Abstract
Sedentary, consumption-based lifestyles are placing entire populations at serious health risks; obesity is a prime example.
The individual approach to obesity, which targets those at risk, has largely failed because it ignores wider influences on behavior. Although the population–ecological approach is gaining support, it cannot disentangle clear targets for policy change. Consequently, health promotion has been relegated to the mass marketing of healthy behaviors, which is based on a rational notion that informed people tend to behave in their best interest.
Creating environments that support behavior change and providing individuals incentives can be more effective to reduce lifestyle-related risks. A paradigm shift from trying to sell health to the public to creating the conditions whereby healthy choices become accessible and affordable is required.
Individual and population approaches have been the defining paradigms of public health research and intervention. The individual approach focuses on understanding and directly modifying individual-level risk factors, focusing on at-risk groups. In contrast, the population approach targets wider determinants of risk and prevention, such as socio-environmental policies.1 Targeting children at risk for obesity with a program to improve their nutritional habits is an example of the individual-level approach, whereas a policy that bans food marketing to children exemplifies the population approach. In recent years, the individual approach has been criticized by public health scholars for its failure to effectively combat lifestyle-related health risks such as obesity, its low cost-benefit ratio, and its failure to consider upstream causal pathways of behavioral risks (e.g., socioeconomic and political factors).2–5 But although population-based prevention is increasingly believed to offer the best hope to deal with obesity, this approach still lacks a clear action plan.5–9
The obesity epidemic is the product of changes in the lifestyle of entire populations driven by techno-economic development. Currently, 1.6 billion adults around the globe are overweight, and the number is projected to increase to 2.3 billion by 2015, increasingly at the expense of developing countries.5,10 In the United States, the prevalence of obesity among adults increased by approximately 50% per decade throughout the 1980s and 1990s, and two thirds of adults today are obese or overweight.11 Such a colossal problem cannot be solved by intensive programs targeting individuals or groups or by a health care system already overwhelmed trying to cope with the health problems associated with obesity.5
Obesity's population-prevention agenda has been driven mainly by the ecological framework, which recognizes the importance of multiple levels of influence on health behavior, including individual, family, community (e.g., school and neighborhood), and society (e.g., urban design, trade policies), as shown in Figure 1. 5,7,12–18 The ecological approach is also embodied in recent behavioral models that view behavior as the result of intentions and abilities, whereby factors acting on the individual level (e.g., attitudes, social influences, and self-efficacy) determine intention, and wider environmental influences (e.g., availability, restrictions) determine whether intentions are acted upon.19–22 The World Health Organization's (WHO) “Health for All” initiative builds on such a vision to devise better population health models that highlight the complex political and social processes involved in people's health.23 In the United States, where traditionally a more individualistic and health care-oriented approach prevails, a change toward acknowledging the importance of creating supportive environments for behavioral change is emerging.8,24,25
FIGURE 1 Simplified multilevel approach to the study of environmental influences on obesity.
Note. PC = personal computer; SES = socioeconomic status. Source. Maziak et al., 2008.5
Despite emerging evidence of the effectiveness of the population approach via public policy change (e.g., the implementation of smoke-free policies in Scotland has led to a 67% decrease in the number of admissions for acute coronary syndrome among nonsmokers),26 the translation of this model into a clear public health agenda has been slow to materialize.27,28 Several factors can be implicated in this delay, including (1) the difficulty in assessing the contribution of distal factors (e.g., the influence of trade treaties on food choices via expanded global markets, advertisement, and price decreases), (2) the huge resources needed to intervene at the population level, (3) the complexity arising from the ecological model's attempt to consider all possible interactions influencing risks, (4) the lack of attention to power balance in the society (e.g., the leverage of big businesses on policymaking and public opinion), and (5) the lack of a clear vision for the role of the health care system in prevention.5,12,27–29
Moreover, the formulation of population health programs around specific goals and targets (e.g., the Healthy People 2010 target of eliminating health disparities) has led to confusion regarding the forces driving health risks with factors that make certain individuals or groups more susceptible to these forces. For example, the fact that some ethnic or low-income groups suffer more from obesity has led to calls for interventions targeting these groups rather than trying to understand why they are more susceptible to the obesogenic influences affecting all of us.5 The pervasiveness of obesogenic environments is demonstrated by the narrowing socioeconomic gap in obesity levels in developed countries, despite the persistent, or even widening, socioeconomic disparities in other health outcomes.30,31 Identifying potential targets for upstream interventions will depend on improving our understanding of how these determinants influence different sectors of the society.32
But even in the context of the population approach, which is based on creating environments that support behavior change, little attention is devoted to the fundamental question we are trying to address here: Why should people make use of environmental measures supportive of active lifestyles rather than continue to enjoy the comfort of sedentary behavior and the satisfaction of “unhealthy” food?
Perhaps the complexity surrounding the population approach and the considerable resources it requires has reduced it to the mass marketing of behavior change.3,33,34 Such social marketing of health is based on a doctrine of personal responsibility and free choice and the power of information to induce behavior change.34–36 The underlying assumption is that when they are provided with necessary information, people tend to behave in their best interest. This notion has its roots in the Theory of Enlightened Self Interest and the Knowledge-Attitude-Behavior framework.37 In her opening statement for the 2002 World Health Report “Reducing Risks, Promoting Healthy Life,” Dr. Gro Harlem Brundtland, at the time Director-General of WHO, highlighted the role of personal choice in health promotion: “We know that most people will choose to adopt healthier behaviors—especially when they receive accurate information from authorities they trust.”38(p5) The same personal-choice view resonates in several population-based initiatives in the United States.39–41 Understandably, the past successes of social marketing (e.g., prenatal care, breastfeeding, condom use),42 together with the modest investment of resources it requires compared with other population-level interventions, has worked to its advantage. However, health marketing has been most successful for behavior change involving a high benefit-to-cost ratio and little opposition from influential interests.
The introduction of guidelines or recommendations (e.g., the Centers for Disease Control and Prevention/American College of Sports Medicine physical activity guidelines) has further energized the health marketing approach by providing standards that can be easily communicated to the public.43–45 With health care systems lacking clear mandates or incentives for prevention, health promotion has been relegated to health professionals trying to sell hard-to-achieve behavioral standards to the public, for which they have neither the time nor the proper training.5,14,46 As such, healthy choices have become another prescribed treatment of the masses, while the view of health as a continuum and life resource continues to be lost.
Given that the obesity epidemic continues to grow despite widespread awareness of its determinants and consequences, the mass marketing of health is obviously not working. One can argue that such an approach may even exacerbate health disparities, because the more educated are likely to have better access to information and more resources to adopt the promoted healthy behaviors.4,34,35 Another caveat of the health marketing approach for lifestyle-related risks is that it can undermine people's trust in public health. For example, some of the health recommendations for obesity, like 5 daily servings of fruits and vegetables or 30 to 60 minutes of activity per day, are hard to follow for the majority,47–49 which can lead to people's frustration and alienation from mainstream public health.
The basic assumption of the health marketing approach—that when provided with appropriate information, people tend to make rational choices about their health—may be too simplistic to be useful in a market economy. There are several reasons for this. First, this rational choice concept fails to consider that technological progress, which can be both the problem and the answer, influences these choices not only at the level of the individual (e.g., by encouraging energy overconsumption while obviating expenditure) but also at more complex levels (e.g., economic systems, globalization of trade) that are not easily changed with this approach. Even ignoring these higher-level influences, the notion of rational choice for the individual in a market economy gets blurred when one is bombarded daily with hundreds of consumption options, each accompanied by its own set of “rational” arguments, including purported antidotes to avoid the health risks associated with these options (e.g., weight-loss products).
Furthermore, biology and culture cannot be overlooked. Many people will defer choices involving future rewards (e.g., the long-term benefits of healthy eating) in favor of those with immediate ones (e.g., the gratification of junk food or choosing an afternoon of televised sports rather than participating oneself).50 Although this delay of gratification conflict is well-known, what is often missing from the health behavior debate is that the pull toward immediate gratification has evolutionary roots. Humans evolved mainly in environments where food supplies were scarce, so there was an advantage to conserving energy stores to be used later to run, climb, or move from one place to another for survival.51–55 This is perhaps why we instinctively prefer to eat energy-dense food and remain idle. But, whereas harsh ancient environments facilitated the utilization of our energy stores, the combination of food abundance, food marketing, and labor-saving technologies can be deadly, as the obesity epidemic is beginning to show us. Also, cultural conditioning can underlie many of our preferences and choices that otherwise seem to us as personal and free from external influences (e.g., a taste for fried food, not sushi or vegetables, depends on the local culture).
Last, market forces influence not only people's consumption choices, but also their ability to have a say about their own health. In the United States, for example, we are at a stage of the new global market economy in which powerful interest groups, such as the food industry lobby, shape public policy, and where governments are increasingly more responsive to business interests than prohealth pressure from individuals or communities.56–58 The operative principle seems to be that competitiveness of national products and sustainability of economic growth is the top national priority, and health is expected to be a byproduct of economic wealth.59–61 This view is being challenged by evidence that population health is more about income distribution than absolute level of economic development, and by the strong health performance of many Western democracies that have achieved economic success within a strong welfare system.62–64 It is not surprising, therefore, that the United States ranks at the bottom of industrialized nations in terms of population health indicators, despite outspending these countries on health by two to one.64 In fact, over-reliance on the market's ability to drive down health costs and reduce disparities represents another form of the idealistic rationalist paradigm, assuming that markets follow a preplanned progressive path that has common good at its core. Some even argue that ill health is not a byproduct of unrestrained market activity, but a primary consequence that is likely to affect the disadvantaged disproportionally and exacerbate health disparities.65,66
Navigated wisely, however, market forces can work for health as much as for special interests, particularly as people and businesses are increasingly questioning why they should subsidize health problems arising from bad behavioral choices such as smoking.67,68 With the rising costs of health care, many employers (e.g., Microsoft) and health insurers, particularly companies that underwrite their own health insurance for employees, are responding by opting to reward healthy behaviors that can be objectively verified, such as smoking cessation and weight loss. Recent changes in regulations for group health plans in the United States make it permissible for employers to reward (or punish) employees for healthy (or unhealthy) behaviors.69 For instance, an employer may reward employees with a discount on their health premiums for receiving a low score on an annual cholesterol test, or can screen and fire workers for unhealthy behaviors like smoking.69,70 So while we are debating strategies to improve population health, economic realities are turning debate into action and shaping the health agenda of the future.
Health promotion, therefore, should adapt to emerging economic realities and the inadequacy of the health marketing model for lifestyle-related risks. What is needed is a health promotion approach that not only creates environments supportive of healthy lifestyles, but provides incentives to counterbalance the decision-making cues that favor short-term rewards, as well as market forces influencing our choices. If fruits and vegetables were accessible and affordable relative to fast food, our streets were safe, and playgrounds and bike routes were available even in poorer neighborhoods, healthy lifestyles would probably be easier to promote and adopt. Improvements would be even more likely if people were offered additional incentives to engage in healthy behaviors. In other words, it is time for health promotion to come to terms with the fact that as free individuals in a global market economy, our behavioral choices are not necessarily shaped by what is good for us, but by the myriad of choices we have and those we like.
Such a perspective can perhaps provide a response to the central question asked earlier about what would motivate people to engage in healthy behaviors in the face of their natural preferences and external factors affecting their choices. Moreover, an incentive-based health promotion model is likely to be particularly effective with poorer individuals, leading to the narrowing of health disparities and to the generation of local resources that will empower communities and increase their control over their lives. Although the translation of this vision into actual public health practice can be difficult, recent crises related to fuel prices, air pollution and climate change, and rising health and economic disparities offer common solutions.71 Evidence for such potential is emerging from studies showing that activity-supportive features of the built environment reflect positively on obesity, air pollution, fuel consumption, and traffic jams and injuries.72,73
A pioneering program in New York City, New York (Opportunity NYC) already applies this incentive-based approach by helping people make choices with long-term benefits (e.g., investment in education and preventative health care) by covering some of the immediate costs incurred by these decisions.74 Other potential approaches include providing tax breaks to people to conserve energy, which can lead to wide-ranging positive changes for health and the environment, including more active lifestyles (via active transportation), reduction in resources depletion, and reductions of greenhouse gases emissions. Moreover, energy scavenging technologies that can harvest and store energy during human movement and activity can also provide an incentive for physical activity, as do active video games for children.75,76 Evidence also is emerging of the effectiveness of financial incentive-based approaches to promote weight loss and smoking cessation.77,78
This vision is likely to be met by some resistance, especially in the United States, where individualism and free choice are core values.65,79,80 But we should remember that these values have been manipulated by vested interests for the wrong reasons (e.g., tobacco companies using “tolerance” and “free choice” to challenge clean air laws), that free choice is meaningless without the means to achieve it, and that such a vision does not paternalistically assume that government knows better than individuals what is best for them. Rather, it is about helping people make decisions in their self-declared long-term interest, without prohibition or penalty, but with help and incentives. It reflects a realistic understanding that most people do not have perfect information, resourcefulness, or motivation to make healthy choices, but will welcome assistance to act in their own best interest.50
We are living in a drive-through, dial-up, and log-on consumption-oriented society marketed under different pretexts but driven mainly by vested interests. These developments are shaping the lifestyle of whole populations and predisposing them to serious health risks,81 as well as negatively impacting the environment and natural resources to the extent that sustainable economic activity is threatened.82 The prescription of healthy behaviors to the masses has failed, because it ignores the socioeconomic context and environmental influences shaping people's choices. But, even a comprehensive understanding of health risks of the technology age can lead nowhere without addressing the internal and external drives shaping human behavior and choices. Aligning policies with rewards in an overall ecological framework addressing the health, economic, and environmental needs of society can affect multiple junctions of healthy behaviors and lifestyle choices in a sustainable and irreversible way.
We have few choices left to prevent environmental depletion and degradation and our virtual abandonment of huge segments of our society to sickness and poor quality of life. The myth of the supremacy of economic growth is giving way to a realistic awakening to the unsustainability of economic activity without an overall vision of a healthy society and environment.82,83 In the end, we need a paradigm shift from trying to preach healthy choices to the public to creating an environment in which healthy choices become not only more feasible but also more affordable.
Human Participant Protection
No protocol approval was necessary because the writing of this article did not involve human research participants.
