Monday, May 19, 2014

Presidential Active Lifestyle Award Program + : Critique of an Exercise and Healthy Eating Campaign - Sarah Coleman Background

           Adherence to a healthy lifestyle has decreased in the United States over the past eighteen years. Fewer people are engaging in physical activity and eating healthy, which has lead to a public health obesity epidemic. The prevalence of obesity in children and adolescents in the United States is on the rise (1). Between 1998 and 2010, obesity rates increased from 7.2% to 12.1% in children 2-5 years old, 11.3% to 18% in children 6-11 years old, and 10.5% to 18.4% in adolescents 12-19 years old (2).  Obesity is defined as having excess body fat. It can lead to a number of immediate and long-term health effects. For example, obese youth are more likely to have risk factors for cardiovascular disease such as high cholesterol or high blood pressure. Obese adolescents are more likely to have prediabetes, which is an indicator for the development of diabetes. Furthermore, both children and adolescents who are obese are likely to also be obese as adults and therefore have a higher risk for problems such as heart disease, type 2 diabetes, cancer and osteoarthritis (3). Physical activity and healthy eating habits can prevent obesity, Therefore, public health interventions should strive to create programs to help people maintain good habits(1).
Doing regular physical activity and eating well can help prevent obesity and its associated adverse health outcomes (4,5). Under the U.S. Department of Health & Human Services’ physical activity guidelines, children and adolescents should do 60 minutes or more physical activity daily. Children can reach this guideline by doing a combination of aerobic, muscle strengthening and bone strengthening exercises at different intensities. For example, some activities that children can engage in are bicycle riding, jumping rope or playing running games, such as tag (6).  Unfortunately, fewer than one in five high school students meets the recommendations to get 60 minutes of daily physical activity, related to a rise in obesity levels (4). Furthermore, maintaining healthy eating habits can also prevent obesity. The 2010 Dietary Guidelines for Americans has recommendations for child and adolescents, such as increasing fruit and vegetable intake(7). However, a recent national report found approximately 37% of adolescents report having less than one fruit or vegetable daily (8).
It is important that public health practitioners create a social and physical environment for children and adolescents that will support physical activity and eating healthy (5). However, many Americans live in an environment that often makes it easier to be sedentary or maintain bad eating habits, such as travelling to school on a bus and not biking, or eating food on the go that does not contain as many fruits or vegetables (2,4). It is also important that public health campaigns address these issues from an environmental and group level perspective, not just an individual’s ability to have positive behaviors.
One public health campaign committed to promoting healthy eating habits and exercise is the Presidential Active Lifestyle Award + program. It is a United States program that is part of the President’s Council on Fitness, Sports, and Nutrition, administered through a co-sponsorship agreement with the Amateur Athletic Union (9).The goal of this program is to help children and adults build healthy habits by committing to regular physical activity five days a week and eat healthy over a six week period (9).This program is set up so that people can create an account online on their own or register as part of a group. They can log their exercise and eating patterns online or print paper worksheets to keep track of this information. The program can be implemented on an individual basis for adults or children and adolescents ages 6-17, as well as for groups or schools (9). This critique will be focusing specifically on the PALA+ weaknesses as a campaign to help children and adolescents live a healthy lifestyle (4,9).
Critique 1: Health Belief Model
            The PALA program is fundamentally flawed in its reliance on the Health Belief model. The health belief model is an individual level model that posits that people make rational decisions based on weighing out the perceived benefits of doing a behavior in comparison to the perceived cost and barriers (10). The model is based on the fact that people will do a behavior (in this case, sign up for the PALA+ program and maintain healthy habits), based on their perceived susceptibility about an outcome associated with that behavior, such as becoming obese, and how severe the consequence would be of becoming obese. However, people might not think that they are likely to become obese so they might not want to go through the effort of signing up for the program. On this note, the benefits of the program might not push them to want to sign up for it if they don’t think they are likely to be obese. Although exercising and eating healthy have been shown to prevent obesity (5), there is not necessarily evidence that the act of going online to record your eating and exercise habits will make someone lose weight, making the benefits of the actual tasks involved with the program less clear. People may adhere to some healthy eating and exercise habits, but they might not see the benefit of strictly following the PALA+ program’s structure of keeping track of those habits.
            There are also barriers and costs associated with the program such as time and effort, so this could deter someone from wanting to sign up if they are busy, do not have access to a computer or do not understand on (10,11). Particularly, it could be a barrier for a young child to maintain this program if they have to share a computer with their family or don’t understand how to use the Internet. Similarly, the rewards of the program, such as winning a t-shirt or plastic trophy, might not be enough of an incentive to spend effort and time online with this program. Furthermore, this model assumes that individuals make rational decisions about their behavior, and behaviors such as eating and exercise are often irrational, as described in the Theory of Planned Behavior (11,12).
Critique 2: Theory of Planned Behavior
            One of the fundamental problems with this campaign is that it works on an individual level and not group level principles. As such, one of the theories that this program is based on is Theory of Planned Behavior. This theory, an updated version of the Theory of Reasoned Action, posits that a person’s behavior is determined by their intention to perform the behavior. This is based on their attitude toward the behavior, evaluation of subjective norms and their perceived behavioral control (11,13)
            This model assumes that people will make rational decisions about their behavior (13). However, as explored in Predictably Irrational (12), people are often irrational in their behavior. Even if they have good intentions and perceive themselves to be in control of their actions, they may not carry out the behavior that was planned. In the PALA+ program, children and adolescents could have good intentions to exercise and eat well, sign up for the program and feel that they are in control of these actions. This knowledge may not necessarily translate into the concrete actions of eating well and exercising. Human behavior is irrational and planning out activity and self- monitoring on a website does not necessarily lead to behavioral change, especially for behaviors that are so sensitive to the social and physical environment that children and adolescents are in (12). This could be especially hard for children and adolescents who are susceptible to the interactions of their friends or may not have as strong planning skills as adults. For example, adolescents may be influenced by external factors such as their friends all wanting to go out for pizza on a whim. A teenager might not rationally think about how this would affect their status in the PALA+ plan because they are focusing on the social aspect of eating, even if they have good intentions(11). It is also important to note that the Health Belief Model is similarly flawed in its assumption that individuals will make rational decisions (11). Furthermore, the program may not fit in with someone’s subjective norm of their environment if their friends haven’t signed up or their school does not have an initiative on it(11).
Critique 3: The Ecological Model
            The PALA+ program focuses too much on individual and interpersonal characteristics, and does not fully take into account the ecological perspective that emphasizes interaction between all levels of the life course and environment in looking at a health problem (11). The ecological model takes on a multilevel approach, to which the PALA+ program only focuses on a few aspects of. The PALA+ program does an adequate job of accounting for individual characteristics (such as knowledge and attitudes) by educating individuals on the positive aspects of working out and eating healthy on a person- by person level. People could have the ability to take action and sign up for the program on their own. However, it does not account for the fact that individual’s genetics or physiology as part of the ecological model, that may make them have elevated risk factors for obesity regardless of exercise patterns or eating (14).
             Looking at the interpersonal levels of the ecological model, the program does have an option for people to sign up as a group with members of their family, classmates or friends, getting at an interpersonal interaction with behavior change. However, it does not account for the fact that just by signing up for the program as an interpersonal group, those groups will actually influence individuals to have healthy behaviors. It doesn’t take into account the fact that our physical activity patterns and eating habits are often based on things that are beyond our control at a community level (15). For example, a child’s school might not provide adequate recess time, or their family might not be able to afford fresh fruits and vegetables, which would hinder progress on this intervention and maintain health behaviors. This program assumes that interpersonal relationships will support healthy behavior just because they sign up as a group. However, unless a group’s social norms are to exercise often and eat well, a singular person in that group may not be able to maintain healthy habits.(5,14)
Alternative Approach:
            As described, the PALA+ focuses heavily on traditional and individual level models, which are more limited in scope. The program’s current use of the Health Belief Model and Theory of Planned Behavior assumes that individuals will always plan and make their own decisions about food and activity, particularly if they are aware of the consequences of not exercising or eating well. Both of these approaches, in addition to the limited take on the ecological framework, need to be reconsidered and restructured to frame the intervention from a larger community level (12,14,15).
             An alternative approach to the PALA program would be to tweak the program to incentive people to sign up for the program in groups or with people in their social network. The program is built on a strong foundation by having an option for people to sign up as a group; however, it is crucial to change social norms within a social network to promote healthy eating habits (16). Getting people to sign up together is an important first step, but the program will be even stronger by getting the larger community to maintain the habits. The PALA campaign could employ aspects of people’s social network, the social expectations theory and social marketing theory. The impact of obesity and promotion of healthy behaviors should be thought of from the influence of the environment on individual attitudes, actions and behavior in terms of nutrition and physical activity (17). Specifically, information needs to be communicated from a community perspective with less focus on placing all of the responsibility on individuals to make positive behavior, as the decision is often influenced from outside factors (14).
Social network: 
            Data from the Framingham heart study looking at social networks over thirty- two years suggests that obesity may spread in social networks and groups that depends on the nature of social ties (16). As described previously, obesity is largely caused by a lack of exercise and not making healthy eating choices. One factor that explains why social networks are associated with obesity is that someone might observe a friend gaining weight and then accept their own weight gain (16). Children and adolescents are highly influenced by their friends’ attitudes, values and eating habits both because of social norms and spending time with one another. The relevance of social influence also suggests that public health interventions must harness this same force to slow the spread of obesity and spread positive health behaviors (16,18), in part because people’s perceptions of their own risk may be influenced by those around them. Research has shown that weight loss programs that provide peer support and therefore modify the person’s social network, are more successful than those that do not (18). Therefore, it is pivotal to integrate this group-level thinking into the PALA+ program.
          The proposed intervention would be to create incentives if people signed up as a group- whether that is a school, family, or social group. Although there are already ways to create joint accounts, there does not seem to be an additional incentive for people to do this. The current model disregards the research positing that people’s behavior is largely influenced by other people that they spend a significant amount of time with (18). As described before, even if one person signs up on their own- it may not be effective because their networks are not following the same patterns. Because social networks could spread positive behaviors, working on maintaining a healthy weight and exercising would be easier as a collective group; people could work out together, cook healthy meals together and hold each other accountable to maintain these behaviors. For example, the PALA+ program could reward groups who meet their goals with free exercise classes or coupons for healthy restaurants. There could also be online education modules that explain games and sport activities for larger groups, that children, teachers or families could reference to get further ideas. Currently, there is information on the website for ways that people can exercise on their own, such as doing sit ups, but there was a lack of group-wide activity suggestions (9).
Social expectations theory:
            A study looking at the associations of physical activity and healthy eating on social norms suggests that social norms are important determinants that have a strong influence on healthy behaviors (19). For example, this study showed that women who observe many other people engaging in physical activity or eating behaviors might come to view these behaviors as normative, or socially desirable, and therefore may adopt the same behaviors due to either a positive attitude about the behaviors, a shared belief in their value or a social urge to fit into society (19). Social norms are considered to be general rules that guideline behavior within groups, and these influences play a crucial role particularly in adolescents (20,21). If many people are doing something (such as eating unhealthy or living a sedentary lifestyle filled with children’s videogames), or thinking something (such as that this behavior is pleasurable), then their actions and thoughts could convey what other individuals should think or do (21,22).
            Therefore, it is crucial that the PALA program utilizes this power to instill the social norms in groups of people to engage in a healthy lifestyle, not just by focusing on individuals signed up for the program and change their norms on person- by person basis. This relates back to the same principle of the social network theory that an individual’s network and larger group can promote good behaviors, so creating a social norm of good behaviors in this network will enhance maintenance to healthy behaviors (16). The new PALA+ program can build off social expectations theory because it will incentivize groups to sign up together so that people are surrounded by peers where keeping track of exercise and food choices, as well as actually doing these activities, is the norm. Additionally, the PALA+ program could make exercise and healthy eating part of social norms in schools and with adolescents by adding a calendar aspect to the program, where groups could plan to go to exercise classes or activities together on a regular basis. By making that part of their regular lifestyle and social interactions, it would shift the norms towards a healthier lifestyle.
            It is also important to ensure that keeping track of exercise and food habits becomes part of social norms in adolescent and children populations in a positive way that boosts their self-esteem. Part of why the program could be currently ineffective for these groups is because logging these habits elicits could elicit some of the same aspects as dieting, obsessive eating patterns or disordered eating, which is not a social norm that is welcomed in young child (23). Although that is more of a norm in adolescents, it’s important that it is framed from a positive and healthy way. Therefore, the PALA program should also work to make this conversation healthy by training health educators (in schools that implement this program) to facilitate healthy conversation about eating and exercise in the classroom.  This will make healthy behaviors associated with a positive social norm. Furthermore, this program should be the social norm for people of all weights, not just those who think they are susceptible to becoming obese, as seen in the health belief model (11).
            Peer pressure plays a role in social norms of adolescents (22). Therefore, it is also important to channel this into a positive influence. Perhaps adolescents might feel pressured to join the program and engage in healthy habits if their friends are already in it (22). This theory further strengthens the PALA’s use of the theory of planned behavior. The theory of planned behavior takes into account the role of social norms for a person to make a decision, so if the norms are changed to promote positive behaviors, teenagers intentions behind engaging in healthy behaviors could translate into real activity (not just making an account online) if their peers are doing so too (11).
Social marketing and advertising theories:
            Social marketing theory is an innovative, group-level model to create and package a product so that it appeals to the core values of your campaign audience and fulfills their needs and values (17,24,25). In creating a public health social marketing campaign, it is important to research the target audiences’ dreams and aspirations in order to package the program to fit these needs. This can be done by figuring out core values of the population, such as freedom, belonging or justice. Marketing campaigns have an element of branding in them so that all of the elements of the campaign are consistent with the core value and needs of the target audience. Traditional public health campaigns often market their programs towards a health core value, however other values have a stronger pull and could be more effective (17). The PALA+ program has not successfully utilized social marketing theory to date, but there is potential for its addition to make the program more successful.
            Research has already shown the effectiveness of social marketing in public health campaigns promoting physical activity, such as seen with the VERB campaign. This program was highly successful for many reasons, such as its extensive marketing research to determine youth core values, mass-media advertising and partnership with local communities to improve outlets for physical activity. It also capitalized on the influence of a social network of parents, teachers and friends to promote physical activity (12,17,19). After one year of this program’s implementation, there was a 34% increase in weekly free-time physical activity sessions among 8.6 million children ages 9-10 in the United States (17). The same tools used in the VERB campaign could help make the PALA + program more effective. This campaign tailored the program to youth values such as fun and being cool, which helped motivated children to exercise. It did not take on a health belief model approach of just stating the facts about why exercising is important, which is what PALA+ does (11,25).
            Currently, the PALA+ program does not harness its social marketing capabilities. It is marketing the campaign to the values of health by focusing on it as a way to be active, however, this are not necessarily the core value of the youth and adolescents they are trying to target (25). Instead of framing the campaign to the core value of health, PALA+ could focus on core values of freedom and identify- values of youth empowerment (26).They can frame the intervention towards the core value of freedom by empowering adolescents that they have the ability to make their own physical activity and food choices by choosing what activities work for their lifestyle. These kinds of messages could be conveyed throughout the website’s material. The PALA+ can also center itself around the value of identity, by promoting people to sign up in groups and make it a social norm for people to exercise and eat well(22) .
            Similarly, the campaign could build off advertising theory. Advertising theory focuses on a promise from the brand to the customer, backed up by support through visuals and stories, which get at core values in the target audience (25). Research has shown that when messages are given from someone who is relatable to the target audience, people are more likely to do what the messages tell them, have increased compliance and not react against the message (27). The PALA+ could utilize these tools through a few simple additions to their program. The program could put up personal stories and pictures on their website from children and adolescents who found the program to be successful. This speaks to children adolescents feeling a sense of belonging, the core value described above (26).
            PALA+ advertise the program and instill identity through the use of mass-media, which will integrate aspects of social networking and change social norms (16,22). A way to do this is that when adolescents join the PALA+ program, a notification could go up on their Facebook page advertising that they’ve joined or won an award for participating. There could also be a tool to share the program with their Facebook friends and invite them to join. This would not publicly display their activity and food data, but just state that a person has joined. This will make it more of a social norm to be a part of this program, create a sense of belonging to the program. It should increase registration, based on research showing that people are largely influenced by their peers (20,22,24).
            In conclusion, the PALA+ program demonstrates a solid foundation of a campaign to increase physical activity and healthy eating as a way to combat conditions such as obesity. However, its extensive use of traditional, individual level models limits its capabilities to take off as a highly successful intervention. There is potential to make it a much more effective program through use group-level models. Specifically, designing the program in a way that integrates the social network theory, social expectations theory and social marketing and advertising theories are crucial to helping the PALA+ program soar, and instilling healthy behaviors among the youth of the United States.

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