Why the Shape up Somerville community intervention to decrease childhood obesity is flawed - Andrea Crete
A Massachusetts, community-based, environmental change intervention called “Shape up Somerville” (SUS) intended to prevent obesity in culturally diverse, early elementary school children.This program was designed by researchers from the Friedman School of Nutrition Science and Policy at Tufts University and the Tufts University School of Medicine in collaboration with the Somerville community(1).
This program used a range of initiatives designed to provide and promote healthy eating options at local restaurants and in the elementary school cafeteria, and physical activity among the elementary school-aged children in Somerville, MA.The elementary school cafeteria offered healthier foods, developed more healthful recipes, and promoted the consumption of new foods through interactive education programs.New after school curriculum involved creative cooking classes, yoga, games, and field trips to farms to teach the children how food is grown and to appreciate where it comes from.New in class curriculum included daily “cool moves” sessions, weekly nutrition and physical activity lessons, and fun and healthy giveaways.Not only was the elementary school intimately involved in the program, but the parents of the children and Somerville community participated as well.Parents were encouraged to get involved in the after school and community events.Forums were made and sent to the different language communities in Somerville along with news letters containing healthy tips, fitness contests, and coupons for healthy foods.The local restaurants also collaborated with the program by developing an “SUS” stamp of approval indicating that the restaurant offers healthy menu options (1).
A BMI-z-score was used as a measure to report weight gain or loss during this one year program. The results of this program were a one pound reduction in weight gain on average over eight months for an eight year old child (1).
This paper will provide three arguments as to why this intervention is flawed.
It is believed that childhood obesity is strongly associated with psychosocial morbidity.Psychosocial effects of obese children can include social isolation, discrimination, and peer problems.This can lead to increased rates of sadness, lower self esteem, loneliness, and nervousness by adolescence (2).A stronger association between body fat and self esteem is generally reported when body esteem or body image is the primary aspect of self esteem being measured (2).
This may be the case with using BMI-z-scores in the elementary children.The scores place children in categories of normal (non overweight), overweight or obese.Longitudinal studies have shown greater decreases in self esteem for obese children than non obese (2).
In the study done by Hesketh et.al, a temporal relationship was shown between self esteem and BMI in a cohort of young children tracked for three years from early to late elementary school.At the beginning of the study and at the end, children’s height and weight were measured.BMI was calculated and transformed to z-scores.Parents of the children completed a self esteem scale at the beginning and end of the study for the children.Low self esteem scores were defined as those falling below the 15th percentile (2).
Results of the self esteem scores and BMI indicated that higher BMI scores (at the beginning of the study) predicted poorer self esteem scores at the end of the study.Children classified as overweight or obese in the beginning had lower self esteem scores at the end of the study.Self esteem and BMI are clearly related.BMI may play an important role in the development of lower self esteem experienced by many overweight and obese elementary school children placing them at risk for psychosocial effects.
According to the Stigma or “labeling” theory in public health, if these elementary school children are labeled as obese or overweight according to their BMI z-scores, the children will actually change their behavior to fit their label.This stigma becomes a barrier to behavior change thereby increasing BMI and contributing to the childhood obesity epidemic.
Argument 2.Other causes of childhood obesity are ignored.
Using the health belief model by providing and promoting these two environmental and community changes it is assumed the children will make the decision to eat healthy and exercise.Especially when their BMI z-score indicates they are overweight or obese.This gives the child a perceived susceptibility that they are at risk and the decision to make a healthful change will follow.The health belief model has proved ineffective in many public health interventions.
The Shape up Somerville intervention only incorporates diet and physical activity as a means to lower BMI among the elementary school children in the community.According to Robinson, most prevention programs that specifically aim to reduce fat and energy intake and increase physical activity have been ineffective at changing body fatness (3).
Television viewing has been speculated to be one of the causes of obesity among children.American children spend more hours watching television and playing video games than they do anything else besides sleep.This may lead to reduced physical activity and increased dietary energy intake either as a result of television food advertisements or during viewing (3).
Robinson developed an intervention designed to decrease media use alone without promoting active behaviors as replacements.The intervention, based on Bandura’s social cognitive theory, incorporated self monitoring lessons for the elementary children to report on regarding total television, and video game use to reduce the time spent in these activities.Lessons were followed by a television turnoff, where the children were challenged to watch no television, video tapes, or video games for ten days.The children were also asked to report the amount of food they ate during the day, and while watching television.BMI was measured at the beginning of the study and at the end to determine body fat loss or gain from the intervention (3).
Robinson found that compared with controls, children in the intervention group significantly reduced the number of meals they reportedly ate in front of the television.Compared with controls, the children in the intervention also had statistically significant decreases in BMI, triceps skinfold thickness, waist circumference, and waist to hip ratio.Robinson concluded that reducing television, video tape and video game use may be a promising, population based approach to prevent childhood obesity (3).
If SUS changes the environment the children live in by promoting physical activity and healthful food options, other factors including behavioral changes (tv viewing and video games) need to change as well.Children’s BMI may still increase if television watching and video games are not reduced.
Argument 3.Social Inequalities of obese children and their families in the community are ignored.
The Institute of Medicine reported that on assessing progress in childhood obesity prevention, some risk factors are relatively everywhere across all settings, but more concentrated in low-income communities of color (4).In schools, participation among female, racial/ethnic minority and lower income students are low for varsity and intramural sports.School SES and racial/ethnic composition are inversely correlated with BMI even after controlling for individual race/ethnicity and SES (4).
Crime rates and perceptions of danger are higher in low income neighborhoods.Unsafe neighborhoods do not attract walking to school and playing outdoors after school, at home, or in parks.This not only displaces physical activity among children, but also promotes increases in television viewing and video games.Lower income families with a high cost for housing and other living expenses may have little money left over to buy healthful foods thereby relying on inexpensive, but high calorie foods.Isolated environmental changes cannot be expected to break longstanding eating and physical activity patterns among populations undergoing ecologic stress who have adapted to their circumstances (4).The African American ethnicity for example incorporates high fat and high calorie “soul foods” into their diet as a positive connotation to help define their culture.Health advice coming from the majority culture may not be met with trust, generalizing from past experiences with discrimination (4). The SUS intervention may not reach the lower SES families of some obese children.Nothing in the intervention addressed how these families would be integrated into the program.The intervention to improve diet and increase physical activity in Somerville may be too weak or insufficiently focused to have an affect on the obesity epidemic in African American, Latino or Native American children.
In conclusion, the Shape up Somerville intervention to decrease childhood obesity by promoting a healthful diet and physical activity rich environment fails to address issues that may be contributing to the obesity epidemic of children.Using BMI z-scores have shown to cause low self esteem among some children who are labeled as obese or overweight, and have increased their BMI as a result.
Behavioral/life style changes such as watching less television and playing less video games have shown to decrease BMI and also decrease food consumption. The SUS intervention only strives to increase healthful food consumption and physical activity, failing to address these other causes of obesity including the lower SES families and how to incorporate them into the intervention.
Counter Proposals for the Shape Up Somerville Community Intervention –
The Shape Up Somerville intervention to decrease childhood obesity by promoting a healthful diet and increasing physical activity fails to address other issues that may be contributing to the obesity epidemic of children.Using BMI scores to label children as obese or non obese; solely focusing on diet and exercise; and failing to incorporate lower SES families; are some of the flaws that are addressed in this paper.This paper will discuss a new intervention that improves upon the Shape Up Somerville Intervention by developing counter proposals for the flaws mentioned in the previous paper.
Counter Proposal for Argument 1.
Studies have shown that children’s BMI can actually increase based on their scores.A BMI that labels a child as obese lowers that child’s self esteem which can eventually lead to an increase in BMI over the years to come.Self esteem and BMI are clearly related.BMI may play an important role in the development of lower self esteem experienced by many overweight and obese children, placing them at risk for psychosocial effects (2).Although BMI is a measurement currently used for assessing the growth of children, it is only a rough estimate of risk for overweight.For an individual child, BMI is likely to change over time in regards to changes in height and weight as the child’s muscle mass and stage of puberty change accordingly.There are also some children who have a high BMI that are actually not at risk of having too much body fat, while others with lower BMI have more body fat and are at risk.BMI can also give a false positive reading for obesity for some children with a high BMI that do not have high body fat (6).These are some of the inaccuracies of BMI scores.
I propose that the Somerville intervention dismiss the idea of using BMI to label a child as obese or non obese, putting them in a category that is subjected to lowering self esteem and hence defeating the purpose of lowering BMI.Developing an intervention that focuses on the importance of physical activity and healthy eating to lose weight and be healthier will be more effective in lowering BMI.Instead of using BMI as a means to measure weight loss and program effectiveness, I suggest that children’s weight be measured using a scale in the nurses’ office.The child’s weight can be measured twice a month for the length of the intervention.The weight loss or gained can be reported to the parents.Rewards are given for child participation in the program, not whether they lost weight or not.
This improvement avoids stigma or “labeling” theory commonly used in public health and in the Somerville intervention by using BMI scores and categories.
Counter Proposal for Argument 2.
The Shape up Somerville Intervention only incorporates diet and physical activity as a means to lower BMI among the elementary school children in the community.Programs and interventions that primarily aim to reduce fat and energy intake and increase physical activity have been ineffective at changing body fatness (3).Due to the fact that American children spend many hours watching television and playing video games, this may lead to reduced physical activity and increased dietary energy intake either as a result of television food advertisements or during viewing (3).I propose that parents of the children in the Shape Up Somerville intervention monitor and reduce the amount of television used (tv watched and video games played) to further increase the effectiveness of the intervention.Community and after school activities would aim to increase children and parent participation to limit the time children spend home with the television.
Interventions have been developed to decrease media use alone without promoting physical activity as a replacement.These studies have shown that reducing television, video tape, and video game use may be a promising, population based approach to prevent childhood obesity (3).
Counter Proposal for Argument 3.
The Shape Up Somerville intervention may not be effective in reaching the lower SES families in some obese children.Nothing in the intervention addressed how these families would be integrated into the program.Studies have shown that crime rates and individual perceptions of danger are higher in low income neighborhoods.Families that have a lower SES and a higher cost of living tend to buy less healthful foods which are lower in cost.Unsafe neighborhoods deter walking to school and playing outdoors or in parks.This increases television viewing and video games among children (4).Numerous studies have associated lower SES with poorer health.Neighborhood stressors such as exposure to violence and the physical condition of the neighborhood are also linked to SES and may affect physical health (5).Social networks in a neighborhood may define the level of trust and norms of cooperation and behavior thus also relating to both SES and health.Childhood health problems such as obesity have been documented as related to low SES (5).
I propose neighborhood activities be designed to get the different neighborhoods involved including the lower SES and work together.A feeling of being part of the community may increase moral in lower SES neighborhoods.I would develop a program that would make unsafe neighborhoods safer by setting up neighborhood committee’s that would work together in assessing their neighborhoods’ needs and improvements.Residents in the neighborhoods can collaborate to make improvements, do some landscaping/gardening to make the appearance better, help those in need with fixing up homes and yards, and developing activities for the children to do outdoors to increase physical fitness.
This would ideally change the perceptions of the neighborhoods being unsafe and promote activities outdoors, potentially decreasing child obesity among lower SES families.
Using a scale to measure children’s weight bi-monthly is a more effective way of lowering BMI in children as opposed to using BMI z scores which can lead to lowered self esteem and an actual increase in BMI.Decreasing the amount of television viewed and video games played along with increasing physical fitness and healthful eating can also decrease body fat in children.Lower SES families and neighborhoods need to be involved in community events and activities.Making neighborhoods safer, cleaner and unified may help change some of the negative perspectives residents have about their neighborhoods and increase child outdoor activities in those neighborhoods.An intervention that incorporates the above would be a more effective approach to decreasing childhood obesity.
1)Fennelly, Christine.Childhood Obesity Intervention Shows Promising Results.TuftsUniversity, Health Sciences. May 10, 2007.
2)Hesketh et.al.Body mass index and parent-reported self esteem in elementary school children:evidence for a causal relationship.International Journal of Obesity (2004) 28, 1233-1237.
3)Robinson, N. Thomas.Reducing Children’s Television Viewing to Prevent Obesity.JAMA, October 27, 1999-vol 282. No. 16, 1561-1566.
4)Yancey, K. Antronette et.al.Bridging the Gap: Understanding the Structure of Social Inequalities in Childhood Obesity.American Journal of Preventive Medicine (2007); 33 (4S) S172-S174.
5)Chen, Edith and Peterson, Laurel.Neighborhood, Family, and Subjective Socioeconomic Status:How Do They Relate to Adolescent Health?Healthy Psychology (2006); vol. 25 No. 6, 704-714