Developing Adaptive Learning Environments to Support Long-Term Health Promotion

Abstract

Health promotion strategies typically include changing the environment, providing supervision to decrease the likelihood an unhealthy behavior will occur, and increasing skills to make decisions supporting health in environments in which such choices are challenging to make. The first two strategies are important in improving the environment to promote healthy decision making. However, the creation of restrictive environments has repeatedly shown to not support disease prevention in the long term. Restrictive environments do not support the development of skills to make healthy choices when restrictions are not in place. This is particularly true for children who are learning to navigate their environment and make health decisions. The creation of adaptive learning environments should be prioritized to help individuals develop the skills needed for long-term health promotion.

Prevention remains a fundamental cornerstone in lifestyle medicine.

Prevention remains a fundamental cornerstone in lifestyle medicine. Strategies for making safer environments typically include removing dangerous items or situations, supervising in situations with increased risk, and/or providing training that promotes competencies in hazardous situations. In the instance of drowning prevention, fences or barriers around pools are attempts at removing a dangerous situation (ie, unsupervised access to a pool), swimming in lifeguarded situations is an attempt to have supervision in an instance of increased risk, and improving skills in water through swimming lessons is an attempt to increase competency. In this issue, Dellinger and Gilchrest ¹ discuss the importance of considering a child’s developmental stage when providing education and creating plans to promote a safe environment for youth. Specifically, Dellinger and Gilchrest ¹ highlight how risk taking is a part of healthy development, and how the identification of behaviors and environments that are most likely to contribute to severe injuries requires education for both parents and children on how to most effectively handle such situations.

This type of education is essential throughout lifestyle medicine. Effectively addressing difficult situations that affect health is one of the most important tasks faced by individuals trying to make a lifestyle change. However, a difficulty arises in determining how to create an environment that best supports long-term behavior change. Removing a situation that may be dangerous is straightforward. Providing supervision to decrease risk is also something that can be easily translated across disease prevention strategies. Increasing skills, however, is more complex. While short-term change can be prompted through the first two strategies, long-term behavior change likely requires the development of skills to handle situations in which making the healthy choice is challenging. The instance of providing disease prevention through dietary changes provides a clear illustration of this.

The Problem of Creating a Restrictive Learning Environment

A child’s food environment is shaped by physical access to foods, rules set about eating, and the overall emotional climate surrounding feeding. The removal of certain foods that are more frequently eaten during times of stress or boredom may be beneficial. ² This is termed stimulus control and is a core technique to support behavioral change. ³ Having a more structured environment can create a “safe place” and make it easier to make healthy choices. While stimulus control ensures that the unhealthy choice is difficult to make, it is important to not restrict food altogether. Restriction of food has been shown to create problems in terms of increased intake and feelings of loss of control. ⁴

Parents often act as gatekeepers and are the primary determinants of children’s health environments.^5,6 Concerned about their children’s weight status and health risk, parents often establish an environment that restricts their children’s access to specific foods or amounts of foods. ⁷ Such restrictive feeding practices are maladaptive and can increase children’s desire for and intake of restricted foods, which may lead to unhealthy weight gain.^7,8 For example, restricting preschooler’s access to palatable snacks was found to lead to increased intake and increased frequency of requests and attempts to access the restricted food. ⁹ Youth who experienced the restriction of palatable foods were 4.6 times more likely to be overweight than their counterparts not experiencing restriction, ⁹ and restrictive feeding environments at age five predicted higher body mass index at age seven. ¹⁰ Overall, the creation of a restrictive learning environment in the home is not effective at promoting the development of self-regulation in children.

The restriction of palatable foods has extended beyond the home into the community. For example, junk food and sugar-sweetened beverages have been restricted in schools. No significant differences were found in terms of overall junk food consumption, sugar sweetened beverage consumption, or body mass index between fifth-grade students with and fifth-grade students without access to a vending machine. ¹¹ State regulations on in-school purchases of sugar-sweetened beverages have decreased in-school access; however, it appears that they have not impacted overall consumption. ¹² Although it is beyond the scope of this article to discuss issues such as schools being “safe zones” for health, it may be important to consider the effectiveness of creating environments that remove the option of junk foods and sugar-sweetened beverages.

A final example of the problem of restrictive eating environments is the television series, The Biggest Loser. Participants on this show receive an extreme weight loss intervention with very restrictive diets and excessive exercise. Caloric intake is restricted by an average of 65% with the individuals eating approximately 1300 calories per day, and individuals’ eating and exercise behaviors are highly supervised. ¹³ This restrictive environment in which weight loss occurs does not resemble participants’ home environments. Ultimately, participants are unable to maintain their restrictive diet when they return home and regain weight. It is clear across all of the settings described that restrictive environments may produce results in the short term, but longer term maintenance is difficult to achieve through restriction.

Creating Adaptive Learning Environments

Restrictive practices are not conducive for the development of adaptive learning environments. When choices are restricted, children cannot develop and practice the skills to make healthful decisions in an environment that promotes unhealthy choices. It is essential that health care professionals assist parents and school staff to develop positive learning environments for their children. If the ultimate goal of childhood lifestyle disease prevention efforts is for children to gain the skills to make healthy choices, they must be provided a safe learning environment in which they can practice making eating decisions. Outside of dietary change, laws that assist young drivers to be safer during times of increased risk exemplify the creation of an adaptive learning environment. ¹⁴ In some states, teens are not allowed to drive with peers after receiving their license and curfews for driving times are put in place. This creates an environment in which the teen gains the independence of driving but removes some of the times that are most problematic in terms of injury. Health care providers and lifestyle medicine researchers should attempt to establish similar learning environments to bring about long-term preventative health change.

Conclusion

Chronic disease prevention is a tremendous challenge in lifestyle medicine. The American environment is often not conducive to health.^15,16 Environmental strategies to make it easier for individuals to make healthy choices are important and many have shown to be effective. However, health care professionals and policy makers should be cautious about recommending strategies that develop a restrictive environment. While restrictive strategies may be effective initially (if the food is not available, it cannot be eaten), they are potentially harmful in the long term because individuals in a restrictive environment may not develop necessary skills to make healthy decisions in an environment that promotes unhealthy choices. More consideration should be given to the development of adaptive learning environments to adequately prepare individuals to make healthy decisions in the long term.