Challenging Dogma - Spring 2009

Monday, May 11, 2009

Food for Thought: How Public Health has Failed to Combat Obesity – Aanchal Sharma

Oftentimes, small issues that remain untreated can escalate into large scale problems. This is the case with obesity, defined as having a body mass index (BMI) of 30 kg/m2 or higher (12). Obesity has now become an epidemic in the United States, where approximately seventy million Americans are obese and more than one in three of all adults and one in five of all children are overweight (3). Many intervention programs have been launched to deal with this public health issue. A number of the programs are aimed at improving the nutritional health of young children so that they will maintain a healthy diet into adulthood. Among these interventions is the implementation of a weight report card system for schoolchildren. This intervention has been proposed in different forms in various states and has met with mixed emotions from both parents and children.

The Weight Report Card

The general concept of the weight report card is to keep parents informed about the nutritional status of their children and to help them teach their children about proper eating habits so that obesity does not becomes an issue. The way the weight report card works is that the school measures the weight and height of all the students and then uses these measurements to calculate their BMI. The BMI is then scaled against what is considered underweight, healthy, overweight, or obese and these finding are sent home to parents just like an academic report card (4). While the goal of the weight report card is similar that of most public health interventions – to stimulate a change in the behavior of both parents and children – it has not been documented to have achieved such success (16). Nevertheless, the weight report cards did increase awareness among parents about the health of their children. The lack of success of the weight report card intervention program can be attributed to issues with stimulating an intention to change behavior, self-efficacy, and framing. Each of these factors has a key impact on how people with react to the intervention and whether or not they will be influenced enough to change their behavior.

Critique 1: The Inability to Create an Intention to Change Behavior

The weight report card does not create an intention to change behavior. Intention to carry out an action or behavior is an important component of the traditional health behavior models (15). Though intention does not always lead to the execution of a behavior, the existence of intention is necessary to have some sort of desire to change a behavior. The weight report cards are intended to stimulate a change in behavior that will lead to healthier lifestyles for children (16). However, by just pointing out the children who are overweight and obese, there is no true motivation to improve health. Furthermore, in cases where programs are offered to the children and the families of the children who have higher BMIs, there is a lack of intention for families to get involved because of the stigma that is associated with these programs. If the school were to offer to all of the schoolchildren a program that would have components aimed at increasing physical fitness and improving eating patterns, children and their families would be more inclined to get involved since the programs would be associated with healthier lifestyles, rather than only helping those who are obese or at risk (6).

In Wyoming, the school district that distributed weight report cards also offered students and their families an opportunity to get involved in a program called the Healthy Kids Club, which included a weekly exercise regime. Rather than having the intention to change their behavior and have their families become more physically active, parents of the children who were offered this program due to their high BMI were offended and outraged. They did not want to subject themselves or their children to a program that implied that their family was incapable of taking care of themselves and of making healthy decisions (6).

In Arkansas, the weight report cards do offer suggestions on ways to improve the quality of health, but there are not concrete examples being offered to parents (2). There is no acknowledgement of the fact that the problem may also be due to parents who are unaware of how to go about changing the behavior of their children. In some cases, parents may realize that there is a problem, but may not know how to approach the situation or may need help in finding a solution. Thus, it is essential to incorporate a component of common ways to improve the nutritional health of individual and this can even be presented through informational sessions at local schools or community centers. These sessions should be offered to any parents who may be interested in the issue and during these sessions, the parents can be informed of ways to motivate their children to be more physically active and improve the quality of their health. The addition of these components into the weight report card program could help create the intention necessary to change behavior among the target population.

Critique 2: The Concept of Self-Efficacy

Many of the traditional health behavior models include the concept of self-efficacy. Self-efficacy can be understood as an individual’s belief as to whether or not he or she can carry out an action or behavior (15). In the case of the weight report cards, it seems as if the intervention completely disregarded the concept of self-efficacy. By pointing out children who are overweight or obese, the intervention creates a division between the children. This can really have a negative effect on the self-esteem of the children who may be more at risk for obesity as compared to their classmates. This can also result in reduced self-efficacy among the children who are more overweight as they may become increasingly self-conscious and place greater blame on themselves for their physical condition. Thus, they may not feel like they are capable of doing anything to improve their physical health or may not be motivated to change their behavior due to the lack of positive reinforcement from the intervention program. In addition to this, children may be more prone to develop unhealthy eating habits or eating disorders due to the stigma that is associated with getting a high BMI on their weight report card (26).

Self-efficacy is an essential mediating mechanism in enhancing the understanding of the treatment of those who are overweight and obese (27). Research that assessed the importance of self-efficacy has shown that treatment programs for weight are incomplete without this component of the model (4). Weight loss can only be achieved when an individual makes an effort and feels like he or she can achieve successful results by altering eating patterns and increasing physical activity. Personal health care and management requires a drive that comes from within the individual, which includes a desire to change behavior and the confidence that he or she is capable of changing the behavior. Self-efficacy has a great impact on self-management and is a key component on one’s initiative to change behavior and promote healthy living (7). Thus, without the component of self-efficacy, it becomes difficult to implement a program to successfully help with the obesity epidemic.

Critique 3: Framing Obese Children as Failures

One alternative model for public health intervention is the framing theory. The framing theory is based on the principle that if you frame something the right way, you can change the mentality of a group and influence a change in behavior by appealing to the core values of a group (15). Proponents of the weight report card program may argue that they are trying to appeal to the value of good health; however, there is a stigma attached to a report card. A bad grade on a report card can really harm the self-esteem of children and may make them feel like failures. The weight report card does not take external factors into consideration. It implies that it is the child’s fault that he or she is overweight or obese. Like self-efficacy, self-esteem is a key factor to consider when assessing weight report cards (19). Obese children with decreasing levels of self-esteem demonstrate emotional problems and engage in high-risk behaviors, such as smoking or consuming alcohol (28). They are generally more disengaged and tend to exhibit signs of sadness, loneliness, and even depression. Research has also shown that middle school females who perceive themselves as overweight are significantly more likely to be associated with suicidal thoughts and actions, and for middle school males, perceptions of being underweight or overweight were significantly linked to suicidal thoughts and actions (29). If the weight report cards are issued in schools and boys and girls are being told that they are overweight or obese, there is a direct negative effect on their mental health and self-esteem. Thus, the weight report cards need to be reconstructed so that they are not as harmful to the self-esteem of schoolchildren.

Generally, school grades are meant to reflect the caliber of a student’s performance in class and are an assessment of their ability to do well both in class and on exams. Similarly, the weight grade can be associated with poor eating habits and lack of physical activity, framing the problem as a result of poor performance on the part of the child. This may be the case for some children; however, there are often biological issues that can result in higher BMIs for certain children, such as slower metabolism or a problem with the stomach, liver, or kidneys. Furthermore, BMI does not take body composition into consideration and therefore can misclassify someone who is healthy with greater muscle mass as overweight. The American Academy of Pediatrics conducted a study that shows that if one parent is obese, the odds ratio is approximately three times the normal risk for that child to become obese in adulthood. If both parents are obese, the risk increases to ten times the normal risk (20). The weight report cards do not account for these issues. Thus, the way the intervention is framed does not have a sympathetic tone; instead, it is rather critical and places the blame on the individual and his or her family and lifestyle.

Framing interventions in a particular way has a direct impact on the emotional response of an individual to the information being presented (13). The emotional response of an individual will influence how they will approach the intervention and whether or not they will be open to the information being presented to them. It is also important to frame the issue of obesity in terms of external environmental and societal factors in addition to the personal factors that the weight report card focuses on (14). For example, availability of healthy foods and socioeconomic status may be linked with why certain communities have a greater percentage of overweight and obese people. Each of these aspects of framing can make a great difference in the success rate of the intervention program.

Food for Thought: Where Do We Go from Here?

Even though the weight report cards are not the key intervention to help reduce obesity among schoolchildren in the United States, it still has strong elements that can be further developed to create a more effective public health program. The weight report card was effective in creating raised awareness about the issue of obesity (16, 19). This is a key aspect to creating interventions that will have successful results. Increasing awareness about an issue increases the perceived susceptibility and perceived severity of an individual towards a problem (15). However, this is not enough to create an intention to change behavior.

A better suited intervention program would stem off of the idea of using school as a medium for assessing the health of the children. Instead of alienating children who have a BMI that categorizes them as overweight or obese, the school administration should educate all the children about the importance of proper eating habits and physical fitness. Classroom presentations, healthier lunch options, and more physical activities for children to participate in are all components of making the school environment more conducive towards providing children with outlets for improving the quality of their health (25). By educating children about how they can better take care of themselves and improve their own health, there will be less of a stigmatization towards children who may be at risk for obesity and there will be more positive reinforcement to encourage children to change their behaviors.

The weight report card allows public health officials to realize how physical health is a sensitive topic that needs to be dealt with using discretion. Placing blame and framing the problem in a way that makes people feel guilty will only result in disheartened or angered individuals. Society and media is obsessed with body image and there is a constant emphasis placed on being skinny and how that is associated with beauty. Schoolchildren are aware of this image and are able to draw correlations between weight and lifestyle. Thus, telling children that they are overweight is not enough to stimulate the change in behavior that will lead to weight loss. The interventions laid out by public health officials should focus more on providing solutions rather than pointing out who is at need for the most help, especially since schoolchildren are probably aware of their health status in terms of weight. Such solutions can include programs that focus on better eating patterns and ways to increase physical activity to promote healthy lifestyles. By teaching children about how to adequately take care of themselves and how to make healthy choices, public health officials can lower the incidence of obesity among this population as they get older and eventually diminish this epidemic from the American population.

The LEAP Ahead Program: Live Happily, Eat Healthily, Actively Learn, and be Physically Fit

An intervention that would help reduce the incidence of childhood obesity would be a program that addresses the issue, while constructively motivating children to live healthily. The LEAP Ahead program is meant to motivate children to maintain healthy lifestyles without feeling uncomfortable and ostracized. The various components of the program address public health issues, while incorporating social and environmental factors. Furthermore, when working with children, it is essential to make the program appealing in terms of enjoyment and simplicity. The LEAP Ahead program has components that include multiple areas of the school and range from classroom lessons and exercises to more rigorous physical education programs and more nutritious meal options in the cafeterias. Similar to the LEAP Ahead program is the Planet Health Intervention, which was successfully applied in school settings and provides evidence that school-based approaches are effective in preventing or reducing obesity among schoolchildren (30). The LEAP Ahead Program is meant to be implemented at the school level so that its components fit into the academic curriculum and the physical education and recreational departments. This intervention is intended to enhance the school environment and make it more conducive to healthy living.

Live Happily: Promoting Self-Efficacy

The Live Happily part of the intervention promotes positive self images and boosts the self-esteem of young children. As a supplement to the academic curriculum in the schools, this program will have students do leadership building workshops, teamwork exercises, and personal discovery projects. Each week, teachers will dedicate one part of their lesson to working with their students and helping them build up character and self-esteem. Activities will include creative writing, leadership seminars, and trust building games. Health models look at communities as experts and in this case, it is the schoolchildren that understand what appeals to them and what influences their decisions (15). Giving them the right to make their own decisions and engage in the LEAP Ahead program with their peers will lead to a higher percentage of schoolchildren making positive decisions to change their behavior. A result of this part of the intervention will be the creation of self-efficacy among the schoolchildren.

Promoting a positive self image and creating self-efficacy among schoolchildren is a key component of this intervention because it is the foundation required to motivate a change in behavior (27). Empowering young children and making them feel like they have the ability to make positive health decisions makes the other components of this intervention more feasible. With self-efficacy in place, schoolchildren can make decisions about improving their dietary intake and physical fitness (4). They will feel empowered and realize that they are capable of taking on challenges and living happy and healthy lives.

Eat Healthily: Framing Obesity in a Way that Stimulates Balanced Diets

Using the school lunch program, the Eat Healthily component of the intervention can have the school cafeterias offer well balanced meals to the students during lunch time. One major component of this will be to eliminate sugar sweetened beverages from the menu, especially since significant data suggests that these drinks are linked to obesity in children (33). Instead, there can be an increased emphasis on offering high quality food that is both appetizing and nutritious. Students will be each asked to keep a food journal, students will record what they eat and when both during and outside the school day. Based on the nutritional value and the appropriate quantity, which would be determined off the daily 2,000 calorie diet, students will receive points for healthy eating. The scoring will range from 0-5000 calories. Points will not be given and may even be deducted for students with too few or too many calories. At the end of each month, any student with a score between 1500-2500 will receive a prize as well as a commendation from the principal. Students consistently performing well will be given a special award at the end of the academic year.

This intervention frames obesity as a challenge. Students are challenged to eat healthy food and no child is framed to be a failure if they do not have the recommended calorie intake. Instead, they are invited to participate in the challenge the following month. Since the target population is schoolchildren, the intervention is framed in a way that they will be receptive to. Most children are inspired by challenges and become competitive when asked to complete a task with their peers (30). Unlike the Weight Report Cards, this LEAP Ahead intervention is aimed at empowering children without explicitly segregating children by weight. This is a key issue as weight discrimination has been noted to be as harmful as racial discrimination among individuals (34). Racism has implications of causing disparities in health care and causes stress among individuals that lead to more complicated medical issues (42). Similarly, the stigma and stress associated with weight discrimination can lead to a faster onset of weight related health disorders as well as more sever cases of obesity.

Actively Learn: Create an Intention to Change Behavior

The way interventions can create an intention to change behavior is by addressing the perceived susceptibility and perceived severity related to a behavior that is meant to be changed (15). For children, perceived susceptibility may not be as apparent since they may not be aware of the health issues associated with poor diet and obesity. It is essential to educate schoolchildren about risks associated with unhealthy eating patterns and lack of exercise. By going over the health risks and impairments associated with obesity, schoolchildren will be more inclined to want to take care of themselves since they will better understand the perceived severity associated with unhealthy lifestyles. As a result, they will be more receptive toward the LEAP Ahead program, which provides the dietary and physical activity aspects that will be emphasized in this part of the intervention. The Actively Learn part of the intervention will become a component of the health studies already built into the curriculum. Teachers will go over what it means to be obese and how students can avoid this health issue and maintain healthy lives.

Oftentimes, television is a method used by public health interventions to target youth and adolescent populations (38). However, it is very difficult to create an intention to change the behavior of watching television to becoming more active by simply airing something on the television for a few seconds (39). Instead, interventions created to target obesity must be consistent with the core values of being healthy and should provide visible and tangible alternatives to the sedentary lifestyle adopted by a majority of American youth. Evidence of this is provided by the Eat Well and Keep Moving Program, which effectively improved the dietary intake and reduced the amount of television watched by schoolchildren (40). The LEAP Ahead program incorporates this educational component of the program to not only raise awareness, but to also provide ready to use solutions to the problem.

Be Physically Fit: Framing Obesity in a Way that Stimulates Exercise

One of the major goals of the LEAP Ahead program is to make schoolchildren physically fit. The Be Physically Fit component of the intervention is meant to go hand in hand with the physical education department in the school. The school will be asked to implement a fitness program that consists of fun activities that target the major body systems, such as games that promote cardiovascular exercises. The activities will be varied and offered in random orders so that they keep the schoolchildren engaged and allow them to have fun while exercising. Unlike the Weight Report Cards, which created programs just for the obese children, the LEAP Ahead intervention offers this program to all of the students and is inclusive of all children. Thus, obesity is not being framed as problem for only a fraction of the children; instead, obesity is framed as a problem that everyone may be at risk for if they do not participate in exercises to improve their fitness.

Having this intervention in a school based setting allows students to embrace the program in a setting they are familiar with. When dealing with weight, framing this issue is very important. Since the topic is highly sensitive, it must be portrayed in a way that is respectful of emotions; if not, it can lead to unhealthy and disordered eating patterns among children. A study done by the Division of Adolescent and Young Adult Medicine at the Children's Hospital in Boston provided evidence that school-based interventions can both prevent obesity and reduce the incidence of eating disorders (38). In addition to this, making the intervention become part of the school day as a supplement to either recess or physical education reduces stigma attached to participating in fitness routines; instead, it transforms into something fun that schoolchildren want to engage in with their friends.

Weight Report Cards vs. LEAP Ahead

Although Weight Report Cards and LEAP Ahead are both interventions that are school-based and aimed at preventing obesity, they have key differences in their layout and implementation. Many of the successful behavior change models in public health have the component of self-efficacy (15). Studies have also shown that self-efficacy is needed to ensure the success of weight loss and healthy lifestyle programs (4). The LEAP Ahead program makes schoolchildren feel like they are capable to make choices that will lead to healthy lifestyles. Further, the promotion of self-efficacy is essential for the other components of the program, while require the student to make the right choices and take on the challenge to be healthy and physically fit. In addition to this, behavior change models state that there must be an intention to change before an individual changes his/her behavior. Also, other models show how social factors also impact whether or not an action will be carried out (15). Unlike the Weight Report Cards, the LEAP Ahead program goes beyond singling out obese children and challenges all of the students to excel in each of the components of the intervention without attaching any stigma to the participants. Finally, the Weight Report Cards had a major flaw as framing the problem of obesity as the individual’s fault and making the obese children feel like failures (5). The LEAP Ahead program frames obesity as a problem that all of the schoolchildren are challenged to overcome by eating balanced diets, exercising regularly, and making healthy life decisions. Thus, with each of these improvements, the LEAP Ahead program is expected to have a greater success rate than the Weight Report Cards.


The problem of obesity affects people of all ages throughout the United States. There have been many interventions laid out to combat this problem. However, many of these interventions have not proven to be successful due to limitations in their layouts. Thus, new interventions must be constructed that take social and environmental factors into consideration and create programs that motivate participation among communities. The Weight Report Cards made an effort to reduce the incidence of obesity; however, due to its drawbacks, namely failing to take social theories into consideration, it was not a successful intervention. The LEAP Ahead program addresses all of these shortcomings and is structured so that schoolchildren become empowered to make healthy life decisions. Similar multi-faceted school-based interventions are feasible for implementation in public schools can lead to increased awareness and can reduce the cases of obesity (35).

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