Sunday, May 5, 2013

The Fight Against Childhood Obesity, A Social Norms Intervention –Britton Donato

            Over the course of the last few decades, the United States, along with several other developed and developing countries, has seen the prevalence of childhood obesity reach values never thought possible. As our society has evolved toward a relenting pursuit of convenience, many factors have greatly contributed to the obesity epidemic around the world. In 1976, the percentage of children ages 12-19 was estimated to be 5.0 percent, while in 2010, 18.4 percent of the same demographic were determined to be obese (1). This dramatic upward trend has also been intensified within specific ethnic populations, most notably non-Hispanic black boys, and Mexican-American boys.
            The most concerning issue that arises in the discussion of childhood obesity is the long lasting health effects that occur as a direct result of obesity. The most common effects of obesity are hypertension, dyslipidemia, chronic inflammation, hypercoagulative state, endothelial dysfunction, and hyperinsulinemia (2,3,4). These primary effects of obesity are considered significant risk factors for the development of several other life-threatening diseases such as cardiovascular disease and Diabetes Mellitus Type 2 (DM2). Ironically, before the onset of the childhood obesity epidemic, Diabetes Mellitus Type 2 was referred to as adult-onset diabetes, as children almost never developed the disease. Tragically, a significant proportion of individuals diagnosed with DM2 each year are children (5).
            The most common means by which to classify an individual as obese is using the body mass index or BMI, which is determined by the ratio of one’s weight in kilograms to the square of their height in meters. The CDC has set the cutoff values for obesity in children and adolescents as a BMI value at or above the 95th percentile of the sex-specific BMI growth charts (1). When analyzing the changes in distribution of BMI in the population, over the past few decades there has been a shift such that the most obese children at greatest risk of suffering from complications have been affected most severely. This has likely been the result of profound environmental changes in a population that is very susceptible (6).
            There have been a wide variety of interventions implemented to reduce the prevalence of childhood obesity. The most of these interventions have been family-based interventions, school-based interventions, and pharmaceutical and surgical treatments (3). This paper will focus on the use of school-based interventions as an effective means to reduce childhood obesity, provide three critiques as to the ineffectiveness of the intervention, and finally propose alternative methods, which may be more effective in achieving their goals.
School-Based Childhood Obesity Interventions
            While there have been a variety of proposed interventions to fight against the rapidly worsening childhood obesity epidemic, school-based intervention programs have been considered to have great potential.  Because obese and overweight children suffer from many psychosocial issues such as low self-esteem, discrimination, stigmatization, and peer rejection, along with the myriad of physical effects, using schools as the setting for obesity interventions has the possibility of addressing both aspects of the problem (7).  
            The aim of the school-based interventions are to modify the quality and healthiness of the food available to the children, as well as increasing the amount of physical activity each child receives each day. The modifications to the diets are accomplished mostly by removing foods that are high in fat, as it is a well-known fact that fat is the most dense supply of energy for the body.
            The most straightforward aspect of the intervention strategy is the increase in the amount of physical activity per day. The more physical activity a child experiences per day, the more calories that will be expended, the lesser the magnitude between calories ingested and calories expended. As so, there have been many studies, which have shown a reduction in obesity with an increase in physical education classes, or extended physical activity times (8).
            While these aspects of schools-based obesity interventions have been shown to be effective in reducing overall bodyweight in the short-term, there is still much debate as to the effectiveness of the interventions in the long run, as many exterior factors have a significant impact on the ability of the interventions to be successful. 
Criticism of Intervention 1: Reducing Fat Consumption as a Dietary Modification Is Not Effective in Reducing Bodyweight
            As mentioned previously, modification of the food provided to children by the school is a major component of most school-based obesity intervention programs. The concept behind the diet modification is that by removing the amount of calories in the diet from fat, that less will be stored as adipose tissue, thus the progression towards obesity will be decreased.  However, recent studies have suggested that reductions in the amount of fat calories consumed by children per day do not result in a net loss of overall body weight. It is therefore most plausible that it is the amount of calories ingested from carbohydrates that are likely playing the greatest role in the development of obesity (9,10).
            As the proportion of each meal containing fat is reduced, it is replaced by carbohydrates. For this reason, the amount of carbohydrates being consumed at each meal has markedly increased over the past several years. An example of such an instance is the removal of high fat milk products being served to children. As the higher fat milk was replaced by lower fat milk, children began to drink more soft drinks and non-citrus juices, which are incredibly saturated with complex sugars (11). When consuming beverages so high in sugars, the postprandial blood glucose excursion is much more exaggerated, which may be playing a role in insulin resistance and development of DM2.
            It is also likely that it is most acceptable to the public, especially the parents of the children at the intervention schools, to hear that there will be less fat in the food being served. The most accepted concept by much of society is that dietary fat is stored in the body when eaten too much. It is therefore concluded that dietary carbohydrates do not make an individual gain weight, so there is no consequence to eating foods high in carbohydrates. Unfortunately for many, carbohydrates do have the capacity to be converted in vivo to very long glycogen chains, which act as a storage form for carbohydrates in the body, just as dietary fat does.
            While reducing the amount of fat in the food being served to children in schools has not conclusively shown any real effect on the reduction of childhood obesity, it is still improving their health in other ways, such as reducing their risk of developing cardiovascular disease. However, it is vital that what has been accepted as truth, that only eating fat will make you fat, be corrected. To make dietary decisions influenced by the misconceptions of society will inhibit the ability of intervention programs to have long-lasting positive effects on childhood obesity.
Criticism of Intervention 2: Large Corporations and Politics Largely Control the Type of Food Being Provided By Schools
            In a time when the U.S. economy has been struggling, educational systems all across the country have been especially impacted. As so, many schools have been doing whatever it takes to keep their doors open to new students. Unfortunately, the big players in the food industry are also aware of their dire circumstances, and have no apparent moral or ethical dilemma with taking advantage of the situation.
            With respect to advertising, this becomes blatantly obvious when considering the fact that the food industry spends approximately 12.7 billion dollars are marketing campaigns that targeted children by creating associations between their products and the most popular toys and movie characters at the time (12). By associating their food products, which are often the least healthy foods, to things which the children identify as cool or hip in society, many children are likely to make the connection that the specific advertised foods are also what is most socially acceptable, and that by eating such foods, they will be more accepted by society. This is evident by simply going to the closest fast food restaurant and observing the graphics they have chosen to display on their beverage cups.
            By using such marketing schemes, the food industry is leading children to believe that they will not be socially accepted if they do not eat the food products they provide, which alternatively is saying that eating healthy food, like the food which is being provided by the childhood obesity intervention programs, will make them less accepted. The healthy diet aspects of the intervention plans have failed to discredit the idea that eating fast food is a social norm and that healthy food is not as socially acceptable. Because the feeling of acceptance is such a vital aspect of many young people, they will likely to make their dieting decisions not based on the health value of the food, but whether they will be improving their probability of being socially accepted.
            The food industry also obstructs the goals of most school based intervention programs by taking advantage of their likely financial needs, and offering schools money in exchange for the ability to sell their products on the school campus. Because the least unhealthy food is often the most inexpensive to produce, the food industry who is driven by profits, puts priority not on the health outcomes of the children, but on the method which will produce the most money (12). This is especially true when considering the invasion of vending machines on many school campuses. These contracts have become known as “poring rights,” enabling the sale of unhealthy food and drinks on campus (13). If schools continue to allow the food industry to sell such unhealthy food on campus, the quality of their childhood obesity intervention will become irrelevant, and have absolutely no chance of being successful.
            Yet another means by which politics are influencing the effectiveness of obesity interventions in schools is by limiting the resources available for physical education classes. As previously discussed, physical activity plays a very important role in the fight against obesity of all kinds, and many schools are failing to recognize its value. While academics will always be at the forefront of any schools priorities, classes on physical education are being rapidly removed from many curricula across the nation (2). These physical education classes were able to provide the caloric expenditure so desperately needed by many children fighting obesity, as well as vital education on how to live a healthier life. Without placing priority on the importance of physical activity and health education, the school-based obesity intervention programs will never produce the impact that they are striving for.
Criticism of Intervention 3: Failure to Address the Toxic Home Environment
            While improving the diet and physical activity level of children while they are at school may prove to be effective in reducing the prevalence of childhood obesity, without adequately addressing the home environment that the children will spend the majority of their time, no real long-term changes can be made. The impact the home environment can have on a child can be staggering, and can begin at very early ages. For example, a child that has been neglected by their parents has a nine times the probability of becoming obese compared to a child that was not neglected (14).
            When addressing the home environment of a child, and its effect on the health of the child, many factors must be considered. Such factors include the health practices of the mother, socioeconomic status, race, marital status, and cognitive stimulation (14,15,16). All of these factors have been shown to dramatically effect the development of obesity in childhood, and must therefore be addressed by the school-based intervention program.
            There have been very few school intervention programs that have included the parents by means of education. Without educating the parents on the importance of the home environment on the children, efforts made at school will likely be in vain. Children will behave at home in accordance with the social norm for their household, what they have learned through experience are acceptable behaviors. Many intervention programs have failed to even communicate to the children that the way they act when they are at home really affects their health today, as well as the rest of their life. Because most of society places such value and importance on things that are convenient, we cannot expect our children to not think the same. Most importantly, we must understand that every obese child has become so while living in their home environment, under the watchful eye of those who care for them, who have in some way encouraged overeating and inactivity (17). For this reason, if obesity interventions fail to address the values and norms of society with respect to diet and exercise outside of the school environment, they will continue to see unimpressive results. To truly make a long lasting difference, the value that society places on health and well being with respect to exercise and diet must be dramatically shifted.
New Intervention Proposal: Using Mass Media to Influence Social Norms By Community Education and Awareness
            It is quite clear that the only way to effectively halt the rapidly expanding childhood obesity epidemic is to change social norms. Over the past several decades, the United States in particular has become obsessed with convenience, getting the most out of something for the least amount of work. Additionally, with the explosion of social media, the ability to chat with friends and family, finish your homework, plan a weekend trip, and order dinner can be accomplished all without having to leave your desk chair. I am proposing a childhood obesity intervention that takes full advantage of the power of social media to dramatically alter the societal norms regarding a healthy, active lifestyle.
            In order to change the way children and adolescents feel about a healthy balanced diet and physical activity, we must first change the social norms by which they base their decisions. This will be accomplished by using a group level model to shift the social norm from that of doing the least amount of work possible to achieve maximum results, to a social norm that places great revere on those that work hardest to ensure they achieve maximum results. Because group level models are most effective when they encompass a very large number of people, social media will be used to ensure that a very high proportion of the population is exposed, and exposed often. This approach will provide the greatest opportunity for the social norms that have halted progress toward a healthier society to be forever changed.
            It is of equal importance that the means by which we reach out to our audience is maximally effective. Because many children and adolescents are highly influenced by popular culture, using this avenue to change what they believe to be socially acceptable can be most effectively attained. This will be accomplished by utilizing popular figures in society that many adolescents will associate with. By changing what adolescents view as norms, we will effectively be changing the foundations on which their decisions on what they value are made. The social norms theory also predicts that interventions that correct misconceptions by revealing a healthier norm will have positive effects on most people by encouraging them to engage in healthier behaviors (18).
            The final aspect of the intervention to reduce childhood obesity is to exploit the power of the newly acquired social norms that prioritize healthy lifestyles to force changes in policy. To ensure that the financial motives of politics do not impinge on the quest for a healthier, more productive society, it is vital that policies be enacted to inhibit large food corporations from flooding the community with unhealthy, but profitable food. By successfully altering what is considered the norm, the people will have the power to ensure such policies are passed and implemented, as to grant them the ability to attain the health, active lifestyles they now value.
Defense of New Intervention 1: Shifting the Social Norm Using Group Level Models
            The most crucial aspect of creating an intervention that will stop the childhood obesity epidemic is to shift the social norms that many children base much of their decision-making. Because children are especially concerned with fitting in and being accepted by their peers, a group level model that can effectively change the perceived norm with respect to diet and physical activity has the potential to be tremendously effective in this age group. Such an approach is supported by the social norms theory, which in short predicts that people express or inhibit behavior in an attempt to conform to a perceived norm (18). Therefore, the obesity intervention being proposed is, at its core, a social norms intervention.
            The social norms theory has been used as a strategy to combat a variety of adolescent issues that are the result of skewed or misperceived social norms. It is effective because it creates the perception that the ideas of the social norms intervention are also those of their peers (19). Because children and adolescents base their decisions largely on conformity with what they perceive to be accepted by their peers, this intervention has the potential to change behavior on a large scale.
            The social norms most hindering progress toward ridding the U.S. of both child and adult obesity is an obsession with convenience and the desire for results without putting in the hard work. As a result, people are often trying to attain the maximum amount of outcome with minimum exertion. Such a norm has infiltrated the way we think about food, which is evident by the explosion of fast food restaurants all across the country. If you really consider what fast food represents, it is an exact reflection of the social norms, which have caused the obesity epidemic. Fast food allows you to attain large amounts of food for a lesser cost, in less time; all without having to even get out of your car. The priority that we as a society place on convenience now completely supersedes those of a healthy lifestyle. Until a norm is accepted that places the health benefits of diet above convenience, obesity will continue to plaque our society.
            Therefore, this intervention will perpetuate the norm that when making decisions about the food one decides to put into their body, the healthiness of the food far supersedes the convenience by which the food is received. Most importantly, for a norm to be perpetuated in society it is not necessary for the majority to believe it; it is only necessary for the majority to believe that the majority believes it (18). By leading the children and adolescents of our society to believe that a healthy diet and an active life style is a priority of their peers, and that by making healthy decisions about diet and exercise, they will be conforming to the social norm, and we will have succeeded in our goal. The first step to stopping the childhood obesity epidemic is to change the norms of society, and everything else will then follow.
Defense of New Intervention 2: Using Popular Media to Perpetuate Social Norms Interventions
            A shift in social norms cannot be propagated without an appropriate outlet to do so. The outlet is required to reach as many people as possible, as effectively as possible, as many times per day as possible. Social media has become a significant part of daily life. Many children spend great proportions of their day using the many facets of social media available today. Therefore, social media is an ideal platform to most effectively perpetuate a social norms intervention.
            The intervention will be most effective if the intervention media replaces current media concerning food and diet. Because the majority of commercials during children’s programming are for things like candy, soft drinks, sugared cereals, and other unhealthy foods with low nutritional value (20,21), kids acquire the perception that these foods are the social norms. Therefore, to be most effective, the intervention must counter these ads with ones that most strongly create the perception that society puts greatest priority on eating healthy foods, and that by doing so, you will be more accepted by your peers. The social norms intervention ads will be more effective than the current unhealthy diet ads because much effort will be placed on making sure than the viewer is able to associate more with the people and thing they observe on the intervention ads than the junk food ads. The social cognitive theory supports such an approach, as it proposes that people learn from observing others (22), and that viewers of media are more likely to pay attention media models they see as similar to themselves (23).
            By creating ads in the media that young people can associate with, there is the greatest probability that hey will adopt the ideas of the obesity intervention, and the social norm intervention will being to be accepted and perpetuated in the community. By creating effective advertisements, as well as using many facets of social media, the intervention ads will be seen several times per day by millions of young people across the country, which will spark a shift in the social norms or diet and health.  
Defense of New Intervention 3: The Newly Acquired Values of Society Have the Power to Enact Changes in Policy
            As the norms of society are shifted with respect to the priority placed on a healthy diet and active lifestyle using social media, which will be effective according to the social cognitive theory, the pressure on politicians to enact legislation that best suits the values of society will be markedly increased. According to the media agenda setting theory, the media can play a substantial role in shaping what society places great value on, so as a result of the obesity intervention media ads, the value placed on healthy diets will be greatly amplified (
            As a result of societies value placed on a healthy diets and active lifestyles, politicians will be placed under great pressure to adopt ne policies which will better suit the most recent values of the community. This will be a crucial step in insuring the long-term efficacy of the obesity intervention. By placing strict regulations on the quality of food that many food corporations can produce and advertise, the amount of low nutritional value food items will become scarce. Additionally, policies that restrict the advertisement of unhealthy food items, especially during child programming, will further instill the shift in perceived social norms.
            The enactment of new policies that aid in the fight against childhood obesity is a vital component of the intervention. Social norms are bound to change with time, and as new generations come and go much more easily than do hard and fast policies restricting the marketing and sale of unhealthy foods.
            Extensive efforts to effectively treat obesity from a behavioral approach have been attempted since the 1960s, starting with the learning theory (25). While this theory considers eating and exercise behaviors that are learned, and thus can be modified by behavioral treatment, it fails to encompass the tremendous impact that societal norms and the desire to be accepted play in the decision making process with respect to diet and exercise. It is this gap that the proposed intervention hopes to address.
            By using proven behavioral models to shift the perceived social norms of children and adolescents, the intervention will establish an incredible motivation to comply with the perceived social norms as the desire of young people to be accepted by their peers is substantial. To perpetuate the social norm interventions, social media will be implemented, and ads will be created to most effectively associate with the target audience. After creating a shift in the value placed on a healthy diet and active lifestyle, society will posses the power and motivation to demand policy changes, ensuring the long-term success of the childhood obesity intervention.


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