Challenging Dogma


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

Thursday, April 26, 2007

The Failure of Educational Campaigns to Prevent Childhood Obesity in the US: When Knowledge Isn’t Enough Power to Keep Kids Healthy –Joyce Alencherril

Childhood Obesity and Educational Campaigns

In 2004, there were over 12.5 million children who were overweight in the United States, or roughly 17% of youth between 2 and 19 years of age (1). Over the past thirty years, the prevalence of overweight has tripled for this age group (2). Children who are overweight have been found to be at higher risk for other health-related problems such as cardiovascular disease, Type 2 diabetes, and asthma (3). The Center for Disease Control and Prevention’s Healthy People 2010 initiative identified overweight and obesity as one of the top ten leading health indicators. However, attempts to reduce the proportion of children and adolescents who are overweight or obese have been met with little success. Efforts, both large and small, have been made in schools, homes, communities, and the media. Educational campaigns aimed at encouraging children to eat healthy have contributed to the failure of anti-obesity efforts.

In 2004, the Wellness, Academics, and You (WAY) Program was conducted in Delaware, Florida, Kansas, and North Carolina and included 1,013 fourth and fifth grade students (4). The WAY Program used a multidisciplinary approach to develop health attitudes while building academic skills. Activities were incorporated into the core curriculum subject areas such as language arts, mathematics, and science, designed with academic standards in mind. Body Mass Index (BMI), fruit and vegetable consumption, and physical activity were used to qualitatively measure the effects of the program between an intervention group and a control group. After a five-month period, the change in BMI was the only significant result, and minimal at that. Both groups increased their fruit and vegetable consumption, but were still below recommended levels. Physical activity levels also increased for both groups, although slightly more for the intervention group (4).

The WAY Program has been just one of many such educational campaigns. Others such as the Know Your Body Program in the Bronx and the Pathways Program in the Southwest used similar curriculum changes to promote healthier lifestyles and prevent obesity (5). Besides lacking any sort of long-term follow up to determine the sustainability of the program’s effects, programs aimed at simply providing knowledge to students suffer major weaknesses. By relying on the Theory of Reasoned Action, the WAY Program and others ignore the interpersonal, institutional, and environmental barriers that may still prevent the promotion of healthy behavior.

The Theory of Reasoned Action

The Theory of Reasoned Action is based on the belief that a person’s intentions to act are determined by two things: the person’s attitude towards a behavior and the perceived social norms regarding that behavior. Fishbein and Ajzen define attitude as “a learned predisposition to respond to an object in a consistently favorable or unfavorable manner.” Knowledge can thus have an impact on one’s individual attitude. Furthermore, if one feels that other people would respond favorably to a particular behavior, one would be more likely to have the intention to act in a certain way. It then follows that if a person intends to behave in a certain way, he/she will do so (6). Programs based on the Theory of Reasoned Action have been used to influence behaviors relating to tobacco use, physical activity, and science learning. The WAY Program similarly was based on the Theory of Reasoned Action. By engaging students in learning modules that enhanced their understanding of critical health issues and examined their beliefs and behaviors (knowledge), the program was thought to directly influence students’ attitudes about healthier behaviors. By addressing the students amongst a group of their peers, the program attempted to alter the students’ perception of social norms so as to give them the awareness that a healthy lifestyle was important and acceptable (4). However, even the short-term results of the study showed no significant changes in students’ behavior related to fruit consumption and physical activity. To this end, the Theory of Reasoned Action ignores several important factors that might also play a part in determining one’s behavior, namely the family’s attitude towards healthy eating, the school’s provision of healthy food, and the media’s advertising of unhealthy foods and promotion of sedentary lifestyle. Together, these factors present a considerable barrier to any anti-obesity program based on the theory of reasoned action.

Interpersonal Barriers – Family Attitudes

As important as the knowledge to eat healthy is, it is useless if students are not able to put it into practice. Obesity rates have been found to be highest among the most disadvantaged groups: those with low incomes, low education, and minorities (7). Children and their parents may lack the resources (time, money) to eat healthy at home and reinforce what was learned at school. Drewnowski and Darmon propose that food choices are made on the basis of taste, cost, convenience, and, to a lesser extent, health and variety (8). Taste describes the sensory appeal of certain foods. Cost refers to the purchase cost per unit of energy. Convenience denotes the time spent on buying, preparing, and cooking food. These three qualities are related in that energy dense foods that provide more energy per unit weight tend to be more palatable, cheaper, and convenient. In addition, palatable, energy-dense foods are associated with diminished satiation and leaving people to feel less full. The result is overeating, reinforced by foods that provide more sensory enjoyment and pleasure. Diets of lower-income households tend to be composed of cheap, concentrated energy from fat, sugar, cereals, potatoes, and meat products, and were scarce in terms of whole grains, vegetables, and fruit (8). Low-income consumers also tend to frequent fast-food restaurants over full-service restaurants and live in areas with less physical access to healthier food (7, 8).

Furthermore, although children are being taught how to eat healthy, their parents might not have this same sense of awareness. Insufficient knowledge about healthy nutrition and unhealthy eating behaviors on the part of the parent are likely to affect the eating behaviors of children. For example, many parents traditionally pressure children to “clear their plate”, which may promote overeating. Conversely, when children begin to show signs of overweight, parents might react by restricting certain junk foods, which then increases the preference for these foods and results in additional weight gain. Some parents express frustration when their children refuse to eat new foods. However, while initial rejection of unknown food by children is normal, studies show that five to ten exposures to new foods may be needed before they are accepted (9). When exposure is initiated by parents, children’s acceptance of vegetables has been found to increase (10). Such early exposure is likely to affect children’s decision making when they are older and more independent to make their own food choices. In this way, parents are important vehicles in shaping children’s food choices in both the short and long term.

Institutional Barriers – Schools

Schools are an important component in the primary prevention of childhood obesity because of its predominance in the lives of youth: 6-8 hours of the day are spent at school and 1-2 meals are consumed in schools. However, many students can sit through a class where they learn the importance of eating healthy and counting calories, only to go to the cafeteria and be faced with unhealthy options like French fries, soda, and candy bars. These mixed messages can negate any potential effects of health education, providing no outlet for students to apply what they’ve learned. However, the issue is more complex than simply removing junk food from the lunch line. Some parents and school administrators, panicked by the rising rates of child obesity and diabetes, say schools should provide the model of healthy eating. Others say such changes take away the right of children to make autonomous decisions and aren’t feasible on a broad scale (11,12). For example, school districts that qualify for federally subsidized school lunches generally have less discretion on what foods can be offered because they rely on products provided by the government. Furthermore, many schools rely on the sponsorship of soft-drink companies for resources like scoreboards and desks in exchange for having vending machines that sell soft drinks and unhealthy snacks.

Change has been slow in coming. By September 2007, most schools in New Jersey will have banned soda, candy, and foods listing sugar as the first or principal ingredient (11). Connecticut is several steps behind, attempting to pass legislation that would restrict the sale of soda and snack foods from kindergarten through high school (11). The bill was vetoed by the Governor, but nutritional guidelines are to be issued by the state education commissioner for the school districts. Legislation in New York seems to be under even more resistance, namely by the State School Boards Association which argues that food and health issues should be made by local officials, not the state (11).

Equally important (and lacking) is that schools emphasize the importance of physical activity in addition to healthy eating. In contrast, however, many schools have been following the trend of reducing the amount of physical education provided. A 2000 survey found that 8% of elementary schools, 6.4% of middle/junior high schools, and 5.8% of high schools provided daily physical education (13). In addition to physical education, schools should expand physical activity opportunities such as intramural and noncompetitive sports.

Environmental Barriers - Media

One of the hardest factors to control in the anti-obesity movement has been the media. The explosion in media targeted to children in recent years has adversely affected obesity prevention by promoting a sedentary lifestyle and making children vulnerable to advertising campaigns that promote junk food. After 6-8 hours of school, children spend an average of five and a half hours a day using the media in its various forms: television shows, movies, video games, computer activities, and Internet Web sites (14). As far back as 1985, Dietz and Gortmaker found that, after controlling for prior obesity, race, and socio-economic status, the prevalence of obesity among 12-17 year olds increased by 2% for each additional hour of television viewed (15). The Framingham Children’s Study published in 2003 found a relationship between children’s weight and the time that they spent with media, after following 100 children from early childhood into adolescence (16).

In all those hours spent using media, children watch an estimated 4,900 food commercials a year (12). Many of those ads are for candy, high-sugar cereals, and fast food. Using catchy songs and popular celebrities, these ads promote eating unhealthy foods as well as asking mom and dad to buy high sugar, low fiber foods from the grocery store. One study found that the amount of television viewing was significantly related to caloric intake and the number of requests to parents to purchase specific foods as seen advertised on television (16). Advertising and marketing campaigns are succeeding in their attempts to have children buy-into their products. If only educational campaigns could be as successful.

Educational campaigns to prevent obesity are important in that they provide the knowledge necessary to know how to eat healthy. However, they are only the beginning. Educational campaigns need to be integrated together with other components such as improved access to and knowledge of healthy foods for families, funding for schools to provide healthy meals and physical education, and restrictions on the media’s influence in making unhealthy decisions. Knowledge is power, but it’s not enough.

REFERENCES:

1. Centers for Disease Control and Prevention/National Center for Health Statistics. Obesity still a major problem. April 2006. Available at: http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/index.htm.

2. Centers for Disease Control and Prevention. Obesity and Overweight: Introduction. Available at: http://www.cdc.gov/nccdphp/dnpa/obesity/index.htm

3. Centers for Disease Control and Prevention. Obesity and Overweight: Consequences. Available at: http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/consequences.htm

4. Spiegel SA, Foulk D. Reducing overweight thru a multidisciplinary school-based intervention. Obesity 2006; 14(1): 88-96.

5. Budd GM and Volpe SL. School-based obesity prevention: research, challenges, and recommendations. Journal of School Health 2006; 76(10): 485-95.

6. Theory of Reasoned Action. Wikipedia. Available at: http://en.wikipedia.org/wiki/Theory_of_reasoned_action

7. Drewnowski A and Specter SE. Poverty and obesity: the role of energy density and energy costs. American Journal of Clinical Nutrition 2004; 79: 6-16.

8. Drewnowski A and Darmon N. The economics of obesity: dietary energy density and energy cost. American Journal of Clinical Nutrition 2005; 82: 265S-73S.

9. Wabitsch M. Preventing Obesity in Young Children. In: Tremblay RE, Barr RG, Peters RDeV, eds. Encyclopedia on Early Childhood Development [online]. Montreal, Quebec: Centre of Excellence for Early Childhood Development; 2006: 1-12. Available at: http://www.excellence-earlychildhood.ca/documents/WabitschANGxp.pdf.

10. Wardle J, Cooke LJ, Gibson EL, Sapochnik M, Sheiham A, Lawson M. Increasing children’s acceptance of vegetables; a randomised trial of parent-led exposure. Appetite 2003; 40 (2): 155-162.

11. Lombardi KS. A Cafeteria Food Fight Over Health. The New York Times February 26, 2006.

12. Santora M. East Meets West, Adding Pounds and Peril. The New York Times January 12, 2006

13. Institute of Medicine of the National Academies. Schools Can Play a Role in Preventing Childhood Obesity. Fact Sheet from Preventing Childhood Obesity: Health in the Balance 2005. Available at: http://www.iom.edu/Object.File/Master/22/615/Fact%20Sheet%20-%20Schools%20FINALBitticks.pdf

14. Roberts D and Foehr U. Kids & Media in America (Cambridge, MA: University Press, 2004).

15. Dietz W and Gortmaker S. Do we fatten our children at the TV set? Obesity and television viewing in children and adolescents. Pediatrics 1993; 91: 499-500.

16. The Henry J. Kaiser Family Foundation. The Role of Media in Childhood Obesity. Issue Brief February 2004. Available at: http://www.kff.org/entmedia/upload/The-Role-Of-Media-in-Childhood-Obesity.pdf.

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