Challenging Dogma - Spring 2009

Wednesday, May 6, 2009

We Can! Campaign Targeting Obesity Translates to We Can Fail –Ta-wei Lin


According to the World Health Organization, chronic diseases, such as heart disease and stroke, represent 60% of all deaths worldwide (1). Consequently, the public health field is continuing to shift its focus from traditional infectious diseases to chronic diseases. Of these, obesity is among the most dire. The WHO estimates that approximately 1.6 billion adults worldwide are overweight, with 400 million reaching levels of obesity (2). The Center for Disease Control (CDC) reports that among adult males in the United States, the prevalence of obesity reached 33.2% in 2005-2006. Among adult females, that number reached 35.3%. Children have also been affected by these recent trends, with an obesity rate of 16.3% among children from age 2 – 19 (3).

Increased body mass index (BMI) is a major risk factor for a number of health conditions, such as coronary heart disease, Type 2 diabetes, cancer, and stroke(4). Overweight and obesity also poses as a major economic burden. Medical expenses attributed to overweight and obesity may have reached as high as $78.5 billion in 1998, half of which was paid for by Medicaid and Medicare (5). The severe negative consequences of obesity necessitate a major public health response.

The National Heart Lung and Blood Institute have implemented a national program to address the issue of obesity in children called We Can! We Can! stands for Ways to Enhance Children's Activity & Nutrition. The program is a national education program designed to allow parents help children from age 8-13 stay at a healthy weight(6). The basic premise of the program is to provide science-based information to parents and caregivers to promote healthy eating habits, increased physical activity, and decreased time in front of televisions for children.

The We Can! program is a good demonstration of the health belief model. It runs under the assumption that what is lacking in the fight against obesity is education and awareness, while ignoring other underlying and complex factors. The program makes the generalization that all parents and communities have equal access to resources and information and chooses not to address the social and economic discrepancies that exist throughout the country. As a result, the program will have very limited success.

Solely Providing Information is Often Insufficient for Producing Behavior Changes

The Health Belief Model has traditionally been the theory behind which many public health interventions are derived from. The model states that behavior related to health is motivated by four factors: perceived susceptibility, perceived severity, perceived benefits of action, and perceived barriers to action (7). These factors lead to an intention, which then leads to behavior.

Critics of this behavior model have pointed out that focusing solely on the individual level has very limited utility (8). The model ignores any social or environmental factors that people may be influenced by. It also assumes that behavior is the result of calculated, rational thought. The model also runs under the assumption that everyone has equal access to information and resources (7).

The We Can! program is subject to the same criticisms. The main principle behind the intervention is providing parents with information about obesity and how to prevent it through diet changes, physical activity, and parenting guides. Perceived susceptibility is increased by providing prevalence statistics on overweight and obese individuals. Perceived severity is increased by listing the risk factors involved with elevated BMI. Perceived benefits of behavior change are increased by the promotion of health. And perceived barriers to behavior change is decreased through diet tips, physical activity ideas, and an “Eat Well and Move More” track sheet that allows one to see their progress. The program also promotes the maintenance of behavior change through ideas for non-food rewards for positive behavior, such as a day at the park to fly kites with the family, new workout clothes, or a ball (9).

If the health belief model were to work in all situations, the We Can! program would inevitably be a success if implemented properly. However, this is not the case. As with most chronic illnesses, the issue is not simply lack of information. A study of the prevalence of smoking among patients after lung cancer surgery showed that 37% of patients smoked 12 months after the operation, and 43% smoked at some point after (10). It can be argued that perceived susceptibility and perceived severity is highest in these patients, yet the health belief model failed to predict their behavior with almost half choosing to smoke once again.

Individuals function in a social environment subject to many factors that lie outside of their immediate control. Studies have shown that adult body weight and obesity are inversely related to socioeconomic advantage (11). In other words, there is a higher prevalence of obesity among individuals with low socioeconomic status (SES). This trend hints towards the complexity that surrounds the obesity epidemic. Simply providing parents and children with information on obesity that may already be widely known will likely result in no effect.

Interventions Targeting Obesity Must Consider Environmental Factors

One way the We Can! program attempts to influence diet is through the labeling of Go, Slow, and Whoa foods (12). Go foods are products that can be eaten anytime, such as fruits, vegetables, and nonfat milk. Slow foods are foods that can be eaten sometimes, such as French toast, peanut butter, and whole eggs. Whoa foods are foods that should only be eaten once in a while such as cookies, fried meals, and soda. The program also attempts to increase physical activity through promoting family activities such as biking, swimming, or running (13).

While improving diet and physical fitness is essential for reducing obesity, the program makes no attempt to recognize environmental factors that affect one's ability to take such actions. Studies have shown that the prevalence of obesity is higher in areas with fast food chains and small grocery stores and lower in areas with supermarkets (14). This reflects the effect that the environment has on diet choices and obesity. Therefore, simply telling individuals that they should eat more Go foods, such as fruits and vegetables, and less Whoa foods, such as fast food burgers, will have no effect on those individuals have no access to supermarkets, but easy access cheap, fast food.

Physical activity is also largely dependent on the built environment. Our urban sprawl model for development has created car-dependent communities all across the country. While encouraging people to bike to school and work is a great way to increase physical activity, it is simply not possible for those with long commutes and for those living in areas where biking is not possible. The other suggestions given by the We Can! program are also largely dependent on the environment. Swimming and running both require areas in which to do so.

It is clear that sedentary lifestyles and poor diet are major causes for obesity and public health interventions need to address these issues. However, simply providing guides for behavior and failing to consider environmental factors is not sufficient. Dietary tips will only be effective if individuals have access to cheap, healthy food. Therefore, promotion of farmer's markets or supermarket development in conjunction with community outreach for improved diet will be far more effective. In a similar fashion, exercise promotion will only be effective in conjunction with changes in the built environment, such as bike paths, sidewalks, parks, hiking trails, etc.

The Intervention Assumes Behavior Change in Children Relies Solely on the Parents or Caregivers

The We Can! program is specifically targeted towards reforming the behavior of children age 8-13. However, the program makes no attempt to address the target age directly. Instead, it places all the responsibility and decision making in the hands of the parents and caregivers. While parents have a very large influence on the values and behaviors of children, they are by no means the only influential factors in children's lives.

Albert Bandura's concept of self-efficacy is the belief that one has the ability to perform a certain action or attain a certain goal (7). This concept is included in many behavioral learning theories. By not addressing these children directly and placing all of the control in the hands of the parents, the program is not instilling a sense of confidence that is essential for behavior change and maintenance.

According to the psychological reactance theory, reactance will occur when rules threaten or eliminate certain freedoms. Forcing the decision upon individuals them rather than allowing them to make the decision for themselves may produce an unwanted, opposite effect of rebellion. In this situation, forcing children to watch less television and eat more vegetables may cause a desire to perform the opposite action. This effect is heightened when a dissimilar group is delivering the message. Reactance was seen in the Above the Influence Campaign. The campaign was perceived by youth as a removal of freedom and actually had a counterproductive effect on drug use according to a study performed by the Government Accountability Office (16).

Social and Economic Disparities Exist and Cannot Be Ignored

The major flaw in the We Can! program is that it completely ignores socioeconomic, racial, and gender disparities that exist in the United States and throughout the world. Failing to address these social issues is not limited to this program alone, but is pervasive throughout the field of public health. General programs that assume equal resources and equal access to information fail to understand the world in which we exist and consequently will fail to resonate with a large percentage of the population.

In 2000, According to the American Obesity Association, 28.7% of non-Hispanic whites were obese, compared to 34.4% of Hispanics, and 39.9% of African Americans (17). Across all racial lines, women experienced higher prevalence of obesity than men, with African American experiencing the highest prevalence of obesity at 50.8%. There is also evidence that suggests poor health during childhood is associated with lower education, lower social status, and health problems, suggesting a mechanism by which economic status is transferred (11).

The We Can! program can only benefit those that have access to the resources necessary for a healthy lifestyle. Low-cost, energy dense foods may be the only option for certain people. The program not only fails to provide an alternative for these individuals, but fails to recognize that they even exist. By assuming a level playing field, socioeconomic disparities not only remain but are perpetuated. Minority populations, being the most affected by the obesity epidemic, should be targeted, not ignored if significant progress is to be made to reverse the obesity trend. Culturally sensitive information should be made available to all populations in various languages for a comprehensive program to work.


The We Can! program provides the keys for a healthier lifestyle. Poor diets and lack of physical activity are major causes of the obesity epidemic and need to be addressed by the public health field. However, the limited understanding of how individuals function in our complex world will inevitably lead to the program's failure.

The solution to the obesity epidemic cannot simply be reduced to “Go Foods” and exercise. Providing individuals with information is not sufficient for producing behavior change. This is because health is not always highest on an individual's priority list. The We Can! program relies too heavily on the health belief model. The health belief model is strictly an individual level theory that fails to understand how we make decisions. We do not consciously calculate benefits and barriers prior to making choices. The power in making those choices also does not solely lie on the individual, but is rather a culmination of social and environmental forces.

The We Can! program also fails to consider environmental factors involved with obesity. Telling people to eat healthier is not useful if they do not have easy access to affordable, healthy groceries. Telling people to bike or run is not useful if they live in areas without sidewalks, bike paths, or parks. Changes to the built environment are essential for combating the sedentary lifestyle that many have grown accustomed to.

The program, like so many other public health interventions, must stop ignoring the socioeconomic, racial, and gender disparities that exist in the world today. The assumption that people have equal access to resources and information represents a major flaw in many public health programs and marginalizes the most sensitive populations that we should be focusing on. Public health practitioners cannot simply be distributors of health information, but rather leaders of social change. The social disparities in health need to be addressed, rather than perpetuated through programs such as We Can!

Community Leaders Fighting Obesity: A Public Health Intervention Utilizing the Social Sciences – Ta-wei Lin

The Community Leaders Fighting Obesity (CLFO) program is a hypothetical intervention with the goal of reversing obesity trends through community involvement and empowerment. The intervention involves the cultivation of local community leaders and providing them with the tools to develop their own interventions that address their specific needs. Unlike the We Can! Program, which is a very broad, generalized program for the entire country, this intervention is highly tailored towards specific communities.

The first step in the CLFO program is to identify communities with a high risk for obesity. Because obesity rates are much higher among African American and Hispanics compared to non-Hispanic whites, the program will mainly target minority rich, lower SES communities (17). Once communities are chosen, we will then recruit a board of local community members of different ages and backgrounds. These individuals may include involved high school students, teachers, coaches, local business owners, and active seniors.

Once the board of community leaders is formed, the next step is to identify the strengths and the needs of the community to design a proper intervention to target obesity. The intervention will attempt to highlight the strengths of the community while addressing the needs. The board will assess the community on individual, environmental, and policy levels.

On the individual level, the board will look at things such as overall level of physical activity, general eating habits, predominant modes of transportation, and interest in organized events like sports leagues, spinning classes, yoga lessons, etc. The board will also assess the overall comprehension level of obesity and its risk factors. If comprehension is high, then there would be no need for the programs to focus on the distribution of information.

On the environmental level, the board will assess the built environment of the community as well as the identify possile impediments to outdoor, physical activity and healthy eating habits. This may include an assessment of local parks, presence of swimming areas, bike lanes or bike friendly roads, walkable sidewalks, amount of green space, availability and affordability of fresh, healthy foods, and presence of fast food restaurants. These programs will attempt to highlight the positive aspects of the built environment in various ways, such as keeping these resources clean and accessible and organizing events centered around these areas. The board can also try and ensure the availability of fresh fruits and vegetables by organizing a farmer's market with local farms. A crucial aspect of the environmental level assessment is that it requires an honest and comprehensive look at the communities strengths and needs. Programs cannot encourage physical activity without ensuring that individuals have a convenient way to engage in them.

On the policy level, the board will try and address the weaknesses of the community through policy change. For the program to be successful, it is crucial that elected officials be involved in the process. The board, acting as an organized and well-versed lobby of community members, can work with these elected officials to address the needs of the community. For example, the board can improve the state of the local parks by lobbying for increased funding for the department of parks and recreation. The board can also lobby for other built environment changes such as bike paths, hiking trails, and zoning changes to stop the growth of unhealthy food vendors. This level is crucial because policies can have a drastic positive and negative effect on behaviors and social change.

CLFO Does Much More Than Just Provide Information

One of the main weaknesses of the We Can! program is its reliance on the health belief model. The health belief model relies on the generation and distribution of generalizable knowledge to predict, explain, and control behavior (18). While this model is not without merit, it has very limited utility when dealing with more complex health issues. Current attempts to target the obesity epidemic have largely been limited to distribution of information. However, much like cigarette smoking, the issue isn't lack of knowledge.

The CLFO program is a very general, highly flexible program geared towards community involvement and community empowerment. All communities across the country have a unique collection of individuals, resources, strengths, needs, and challenges. It is not plausible to organize a general public health intervention for all communities in response to a complex chronic disease and expect widespread success. The key feature of the program is that it makes little to no assumptions about a community prior to forming the intervention. Instead, the program elicits help from community itself to design its own intervention based on their strength and needs.

While the program will most likely involve the distribution of information on the risk factors of obesity and obesity trends, that is a very small part of what the program will provide. Unlike the We Can! program, this program is not solely an individual level intervention. The program addresses the obesity problem on an individual, environmental, social, and political levels. Focusing solely on the individual level may ignore the fundamental cause of this disease (19). This is why a comprehensive, mulit-level response is necessary.

Environmental Factors is a Major Part of the CLFO Response to Obesity

While the choice to eat healthier and get more exercise is an individual level decision, it is strongly influenced by the environment in which a person lives. The built environment and its effect on health is quickly becoming a major focus of the public health field (20). Walkable city designs, presence of green space, and zoning all have major impacts on activity levels and overall health. Before encouraging people to be more active and adopt healthy eating habits, we must ensure that they have the opportunity to do so.

The We Can! program, while encouraging physical activity such as biking, running, and swimming, makes no attempt to address disparities in the built environment across different communities. The program assumes that everyone has access to areas where physical activity is possible. Unfortunately, this is not the case. A successful public health response must not only encourage physical activity, but ensure that the environment is conducive for health.

The CLFO program is largely focused on environmental changes to encourage a healthier lifestyle. This may involve something as simple as cleaning up a local park to major zoning changes to encourage the development of more health conscious establishments. Because the intervention is designed by the community members themselves, they'll be sure to implement changes that they will take advantage of. Adding a bicycle path in a community that is generally disinterested in biking would not have as great of an effect. The CLFO program attempts to ensure that individuals in these communities have the ability to make proper health conscious decisions, rather than simply giving them lifestyle change tips.

The Message of The Program is Delivered By Peers

A major flaw of the We Can! program is that the message for children to live healthier was delivered by adults. According to Reactance Theory, individuals will feel a sense of rebellion if they perceive their freedoms are being threatened. This effect is heightened when dissimilar groups are delivering the message. While parents do have a large influence on children's decisions, forcing decisions upon them is not always the best way to encourage healthy lifestyle choices.

The strength of the CLFO program is that the entire program is designed and implemented by members of the community. The board of community leaders consists of individuals of all ages and backgrounds, ensuring that various perspectives are taken into consideration and various needs are addressed. Members of a community will be much more receptive to suggestions given by respected community members.

Messages delivered by peers may also help instill a sense of self-efficacy throughout the community. Since the intervention was designed and implemented by the community itself, the members of that community will feel a greater sense of pride in the changes that arise from program. Community members will also be able to see their neighbors utilizing the park or the bicycle path and buying groceries from the new farmer's market, which may encourage them to do it as well.

The CLFO Program Addresses Racial Disparities by Targeting Low SES Neighborhoods

Communities that have a high minority population with low socioeconomic status are at high risk for obesity, as well as many other chronic diseases (17). For this reason, it is essential that the public health field target these populations, rather than ignoring them by implementing a general response for the entire country. By not addressing populations with low socioeconomic status directly, we risk perpetuating the health disparities that exist across socioeconomic and racial lines.

The CLFO program initially identifies communities with high obesity rates. While these are not limited to minority dense populations, obesity trends tend to be the most drastic in low SES communities. Through community empowerment and the cultivation of community leaders, we set the stage for interventions that are not just limited to obesity. The program, if successful, becomes a venue for social progress.

Community building has the effect of encouraging a more heterogeneous population. Low SES neighborhoods tend to remain in the same socioeconomic state due to a concentration of low-income, minority populations. Members of those communities that have relatively higher economic success tend to leave for other areas due to poor school systems, crime, poor living conditions, and other factors. Through additions to a neighborhood such as parks, trees, and playgrounds, properties in that community become more valuable and members in that community may be more encouraged to stay. While this process may take a significant amount of time, visible progress is still being made.


The Community Leaders Fighting Obesity program improves upon the We Can! program in various ways. The CLFO program is not an individual level intervention based on the health belief model. It is a multi-level, comprehensive response aimed towards fighting the fundamental causes of obesity. The CLFO program also is entirely designed and implemented by members of the community. This ensures that community needs are understood and that the interventions are carefully catered towards those needs. This also ensures that the message will be received by other members of the community.

The CLFO also specifically targets high risk, low SES populations. The We Can! program offers a highly generalized response, which assumes equal access to resources and information. This is not beneficial when there is a major disparity in health and SES status. The CLFO program does not ignore SES disparities. On the contrary, the program specifically targets low SES communities. By empowering these communities and providing them with the resources to fight chronic diseases such as obesity, we take a step in the right direction in terms of eliminating health disparities along socioeconomic lines. The public health field needs to be a venue for social change, rather than an impediment.


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19. Link, Bruce. Phelan, Jo. Social Conditions as Fundamental Causes of Disease. Journal of Health and Social Behavior 1995. 80-94

20. National Institute of Environmental Health Studies. Obesity & the Built Environment.

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