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.
Conclusion
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.
References
1.
“Products - Health E Stats - Overweight Prevalence Among
Children and Adolescents 2009-2010.” Accessed April 29, 2013. http://www.cdc.gov.ezproxy.bu.edu/nchs/data/hestat/obesity_child_09_10/obesity_child_09_10.htm.
2.
Ebbeling, Cara B, Dorota B Pawlak, and David S Ludwig.
“Childhood Obesity: Public-health Crisis, Common Sense Cure.” The Lancet 360, no. 9331 (August 10,
2002): 473–482. doi:10.1016/S0140-6736(02)09678-2.
3.
Must, A, and R S Strauss. “Risks and Consequences of
Childhood and Adolescent Obesity.” International
Journal of Obesity 23 (March 1999): S2–S11. doi:10.1038/sj.ijo.0800852.
4.
Freedman, David S., William H. Dietz, Sathanur R.
Srinivasan, and Gerald S. Berenson. “The Relation of Overweight to
Cardiovascular Risk Factors Among Children and Adolescents: The Bogalusa Heart
Study.” Pediatrics 103, no. 6 (June
1, 1999): 1175–1182.
5.
Fagot-Campagna, Anne, David J. Pettitt, Michael M.
Engelgau, Nilka Ríos Burrows, Linda S. Geiss, Rodolfo Valdez, Gloria L.A.
Beckles, et al. “Type 2 Diabetes Among North Adolescents: An Epidemiologic
Health Perspective.” The Journal of
Pediatrics 136, no. 5 (May 2000): 664–672. doi:10.1067/mpd.2000.105141.
6.
Flegal, K M, and R P Troiano. “Changes in the Distribution
of Body Mass Index of Adults and Children in the US Population.” International Journal of Obesity 24, no.
7 (July 25, 2000): 807–818. doi:10.1038/sj.ijo.0801232.
7. ,
, , , . Predicting
obesity in young adulthood from childhood and parental obesity. N Engl J
Med. 1997;337:869-873.
8. Shaya, Fadia T., David
Flores, Confidence M. Gbarayor, and Jingshu Wang. “School-Based Obesity
Interventions: A Literature Review.” Journal
of School Health 78, no. 4 (2008): 189–196.
doi:10.1111/j.1746-1561.2008.00285.x.
9.
Troiano, Richard P., Ronette R. Briefel, Margaret D.
Carroll, and Karil Bialostosky. “Energy and Fat Intakes of Children and
Adolescents in the United States: Data from the National Health and Nutrition
Examination Surveys.” The American
Journal of Clinical Nutrition 72, no. 5 (November 1, 2000): 1343s–1353s.
10.
Jéquier, Eric. “Is Fat Intake a Risk Factor for Fat Gain
in Children?” Journal of Clinical
Endocrinology & Metabolism 86, no. 3 (March 1, 2001): 980–983.
doi:10.1210/jc.86.3.980.
11.
Cavadini, Claude, Anna Maria Siega-Riz, and Barry M.
Popkin. “US Adolescent Food Intake Trends from 1965 to 1996.” Archives of Disease in Childhood 83, no.
1 (July 1, 2000): 18–24. doi:10.1136/adc.83.1.18.
12.
Nestle, Marion. Foos
Politics: How the Food Industry Influences Nutrition and Health. University
of California Press, 2002.
13.
Nestle, Marion. "Soft drink “pouring rights”: marketing
empty calories to children." Public
Health Reports 115.4 (2000): 308.
14. Lissau-Lund I, Sφrensen TIA (1994) Parental neglect during childhood and
increased risk of obesity in young adulthood. Lancet 343:324–327.
15. Sobal J, Stunkard AJ (1989) Socioeconomic status and obesity: a
review of the literature. Psychol Bull 105:260–275.
16.
McLaren, Lindsay. “Socioeconomic Status and Obesity.” Epidemiologic Reviews 29, no. 1 (January
1, 2007): 29–48. doi:10.1093/epirev/mxm001.
17. Bruch H (1975) Emotional aspects of obesity in
children. Pediatr Ann 4:91–99.
18.
Berkowitz, Alan D. "Applications of social norms
theory to other health and social justice issues." The social norms approach to preventing school and college age
substance abuse: A handbook for educators, counselors, and clinicians
(2003): 259-279.
19.
Berkowitz, Alan D. "The social norms approach:
Theory, research and annotated bibliography." Higher Education Center for Alcohol and Other Drug Abuse and Violence
Prevention. US Department of Education (2004).
20.
Kotz, Krista, and Mary Story. "Food advertisements
during children's Saturday morning television programming: are they consistent
with dietary recommendations?." Journal
of the American Dietetic Association 94.11 (1994): 1296-1300.
21.
Taras, Howard L., and Miriam Gage. "Advertised foods
on children's television." Archives
of Pediatrics & Adolescent Medicine 149.6 (1995): 649.
22.
Stern, Susannah R. "Messages from teens on the big
screen: Smoking, drinking, and drug use in teen-centered films." Journal of health communication 10.4
(2005): 331-346.
23.
Bandura, A. (1994). Social cognitive theory of mass
communication. In J. Bryant & D. Zillmann (Eds.), Media effects: Advances
in theory and research (pp. 61–90). Hillsdale, NJ: Lawrence Erlbaum Associates.
24.
Brown, Noel, and Craig Deegan. “The Public Disclosure of
Environmental Performance Information—a Dual Test of Media Agenda Setting
Theory and Legitimacy Theory.” Accounting
and Business Research 29, no. 1 (1998): 21–41.
doi:10.1080/00014788.1998.9729564.
25.
“Behavioral Approaches to the Treatment of Obesity,
Handbook of Obesity: Clinical Applications, Informa Healthcare.” Accessed May
2, 2013.
http://informahealthcare.com.ezproxy.bu.edu/doi/abs/10.3109/9781420051452.014.
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