Challenging Dogma - Fall 2008

Friday, December 12, 2008

The Failure in Developing an Intervention that Addresses the Multifaceted Nature of the Obesity Epidemic – Ami Vikani


In recent times, childhood obesity has become an escalating health problem and a major epidemic throughout the United States (1). For instance, over nine million children over the age of six are considered to be obese (2). Obesity also leads to increased risks of other diseases, such as type-2 diabetes and hypertension (3), as well as psychological and social issues, such as depression, isolation from peers, and low self-esteem. As the issue of obesity becomes more prominent in modern-day children, various attempts have been made alleviate this problem. Some of these ideas include the FDA’s development of the Obesity Working Group (OWG) and the National Cancer Institute’s 5 A Day program (4). Despite these efforts, the number of children at risk of becoming overweight or obese continues to increase.

What’s Wrong?

Although this issue has led to varied levels of debate and increased public concern, efforts need to be made in improving interventions at school, as this is where children spend the majority of their time. Despite the fact that there are numerous changes being made at educational institutions, schools are not fully and properly addressing the issue in order to prevent obesity. In particular, schools have started to address this issue by meeting nutrition requirements and restricting foods and sodas with certain ingredients that may increase a child’s chance of becoming obese. For example, Boston public schools prevented selling snacks and drinks that contained high levels of fat and sugar (5). Likewise, numerous food and drink manufacturers have attempted to promote healthy eating in a manner that is orientated towards children. Even though these attempts are praiseworthy, they are focused mainly on the options offered on the daily lunch menu and the food and drink options available in the vending machines. Focusing on food choices alone fails to take into consideration that obesity is a multifaceted issue that includes aspects such as lifestyle, culture, parental influence and lack of physical activity due to unsafe neighborhoods (2). It is this narrow approach to obesity interventions that is the source of my criticism.

One of the key factors that contribute to the increased risk of children becoming overweight is the lack of their physical activity (6). According to the CDC, the majority of modern-day youths are inactive and out of shape, and therefore, increasing participation in physical activity becomes a key focal point (7). This aspect of the obesity epidemic cannot be addressed by changes in the options available in the vending machines, but rather must be solved by introducing physical education programs that are more widespread and compelling to encourage motivation among children (8). Through the results of previous research, it has been seen that children prefer weight control programs that are interactive and accessible, yet take into account their needs and are open to all children, regardless of their weight (9). Taking these opinions into account is crucial to the success of the intervention, as this is where the principle of self-efficacy comes into play. In other words, children will not engage in physical activities unless they are certain that they will be successful and benefit from engaging in these activities. Although perceived barriers, such as less time being allocated to other activities they enjoy, may interfere, the intervention will have to be designed in a manner to address this issue (10).

Not only are numerous schools lacking proper health education programs, but children are not physically active once they go home, thus encouraging a sedentary lifestyle. The encouragement of this sort of lifestyle outside of school may be due to the large amounts of emphasis placed on various forms of technology, such as computers, video games, and cellular telephones. However, it may also be due to the influence of parents on their children. For instance, children spend a lot of their time outside of school with their parents, such as eating nightly meals together as a family. In fact, it has been noted that children from families who do not eat together are more likely to become obese (11). The Social Learning Theory addresses this aspect of the intervention, as it states that individuals perform certain actions based on the occurrences in their environment, especially if the action leads to a positive outcome. Children look to their parents for guidance, and therefore adopt behaviors and lifestyles accordingly.

For the connection between parents’ actions and those of their children, it can be seen that the problem of obesity can be attacked from a deeper location. Health education must be provided not only to the children, but also to the parents with regards to the importance of healthy eating habits and regular physical activity. Parents must realize that the key is to monitor certain actions, such as eating at regular times, providing moderate portions, and turning off the television during meals. With regards to physical activity, it can be accomplished in various ways, such as dance, playing sports, or helping out with chores, and can be at the gym, in local playgrounds, or in their backyard (10).

Despite these hopes for ideal situations, it must be taken into account that children come from different types of families and live in varying environments. Obesity has been shown to be disproportionately higher among groups with low income and low education (12). For instance, some children are raised in low socio-economic families, and thus may live in a neighborhood that is unsafe and does not allow for proper access to play areas (13). Thus, these parents may feel that it is best to keep their children under their supervision, which may translate into allowing them to stay indoors, watch television and play video games. Through these indirect methods, a sedentary lifestyle is enforced, yet not by choice, but due to environmental factors. In order to address this matter, government officials need to work towards making neighborhoods safer, thus allowing for parents to feel more comfortable letting their children play outside. Furthermore, community level factors, such as violence and crime levels, need to be addressed before an obesity intervention can be successfully implemented (14).

Another factor that must be considered is the economic aspect of the intervention, as financial constraints may limit the types of foods children consume. For instance, shoppers may choose foods that are on sale over those that are healthy due to their interest to save money. Purchasing foods that are low in cost often means that these foods are low in quality (15). As seen in certain cases, the foods that are low in cost are those that are high in sugars and fats, two factors in foods which if consumed in high quantities, can lead to children becoming overweight (16). Furthermore, research has shown that wealthy neighborhoods have a greater number of supermarkets when compared to the quantity in neighborhoods that are low-income (16). This idea of a lesser availability of healthy foods is also extended to the greater number of fast food restaurants in predominantly lower income neighborhoods (17).

It can be seen that the obesity epidemic is not only physical or behavioral, but also has an economic aspect. Therefore, a solution to this issue would be increase the number of open markets that sell fruits and vegetables, as well as making healthier foods more affordable in mainstream supermarkets, thus increasing their appeal in the eyes of those individuals who are on a tight budget. A greater number of educational programs should be created that are directed towards those individuals who are from low-income areas and should be focused on the importance of making the most of the resources that are available to them at their supermarkets and neighborhood at large.

In addition to the economic facet, there is also a cultural aspect that must be taken into consideration when creating a multifocal intervention. America is one of the most diverse locations throughout the world with regards to the number of cultures that are represented. Along with this diversity comes cultural and familial values that are carried over and passed on through generations. Thus, the history behind each culture needs to be taken into consideration, and in certain cases, may need to be specifically geared towards the unique beliefs each culture takes into account when making their lifestyle decisions.

How Do We Attempt to Alleviate the Problem of Childhood Obesity?

As it can be seen from the numerous issues that need to be addressed with regards to childhood obesity, the intervention needs to be multifaceted. This new intervention should take into account social sciences theories and models, educate both children and parents about healthy eating behavior, and encourage physical activity. All three of these goals should be accomplished by keeping in mind the environmental (i.e. type of neighborhood) and cultural differences that are represented within the community. A key overlying theme is that the intervention should not only address these deficits, but also promote overall healthy behavior. If children do not have healthy eating habits or fail to engage in physical activity because they do not have sufficient knowledge of how to do so, then the intervention should have aspects that are used as learning tools. However, there should also be information about how to overcome limitations that prevent children from taking part in healthy eating and physical activity due to circumstantial and environmental conditions (18, 19).

The Social and Behavioral Sciences Theory of Empowerment

In implementing a childhood obesity intervention, it is important to take into consideration the social and behavioral sciences theory of empowerment. Empowerment is used by individuals to take control of their lives, and is used to support them in making the decision that is right for them. In other words, it is important that one comes to the realization on one’s own, rather than blatantly telling the individual what should be done in order to solve the problem (20). This idea of empowerment can be used in the area of nutritional education, yet it is important that the teacher does not dictate to the children what should and should not be done, but rather serve as a facilitator that allows that adolescents to achieve a proper understanding. If one were to only analyze the policies that schools have implemented currently, such as those that only involve replacement of foods in vending machines, then it can be said that empowerment is not part of the intervention. By removing the foods and drinks that are high in fat and sugar, children are forced to choose only amongst the new choices that are provided in the machines, and thus cannot come to the realization on their own.

The Integrated Theoretical Model

Another theoretical framework that needs to be considered is the integrated theoretical model, which states that behavior is driven by the knowledge, skills and abilities to perform the behavior and the intention to perform the behavior (21). In order to effectively intervene in the process and change one’s behavior, research needs to be conducted to understand the current norms and attitudes surrounding the children the intervention will affect (21). Thus, the intervention should identify the factors contributing to obesity and in particular, identify ways in which this intervention can be specialized to take into account the varying norms and attitudes in different communities. For instance, the intervention states that physical activity is a key part in combating childhood obesity. This can be accomplished by playing in the park, or riding bicycles outside. However, there may be some environmental constraints, as indicated by the integrated theoretical model, preventing a child from taking part in outdoor activities, which in turn makes them unable to do their best in preventing obesity. These children could be living in neighborhoods with high crime rates, where playing outside is not an option. Therefore, the intervention should suggest some physical activities that the children can take part in indoors, such as playing in the basement of their house. Furthermore, funding should be dedicated to creating programs at the local YMCA that encourage physical activities for children, such as subsidized dance classes.

Theory of Reasoned Action

The third model that needs to be integrated into the intervention is the theory of reasoned action, which aims to understand factors that influence the intention of performing the healthy behavior (21). It explains that the attitude an individual has towards a behavior as well as the perception of social norms surrounding the behavior, ones which will affect whether a person has the intention of performing the behavior. For example, a child who is already overweight or has an illness that prevents them from taking part in physical activity (i.e. asthma) might not want to exercise because they find it uncomfortable and thus do not enjoy it (their attitude). The child’s family may not encourage them to exercise as a result of them being overweight or because they have the illness (social norms). Both of these factors would negate the child’s intention to exercise. The way this issue can be addressed in the intervention is by addressing the social norms; one could present testimonials of children who are overweight or those with illnesses who regularly exercise, thus increasing motivation in other children within the community.

Educating Parents and Their Children About Healthy Eating

Outside of the integration of the social theories and models, the intervention program should consist of two components: a classroom-based intervention and an environmental intervention. The classroom-based intervention should be a group activity, in which the classes would be held in the evenings at a time that is convenient for both children and their working parents. The classroom-based portion would consist of a structured educational program that would be divided into a specific number of lessons, and there would be activities and worksheets associated with each themed lesson.

The first half of the classes would be aimed at raising awareness about healthy eating habits and participating in physical activities. During the first class, the children and the parents would be provided with diaries to document their eating habits and physical activity for the next five weeks. Each week, the children and the parents would be given an opportunity to reflect upon how their behavior has changed with time and what they gained from this experience. The parents and children would also receive feedback from the teacher, and they would develop weekly goals that they would like to accomplish. Having set goals has been shown the be effective in helping individuals achieve changes in their eating habits and level of physical activity (22,23).

The second half of the classes would be aimed at the children and parents choosing a risk behavior they felt needed the most improvement, and they would improve their self-efficacy with the help of their teachers. The main idea behind this portion of the classroom intervention is not to force them to change a particular aspect of their life, but rather to have the parents and the children choose how and in what area they would want to focus their behavior change. A computerized program is utilized in which personalized feedback is provided to the participants based on the answers they provide on a weekly basis about what they would like to change and the progress they have made. Personalized computerized education has been show to be effective with regards to dietary changes in previous interventions (24).

Guidelines That Should Be Used During Meals

The environmental part of the intervention consists of school-specific advice on the types of foods offered in the cafeteria, taking into account individual school characteristics and possibilities. Some of the changes that would take place include offering smaller portions and taking into account the guidelines proposed by the Food Guide Pyramid. Also, the intervention would make use of the Stoplight Diet Approach, which categorizes foods into green, yellow, and red categories. ‘Green light’ foods can be eaten freely. ‘Yellow light’ foods should be eaten in limited amounts. ‘Red light’ foods should be eaten very rarely. Children and their parents are educated about the Stoplight Diet Approach in the classroom-based portion of the intervention, and they are encouraged to make use of it when they consume meals at home.

Physical Activity

In addition to the encouragement of physical activity outside of school, the school board should offer other physical activity options. For instance, more funding should be dedicated to additional hours of supervised physical activity within the school schedule, and there should be a minimum of 36 weeks (out of the 40 required weeks of school) in which physical activity classes occur. The activities should require no prior knowledge and should be equally accessible to children of all ages and body structures. Lastly, the lessons should encourage the idea that not only are these activities healthy, but they are also enjoyable, thus indirectly motivating them to be physically active in the free time.


In essence, it can be seen that the current obesity interventions that are employed, especially those in schools, are too narrow and only take into account certain aspects of the underlying factors of obesity individually. Obesity is more than a physical condition; economic background, culture, and social behavior are some of the key elements that must be taken into consideration when developing an intervention. In addition, it is seen that the epidemic in not only on an individual level, but also on a community level. In other words, it is equally important that children are motivated to make healthy decisions as it is that communities provide a high level of safety within neighborhoods and that all neighborhoods have equal access to supermarkets and varieties of healthy foods, regardless of the socioeconomic status within those inhabiting the respective neighborhoods. Implementing an intervention with broader perspectives will allow for a more successful intervention, thus decreasing the public health problem of obesity.


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