Challenging Dogma


...Using social sciences to improve the practice of public health

Wednesday, April 25, 2007

California Schools Revamp Vending Machines: Restrictions Leading to Another Unsuccessful Attempt to Eliminate Childhood Obesity – Melissa Lee

Today, the obesity epidemic has spread to uncontrollable measures. Public health officials have developed countless ways to attempt to eliminate obesity, but most have proven unsuccessful. Overweight and obesity rates have increased sharply over the years starting in the mid-seventies and have continued to increase until this day (1). The most current NHANES data surveyed that 32.9% of Americans are either overweight or obese, doubling the amount 20 years ago. The most appalling numbers within the most recent NHANES data are the comparison of childhood obesity between NHANES data taken in 1976 to 1980 and in 2003 to 2004. For children aged 2–5 years, the prevalence of overweight increased from 5.0% to 13.9%; for those aged 6–11 years, prevalence increased from 6.5% to 18.8%; and for those aged 12–19 years, prevalence increased from 5.0% to 17.4% (1). Within a 20-year period, obesity rate in children and adolescents has tripled!

Obesity leads to chronic illnesses such as hyperlipidemia, diabetes mellitus, and hypertension. Because of the high costs (medical cost and loss of productivity) of chronic illnesses, public officials are finding ways to decrease the prevalence of obesity. Healthy People 2010’s goal is to reduce childhood obesity to 5% and adult obesity to 15% of the American population (2). Health officials identify 3 contributing factors to obesity: genetics, behavior, and environment. Currently, there are many health prevention programs focusing on the environmental contributing factors to obesity, which includes the environment at home, childcare centers, schools, and community. Programs such as the National School Lunch Program, adopted in 1946, promotes nutritionally balanced meals for students at school (3) and a more recent program, Go Healthy, motivates students and teachers to encourage a healthy school environment (4).

With the USDA “refusal to enforce its own rules against selling junk food in their public schools”, states are taking matters to their own hands (5). School districts in California, Los Angeles (2nd largest school district in the nation), Oakland, and San Francisco, are banning the sales of soda and unhealthy snacks in vending machines on campus. Under the California Senate Bill 677 (Chapter 415), California schools “ban vending machine sales of carbonated beverages to elementary, middle and junior high school students and replace them with milk, water and juice (6).” Additional amendments to the bill include prohibiting the sales of high-caloric snacks and desserts (6). California officials states, “At the heart of the policy is a growing movement to fight the state's obesity epidemic (7).” By now, it is known that the obesity epidemic is multifaceted, and this policy only addresses the school environmental factor and ignores the behavioral factors of the students. In addition, public health officials continue to impose restrictive measures at schools ignoring the fundamental concepts of the transtheoretical model: a progression model leading to integrated behavioral change.

The transtheoretical model has been used by public officials as the basis of developing effective intervention promoting behavioral change. This model focuses on three primary components: stages of change, processes of change, and levels of change (8). This paper will focus on the five stages of change, which are precontemplation, contemplation, preparation, action, and maintenance and will focus on some of the processes of change. Precontemplation stage describes an individual who is oblivious to problems in his or her behavior. Contemplation stage depicts an individual who recognizes the behavioral problem but is not ready to change. Preparation stage portrays an individual who is ready to change. Action stage is where the individual actually changes their behavior. The final stage, the maintenance stage, is where the individual integrates the changes into his or her lifestyle and prevents any relapse to any previous stages. California’s policy of banning popular, unhealthy items fails to recognize that achieving a permanent behavioral change leading to the reduction of obesity rates include a series of stages, not just the “action phase.”

The transtheoretical model has proven successful when applied to other health intervention programs; specifically, programs dealing with smoking cessation, eating disorders, and drug uses (9). For example, Spencer presents evidence of the effectiveness of smoking prevention and cessation using the transtheoretical model (10). In another research, Perz validated that the transtheroretical model helped cessation of smoking when subjects were given stage-specific tasks (11). When it comes to eating disorders, dieticians apply the theories of the transtheroretical model to counsel their clients; dieticians can use this model to assess their client’s ambivalence towards change (12). With evidence of the transtheroretical model success in achieving effective public health interventions, theories of the transtherotetical model should have been applied when developing California Senate Bill 677.

First, and foremost, simply removing food culprits will not instigate behavioral changes in students; students will continue to consume unhealthy foods unless they are ready to modify their eating habits. By removing the food culprits, public health officials completely omit the precontemplation and contemplation phase of the transtheoretical model. Forcing students to be involved in the action phase without giving them a reason why is a set up for failure. Specifically, those children that are already characterized as “problem child” will further display rebellious behaviors when forced to eat healthier without any reason. Rebellious behaviors may include not eating at all and eating more of the unhealthy foods by bringing them to schools. In addition, British and American research shows that children do not like teachers who are sarcastic and dominating, show favoritism, and punish students (13). Since sweets have always been associated with an external reward to “jump start” student’s motivation to learn, taking it away can be viewed as a punishment (14). But, in this case, students will not understand why they are being “punished” since they were never told what they did wrong. This is analogous to people who are in the precontemplation phase, people that do not know that they are in dire need for a behavioral change.

For California to enforce this policy there must be an educational component. As part of the transtheoretical model, Prochaska believes there are processes of change that help individuals move along the stages of change (8). The missing processes of change in California’s policy are consciousness raising and self-reevaluation. With nutrition and prevention education, the schools can raise student’s awareness of the obesity problem nationwide, and that there are ways students can help slow down the problem. Incorporating self-reevaluation will help the school assess how ready their students are in implementing changes to the school system.

Secondly, even if students consume the healthier foods offered at their schools, students will fail to choose healthier options outside of schools; thus, the maintenance period of the transtheoretical model will never be reached. For students who do not have innate rebellious behaviors, this policy will still not be effective because, again, it does not focus on any educational component. Students spend a third of their time in school, and the rest of their time either at home or somewhere else in their community. If students are consuming better foods in school because they have no other choice, then when they are outside of the school, they will revert back to their unhealthy eating behaviors because their freedom of choice is granted. One of the processes of change Prochaska mentioned is stimulus control (8). Stimulus control works by removing the culprit that causes the unwanted behavior. In this situation, it would be the unhealthy items in vending machines. Although the school is applying this component of the theory at school, at home and places in the community, this process is not used. Thus, the maintenance period will not be achieved; thereby counteracting the efforts done in schools.

Referring back to the educational component, if more nutrition education is given to both students and parents, then maybe, the maintenance period can be achieved. Aside from nutrition education, which was mentioned over and over again as an underlying insufficiency in causing nonconformity to the transtheoretical model, the concepts of Bandura’s Social Cognitive Theory can also aid the success of this policy if applied. Bandura’s Social Cognitive Theory states that learned behavior can be acquired through imitation and observation of others (15). In his research, he showed that children playing in a promoted peaceful environment continue to play peacefully, and children playing in a promoted aggressive environment continue to play aggressively. If this same theory is applied with the transtheroretical model in enforcing California’s policy, it may help slow down obesity rates. The Social Cognitive Theory can be applied by having the school’s faculty members, which are regarded highly by students, eat healthier food items or buying the healthier replacement options in vending machines.

Lastly, the final criticism of banning unhealthy foods in vending machines is that public health officials’ restrictive measures only accounts for one side of the obesity problem: energy intake; it does not consider the multifaceted problems of obesity, and it limits the action phase of the transtheoretical model. This paper has already addressed the issue of the policy being limited to only a school environment and some psychological behaviors, but not one of the major causes of obesity, which is physical inactivity. School officials are failing to address the problem of students not burning the extra amount of calories they consume. Logically, if schools are replacing unhealthy items with healthier options and if the students are consuming these healthier options, the calories are still there! It is just that these calories are healthier and contains essential vitamins. So that brings their student back to square one: gaining weight due to excessive consumption. The other end of the spectrum here is physical activity. If school officials are going to promote healthier eating, they might as well include physical activity into their curriculum. Most people believe that physical activity involves strenuous exercise. This is not the case; NIH defines physical activity as any type of exercise or movement (16). Instead of having study periods, schools can allow students to play outside on school grounds. If students live in unsafe neighborhoods, then they would not get this opportunity at home. Under close school supervision, children can play in the schoolyard and burn those extra calories. Of course, this is just one suggestion of physical activity. The combination of promoting healthy eating and physical activity will then be sufficient to succeed in the action phase of the transtheoretical model.

Thus far, this paper has shown the insufficiency of California Senate Bill 677. In summary, the bill does not conform to the theories of the transtheoretical model, fails to incorporate other theories of social and behavioral sciences, and violates the most basic concept of energy balance. The schools need to provide nutrition education for students, teachers, and parents. The schools should without question give reasons why they are making these sudden changes. Most importantly, the schools need to communicate with their students; let their students voice their opinions. There could be a variety of reasons why children are gaining weight, and schools can collect insight from the children’s voices. Even if the children are baffled by why they are gaining weight, at the very least, the school can raise awareness for their students. The bottom line is that obesity is caused by a variety of reasons, and one measure will not solve it.

In conclusion, there needs to be overlapping interventions reinforcing each other in hopes of one day reaching the goals of Healthy People 2010. The transtheoretical model is one of the many social sciences behavior models developed for public health. The Social Cognitive Theory was also mentioned in this paper. Though both models have its strengths and weaknesses, the combination of these two models and other models will help fight against obesity. Advertising Theory can also play a role in aiding Bill 677. Advertising the healthy replacement snacks during Saturday cartoons will help students gain brand images. When students see these snacks in school or at the supermarket, they will be more prompt to buy them and consume them. Instead of making sudden changes in schools, the schools should walk their students through every step of the way to change their behavior. After all, students are still children and they need guidance and sometimes a little push. Ingredients for success of California Senate Bill 677 include adding the educational component, extra physical activity time, model behaviors, and brand images. Though this calls for extra effort and funding, it may worth it when all is said and done.


References
1. Centers for Disease Control and Prevention. Overweight and Obesity. http://www.cdc.gov/nccdphp/dnpa/obesity/index.htm
2.Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services. Healthy People 2010. http://www.healthypeople.gov/Document/HTML/uih/uih_4.htm
3.USDA. National Lunch Program. http://www.fns.usda.gov/cnd/lunch/
4.Alliance for Healthier Generation. Go Healthy. http://www.healthiergeneration.org/
5.Gay, Lance. Parents angry USDA won't ban junk food. Scripps Howard News Service. 2005.
6.National Conference of State Legislature. Vending Machines at School. http://www.ncsl.org/programs/health/vending.htm
7.San Francisco Chronical. District takes cue from Oakland ban: L.A. schools to stop soda sales. August 28, 2002 http://sfgate.com/cgibin/article.cgi?f=/c/a/2002/08/28/MN144762.DTL
8. Prochaska, James O.; DiClemente, Carlo C.; Norcross, John C. In search of how people change. Applications to addictive behaviors. American Psychologist. 47(9), Sep 1992, 1102-1114.
9.Bridle, C. Riemsma, R. P. Pattenden, J.Sowden, A. J.Mather, L. Watt, I. S. Walker, A. Systematic review of the effectiveness of health behavior interventions based on the transtheoretical model. Psychology & Health; Jun2005, Vol. 20 Issue 3, p283-301, 19p
10.Spencer, L., Pagell, F., Hallion, M. E., & Adams, T. B. Applying the transtheoretical model to tobacco cessation and prevention: A review of literature. American Journal of Health Promotion, 2002, 17, 7–71.
11. Perz, C.A., DiClemente, C.C., & Carbonari, J.P. Doing the right Thing at the Right Time? The Interaction of Stages and Processes of Change in Successful Smoking Cessation. Health Psychology, 1996 15, 6, 462-468.
12.Sullivan, Victoria; Terris, Charlotte. Contemplating the stages of change measures for eating disorders. European Eating Disorders Review, Sep/Oct2001, Vol. 9 Issue 5, p287-291, 5p
13.Magdalena Sulich. Keeping Discipline in the Classroom. English Teaching Forum. 2004
14.Leah Davies. Rewards in the Classroom. http://www.kellybear.com/TeacherArticles/TeacherTip45.html
15.Bandura, A., Ross, D, & Ross, S. Transmission of aggression through imitation of aggressive models. Journal of Abnormal and Social Psychology, 1961, 63, 575-582.
16.NIH. Definition of Physical Activity. win.niddk.nih.gov/publications/glossary/MthruZ.htm

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