Challenging Dogma

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

Saturday, April 21, 2007

Why Current Public Health Approaches Aimed at Decreasing Childhood Overweight are Failing – Frankie Powell

Childhood overweight is a serious public health concern in today’s society. It is associated with a plethora of health complications (1), including increased risk of death from cardiovascular complications (2) and type 2 diabetes (3). The latter has become an increasing concern in some populations, with adolescents now comprising as many a half of new type 2 diabetes diagnoses, and this trend has been linked to an increasing prevalence of childhood overweight (4). Indeed, this increase has been documented in the United States, where the prevalence of childhood overweight has more than quadrupled since 1966 (5). This trend has been observed not only in the United States, but in other parts of the world as well (1).

In the face of data like these, it is obvious that something needs to be done. Interestingly, there have been public health programs implemented to combat childhood overweight for some time, including the Nutrition and Physical Activity Program to Prevent Obesity and other Chronic Diseases (NPAO), an effort implemented by the Centers for Disease Control and Prevention (CDC) since 1999. However, the program and others like it are is clearly not effective in reducing childhood overweight, as per the above data.

There are several reasons for this observation, which are all related by one principle: current public health approaches to reduce childhood overweight are aimed only at the individual and fail to take into account social norms and environmental factors that contribute to the condition. In addition, the current approaches can actually be detrimental, in that they lead to an increase in disordered eating. There is a need to revamp the public health approach to combating childhood overweight and to look at the bigger picture, not the individual, in order to reduce it.

The NPAO is a program that funds the health departments of 28 states, with the aim to “prevent and control obesity” through the promotion of physical activity and good nutrition (6). Although the program has been in effect since 1999, the prevalence of obesity continues to rise (5). This result makes it clear that the NPAO is failing in its mission. The reason for this outcome is not because the NPAO’s tactics are grounded in false beliefs. In fact, it has been made very clear that physical activity and good nutrition are necessary to maintain a healthy lifestyle and have an inverse relationship to obesity (7).

The reason for failure lies in the approach taken by the funded programs to achieve their goals. Specifically, the programs target individual-level behaviors, when the key to success lies in changing social norms and environmental factors that contribute to childhood overweight (8).

Access and Cost

The growing popularity of eating away from home, particularly fast-food, is one of the major contributing factors to increasing childhood overweight that current approaches do not address (9). Since 1977, the number of meals consumed away from home by children rose from 17 percent to 30 percent, and caloric intake from fast-food in particular jumped from 2 percent to 10 percent. These meals are generally of poorer nutritional value than home meals, containing the poor dietary factors that have been attributed to obesity (1, 10). Confounding this issue is an increased reliance on fast-food due to time constraints that result from parents working longer hours (1). If it is more convenient to eat at restaurants, particularly fast-food restaurants, an individual-level intervention is futile, and obesity interventions need to address this disparity in order to be successful.

Along the same lines, a review of the literature suggests that people purchase unhealthy food because it is cheaper than healthier food. When people were presented with healthy food that was equal or less in price compared to unhealthy food, people were more likely to purchase the healthier option (11). This could imply that people do not lack the desire to purchase healthy food, but may feel the need purchase unhealthy food due to cost constraints or availability. In fact, this has been demonstrated in a study by Jeter and Cassady (2006), in which they found that small grocery stores in lower income neighborhoods stocked foods of lower nutritional quality. In addition, at large grocery stores where healthier alternatives were readily available, the cost of purchasing the healthier alternatives overall was 35% to 40% greater than the cheaper, less nutritious option (12). Price and availability are clearly a barrier to healthier eating habits, and public health interventions must address this inequality if they are to be successful in decreasing childhood overweight.

Social Norms

Another factor that is absent from current obesity interventions is the constant exposure to the marketing and advertisement of unhealthy foods in our everyday environment. In the United States, the food industry spent over 1,000 times more money on advertising and marketing than the National Cancer Institute’s “5-A-Day” campaign, which aimed to increase healthy eating habits, did in 1999, and even more than the CDC spent on Health Promotion in general in 2006, which includes funding for the NPAO (1,6). The field of public health has a great deal to compete against in terms of money. It is no wonder, then, that unhealthy foods are increasingly pervading our diets, as they are what the public is exposed to the majority of the time.

In addition, one author has elucidated sponsorship connections between nutritional journals, research efforts, and organizations and the very companies that advertise unhealthy foods, creating a possible conflict of interest (13). It appears that the resources to which we are supposed to turn for help are being influenced by those who are helping create the problem. Public health campaigns should attempt to eliminate these conflicts so that the nutritional resources which are necessary for success can better focus on the needs of the people they are serving, not on corporate interests.

Yet another social norm contributing to childhood overweight is the popularity of sedentary activities, such as television programs and video/computer games. One study demonstrated that children in the United States spend 75 percent of their waking time engaged in sedentary activity, and only about 12 minutes engaged in vigorous physical activity per day (1, 14). Furthermore, the risk of childhood overweight has been shown to be directly proportional to time spent engaged in sedentary activities (15). It is true that decreasing sedentary activity is one of the major focuses of the NPAO, but only as an individual-level approach, and it is clearly not effective. Clearly, participation is sedentary activities has become so normative and acceptable that such an individual-level approach is not sufficient enough to combat it. Public health interventions need to find a way to decrease sedentary behavior on the whole, rather than by the individual.

Perhaps the social norm that is causing the most damage to current public health approaches is the fact that it is acceptable to be condescending to overweight people, and even to make fun of them. Unlike other social norms, this one is particularly harmful because it can actually amplify disordered eating, rather than just failing to stop it, thereby making the problem worse. It has been made clear that there is a bias against obese people in today’s society. Of particular concern is the fact that those in the medical profession, to whom we go for help with health problems, are particularly biased against those with obesity. Studies have demonstrated negative attitudes toward obese people by doctors and nurses, and that this bias may prevent them from administering positive treatment to these individuals. In addition, obese people have been shown to be less likely to seek medical care in general, citing stigma-related reasons as a barrier (16).

In addition, another study suggests that the stigma against obesity has gotten worse over the years. Between 1961 and 2001, school-aged children demonstrated that their bias against obese people increased and that their preference for “healthy” individuals increased, thereby widening the gap on both sides (17). It appears that society cannot help those who are overweight until it overcomes its own bias towards them, and public health campaigns need to address this.
Furthermore, connections have been drawn between perception of weight bias and disordered eating. One study found that “weight-teasing” is frequent among adolescents, with those who are most overweight at the highest risk of being teased. In addition, the investigators found a link between weight-teasing and disordered eating (binge eating and unhealthy weight control), which fits in with findings from other studies (18). Another study suggests a similar link, such that “internalization of weight bias” may lead to binge eating (19). Not only are these pervasive biases aiding in the failure of current public health campaigns, it appears that they can actually cause obese people to engage in even more unhealthy eating, or even cause unhealthy weight loss behaviors, such as anorexia, which are just as damaging.

Clearly, any programs aimed at decreasing childhood overweight must be sensitive to these social norms and avoid approaches that characterize obesity as a problem, furthering weight biases and disordered eating (20).

Unfortunately, some current public health approaches miss the mark with respect to these sensitivity issues. One example is the program recently implemented by the MetroWest Community Health Care Foundation in Massachusetts. At the beginning of 2007, they placed billboards showing an overweight child’s legs on a scale, accompanied by the words, “Fat Chance.” In addition, they ran a television advertisement, showing an overweight child eating unhealthy foods and depicting childhood overweight as a problem (21). In light of the above studies, these advertisements are clearly contributing to the stigma of obesity. While the director of the foundation maintains that the advertisements are aimed at parents and not children (22), it is inevitable that children will see them. If an overweight child is exposed to such a characterization of obesity, it could very well lead to the consequences mentioned above, resulting in the exact opposite effect.

This approach, and others like it, needs to consider societal issues of obesity stigma in their campaign, in order to counteract such stigma. This will likely yield better results as far as decreasing childhood overweight (23).

Built Environment

Finally, a connection has been drawn between built environment factors and physical activity, and ultimately obesity. One study demonstrated that participants living in areas characterized by “high walkablity” (definitive of the built environment in the area) were more likely to participate in walking as a form of transport compared to those living in “low walkability” areas, and they were less likely to be overweight. Interestingly, participants living in “low walkability” areas reported having access to more walking/cycling facilites (24). The creation of such facilities is one of the main goals of the NPAO (6); therefore, it appears that investment in the built environment should perhaps supersede the construction of walking/cycling facilities because they may have a greater effect on physical activity and obesity.

Further, such investment in making changes to the built environment has shown success, as reported by Boarnet, et al (25). This study demonstrated that making improvements in “walkability” increased the tendency of children to walk or bicycle to school, thereby increasing physical activity. Reviews of the literature support the aforementioned findings (8, 26), clearly spelling out the need for investment in improvements to the built environment in order to increase physical activity, thereby decreasing obesity.


It is obvious that current approaches aimed at decreasing childhood overweight are not working, as the prevalence is increasing. The majority of programs are based on changing individual-level behaviors, failing to take into account the social norms and environmental factors that contribute to childhood overweight, such as the appeal and convenience of eating away from home, the cost of food, and built environment factors that impede people from participating in physical activities. Moreover, approaches that reflect stigma against obesity and identify obesity as a problem can actually have detrimental effects on those to whom the campaign is targeting by increasing binge eating or inducing unhealthy weight loss behaviors. Ultimately, public health approaches aimed at decreasing childhood overweight need to tailor their goals so as to combat social norms and environmental factors that contribute to it, as well as address issues of weight bias and obesity stigma, in order to be successful.


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