Challenging Dogma


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

Wednesday, April 25, 2007

Public Health’s Failure to Mobilize and Empower Parents in the Fight against Childhood Obesity – Christine Peloquin

Childhood obesity is the new buzzword floating in the minds of American parents. The trend of increasing numbers of overweight and obese children and teen-agers can no longer be ignored. The prevalence of child and adolescent obesity has tripled in the last 25 years (3). This increase is startling because of the fact that almost 80% of over overweight children will grow into obese adults (5). Study after study has shown that childhood obesity is linked with an increased risk for diabetes, heart disease and cancer later in life (1, 4).
On the simplest, bare-bones level, obesity can occur when the intake of calories consistently exceeds the energy output from the body during daily life and physical activity. However, once you move beyond this simplistic math equation, the problem of childhood obesity becomes extremely complicated. The determinants of childhood obesity are numerous, multi-faceted and multi-leveled. Debate and controversy abound.


Historical and current public health interventions
Public health’s fight against childhood obesity began with assessing and intervening at the level of the individual. During these initial interventions focused on individual health behaviors, it is easy to imagine how this focus on behavioral risk factors created an atmosphere of blame and shame for parents. The problem compounded as parents began to experience feelings of despondency and a lack of confidence when they realized that, even with their best efforts, they could not prevent childhood obesity on their own. There were just too many things outside of their control, including the school, the media, the community, and peer influence. Public health was setting up parents to fail without the appropriate changes to school, media, culture, and legislation.

Public health practitioners realized this and changed approaches accordingly. The public health approach to reduce childhood obesity rightly and successfully evolved to the level of societal factors. Numerous interventions now are developed using a population-based approach and are geared towards toward social, governmental, and cultural organizations. States are banning the sale of soft drinks and junk food in schools. Town, state and federal governments are regulating school lunches and requiring more fresh fruit, vegetables, and whole grains. There is strong interest in regulating the food advertisements geared to children on television. There is pressure on school systems to reintroduce physical education or increase its level. Close to 400 obesity-related bills hit the floor in state legislatures last year (3).

These efforts are wonderful to witness and should be loudly applauded. We need these interventions to continue. However, to combat childhood obesity, we need interventions at all levels, including interventions aimed at changing parents’ behavior. It seems that, in an effort to move away from blaming parents for overweight children, public health has thrown out the baby with the bath water. Public health has failed to realize that, even with all the societal changes, childhood obesity cannot be combattted if parents are not part of the solution. Childhood obesity will continue to increase if public health continues to fail to mobilize parents and get them on board. Too many variables are under the parents’ control, especially in children’s first 12 years of life. The realm of parents’ influence includes what types of food are in the home, what is served for dinner, transportation to restaurants, and money for restaurants, as well as physical activity in the hours not spent at school or childcare. More importantly, parents are role models and shape children’s overall attitudes towards food and physical activity.

Public health’s campaign against childhood obesity needs to move from an atmosphere of blaming parents to an atmosphere of empowering parents. Public health needs to frame the anti-obesity message so it literally beckons to parents. Parents need to know that the United States cannot win the war against fat without them. Public health has failed to acknowledge, respect, and honor parents’ influence on their children, and, because of that failure, its campaign against childhood obesity is not succeeding. Public health has not given parents the tools, vision, and self-confidence to prevent and overcome childhood obesity.

Stalled campaign: Failure to change the level of focus from assessment and identification to intervention
The public health approach to combat obesity has succeeded in raising the nation’s awareness and consciousness. In addition to the public health specter, commercial magazines, newspapers, news programs, and television programs have jumped on board. It is hard for a few days to pass without hearing something about childhood obesity. The message that childhood obesity is a problem has been effectively given and effectively received.

Public health interventions aimed at parents focus on educating parents on the risks of obesity and the changes that need to be made. While this was necessary in the earlier childhood obesity campaigns and should always be some component of public health campaigns, parents need more than that now. The majority of parents realize child obesity leads to increased health risks now and later in life. The majority of parents with an obese child realize the child is obese without a body mass index indicator on a report card to inform them. What most parents do not know how to do is to make the necessary changes happen, and, more importantly, how to sustain these health behavior changes. The public health obesity campaign has stalled by failing to change the level of focus of the obesity epidemic message from one of assessment and identification to one of intervention.

Parents need a vision: Failure to incorporate advertising theory
Childhood obesity is a multi-faceted issue that needs a new vision. It has been said that one of the problems with disease prevention and encouraging health behaviors to promote disease prevention is that prevention has no face. Similarly, the anti-obesity campaign has ‘no face’, or more accurately, it has a negative one. When one thinks of the war against childhood obesity, visions of grossly overweight children zoned out in front of Nintendo flash in one’s head.

Public health has failed to utilize advertising theory. It has failed to remember that people are motivated by the feelings they anticipate will occur as a result of an action (8). Public health’s failure to throw a positive spin on healthy family lifestyles makes one wonder if public health has failed to see the obvious -- that there is something enticing in an anti-obesity lifestyle that would appeal to parents. What could be more rewarding than raising children in a an intentional and thought-out way? There is a lot of joy to be found in cooking with your kids, eating dinner with your children, taking walks together, and kicking the soccer ball around as the sun goes down. While prevention might not have a face, happiness, pleasure and accomplishment do and the public health campaign is not portraying that face.

As parents think, so they do. As parents model, so children act: Failure to incorporate social cognitive theory
Social cognitive theory stresses that inner cognition needs to change before behavior can be changed (7). Attractive, accessible images subtly deposited in a parent’s mind by effective visual ad campaigns could lead to a parent’s change in thinking. A change of thinking could then lead to a change in behavior, which in turn could lead to healthy, active children.

Another facet of social cognitive theory that public health has not embraced is its concept that a person’s behavior is strongly influenced by watching another person perform the behavior (2). This concept has been iterated in endless parenting advice books through the generations. Children, especially teen-agers, are more influenced by what their parents do, rather than what parents say. If parents want children to eat healthy and exercise daily, parents need to model this behavior. As only 19% of adults get an acceptable level of physical activity daily, parents are going to have to change themselves if they hope to help their children live healthy lives (6). Public health is doing a disservice to parents by not stressing that parents must model the behavior they want to see in their children.

Down and out on confidence: Failure to consider self-efficacy
Parents need to know that there are models for behavior change and they need to know which models have proven to be successful and which models have failed time and time again. How many parents have probably berated themselves when, while trying to list the five vegetable and fruit servings on a ‘Strive for Five’ form sent home from school, they struggle to list two servings a day? The parent automatically feels there is something wrong with her or him and immediately starts heading down a self-fulfilling spiral of not being capable of raising healthy, thin, and active children. Would this same parent have a different attitude if they knew that intention is not enough to change behavior and that, for the majority of people over the years, intention alone has not worked? Let parents realize that they are not failing due to their personal weaknesses, flaws, and lack of self-discipline.

The self-efficacy model states that a person’s belief that he/she is capable of performing a desired behavior plays a large role in determining the person’s success at performing the behavior (9). By failing to incorporate this model of self-efficacy, the public health anti-obesity campaign has done little to convince parents that they are up to the task. All the messages have been negative. From billboards with obese children on scales with the uplifting ‘Fat Chance’ slogan in Massachusetts to the back of a bus in California splattered with an image of an overweight ‘tween girl’s lap and upper legs, parents have been bombarded with the negative. Whether or not these print campaigns were designed as a scare tactic, they can take a toll on parents’ confidence, not to mention the delicate self-esteem of an overweight adolescent. Public health has failed to equip parents with the self-assurance that they can prevent their children from being overweight.

But how? Failure to recognize that parents are the experts on parents and failure to utilize the “Tools to Action” model
Public health has failed to incorporate many social sciences techniques, such as surveys, interviews, and focus groups, which have been proven effective in other fields. Remembering that often the targeted group is not consulted on how they perceive the problem and the barriers that they face, I conducted an informal email survey to 25 families with school-aged children in MetroWest Boston. It included three questions asking about the barriers they face to eating healthy food as a family, to parents exercising daily, and to children getting enough physical activity daily. The survey was still informative despite the fact that these families are not encountering the same societal level barriers to good nutrition and adequate physical activity as families from lower socioeconomic communities face. Cost of fresh fruit and produce, access to grocery stores, and safe neighborhoods in which to play and walk to school were not obstacles. The survey pointed out that even with many societal-level obstacles removed, families still encounter obstacles on the individual, behavioral level. While the survey indicated that there were no problems with children getting enough daily physical activity, these families were still coming up short in respect to serving nutritious meals day after day.

Barriers reported included lack of knowledge of meal-planning, not enough time to grocery shop, lack of confidence in cooking ability, limited repertoire of recipes, inability to stay committed to good nutrition week after week, and problems with making nutrition a priority in their lives. Response after response indicated parents have good intentions but were unable to consistently act upon those intentions. It might sound overly simplistic, but American parents could use help with meal-planning, recipes, and knowing a wide variety of healthy snack options. Public health seems to have made an incorrect assumption that all parents have the skills to be good cooks and experienced meal planners. Public health has failed to ask parents where they need help. An inexpensive solution such as a website, updated weekly, with a weekly menu plan including snacks and a corresponding grocery shopping list could deliver a lot of bang for the buck. The current public health approach has failed to take advantage of the “tools to action” model which purports that the key to taking action is having the tools to translate intention into action.

No one said this was going to be hard: Failure to set realistic expectations
Childhood obesity interventions aimed at parents are often framed as a laundry list of small items which sound deceptively easy to do: forbid soft drinks, serve whole grain foods, ban sugar, limit television, play sports with your child, cook homemade meals, avoid fast-food restaurants, and on and on. Sadly, to today’s busy and overtaxed parents, these interventions can read as just another one of the many long to-do lists, soon to be discarded with too few items checked off.

This public health approach has been a disservice to parents by downplaying the commitment required to cultivate a family lifestyle of wellness. There are costs involved on many levels. It is going to take time. It is going to take energy. It is going to take money. Most likely, something is going to have to go to fit in this new health-focused lifestyle. Maybe some of the children’s activities will have to be dropped. Maybe there will be less money for vacation or toys. Maybe parents will have to work fewer hours or modify their work schedule.

The concept of limited resources applies to families. The majority of families cannot add this layer of additional responsibilities without removing something else. The failure of pubic health to point out this reality to parents has resulted in parents failing when they try to take on these new tasks above and beyond their current responsibilities. More devastatingly, public health’s failure to indicate the level of commitment involved has resulted in parents blaming themselves for their failures and deciding that it is a lost cause.

Conclusion
If public health wants to succeed at reducing and preventing childhood obesity, the approach needs to be multi-faceted and multi-layered with interventions at all levels and focused on all many arenas including schools, media, government, and parents. While public health is succeeding with many of the societal –level interventions, the overall campaign is failing because public health has failed to effectively design interventions geared towards parents. The interventions have failed to take advantage of the advertising theory and social cognitive models. The concept of self-efficacy in parents has been ignored. The interventions have not been framed in a manner that respects parents’ intelligence and ability to raise children.

Today’s parents need hope. Today’s parents need a new vision. Today’s parents need to realize they are an integral players in their children’s health outcomes. The fight against childhood obesity needs them; let’s invite the parents and empower them with the necessary tools, resources, and confidence.

REFERENCES
1.Budd GM. Childhood obesity: determinant, prevention, and treatment. Journal of Cardiovascular Nursing 2006; 21(6):43741.
2.University of Twente. Social Cognitive Theory.
http://www.tcw.utwente.nl/theorieenoverzicht/Theory%20clusters/Health%20Communication/Social_cognitive_theory.doc/
3. Tumulty, Karen. The Politics of Fat. Time Magazine 2006: March 19.
4. CDC. Healthy Youth!.
http://www.cdc.gov/HealthyYouth/
overweight/index.htm
5. Action for Healthy Kids. http://www.actionforhealthykids.org/.
6.Department of Health and Human Services. The President’s Council on Physical Fitness and Sports.
www.fitness.gov/activity_levels.htm.
7.University of Twente. Social Cognitive Theory.
http://www.tcw.utwente.nl/theorieenoverzicht/Theory%20clusters/Health%20Communication/Social_cognitive_theory.doc/
8.Illuminations. Toward a Critical Theory of Advertising.
http://www.uta.edu/huma/illuminations/kell6.htm.
9. Pajares, Frank. (2002) Overview of Social Cognitive Theory and of Self-Efficacy. Emory University. http://www.des.emory.edu/mfp/eff.html

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