Informational Approaches Targeted to Promote Physical Activity- the Breakdown and Futility for Our Obese Population- Julie O’Shea

Introduction

A sedentary lifestyle or lack of physical activity contributes overwhelmingly to an individual’s risk of disease which has burdened our healthcare system. The lack of physical activity has been demonstrated to be a contributing cause of the obesity epidemic and may contribute to a decreased quality of health in the public [1, 2]. In the United States, heart disease and stroke have been the first and third causes of death for decades [3]. Also in the US, only 25% of adults report performing the recommended activity level (i.e. 30 minutes of moderate or intense activity on 5 or more days), despite the public’s general knowledge in the benefits of regular physical activity [4]. It has been shown that an increase in physical activity level may decrease coronary disease mortality by 5% suggested by a theoretical estimate of the US public health burden [5]. Additionally, physical inactivity is a factor and associated risk with some cancers [6]. Finally, the initiative from the US government, Healthy People 2010 has ranked physical activity as a leading health indicator [4]. Despite the knowledge of the importance of physical activity, public health initiatives directed at this issue continue to fall short in their impact and effectiveness.

Consideration of the Health Belief Model

Applying the health belief model, most approaches have utilized the notion that by providing health information for risk reduction of disease, people will be motivated to increase their physical activity and change their behavior [7]. This frequently does not occur. The Stanford Five City project is an example of a community based informational campaign that has been shown to be ineffective for this reason [8]. The use of the Health Belief Model, poor framing and lack of knowledge of environmental factors contributed to the failure of this community approach.

The Stanford five City project was a community health education program for improving the knowledge, attitudes and behaviors toward physical activity targeting the residents of 2 communities of California [9]. The dissemination of information promoting the benefits of physical activity was included in the intervention in a stepwise fashion over 6 years. Other parts of the intervention included news column, workshops, organized events, media such as TV segments and worksite and school based education programs. The benefits of regular physical activity communicated via educational messages were the key integral motivating factor this intervention was dependent on [8].

This intervention, which has taken its cue from the traditional Health Belief Model, is flawed on this level. The educational programs of the Stanford Five city project have been outlined in the tenets of the Health belief model. That is, if you provide the information of perceived susceptibility and severity of diseases due to sedentary lifestyle, the people in the community exposed to this message will change their behavior. It assumes the individual will have a rational weighing of the message of risk with physical inactivity and thus change their behavior from the intention they have formulated [7]. This idea is based on people making rational health choices and does not account for multilevel variables at play in the people’s lives that may or may not be altered. The barriers of incorporating exercise are not addressed in this intervention. A person’s time commitments to work, family and care giving are not accounted for or resource availability. The way the information was provided to these communities was based on the health belief model of severity and susceptibility. The education of the public was directed on the individual level. Although the campaign delivered the message on varied channels, it did not account for the environmental variables that could impact the individual’s ability to increase their physical activity. The complex behavior of incorporating physical activity into one’ lifestyle was not taken into account in this campaign [10].

Consideration of Framing and Marketing Techniques

The campaign used the benefits of physical activity and the promotion of health as the core value of the campaign. The interventions were not framed in a deep core value to get the topic of physical activity on the agenda of this population. The way in which the community viewed the behavior of exercise can be impacted greatly by framing through mass media images [11]. This campaign framed physical activity in a value of only health promotion and not surprising the public was not impacted greatly by the intervention [12].

There is a wealth of data that demonstrates the effectiveness of utilizing marketing theory and branding [13]. Consumer research regarding the population to motivate behavior change was not adequately performed in the Stanford Five City Project. This was evidenced by the lack of awareness to utilize framing, agenda setting and marketing techniques.

The framing and presentation of information in the mass media, which is inevitably part of any community wide campaign, can actually systematically effect and impact how the recipients understand the information presented [14]. There is no indication that any mass media research was undertaken or performed to frame the health information in a meaningful way in this intervention. When the community was receiving the health information through the various outlets, there was no dramatic heart wrenching or deeply touching aspect of the campaign that hit people where it matters. The health information was not framed in a compelling way in this campaign. When a person’s heart or soul is impacted, behavior can change. Although in the public health domain in the past, we have not discussed the heart and soul of the public. Advertising has been changing the way consumers purchase by these techniques for decades [11]. I argue that when the community wide campaigns adopt a more compelling and soul touching script of a core value of family, freedom or sex, only then will the population adopt health promoting behaviors such as increasing physical activity.

The Stanford Five project in the early 1980s did little to determine how to alter the people’s behavior. The research that was performed was not integrated in a multilevel system to determine other variables and factors that were preventing the participation of community members.

Consideration of the Environment

The health education intervention occurred in the two communities of Modesto and San Luis Obispo. The intervention did not include a multilevel analysis of contributing factors which discourage physical activity such as availability of a public park or trail system in these communities. Neighborhood features that do not encourage physical activity have been shown to consistently demonstrate an increase body mass index among residents of those neighborhoods [15]. The Stanford Five Project did not put on the agenda sidewalk or park renovation in their intervention. Without access or availability to a park or playground, families are limited in their ability to incorporate physical activity into their lives. In addition, active commuting to school can be an overlooked source for youngster’s activity [16]. The proximity of public parks to residential communities has been associated with physical activity. Parks are common places to exercise and park use and proximity to the park can be predictors of exercise level of the individual [17].

How one interacts with their built environment and the impact of one’s place can directly impact a person’s health [18]. How livable the community is for the population, the availability for walking and bicycling paths and neighborhood design can all impact health promotion [19]. The Stanford Five Project, although determined the community’s attitude toward physical activity with questionnaires, it did not analyze or begin to look at the level of the environment. Whether traffic, lighting or sidewalk maintenance had at all been examined, these urban design factors can be an influencing variable on the physical activity level of the population [20]. In a study by Craig, when university education, income and poverty levels were controlled for, the environment score, which included features of the neighborhood including routes, transportation, visual aspects, safety and crime, was positively associated with walking to work [21]. The environmental barriers to walking were not considered as potentially threatening to physical activity in Modesto and San Luis Obispo in the intervention discussed.

Conclusion

This campaign based off a health belief model approach, framing the behavior change in only a health promotion value and not examining the built environment and other environmental factors has contributed to its woeful results in attempting to improve the physical activity level of the population in these 2 Californian cities. The recent highly publicized increase in obesity rates and health care costs, although have put physical inactivity on the agenda, has not dramatically shifted the approach of what was performed over 20 years ago. Our profession must be innovative in their design and execution of a more compelling way to change the lifestyle of the population to improve physical activity rates. The approach of increasing physical activity in our culture must include policy of environmental approaches, outreach on a more compelling level framed in a way to have impact and must evolve from a health belief model of providing the information and falsely thinking people will change. The Stanford Five City Project took place in the early part of the 1980’s, it is a good warning for a more refined approach to take public health intervention to the next level to produce results and improve the health of the community. Our nation’s population lives in a high risk environment which the public health community must not ignore.

Written Assignment #4

Get Moving or Get Trapped Campaign

Introduction

As discussed, the Stanford Five City Project campaign, a community based informational approach campaign to increase physical activity, has been inadequate and ineffective. The following proposal could solve the previous flaws in the Stanford Five City Project and impact the public’s inactivity and improve the health and wellness of the community. My proposed intervention, ‘Get Moving or Get Trapped’, will be described and could unburden our system with the complications of diseases associated with physical inactivity.

This campaign will be different in a variety of ways. The ‘Get Moving or Get Trapped’ campaign will be modeled on the Diffusion of Innovation Theory rather than the Health Belief Model. The information to increase physical activity will be communicated over time throughout the social system. [22] Various revered members of the community will be delivering the message to increase physical activity for the diffusion to occur more rapidly and most efficiently. The program will not use good health as the core value, but freedom. It will frame physical inactivity as a form of prison, using ad campaigns and propaganda to change people’s perception of how they view walking and biking. This will be combined with a dramatic change in public policy and infrastructure and urban development. Urban planning will be incorporated into the campaign. The community will be beautified with parks, walking and biking paths and a reliable transit system to increase commutes without vehicle use. The mass media approach, diffusing the idea of increasing physical activity via community members, framed in a new way using mass advertising and the change in the built environment combined, will allow for the public to adopt the lifestyle change of increasing activity through walking and biking and be an effective alternative intervention.

Addressing the flaw of the Health Belief Model

The program will not be based on the Health Belief Model, but an alternative model, the Diffusion of Innovation theory. This model allows for a process by which the intervention will be communicated over time through various modes to the public. [22] It will be a social change among members of the public. The message of increasing physical activity will be delivered by high profile members of the community, who are considered a highly credible source. Typically when television ad campaigns are from a trusted source those members of the society are used as an agent for change. [23] In the ‘Get Moving or Get Trapped’ campaign multiple people will participate in the ad campaign on various channels to deliver the message of walking to destinations, increasing activity and changing their physical activity. The information will be diffused to the public and disseminated with this message in a continually reinforcing way.

The message of increasing physical activity delivered by these trusted individuals can be a very efficient jump start to any public health initiative. When a small subset of the population begins to adopt the behavior and increase their activity by walking, the initiative can spread quickly through the social network. [24] This efficiency can be dramatic since opinion leaders in the community can influence the majority of the public and facilitate rapid behavior change through the diffusion process. [25] In my intervention celebrities, community leaders and positive newsworthy individuals will be utilized to deliver the message to increase physical activity. The idea of walking to work, school or errands will be the main message to increase activity. This idea will be diffused rapidly by the opinion leaders since it will be considered better than sitting in your car in traffic. The alternative innovation will appeal to people and be considered a better idea which has shown to increase diffusion of a behavior. [25] The public will therefore increase their level of activity.

Addressing the flaw of Framing and Marketing Techniques

As the message of increased walking will be diffused via the ad campaigns there will be a mass media approach that frames the increase in physical activity not in a value of health, but freedom and alternative lifestyle. The commercials’ will frame driving, being stuck in traffic as being in a prison, a prison of your mind, body and spirit. Walking and/or biking to work, school or the store will be portrayed as a way to exercise your right to be free, your right as an American. The ads will show that sitting in our car is a form of oppression, a way to be trapped. The ‘Get moving or Get Trapped’ campaign will use the framing theory to change how physical activity is viewed which will impact the community. [11]

When the TV stations and radio stations begin to flood the airwaves with this campaign, people will begin to walk to work and school and increase their physical activity without thinking of their health, but their freedom. Their desire to not be trapped, not be stuck, stuck in the car or stuck in a body, will compel and motivate them to incorporate walking into their everyday life. It will become habitual and be adopted as a lifestyle change.

Addressing the flaw of the Environment

As this diffusion of this idea to walk/bike is rapidly catching on, along with the framing of walking as a way to exercise your freedom, the community environment will be examined and modified. In this intervention, ‘Get Moving or Get Trapped’, the community will be studied and areas of improvement will be targeted. Available evidence has demonstrated that if the built environment promotes biking and walking it will help create more active healthier individuals. [26] The access to bike paths, walking trails and recreational facilities has been associated with increases in physical activity levels. [27] The urban design of the neighborhood in the community can impact and influence how active the population will be. [21] In our proposed intervention a task force will study the community and perform focused research on traffic, safety, lighting, sidewalk availability and aesthetic of routes. After this information is gathered, any area without sidewalks or appropriate lighting will be redeveloped for more pedestrian traffic. If safety was determined to be an issue this will be targeted for community development with an increase in police activity patrols on foot and bike. A trail system which will link residential neighborhoods to shopping districts, office parks and any public transportation system available will be implemented.

Additionally a beautification program will be part of the ‘Get Moving or Get Trapped’ campaign. Flowers and trees will be planted in public areas to increase people’s desire to walk and enjoy their environment. The community will want to walk to be part of the growing group of individuals who are using the new sidewalks, benefitting from the changing community aesthetics and therefore their physical activity will increase. The feeling of belonging to a community can motivate individuals to have pride in their neighborhood.

Conclusion

This alternative intervention has addressed the flaws in the previous campaign in a skillful and productive manner. By taking advantage of the diffusion of innovation theory, the idea of changing physical inactivity will catch on like wildfire, especially with the advantage of key opinion leaders in the community. By framing the ad campaign in a value of freedom and not health, the desire to be free and not a prisoner will be more compelling then changing their physical activity for health reasons. Finally, by orchestrating changes to address deficits in the built environment, which detract from walking and biking, the public will change their physical activity level in dramatic ways. As described, the ‘Get Moving or Get Trapped’ campaign could impact a community in a powerful way to shift and alter lifestyles to incorporate walking as a way to increase physical activity and ultimately improve the community’s health.

References

1 Stubbs CO, Lee AJ. The obesity epidemic: Both energy intake and physical

activity contribute. Med J Aust . 2004; 181:498-91.

2 Williams K, Prevost AT, Griffin S, Hardeman W, Hollingsworth W, et al. the

proactive trial protocol – A randomized controlled trial of the efficacy of a

family based, domiciliary intervention programme to increase physical activity

among individuals at high risk of diabetes. BMC Public Health. 4:48 October

2004.

3 Goff D, Brass L, Brown LT, Croft J, Flesch JD et al. Essential features of a

surveillance system to support the prevention and management of heart

disease and stroke: A scientific statement form the American Heart Association

council’s on epidemiology and Prevention, stroke, and Cardiovascular Nursing

and the Interdisciplinary working groups on quality of care and outcomes

research and atherosclerotic peripheral vascular disease. Circulation. 2/9

January 2007; 115 (1): 127-155.

4 U.S. Department of Health and Human Services. Healthy people 2010:

Conference edition. Washington DC: U.S. Department of Health and Human

Services, 2000.

5 Powell KE, Blair SN. The public health burdens of sedentary living habits;

theoretical but realistic estimates. Med Sci Sports Exer . 1994;26:851-6.

6 National Cancer Institute. Physical activity and Cancer: Factsheet. Bethesda,

MD: National Cancer Institute, US National Institute of Health. (Accessed 28

March 2009 at Http://www.cancer.gov/cancertopics/factsheet/physical-

activity-qa.

7 Salazar MK, Cohn MN. Comparison of Four Behavioral Theories. AAOHN

Journal. March 1991; 39:128-135.

8 Young DR, Haskell WL, Taylor CB, Fortmann SP. Effect of Community Health

Education on Physical Activity Knowledge, Attitudes, and Behavior. Am J

Epidemiology. 1996; 144: 264-274.

9 Farquhar JW, Fortmann SP, Caccoby N, et al. The Stanford Five-City Project;

design and methods. Am J Epidemiology. 1985; 122:323-34.

10 Bandura A. Social Foundations of thought and actions: A social cognitive

theory. 1986.

11 McQuail D. Mass Communication Theory: An Introduction (3^rd

edition)Thousand Oaks, CA, Sage. 1994.

12 Schull N. Digital Gambling: The Coincidence of Desire and Design. The Annals

of the American Academy of Political and Social Science. 2005;597 (1): 65-81.

13 MacFadyen L, Stead M, Hastings GB. Social Marketing in: Baker MJ editor.

The Marketing book. 5^th edition Oxford: Buttersworth-Heinneman; 2002.

14 Scheufele DA. Framing as a Theory of Media Effects. Journal of

Communication. Winter 1999.

15 Black JL, Macinko J. Neighborhoods and obesity. Nutrition Reviews. January

2008; 66 (1):2-20.

16 Alison KR. Four Challenges in assessing the implementation and effectiveness

of physical activity and nutrition policy intervention as natural experiments.

Health Promotion International. September 2008; 23 (3): 290-297.

17 McKenzie T, Sehgal A. Contribution of Public Parks to Physical Activity.

American Journal of Public Health. March 2007; 97 (3): 509-514.

18 Glanz K, Lankenau B, Foerster S, TempleS, Mullis R, et al. Environmental and

policy approaches to cardiovascular disease prevention through

nutrition:opportunities for state and local action. Health Education Q. 1995;

22: 512-527.

19 Wang G, Macera C, Scudder-Soucie B, Schmid T, Pratt M, et al. Cost analysis

of the built environment: The case of bike and pedestrian trials in Lincoln,

Neb. American Journal of Public Health April 2004; 94 (4): 549-553.

20 Brownson RC, Baker EA, Houseman RA, Brennan LK, Bacak SJ.

Environmental and policy determinants of physical activity in the United

States. American Journal of Public Health. 2001; 91: 1995-2003.

21 Craig CL, Brownson RC, Cragg SE, Dunn AL. Exploring the effect of the

environment on physical activity: A study examining Walking to work.

American Journal of Preventative Medicine. 2002; 23 (2S): 36-43.

22 Dearing JW. Evolution of diffusion and dissemination theory. Journal of

Public Health Management Practive. 2008; 14 (2): 99-108.

23 Barker K. Diffusion of innovation: A world tour. Journal of Health

Communication. 2004; 9: 131-137.

24 Dearing JW. Improving the state of health programming by using diffusion

theory. Journal of Health Communication. 2004; 9: 21-36.

25 Farr AC, Ames N. Using diffusion of innovation theory to encourage the

development of a children’s collaborative: A formative evaluation. Journal of

Health Communication. 2008; 13: 375-388.

26 Handy SL, Boarnet MG, Ewing R, Killingsworth RE. How the built

environment affects physical activity. American Journal of Preventative

Medicine. 2002;23 (2S): 64-73.

27 Gordon-Larson P, Nelson MC, Page P, Popkin BM. Inequality in the built

environment underlies key health disparities in physical activity and obesity.

Accessed on 13-April-2009 at http://www.pediatrics.org

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.

Conclusion

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).
REFERENCES

1. Barlow SE, Dietz WH. Obesity evaluation and treatment: expert committee recommendation, Pediatrics. 1998; 103, 3.

2. Blome, Ron. "NBC News." In Arkansas report card, F may stand for fat. NBC. 20 July 2004.

3. "Childhood and Teenage Obesity Intervention Strategies." ExRx (Exercise Prescription) on the Net. 29 Mar. 2009 .

4. Clark, M.M., Abrams, D.B., Niaura, R.S., Eaton, C.A. and Rossi, J.S., 1991. Self-efficacy in weight management. Journal of Consulting and Clinical Psychology 59, pp. 739–744.

5. Donvan, John, and Katie Hinman. "Nightline." Weight Grade on Report Cards Angers Parents. ABC. 27 Aug. 2007.

6. Feldman, Donna. "Childhood Obesity: Do Children Need "Weight Report Cards"? | The Diet Channel." Weight Loss, Diets, Nutrition & Exercise at The Diet Channel. 05 Apr. 2009 .

7. Mitchell, Terence R., and Marilyn E. Gist. "Self-Efficacy: A Theoretical Analysis of Its Determinants and Malleability." Academy of Management 17 (1992): 183-211. JSTOR.

8. Pieper K, Barlow SE, et. al. Obesity and Kansas City Kids (2003 Conference), Reardon Convention Center, Kansas City, Kansas.

9. Robinson TN. Reducing children's television viewing to prevent obesity: a randomized controlled trial. JAMA. 1999 Oct 27; 282(16):1561-7.

10. Skinner JD, Bounds W, Carruth BR, Ziegler P. Longitudinal calcium intake is negatively related to children's body fat indexes. J Am Diet Assoc. 2003 Dec;103(12):1626-31.

11. USDA (2005) Dietary Guidelines for Americans, vii-viii.

12. World Health Organization (2000) (PDF). Technical report series 894: Obesity: Preventing and managing the global epidemic.

13. Framing Emotional Response, by Kimberly Gross and Lisa D'Ambrosio Political Psychology 2004 International Society of Political Psychology.

14. Lawrence, Regina G. "Framing Obesity." The Harvard International of Press/Politics 9 (2004).

15. Edberg, Mark Cameron. Essentials of Health Behavior : Social and Behavioral Theory in Public Health. New York: Jones & Bartlett, Incorporated, 2007.

16. Journal of the American Dietetic Association volume 104, Issue 3, March 2004, pages 341 - 344. "School health report cards attempt to address the obesity epidemic." Lee M. Scheier.

17. National Center for Health Statistics, Prevalence of Overweight and Obesity Among Adults: United States, 1999–2000 (2003) Available at: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/obese/obse99.htm.

18. Hedley, AA, Ogden, CL, Johnson, CL, Carroll, MD, Curtin, LR, Flegal, KM. Overweight and obesity among US children, adolescents, and adults, 1999-2002. JAMA 291:2847-50. 2004.

19. V.R. Chomitz, J. Collins, J. Kim, E. Kramer and R. McGowan, Promoting healthy weight among elementary school children via a health report card approach, Arch Pediatr Adolesc Med 157 (2003), pp. 765–772.

20. N.F. Krebs and M.S. Jacobson, American Academy of Pediatrics Committee on Nutrition. Prevention of Pediatric Overweight and Obesity, Pediatrics 112 (2003), pp. 424–430.

21. L. Scheier, Potential problems with school health report cards, J Am Diet Assoc (2004) (in press).

22. Center for Weight and Health at Berkeley, Guidelines for Collecting Heights and Weights on Children and Adolescents in School Settings (2003) Available at: http://www.cnr.berkeley.edu/cwh/resources/childrenandweight.shtml.

23. K. Davis and K.K. Christoffel, Obesity in preschool and school-age children. Treatment early and often may be best, Arch Pediatr Adolesc Med 148 (1994), pp. 1257–1261.

24. R.C. Klesges, L.M. Klesges, L.H. Eck and M.L. Shelton, A longitudinal analysis of accelerated weight gain in preschool children, Pediatrics 95 (1995), pp. 126–130.

25. M. Briggs, S. Safaii and D. Lane Beall, Nutrition services: An essential component of comprehensive school health programs (2004) Available at: http://www.eatright.org/Member/PolicyInitiatives/8474_8243.cfm.

26. Berman, Erica S. "Eating Behaviors : The relationship between eating self-efficacy and eating disorder symptoms in a non-clinical sample." ScienceDirect. 08 Apr. 2009.

27. Clark, D.B. Abrams and R.S. Niaura, Self-efficacy in weight management, Journal of Consulting and Clinical Psychology 59 (1991), pp. 739–744.

28. Strauss, Richard S. "Childhood Obesity and Self-Esteem." Pediatrics 15th ser. 105 (2000).

29. Whetstone, Lauren M., Susan L. Morrissey, and Doyle M. Cummings. "Children at Risk: The Association between Perceived Weight Status and Suicidal Thoughts and Attempts in Middle School Youth." Journal of School Health 77 (2007): 59-66.

30. Gortmaker SL, Peterson KE, Wiecha JL, Sobol AM, Dixit S, Fox MK, Laird N. Reducing obesity via a school-based interdisciplinary intervention among youth: Planet Health. Arch Pediatr Adolesc Med. 1999 Apr; 153 (4): 409-18.

31. Wiecha JL, Sobol AM, Peterson KE, Gortmaker SL. Household television access: associations with screen time, reading and homework among youth. Ambulatory Pediatrics. 2001 Sept - Oct; 1(5): 244-251.

32. Austin SB, Gortmaker SL. Dieting and smoking initiation in early adolescent girls and boys: A prospective study. Am J Public Health. 2001 Mar; 91 (3): 446-50.

33. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar sweetened drinks and childhood obesity: A prospective, observational analysis. Lancet. 2001 Feb 17; 357(9255):505-8.

34. Wang LY, Yang Q, Lowry R, Wechsler H. Economic Analysis of a School-Based Obesity Prevention Program. Obes Res. 2003 Nov; 11 (11): 1313-1324.

35. Wiecha JL, El Ayadi AM, Fuemmeler BF, Carter JE, Handler S, Johnson S, Strunk N, Korzek-Ramirez D, Gortmaker SL. Diffusion of an Integrated Health Education Program in an Urban School System: Planet Health. J Pediatr Psychol. 2004 Sept; 29: 467-474.

36. Cradock AL, Wiecha JL, Peterson KE, et al. Youth Recall and TriTrac Accelerometer Estimates of Physical Activity Levels. Med Sci Sports Exerc. 2004 Mar; 36 (3): 525-532.

37. Boynton-Jarrett R, Thomas TN, Peterson KE, et al. Impact of Television Viewing Patterns on Fruit and Vegetable Consumption Among Adolescents. Pediatrics. 2004 Dec; 112: 1321-1326.

38. Austin SB, Field E, Wiecha J, Peterson KE, Gortmaker S. The impact of a school-based obesity prevention trial on disordered weight-control behaviors in early adolescent girls. Arch Pediatr Adolesc Med. 2005 Mar; 159(3):225-229.

39. Wiecha JL, Peterson KE, Ludwig DS, Kim J, Sobol A, Gortmaker SL.When Children Eat What They Watch: Impact of Television Viewing on Dietary Intake in Youth When Children Eat What They Watch. Arch Pediatr Adolec Med. 2006 Apr; 106(4): 436-42.

40. Gortmaker SL, Cheung LWY, Peterson KE, Chomitz G, Cradle JH, Fox MK, Bullock RB, Sobol AM, Colditz G, Field A, Laird N. Impact of a School-Based Interdisciplinary Intervention on Diet and Physical Activity Among Urban Primary School Children: Eat Well and Keep Moving. Archives of Pediatrics and Adolescent Medicine 1999; 153:975-83.

41. Chavarro JE, Peterson KE, Sobol AM, Wiecha JL, Gortmaker SL. Effects of a School-based Obesity-prevention Intervention on Menarche (United States). Cancer Causes Control. 2005 Dec; 16(10):1245-52.

42. Brondolo, Elizabeth, Linda Gallo, and Hector Myers. "Race, racism and health: disparities, mechanisms, and interventions." Journal of Behavioral Medicine.

43. Carter J, Wiecha J, Peterson K, Gortmaker S. Planet Health: An Interdisciplinary Curriculum for Teaching Middle School Nutrition and Physical Activity. Champaign, IL: Human Kinetics. 2001.