


...Using social sciences to improve the practice of public health

Saturday, April 21, 2007

The Food Pyramid: Its Failure to Address the Social Realities of the Public-Gail Michaelson

The United States Department of Agriculture’s (USDA) food guidance system (FGS) has undergone many transformations in order to accommodate the American public, resulting in "My Pyramid," as we know it today (1). The food pyramid attempts to illustrate the dietary guidelines of the US Department of Health and Human Services and the USDA in a friendly and approachable manner so the American public can incorporate the guidelines into their food intake routine. This new approach uses colorful graphics and slogans. There are individualized materials on there website, and non-individualized materials for print format (2). This paper argues that the food pyramid is ineffective as a public health intervention because it is based on a model which fails to address the social and behavioral impediments people face when attempting to eat properly and healthfully.

Theory of Planned Behavior
The social science theory, theory of planned behavior, helps demonstrate why the FGS is not effective at changing people’s dietary patterns. The theory of planned behavior links attitudes to action (3). The theory of planned behavior can be dissected into three major components: one must believe that the behavior will lead to a positive change, the behavior is a normative behavior, and one is able to overcome the obstacles to doing the behavior. Unfortunately, the long- term outcome of following the FGS is rarely outweighed by the instant gratification one receives with eating, following the FGS is not a normative way of eating, and many people do not believe they are able to obtain and sustain these eating patterns.

Perceived benefit of behavior change
The first component of the theory of planned behavior is perception of benefit of behavior change (4). Many people know that healthy eating and exercise can reduce the risk of cardiovascular disease, diabetes, stroke, and cancer (5). These future benefits are often outweighed by the benefit of instant gratification. The food pyramid does not address the positive benefit one receives through instant gratification. Many people have difficulty regulating their impulses, especially with food.


Marques et al. (6) show that impulse control is directly correlated to an emotional stable personality profile. The emotionally stable personality was measured by the Catan version of the Eysenck Personality Questionnaire-Revised (EPQ-R), measured in three dimensions, psychoticism, extraversion, and neuroticism. This evaluative tool has been tested as has personality’s influence on mood state (7, 8). It has also been shown that many people who show more depressive symptoms have lower self-esteem (9). One could infer that the people who are in the most need of weight loss or healthy eating habits will have the hardest time controlling their impulses. Therefore, those individuals may have a harder time with the delayed gratification of weight loss and good health. In addition to this group of people having a negative perception about their ability to change their behavior, which is noted in the third attribute of the theory of planned behavior (10), Bembenutty (11) explains delayed gratification’s association to resource management, goals, and motivation. As will be discussed in further detail, the FGS does not do an effective job addressing these complex needs.

Perception of normative behavior
The second component to the theory of planned behavior is the perception of the behavior as normative (12). The FGS guidelines are suggested by the United States Department of Agriculture. While this is a governmental organization, it is not wise to assume its guidelines mimics American culture. Reedy et al. show that in a cluster grouped as average Americans, only 29% eat five or more servings of fruit and vegetables per day. In that same group, only 31.9% exercise for 150 or more minutes per week, and 52.7% have a BMI lower than 27 (13). Unfortunately, this study only used participants who had colon or rectal cancer, but the study’s composition included people from a mix of rural, urban, and racial experiences. These participants have the potential to have many different dietary habits that come from cultural, religious, and peer subgroups in the American culture. The FGS has diversified the graphics and servings based on age, height, and amount of physical activity. As suggested in the Dietary Guidelines Advisory Committee Report (14) it is important to address a more diverse group of people. Some ways that the FGS could have, and should have, diversified would have been creating links or recommendations to Kosher, soul food, low carbohydrate, vegetarian or other specific diet resources.


Perception of overcoming obstacles and the concept of self-efficacy
The third component of the theory of planned behavior is the belief that one can overcome obstacles that prevent one from modifying their behavior. Another term that has been used for this same definition is self-efficacy, the belief that one is able to achieve or do the specific behavior (15). In order for such a ­­­­large-scale behavior modification system such as the food guidance system to be efficacious, it must include tools that teach incremental steps to guide one to the complete dietary goals. The main reason why this guidance system is not efficacious is because there are no tools to assist one in attempting to dissect the whole system into smaller more palpable and achievable goals. There are no tools to assist in meal planning, eating out, and learning portion sizes.


The FGS suggests that during a day, a person should eat X amount of vegetables, X amount of grain, X amount of animal protein, and so on based on their individual characteristics, but does not explain how to incorporate this recommendation into one cohesive meal or weekly shopping plan. In order for the FGS to be practical, it must include meal suggestions, recipes suggestions, and skills to use while making general dietary decisions. One example of this type of meal planning is an online diet program called SparkPeople.com. (16)
SparkPeople.com is a comprehensive online weight loss program which includes larger goals which mimic the FGS such as exercise, portion control, and calories. Compared to the FGS, this website is all-inclusive in its services because it offers the additional support of meal plans and recipes, feedback by storing past achievements, connecting people with community support, and practical exercise suggestions. In addition to the support this website offers its members, the diet plan and assistance are completely free. The FGS offers the same end goals referring to energy intake and output but offers none of the essential supports and suggestions that this organization has produced. Furthermore, if an individual has a question, concern or is unable to jump over an attribute of their diet hurdle, he or she is able to post questions and get the support to continue onto his or her individual goal(s).


This complete diet guide even assists people with practical suggestions for eating out at formal restaurants and fast food places. When an individual goes to a restaurant they are faced with difficult choices. Do I eat the steak or fish; do I eat the mashed potatoes or the steamed vegetables? For many people, there is a common assumption that if they want to eat healthy at restaurants they must eat plain bland food. More and more restaurants are offering healthy choices, or nutritional information on the menu (17, 18, 19, 20). There are menus that offer the visual cues for people who want to be diet-conscious and these nutritional choices are helpful; unfortunately, there are still many restaurants that offer little or no assistance in helping people eat consciously and healthfully (21, 22, 23). Because the FGS provides inappropriate tools to assist an individual in his or her total dietary patterns; because people do not feel confident in their decision making choices; and because people are not empowered by community, peer or educational support, the food pyramid guidelines are not efficacious.

In addition to making difficult choices about what to eat, individuals following the FGS need to make choices about how much to eat. It has been shown that individuals have difficulty measuring the serving size of an individual food item during the food preparation process (24) and during the eating process. Schwartz and Byrd-Bredbenner conducted a study to measure the “Portion Distortion” and found that Americans generally eat a very wide range of portion sizes, with no correlation to hunger status, preference for food, experience with measuring cups/spoons, experience with food preparation, and years in college. It has also been shown that if individuals are served more, they have a harder time regulating how much they eat (25). The dietary guidelines Advisory Committee Report is very clear that the many people assume the serving size is bigger than what the USDA serving size implies? Suggests? Is in reality? and goes further by suggesting that portions need to be stressed (26).

There have been numerous studies correlating lack of portion control to weight gain (27), portion size to bowl size (28), and portion size to BMI (29). Brunstrom (30) explains that people learn these distorted portions from various different means. Some people have larger or smaller portions due to individual differences such as flavor-nutrient condition and/or contingency awareness (previous experience) may explain an individual’s inaccurate portion size. Davis et al. (31) researched portion size with psychological factors such as reward sensitivity, binge eating behaviors, and preference for sweet and fat foods. This study used previously tested reliable inventories and found a significant relationship between larger portion sizes and reward sensitivity in obese women. Sensitivity to rewards measures an individual’s “tendency to approach and take pleasure from a variety of rewarding stimuli in their environment.” This example with other researched behaviors leads one to conclude that there are many reasons why a given individual might inaccurately measure portion size. With all of this information, it becomes clear that in order for a food-related health intervention to be successful, it must offer some educational or coping skills to assist one with portion sizes.

Social impediments to following the FGS
The theory of planned behavior does a good job explaining why the FGS is an unsuccessful public health intervention, but it does not explain all the social influences that affect people’s ability to follow the FGS. Some other social influences are education, access to healthy food, and access to diverse food. These socio-economic barriers impede people from following the FGS irrespective of their desire or belief.


In the United States people have many different levels of education. Sometimes people’s academic education is correlated with socioeconomic status, cognitive abilities, health outcomes, and health behaviors (32, 33, 34, 35). One possible explanation for the different health outcomes would be the different coping skills individuals in different classes may learn. Because the food guide pyramid offers no educational training on how to understand labels on pre- packaged and pre-prepared meals, many people are left thinking they are eating one type of food when in reality they are eating foods with completely different nutritional makeup (36). Rothman et al., (37) conducted a cross-sectional study of 200 primary care patients measuring the relationship of the food label comprehension to the given person’s underlying literacy and numeric skills. Rothman et al., found a significant correlation to high income, education, literacy and numeracy. Furthermore, patients with literacy higher than 9th grade still had difficulty accurately interpreting food labels. This is just one example of why education, or lack thereof, is a very big and real barrier for individuals understanding healthy food choices for themselves or their family units. In addition to this difficulty with understanding the actual nutritional information, many people have incorrect associations with the health and caloric attributes of food (38).

It has been shown (39, 40) that healthy eating habits and sociodemographic factors are correlated. Deshmukh-Taskar et al., (41) shows, with a cross-sectional study, that those with higher incomes consumed significantly fewer servings of burgers, sandwiches and mixed dishes. In an additional study, Baker et al. (42), expresses the importance of access to healthy food. These studies are good evidence that support the real external barriers to healthy eating. There are many ways to assist individuals and communities to work towards eating in a healthy manner.

Some people are able to afford to have a wide variety of food and others, unfortunately, are not. Many people are unable to access the variety of food suggested and eat the perishable food suggested because they do not have the financial ability to be so particular. Many people purchase in bulk, go to food pantries, and buy what is on sale. Through a recent search of food stores, the lowest price for asparagus is $2.29/lb. That would mean for 2-3 vegetable servings the individual would pay approximately three dollars for their vegetables. If a person is living off of Emergency assistance for Elders, Disabled and Children (EAEDC), they are living off of $155 per month for food with food stamps (43). These people do not have the luxury of spending $5 per meal. Living off of $300 per month, and $155 per month for food, they are lucky if they can spend an average of $1.80 per meal in total, or $5 per day on food.

Furthermore, with such a low income, many of these people do not have cars. The FGS does not address the transportation aspect to getting and receiving food. If a low-income individual is fortunate enough to have a program or social network that provides food in their home, for them, they eat what they are given. As shown numerous times (44, 45), many individuals do not like waiting for a bus, or asking a friend to give a ride to a special grocery store. This impedes people getting the proper variety and nutritional value in their meals.

Conclusions
Given that the food pyramid guidelines do an incomplete job of addressing the individual and external barriers people face when attempting to modify their behaviors, it is clear why this public health intervention has not been successful. Future interventions should include tools for behavior modification, coping skills, education, and self- efficacy. This could be completed by connecting multiple interventions to weave a complete diet plan, or one larger diet plan with reference to other sources of gratification. Either way, people need to be able to understand the goals of the intervention, and identify a reason why they are working towards these goals. If they are not motivated to follow through, the individuals will not follow through.
By using the theory of planned behavior, one is able to address many social and personal barriers an individual might perceive when attempting to eat healthy. Unfortunately, this model is unable to address the actual barriers an individual might face when attempting to follow the FGS. These actual external barriers are quite real and will not be overcome without real social change. This type of change needs to be modified by programs that affect the low and middle socioeconomic groups. In conjunction with education and empowerment, a successful intervention would include community support, such as a program where people would gain coupons for healthy foods, or tickets for buses to a wider range of food stores. The FGP is a good start to a public health intervention, but is incomplete and totally ineffective as a complete intervention. As discussed, this singular intervention fails to address the any obstacles a given individual faces because it ignores personal, communal, and societal obstacles which individuals must overcome in order for behavior modification to take place.


REFERENCES
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2. See: United States Department of Agriculture and Center for Nutrition Policy & Promotion.
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41. See: Deshmukh-Taskar, P., Nicklas, T.A., Yang, S.J., Berenson, G.S.
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44. Siegel, Mike. Social and Behavioral Health Sciences 721. March 8, 2007
45. Confidential interview. Neighborhood Health Plan. Phone interview 4-5-07.

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