Challenging Dogma


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

Thursday, April 19, 2007

“Fat Chance”: A Massachusetts Community’s Flawed Public Health Intervention Towards Childhood Obesity – Rachel Sayko Adams

In January of 2007 the Metro-West Community Healthcare Foundation launched a $250,000 public awareness campaign to combat childhood obesity (1). The campaign included billboards, television advertisements, print advertisements, an informational website (www.metrowestkids.org), grants to schools, community centers, and social service groups for nutrition, fitness and health education programs aimed at reducing childhood obesity (1-2). The focus of the campaign centered on a billboard that the Foundation designed to get the attention of parents of obese children. The billboard depicted a picture of the legs of an overweight child standing on a scale, alongside the words: “Fat Chance: Obese children are a good bet for type 2 diabetes, heart disease, stroke, cancer, sleep apnea and depression” (3). Despite the merit and educational value of many aspects of the Metro-West Community Healthcare Foundation’s campaign, the negative picture that the “Fat Chance” billboard painted regarding childhood obesity overshadowed the potential positive components of the campaign. The Metro-West Community Healthcare Foundation’s public awareness campaign to combat childhood obesity, centered on the “Fat Chance” billboard, is a flawed public health intervention because it failed to take into account Social Cognitive Theory and the value self-efficacy.

The Metro-West Community Healthcare Foundation’s public awareness campaign relies on an overused and often flawed public health model – the Health Belief Model. The Health Belief Model was developed to explain health-related behavior at the level of the individual decision maker (4). The model contends that when individuals are thinking about making a decision regarding health behavior, that they weigh their perceived susceptibility of poor health outcomes and the perceived severity of the poor health outcomes against perceived barriers to action. If the perceived benefits outweigh the costs (barriers), individuals will rationally intend to do the behavior, and will therefore act.

By relying on the Health Belief Model, the Foundation has assumed that the “Fat Chance” billboard will effectively reduce childhood obesity by shocking the parents of obese children into action with the image of the obese child on the billboard (perceived susceptibility of obesity) along side the dreary list of negative health outcomes for their child (perceived severity of poor health outcomes), and consequently decide to act by changing the dietary and exercise habits of their children. The “Fat Chance” billboard and its use of the Health Belief Model is a flawed public awareness campaign because it fails to address the following issues: socioeconomic factors that affect children’s eating and exercise behaviors; the need to provide parents of obese children with the education and tools to be able to change their children’s eating and exercise habits; and cultural and societal influences that affect the eating behaviors and weight of children. By ignoring these key factors related to parent’s ability to promote health and reduce obesity among their children, the “Fat Chance” billboard denied parents self-efficacy.

Ignoring Socioeconomic Factors Related to Eating and Exercising
The “Fat Chance” billboard campaign did not acknowledge that socioeconomic factors impact eating and exercise behaviors of children. It is well documented in numerous research studies that individuals with low-incomes often cannot afford healthy food options such as fruit and vegetables. Often, low-income communities do not have grocery stores that carry a variety of healthy food options. And in addition, fruit and vegetables are often priced too high for low-income families to be able to afford. Rather, food choices that are within the price range of low-income individuals are often more processed foods, high in fat and cholesterol. Sallis and Glanz argue, “A lack of access to and the high costs of fruits, vegetables, and other nutritious foods may keep children from consuming them” (5). In a recent study by Kumanyika and Grier they discussed how the higher prices of healthy foods affect low-income individual’s eating habits. They said, “Families need more protection from the ‘invisible hand of the free market’ as the primary determinant of affordable, accessible, and healthful food options” (6). Additionally, James reported on a study done with African Americans that, “Several participants said the cost of food, especially fruits, vegetables, meats, and cereals, prevents many African Americans from eating healthfully” (7).

Kumanika and Grier present another example of how socioeconomic status affects children’s dietary habits. They point out that, “The view that a ‘fat child is a healthy child’ or that children’s weight follows a natural trajectory where heavy children will ‘grow out of it’ may be more common among families that are food insecure or where hunger concerns are part of a group’s identity” (6). This belief about a ‘fat child is a healthy child,’ which often correlates to families where food is scare, reflects how socioeconomic status affects eating behaviors and attitudes towards eating and what is healthy.

Socioeconomic status also affects children’s access to physical activity. In many low-income communities there have been reductions in gym and physical fitness activities in schools due to budget cuts. Access to health and recreation facilities can be a barrier for those living in low-income communities. Sallis et al. demonstrate that children and adolescents with access to recreational facilities and programs, usually near there are homes, are more active than those without such access (8). In addition, the safety of a community can affect children’s ability to be physically active outdoors. Sallis and Glanz point out that, “Without safe places to play near home, for example, children may spend more time being inactive indoors” (5). It is often true that lower-income communities are less safe than higher-income communities, and therefore, this would once again limit children living in low-income communities from opportunities for physical activity.

The research demonstrates that there are numerous socioeconomic factors that have a negative impact on the ability of low-income children to eat healthy and be physically active. The “Fat Chance” billboard ignores these socioeconomic factors that impact childhood obesity and rather focuses on shocking parents of obese children with the negative consequences that their children might suffer from; leaving them to feel guilty and without any new resources to believe that they can successfully help their children.

Overlooking the Importance of Educational Tools
By focusing on childhood obesity rather than nutrition and health, the Metro-West Community Healthcare Foundation’s “Fat Chance” billboard steered parents of obese children away from learning about methods and opportunities for improving their child’s nutrition and exercise habits. For many parents of obese children, the billboard likely made them pessimistic about their child’s ability to overcome obesity. The words, “Fat Chance” on the billboard imply that there is an unlikely chance that an obese child can avoid eventually suffering from the list of negative health outcomes, such as heart disease. The words do not give parents the belief that they have reason to be optimistic and believe that they can help their children lead a healthy lifestyle; thus presenting a barrier to self-efficacy. Because of the negative campaign, many parents will not pay particular attention to the small print on the billboard that directs them to the informational website, www.metrowestkids.com, which would provide them with useful information regarding nutrition and exercise for their children.

Parents are in a unique position of being able to positively influence their children’s eating habits and physical activity patterns, however, they first need to be provided with proper education about nutrition and health before automatically knowing how to incorporate these practices into their family life. According to Lindsay et al., “By better understanding their own role in influencing their child’s dietary practices, physical activity, sedentary behaviors, and ultimately weight status, parents can learn how to create a healthful nutrition environment in their home, provide opportunities for physical activity, discourage sedentary behaviors such as TV viewing, and serve as role models themselves” (9). In fact, studies show that parents would like more information about how to help their children foster a healthy eating and lifestyle pattern. In a study by Green et al., they found that, “Parents, as a generation in particular, felt the need for more access to education and support regarding healthy limits for pre-puberty and puberty stages” (10).

The Foundation’s “Fat Chance” billboard did not focus on providing parents with information about how to positively help their children to lead a healthy lifestyle. The negative focus of the billboard will lead many parents of obese children to turn away from the image with feelings of shame and fear that their child might develop the negative health consequences listed on the billboard: drawing their attention away from the website directing them to useful educational tools to know how to help their children.

Discounting Cultural and Societal Influences
By relying on the Health Belief Model to design the “Fat Chance” billboard the campaign suggests that obesity is only related to individual choices made by children and their parents, in terms of the child’s behavior, and their parent’s influence on them. The billboard does not acknowledge any societal or cultural factors that have a direct impact on what children eat and their physical activity levels, but rather, shifts the blame to the parents to be solely responsible for their overweight children. In a study done by the Kaiser Family Foundation in 2004, the Foundation contends that experts have pointed to a number of contributors to the rise of childhood obesity, including, “a reduction in physical education classes and after-school athletic programs, an increase in the availability of sodas and snacks in public schools, the growth in the number of fast-food outlets across the country, the trend toward ‘super-sizing’ food portions in restaurants, and the increasing number of highly processed high-calorie and high-fat grocery products” (11). It is important to note that none of these factors identified by experts as contributors to childhood obesity are directly caused or controlled by parents of obese children. The factors all represent societal influences on children related to eating and physical activity. The “Fat Chance” billboard does not directly address any of these contributors to childhood obesity.

In addition to the factors listed above, we know that children are bombarded with media advertisements and societal pressures that encourage them to desire food and drinks that are high in sugar and relatively low in nutritional value. A USA Today article in March 2007 reported on a recent study by the Institute of Medicine which showed that more than $10 billion a year is spent to market foods and beverages to children, mostly for products not considered nutritious (12). This highlights an additional factor that influences the types of food and beverages that children want to eat in the U.S.

It is also important to acknowledge that eating and diet is largely affected by culture and tradition. According to Bruss et al., “Sociocultural messages reflect historical influences and social experiences impacting caregivers’ perceptions of child feeding. It is within informal forms of communication that messages are sent regarding particular attitudes, beliefs, and values places on certain foods and eating patterns” (13). Public health interventions that ignore cultural influences will miss a large piece of the picture regarding nutrition and physical activity of children. For many ethnic groups, cultural norms surrounding eating include foods that are high in fat and cholesterol. Therefore, public health interventions, which condemn foods high in fat and cholesterol can be misinterpreted as criticizing the cultural practices of particular people, unless carried out with cultural sensitivity. According to a study conducted by James with African Americans, “There was a general perception that ‘eating healthy’ meant giving up part of their cultural heritage and trying to conform to the dominant culture (7).” James listed other cultural barriers to eating a healthful diet among the African American respondents as: no sense of urgency, the social and cultural symbolism of certain foods, the poor taste of ‘healthy’ foods, the expense of ‘healthy’ foods, and lack of information (7).

James summed up the need for public health campaigns to be culturally sensitive by stating that, “Individuals must believe nutrition education and health messages are relevant to them and their loved ones for them to want to make changes” (7). The “Fat Chance” billboard completely ignored cultural and societal impacts on childhood obesity and rather approached the problem as one that is caused by individual behavior.

Conclusion
By relying on the Health Belief Model to design the “Fat Chance” public awareness campaign, the Metro-West Community Healthcare Foundation missed an opportunity to approach childhood obesity from a framework that acknowledges social, cultural and socioeconomic influences on eating and physical activity for children. The Foundation chose to target the billboard towards parents of obese children; assuming that parents have the sole power to change their children’s eating and exercise habits. While parents do have some control over what their children eat and their activity levels, they first need: access to affordable and healthy food choices and safe environments where their kids can exercise; education and resources regarding nutrition and recommended exercise activities, and culturally sensitive interventions designed to be respectful of sociocultural attitudes related to eating and weight.

The Metro-West Community Health Care Foundation should move forward with its important mission of reducing childhood obesity by re-developing a public awareness campaign that provides parents with the educational tools to help create a healthier lifestyle for their children. The Foundation should partner with the schools in the community to create educational seminars for parents and children regarding nutrition and exercise. They should develop a monthly newsletter to send home to parents with culturally sensitive ideas for eating healthy and exercising, as well as ideas for affordable recipes and foods. The Foundation should sponsor after-school and weekend activities that provide opportunities for physical activity for children and their parents. Lastly, after the new public awareness campaign is in full motion and parents have received a great deal of educational information about how to help create healthier eating and exercise habits for their children, the Foundation should sponsor a new billboard which focuses on parents enjoying time with their healthy and happy children while eating nutritious foods and being physically active; demonstrating to parents that they do have the efficacy to be able to positively influence their children’s eating and health.

References
1. Drake J. Obesity ads aim to jolt parents. Goal: Improve children’s health. The Boston Globe. Boston, MA: January 28, 2007.
2. The MetroWest Community Health Care Foundation. Foundation Launches Campaign to Address Childhood Obesity. http://mchcf.org/special_initiatives/obesity.
3. Manuse A. Spotlight on parents of overweight kids. The MetroWest Daily News. Framingham, MA: January 28, 2007.
4. Salazar MK. Comparison of Four Behavioral Theories: A Literature Review. AAOHN Journal 1991; 39:128-135.
5. Sallis J. and Glanz K. The Role of Built Environments in Physical Activity, Eating, and Obesity in Childhood. The Future of Children 2006; 16:89-108.
6. Kumanyika S. and Grier S. Targeting Interventions for Ethnic Minority and Low-Income Populations. The Future of Children 2006; 16:187-207.
7. James D. Factors Influencing Food Choices, Dietary Intake, and Nutrition-Related Attitudes among African Americans: Application of a Culturally Sensitive Model. Ethnicity & Health 2004; 9:349-367.
8. Sallis J., Prochaska J., and Taylor W. A Review of Correlates of Physical Activity of Children and Adolescents. Medicine and Science in Sports and Exercise 2000; 32: 963-75.
9. Lindsay A., Sussner K., Kim J., and Gortmaker S. The Role of Parents in Preventing Childhood Obesity. The Future of Children 2006; 16: 169-186.
10. Green J., Waters E., Haikerwal A., O’Neill C., Raman S., Booth M., and Gibbons K. Social, cultural and environmental influences on child activity and eating in Australian migrant communities. Child: Care, Health & Development 2003; 29:441-448.
11. The Henry J. Kaiser Family Foundation. The Role of Media in Childhood Obesity. Menlo Park, CA: February 2004.
12. Hellmich N. No sugar-coating this: Kids besieged by food ads. USA Today. March 28, 2007.
13. Bruss M., Morris J., Dannison L., Orbe M., Quitugua J., and Palacios R. Food, Culture, and Family: Exploring the Coordinated Management of Meaning Regarding Childhood Obesity. Health Communication 2005; 18:155-175.

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