Challenging Dogma

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

Monday, April 30, 2007

Steps to a HealthierUS: Is the DHS Program Aimed at Lifestyle Change for the Obese Leading the U.S. Down the Right Path? - Amy Bitterman

The Office of the Surgeon General believes that America has a weight problem. In 2001 it published “The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity (1).” The statistics are disheartening. Since 1980, the prevalence of overweight children has doubled, and the prevalence of overweight adolescents has tripled (2). In response to this, and other related health risks for people of all ages, the Secretary of Health Tommy Thompson launched the “Steps to a HealthierUS” (“Steps”) initiative. The program has two major components, the national education initiative, which provides tools and information about leading a healthier lifestyle (3), and the Steps to HealthierUS Cooperative Agreement Program that funds communities implementing chronic disease prevention and control programs focused on obesity, diabetes, and asthma, as well as their underlying risk factors of physical inactivity, poor nutrition, and tobacco use (4).

While Steps multi-level approach is a move in the right direction, Steps stumbles with its top down methods and failure to address some of the larger systemic problems that keep its target communities at-risk. America doesn’t have a weight problem, America has much more fundamental problems, and the program doesn’t address them. The program purports to implement socioecological strategies, but further examination reveals that Steps frames the risk factors for obesity and chronic illness as behaviors chosen by individuals, reflecting that the blame still rests where it traditionally has, on the shoulders of those at risk (5). Steps failure to implement its theoretical adherence to a socioecological approach is apparent through the limitations of its methods for promoting health. The Steps to a HealthierUS strategy for reducing the burden of chronic illness through promotion of healthy eating and physical activity is limited by its adherence to the health belief model which deemphasizes external factors, its focus on individual behavior and responsibility for conditions that often carry a stigma, and its failure to recognize the importance of Maslow’s Hierarchy of Needs in relation to behavior change.

The Socioecological Approach or Business as Usual?

The Steps to a HealthierUS promotion of healthy eating and physical activity guidelines spend a fair amount of time discussing the ways in which the program seeks to integrate all the components of the socioecological model, individual, interpersonal, organizational, environmental, and policy (6). The initiative acknowledges that interventions have the best chance of succeeding when they are directed at all members of a social network (family members, friends, colleagues, acquaintances) at once (7). However, while espousing the importance external social factors, the guidelines recommend that all interventions focus on behavior change strategies that focus on individual choice. The program looks at only highly prevalent risk factors that are modifiable by individual behavior change (8). This means that while the program pays lip service to the need for change in physical and social environments to allow for enduring change in lifestyle, it stops short of promoting any changes to the external environment, choosing instead to attempt to impact individuals health behavior choices. Its broad requirements for community partner programs call for social integration of changes, providing recommendations in seven major areas, including 1) leadership, planning/management, and coordination; 2) policy change; 3) mass communications; 4) community programs and community development; 5) programs for children and adolescents; 6) health care delivery; and 7) surveillance, epidemiology, and research (9). These areas do not target the physical environment or socioeconomic entrenchment, external behavior determining factors, but do represent an important step away from a completely internal decision making process. Nevertheless, the programs own national strategy belies even this slightly more enlightened approach.

Exclusion of External Factors Indicates a Limiting Adherence to the Health Belief Model

The Steps national campaign is mainly a web-based education tool. An interested person clicks on the link, and gets brightly colored pictures ordering them to “Be Physically Active Each Day,” and “Eat a Nutritious Diet (10). The set up implies that the reason people are not healthier is because they don’t know how, or understand how their actions impact their health. The multi-million dollar, supposedly socioecological approach to encouraging physical fitness includes instructions about the minimal amount of exercise required to attain the benefits of physical activity, a list of the benefits, and the potential harms of a sentient lifestyle. This particular set of information suggests that the national program was designed according to the health belief model.

The traditional health belief model is a psychological model that attempts to predict behavior change. The model is structured around four key concepts: perceived susceptibility, perceived severity, perceived benefits, and perceived barriers. The model is useful to the extent that it takes into account the influence of individual values and expectations, but because it assumes rational decision-making taking place entirely at the individual level, it limits the potential of a public health intervention to meaningful effect behavior change. Consider one of the Steps program’s target populations, underprivileged urban youth. The HealthierUS website recommends “walking your dog,” or “digging in your garden (11).” For children and adolescents living in an apartment, the likelihood that they have a dog or garden is very slim. Moreover, even if they did have a dog or garden the neighborhood may be too dangerous to go out, particularly alone if they have parents that work long hours. The goal of the information on the website is to help individuals choose a healthier lifestyle, but then promotes activities that may, due to entirely external factors, be impossible for its target population to “choose.”

It is also ironic that this information is available primarily on the internet, where the target populations, particularly the urban youth and the underserved elderly, are unlikely ever to see it. By failing to look at external factors, the program may fail to even interact with the communities it hopes to impact.

Methods that Discount Self-Efficacy and Reinforce Stigma

The Steps Program improperly frames the cause of chronic illness by emphasizing individual decision-making and therefore personal responsibility for medical conditions. This focus on the individual choices associated with physical activity and nutrition compromises the potential efficacy of the Steps program because it implies that the population suffering from the chronic conditions Steps is combating are to blame for their own poor health. People begin to associate their diagnoses of obesity or diabetes with other unfavorable characteristics, reducing their self-esteem. An example of this is the reduced self-esteem that comes with childhood obesity. Children associate being “fat” with being lazy and unattractive, images perpetuated and supported by the media, their peers, and health programs that tell them they’d become beautiful and fit if they’d just exercise a little and take some initiative. Their sense of responsibility for creating these characteristics in themselves can lead to self-loathing, and even depression (12). Moreover, promoting this view of individual responsibility can create a societal impression of individual responsibility, reducing empathy and creating stigma. People will not want to be diagnosed for conditions they associate with these negative stereotypes, leading to untreated chronic conditions. An example of this is the social stigma associated with Diabetes. In some communities where individual responsibility for this chronic condition is emphasized, people see sufferers as “self-inflicting the disease as a result of over-indulgence.” There is also anger at individuals with diabetes for their poor choices using up society’s health care resources. Sufferer’s then don’t want to let people know they have the disease for fear of drawing this stigma. This can cause them to fail to check their blood sugar with sufficient frequency or self-administer necessary insulin injections, activities which could out them as over-indulgent and selfish diabetics (13). If someone is not yet diagnosed, they may be resistant to a diagnosis of diabetes that will label them in this way, or put off seeing the doctor if they suspect a diagnosis of diabetes will result. What this example illustrates is that if there is a stigma associated with a condition, sufferer’s reduced self-esteem can impact their self-efficacy, their sense that they have the ability to and should positively impact their health. If stigma prevents people from getting diagnosed early, it compromises their actual ability to positively impact their health. Steps strategies of individual action and responsibility promote stigma by subtly reinforcing this concept of self-infliction of disease, and should be rethought, considering external factor, to promote the self-efficacy of their target populations.

Unrealistic Assessment of the Needs of the Target Populations

The Steps Program focuses on behavioral alterations that relate to higher order needs in populations that are struggling to meet their most fundamental needs. A useful tool for describing the needs of individuals is Maslow’s Hierarchy of Needs (14). Maslow’s Hierarchy is broken down into five basic needs, (1) physiological needs (2) safety needs, (3) love needs, (4) esteem needs, (5) self actualization needs (15). The needs are organized in the order in which they will consume a person’s conscious actions as goals. For example, one will not bother with a love need (affection, belonging), until his or her physiological needs are substantially met (16). Steps has selected as its populations of interest urban residents, small town residents, and tribes. Within those categories it has selected to target border populations, Hispanics/Latinos, American Indians, African Americans, Asians, immigrants, low-income populations, people with disabilities, youth, senior citizens, and people who are uninsured or underinsured (17). While the racial categories are poorly descriptive, the other categories of target populations describe groups that are often struggling to meet their most basic needs.

The Steps program, by failing to recognize external factors that lead to unhealthy lifestyles, fails to recognize that until someone can be assured that they will eat, they will not worry whether or not they are eating right. This premise could perhaps be extended into choices that parents make for their children. The Steps program recommends that parents monitor and budget their children’s television watching time to promote their increased physical activity (18). While parents are concerned about the health of their children (a safety need), they will not sacrifice their livelihood (a physiological need) in order to make sure they are reducing their children’s television watching time. Low-income wage earners without much job autonomy cannot ensure that they are around to watch their children after school. They will not be able to effectively budget and monitor their children’s TV watching behavior and will not sacrifice to do so. Another example is the recommendation that women breast feed for six months after giving birth (19). If all of their basic needs were being met, many women would breast feed. A person is unlikely to breast feed when they need to get back to work to ensure that they themselves are fed.


The Steps to a HealthierUS initiative suffers from several limitations. The program attempts to integrate a socioecological approach into its strategies, but often falls back onto the health belief model, focusing strictly on individual decision-making, and ignoring external factors. The emphasis on individual decision-making may have a negative impact on its target populations, making them feel they are responsible for conditions beyond their control. They may begin to associate their conditions with negative stereotypes and feel or be stigmatized by their diagnosis. This stigmatization has the potential to decrease the target populations self-efficacy or actual ability to engage in behaviors that can positively impact their health. Finally, the Steps initiative does not take into account the needs of their target populations. These shortcomings may significantly impact the efficacy of the program, and lead public health workers down the wrong path, away from a healthier U.S.


1. Office of the Surgeon General. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Rockville, Md: Office of the Surgeon General, 2001;

2. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999–2000. JAMA. 2002; 288:1728–1732

3. U.S. Department of Health and Human Services. HealthierUS Education Tools. Washington, DC: DHHS

4. Center for Disease Control and Prevention. Steps to a HealthierUS Homepage, Atlanta, GA: CDC.

5. U.S. Department of Health and Human Services. Essential Strategies: The Socioecological Approach. Washington, DC: DHHS.

6. McLeroy KR, Bibeau D, Steckler A, Glanz K. An Ecological Perspective on Health Promotion Programs. Health Education Quarterly 1988; 15:351-377.

7. Center for Disease Control and Prevention. Promoting Healthy Eating and Physical Activity for a Healthier Nation, 7-5. Atlanta, GA: CDC.

8. Id.

9. Id.

10. supra n. 3

11. U.S. Department of Health and Human Services. HealthierUS Physical Activites Website. Washington, DC: DHHS.

12. American Obesity Association. Childhood Obesity. Washington, DC: AOA.

13. Ann Tak-Ying Shiu, Jo Jo Yee-Mei Kwan, Rebecca Yee-Man Wong. Social Stigma as a Barrier to Diabetes Self-Management: Implications for Multi-Level Interventions. Journal of Clinical Nursing 2003; 12:149-150.

14. U.S. Department of Health and Human Services. Steps to a HealthierUS Cooperative Agreement Program. Washington, DC: DHHS.

15. Maslow A. A Theory of Human Motivation, Psychological Review, 50(4):370-396.

16. Id. at 395

17. Id. at 381

18. supra n. 6 at 7-7; Robinson TN. Reducing Children’s Television Viewing to Prevent Obesity: A Randomized Controlled Trial. JAMA 1999; 282(16):1561-1567.

19. supra n. 7 at 7-2

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