The Failure Of The Shape Up Somerville Program To Adequately Address Children’s Healthy Behaviors Outside Of School

Introduction

“Shape Up Somerville: Eat Smart. Play Hard.” was a three year long program that began in 2002 aimed to lower the body mass index of early elementary school children in the city of Somerville, Massachusetts. This program was comprised of a number of interventions geared towards promoting healthy eating and exercise behaviors in these children before, during, and after school. Although this program succeeded in lowering children’s body mass index after the first year of implementation (4), it failed to adequately address children’s unhealthy habits outside of school. A recent research study found that “Hedonic factors, rather than reasoned judgments, may help drive children's intentions” (6). These hedonic factors reinforce the importance of addressing children’s eating and exercise behaviors outside of the school setting. This all-encompassing approach is crucial to long term success in the promotion of healthy behavior promotion in children.

Children spend five days a week, nine months out of the year in school and may only consume one meal at school during the school day. This is one meal out of three a day that can be directly impacted by the school’s healthier food interventions. Also, only about 60% of the Somerville study population participated in receiving a school lunch; leaving 40% that would not benefit from an in-school healthy food intervention (6). It is therefore critical that the Shape Up Somerville program consist of multiple comprehensive interventions aimed at addressing children’s healthy eating and exercise behaviors outside of school. The interventions that were initiated outside of the school setting were inadequate and did not address children’s access to healthier foods, target the children’s families appropriately in disseminating information about healthy interventions, or accurately target lower activity level improvements in children.

Addressing Children’s Accessibility to Healthier Foods Outside of School

The Shape Up Somerville program does not address the population’s access to healthier foods, notably this population’s financial and geographical barriers. A previous study examining the link between parents and their ability to change their children’s obesity status has shown that families with a higher income level are more likely to adhere to healthy behaviors (8). Fresh produce and healthy food products are traditionally more expensive than processed foods with lower nutritional value (10), so it is expected that lower income families will have problems purchasing healthy foods. The median household income of this study population was around $42,000 with approximately 13% of the families living below the poverty level (4). The study population was comprised of low to middle income families, thus a significant financial barrier is in place that prevents these families from being able to purchase healthy foods. No interventions were put in place in the Shape Up Somerville program to address these financial barriers.

Parent outreach and education was the only out of school intervention implemented as a means to boost healthier eating behaviors. The idea of educating parents about healthy eating follows the Health Belief Model. This model finds that once individuals are educated on the benefits and importance of a healthy behavior, they will adhere to the healthy behavior. Individuals, in fact, may be educated on a healthy behavior, but may not choose to engage in the healthy behavior. A study assessing environmental contributions to obesity found that telling individuals to eat healthier without addressing their current food supply as seen in parent outreach and education will only result in limited success (11). A list of restaurants adhering to the “Shape Up Somerville” health campaign was also developed as a part of this program, but for families who are struggling financially, this information is irrelevant due to the cost associated with eating at restaurants.

Being located in an urban area, these families also have geographical barriers in place to prevent them from eating healthy. As noted earlier, Somerville is a predominantly low to middle class income area and grocery stores in higher income areas are likely to have more nutritious foods than grocery stores in lower income areas (7). There may not be grocery stores with healthy foods within walking distance or within a comfortable public transportation distance. With financial barriers already in place to prevent families from eating healthfully, it is unlikely that these families have cars that they can use to drive to grocery stores that have fresh produce and/or natural food products. In a New England Cable News video clip describing the Shape Up Somerville program and its increase of fruits and vegetables within the school, Mary Jo McLarny, director of Somerville Food Services, discussed the success of the program within the school and stated that they had to “… teach children what these fruits and veggies are because they don’t have the opportunity to eat them at home” (13). It is unfortunate that public officials who are involved with the Shape Up Somerville program are aware that children cannot receive healthy foods such as fresh fruits and vegetables at home and do nothing to address this deficiency. It weakens children’s self-efficacy when they have access to fruits and vegetables in the school setting and are educated about eating healthy, but are then unable to eat the same healthy foods and implement what they have been taught about eating healthfully when they are at home. This also puts parents in an awkward, and potentially shameful, situation because they may be forced to explain to their children why they are unable to eat as healthfully at home as they do in school. As part of the Shape Up Somerville program, children went on field trips to organic farms to learn more about fruits and vegetables. These trips were counterproductive in that children were exposed to fresh produce and its benefits, while there is limited or no access to healthy produce at home.

Insufficient Healthy Eating and Exercise Information Dissemination to Children’s Families

This program does not accurately target its audience; moreover its intervention to disseminate information to families on how to develop healthier eating and exercise habits is fundamentally flawed. It is helpful for healthy interventions to focus on parental behaviors because parents determine the diet and physical activity practices of their children (12). It is also likely that parents need assistance with healthy behavior adaptation when their children need help” (8). The interventions used in the Shape Up Somerville program to educate parents on healthy eating and exercise habits disseminated instructive documents online, provided information through a bi-monthly newsletter, and discussed healthy behavior changes through in-person parent nutrition forums. Online information and in-person parent nutrition forums are not likely to help families with financial barriers because these families may not have the luxury of a computer and internet connection at home or they may not be able to spend time outside work or family to attend an in-person forum. These interventions also did not take the cultural diversity of the study population into account.

The Principal Investigator admits that “Given the ethnic diversity, different languages spoken….we were not able to gain consent for all eligible children in the three communities” (4). Despite recruiting a study population that admittedly does not mimic the ethnic diversity within the city of Somerville, one third of the families involved in the Shape Up Somerville program did not speak English at home (4). There was an understanding at the beginning of the study that diverse cultures were present in the study population and efforts were initially made to engage these populations. At the beginning of the program, parents were sent a pre-intervention questionnaire to fill out that was translated into Spanish, Portuguese, or Haitian-Creole when appropriate. (4) A research study that focused on healthy interventions in minority populations found that healthy eating and exercise interventions “…may be particularly critical for African Americans and Hispanics, a relatively neglected and greatly expanding sector of the population” (5). These minority populations are therefore important to keep in mind while generating healthy eating and exercise materials for families. The educational materials available online included various types of information such as tips on how to grocery shop for healthy foods and how to develop a family plan for a healthier future. Unfortunately these online documents and the bi-monthly parent newsletter were only provided in English and thus did not educate parents who may not speak English fluently. The parent nutrition forums that were offered did not appear to be offered in multiple languages and thus would also only help parents who speak fluent English. The healthy eating information provided in these documents focuses on healthy American foods, which may not be the staple food within a child’s home. Providing information on how to eat healthfully within a cuisine that is not consumed in a family’s household is much less likely to result in a healthy food modification. For example, the “Healthy Snack Guide” focuses on snacks low in sugar, fat, and sodium (2), which is contrary to some of the cuisines represented in the cultures of Somerville. One example is Haitian cuisine, which consists of foods that are traditionally high in carbohydrates and fat (9). The development of a healthy eating plan must take the various ethnicities of Somerville and their traditional cuisines into account. This will ensure that families will see the healthy eating plan as a viable alternative because the plan will encompass the families’ culture and traditions.

Targeting Low Activity Level Improvements Outside of School

This program does not accurately target low activity level improvements outside of school. The only intervention developed to address low activity levels in these children outside of school was through a Walk to School campaign. Somerville is a relatively population dense urban area with two major highways running through the city. It also contains multiple subway stations and bus stops. The children enrolled in this program are in Grades 1-3 and are therefore between 5 and 10 years of age, which is a young age to be walking to and from school regardless of adult supervision. Safe routes for children to use to walk to school were developed, but the criteria used to determine safety were not delineated. One could argue that the safe routes were deemed safe because they include pedestrian signage or painted crosswalks at road intersections. These routes may not take into account areas that are known to have large volumes of vehicular traffic or higher crime rates. A child’s safety and security is much more important than the limited exercise that would be received through walking to and from school.

Parents in urban areas have reported that they “…prefer having their children watch television at home rather than play outside unattended because parents are then able to complete their chores while keeping an eye on their children” (3). No out of school interventions to address low activity levels within the home were created as a part of this program, which further fails to engage this target urban population. A recent study found that girls of all races and non-Hispanic blacks are most likely to have low activity levels and high levels of watching television (1). This subpopulation would benefit from additional incentives and there are no aspects of this program that seek to cater to this population in need.

Conclusion

By concentrating the majority of its healthy eating and exercise interventions within the school environment, the Shape Up Somerville program compromised its level of effectiveness. Increased interventions outside of school, along with more substantive contact with children’s parents and families, would have resulted in a higher success rate of reducing obesity within the study population. The out of school interventions also do not taken the ethnic diversity of the city of Somerville into account, which also impeded the program’s success. Addressing all aspects of a child’s environment is crucial in promoting a healthy behavior change.

Addressing The Failure Of The Shape Up Somerville Program To Adequately Address Children’s Healthy Behaviors Outside Of School

Introduction

The Shape Up Somerville program was successful in teaching children within the school setting to employ healthy behavior changes such as eating fruits and vegetables and exercising, but failed to initiate successful healthy behavior change programs outside of the school setting. Although school is an ideal place to affect healthy behavior changes in children, settings outside of school can also be effective in employing healthy behavior change (3).

A successful healthy behavior change program outside of the school setting must take the surrounding community into account. There are social, cultural, and geographical aspects of a community that must be reviewed in order to develop a successful healthy behavior change program. These various aspects of a community have been addressed in the following revised Shape Up Somerville program. This program ensures that children have access to healthy foods outside of the school setting, children’s families are educated in a culturally sensitive manner, and children are given a wider range of options to exercise outside of the school setting.

Addressing Children’s Accessibility to Healthier Foods Outside of School

Food prices affect the way a family will conduct their grocery shopping, i.e. food that is cheaper, although nutritionally poor, is more likely to be purchased than food that is more expensive and healthier (3). Consequentially, families with economic hardships are at a disadvantage because they are more likely to purchase cheaper nutritionally inadequate food. The city of Somerville contains a large amount of low and middle-income families (4), which need to be taken into account in the revised Shape Up Somerville program in terms of getting children to eat healthier. This financial barrier will be reduced by giving economically disadvantaged families access to no-cost or low-cost healthier foods through organic produce deliveries or organic farms.

Boston Organics is a company that delivers organic locally-focused produce to the Boston area on a weekly or bi-weekly basis (14). As part of the revised Shape Up Somerville program, economically disadvantaged families would receive the organic produce delivery at reduced or no cost, which would improve families’ access to fresh produce. Boston Organics supports local produce and by participating in this program, they would also support local communities and be able to advertise their charitable campaign. By drawing attention to one of the many hardships that economically disadvantaged families face, Boston Organics is setting the agenda to help neighborhoods in need of access to fresh produce.

As part of the original Shape Up Somerville program, children were sent on field trips to organic farms to be educated on the different types of fruits and vegetables and how fruits and vegetables are grown. This field trip would be expanded to include children bringing home some of the fruits and vegetables at a reduced cost or at no cost to improve family access to fresh produce. The organic farms could provide this produce by giving fruits and vegetables that are good, but perhaps smaller in size or closer to expiration and thus not profitable to sell. These farms could market their charitable giving to further set the agenda of providing healthy foods to families in need, like Boston Organics. Giving families increased access to fresh produce is not guaranteed to employ a healthy behavior change; however the children receiving and eating fresh produce within the school setting will generate a social norm of eating fruits and vegetables. This social norm will influence children’s parents and families to eat and cook with fruits and vegetables within the home.

The original program generated a list of restaurants within the area that carry healthy dishes. Eating at these restaurants is considered out of reach for many of the low to middle income families who cannot afford to eat out. These restaurants would employ time periods and days (for example. Tuesdays between 6:00 and 8:00 pm) where prices are reduced so that families with a lower income are able to afford a healthy meal outside of the home. The restaurants could choose this date and time based on their internal food deliveries so that food that would normally spoil and go to waste is instead sold and eaten on the reduced price night. The restaurant will also garner increased business on the reduced price night than it would during the same time period without the price reduction. The reduced price night implementation would not stigmatize economically disadvantaged families because they would not be singled out for their lower economic status.

A major geographic barrier that children’s families face is grocery stores with limited fresh produce near the families’ homes or fresh produce available at grocery stores that are outside of walking distance or comfortable public transportation distance. A solution to this geographical barrier involves recruiting farmer’s markets to neighborhoods in need. Farmer’s markets traditionally sell fruits and vegetables at a lower cost than grocery stores, which improves financial accessibility of fresh produce to lower-income families. A program would also be established to provide periodic weekend busing to healthy grocery stores to improve geographic as well as financial barriers to children and their families. Children and their families will have an increased sense of self-efficacy with these interventions in place because eating healthy will not occur only within the school and will no longer be out of reach outside of the school.

Healthy Eating and Exercise Information Dissemination to Children’s Families

Currently there is more information disseminated by the media regarding overeating and eating poorly than there is about portion control and eating healthy foods (7). Although children have been educated about eating healthy and exercising within the school setting, they are unable to control their household’s healthy eating and exercise habits. The previous Shape Up Somerville program disseminated educational information about eating healthy within the American cuisine in English via newsletters and websites. Children’s families should be educated about eating healthy in a language that they can understand and in a manner that is consistent with the traditional cuisine served in their home. The revised Shape Up Somerville program caters to a broader audience of families through culturally sensitivity and increased modes of communication.

Information about eating healthy and exercising will be disseminated in some of the major languages spoken in the area of Somerville beyond English, namely Spanish, Portuguese, and Haitian-Creole (4). Individuals within the communities who are bilingual will be recruited to translate this information to assure that the translation is done in an understandable layman’s term format and as a method to reduce costs. For those who do not have internet access within the home, the online newsletter information that is translated into the appropriate language will be disseminated at school and brought home by the child in paper format.

The in-person nutritional forums that were taking place will involve interpreters, who would be members of the community, to serve as interpreters for the forums. Initially, a wide range of families within the community will be sampled to ensure that individuals who speak different languages within the community would attend the in-person nutrition forums. The forums may prove not to be beneficial to this population, who may be busy with work and home life responsibilities.

In order to address the different cuisines eaten by the study population, the respective cultural communities will work with students studying dietetics to develop healthier recipes that adhere to a family’s cultural cuisine. Students from nearby colleges pursuing a degree in nutrition would be tapped as a resource to help develop healthier recipes. The use of students would keep costs down, while ensuring a level of nutritional specialization. This collaboration would also prove helpful to the student and would be incorporated with his/her coursework. With this intervention in place, future dietitians will be sensitive to an individual’s culture and traditional cuisine in their nutritional advice and consultation.

Targeting Low Activity Level Improvements Outside of School

The previous Shape Up Somerville’s program to address low activity levels outside of school through a walk to school program is insufficient because it compromises the safety of the children. The revised program employs other means of exercise outside of school to ensure that low activity levels are targeted and alleviated.

Different means of exercise can occur within the home or in an after school program.

Video game play involving movement and significant caloric expenditure has recently come to the forefront in U.S. media. Two video game methods that are known for their aerobic abilities include the use of the Wii console and the video game Dance Dance Revolution. The Wii console and controllers are developed in a dynamic way that encourages player movement, instead of traditional video game controllers that limit a player’s movement to use of the hands only. There are numerous games for the Wii that promote physical activity such as tennis, basketball, and a game called the Wii fit that showcases activities such as yoga and skiing. Dance Dance Revolution is a game that is based on a player jumping on a board of four arrows in tune with the sounds and movements emitted through the speakers and on screen, ensuring a formidable workout. These consoles and games would be donated from the companies who developed them, sell them, or from members of the community who no longer use them.

A recent study finds that “Children who are approaching adolescence, girls, and non-Hispanic blacks are most likely to have low levels of active play and high screen time” (1). An afterschool program has previously been developed that targets these populations in the form of a Latino dance class. This class, called Dance for Health, was originally developed in California as a 12 week program for the seventh grade population (5). The dance class was offered in place of physical education during the school day and was successful in lowering BMI and heart rate among participants (5). This class would be offered after school in the context of the Shape Up Somerville program after school, on weekends, and/or both. Dance class is a method of packaging exercise as a fun way to spend time with friends along with the side benefit of caloric expenditure.

Conclusion

Addressing healthy behavior change outside of the school setting will reinforce the aims of the Shape Up Somerville program and make the program more effective. By taking into account previously neglected aspects of the children’s community such as geography, culture, and socio-economic status, a successful healthy behavior change program can be implemented. The Shape Up Somerville program can now fully encourage participants to “Act Right, Play Hard.”

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