Challenging Dogma - Fall 2008

Thursday, December 18, 2008

MetroWest's Fat Chance at Fighting Childhood Obesity- Maithili Davada


Due to economic inequalities many people around the world suffer from starvation and malnutrition; meanwhile many others suffer from obesity and the health and social problems associated with it.(1) Obesity is an issue that concerns not only adults but children, too.(1) Childhood overweight and obesity are issues of growing concern in the United States. According to a survey conducted by the National Health and Nutrition Examination Survey (NHANES), in 2003-04, 17 percent of children and adolescents ages 2-19 years were overweight. (2,3)

The MetroWest Kids campaign, launched by the MetroWest Community Health Care Foundation, aims at decreasing the prevalence of childhood obesity. The campaign includes local billboards, print advertising, a website ( that tries to provide useful tips for parents, kids and schools.

However, firstly, the campaign not only fails to inspire self-efficacy and provide positive reinforcement, but also ends up traumatizing the kids and assigning stigma to obesity. Secondly, the suggestions made on the website fall into the most common fallacy of using only individual level factors, and they do not play on group dynamics and they lack practicality, also, some of the suggestions are unsafe. Finally, the intervention also does nothing to address important environmental factors like availability and affordability.

“Fat Chance!” Fat chance of losing weight?

Bandura’s Social Cognitive Theory states any change in human behavior is influenced by: environmental, social and individual factors. Self-efficacy is one of the individual level factors explained in the theory. Self-efficacy is an individual’s confidence, faith, belief in their ability to successfully complete any behavior. Reinforcement is one of the environmental factors. Reinforcements may be in the form of positive or negative response to their behavior.(7,9)

Their billboard says “fat chance” and shows the chubby feet of an overweight child standing on a scale. Unfortunately, it conveys a message of doom and gloom and hopelessness as opposed to inspiring hope and determination to fight the battle against childhood obesity. According to Catharine Curran-Kelly, an assistant professor of marketing at the University of Massachusetts at Dartmouth, the billboards instill fear in people who do not have the problem, and parents whose kids are obese tend to argue against it.(4) The parents’ response may be one of righteous indignation.

Not only are these billboards nonproductive, they may also be counter-productive. “They traumatize the very children they're trying to help," said Peggy Howell, a spokeswoman for the California-based National Association to Advance Fat Acceptance, a group that works for social acceptance of overweight people. According to her, the image on the billboard results in further bullying of obese kids by their peers, and provides reinforcement of this kind of negative behavior.(5) Competition, teasing and bullying are major barriers for students to be physically active during physical education class, on sports teams, and before and after school activities. (6) Thus the billboard not only causes internal and emotional trauma to the kids, but it also results in them being bullied, which results in harming self-efficacy. This is especially the case when it comes to obese children, resulting in them not participating in the above activities and leading a sedentary life resulting in further weight gain. Being bullied and teased results in negative reinforcement and hence lack of participation of obese kids in these activities. That reinforcement plays a major role in bringing about behavior modification is well-explained by Bandura’s Social Cognitive Theory (SCT). (7,9) Thus, the billboard not only results in negative reinforcement of healthy behavior in obese children, it also adds to the problem by causing positive reinforcement to bullying and as a result traumatization of these kids by their peers, which also negatively affects their sence of ‘self’, self-worth and self-efficacy.

That stigma negatively affects the self-esteem of individuals which also affects their self-efficacy is supported by several theories, which include social comparison theory (8,10), and social identity theory.(8,11) Even though the billboards are aimed at parents of obese children, the children themselves see them, too. The billboards assign stigma towards obesity resulting in harm to self-esteem of these children. This in turn has a negative effect on self-efficacy which, according to the social cognitive theory, is an important factor in enabling positive behavior change. (7,9) Dr. Gordon Cochrane, a registered psychologist, supports this idea. He presents the idea that an enhanced sense of self worth and self-efficacy give a person enough faith in themselves to follow healthy behavior and achieve an ideal weight and as a result overcome obesity. (12) Thus, by stigmatizing obesity, not only does the intervention fail to encourage and promote self-efficacy; in fact, it negatively affects the self-esteem and self worth of these children and as a result negatively affects their self-efficacy.

Are some of the options really safe or feasible?

Social norms and the social network, that an individual belongs to, play a major role in affecting behavior change. This idea is supported by the Social Expectations Theory and the Social Network Theory, respectively.(7,13,14) The intervention does not address these factors and focuses only on individual activities.

The MetroWest Kids website lists a few suggestions to help increase activity levels of kids. Some of the activities that the website suggests are not practical or safe and none of them take into account the effect of social norms, group dynamics and herd mentality. Although the website itself has a lot of useful information, sitting in front of the computer and reading information does not get kids to indulge in any physical activity. Also, the activities listed on the website are all solitary, so even if kids do follow them, they might eventually get bored of those activities and fall back into their old sedentary lifestyle. Furthermore, these activities do nothing to change the social norms, which according to the social expectation theory are an important factor affecting behavior change.(7,13) According to the social network theory, behavior change occurs and is maintained in groups(7,14), and none of the activities mentioned on the website are group activities.

One of the activities mentioned is going for a walk, but kids are in school all day and by the time they get back home and eat, it is already dark outside and if they live in an unsafe neighborhood, they cannot possibly go out. Some of the other activities suggested include rearranging the furniture, crawling under the table, setting up an obstacle course in the house, etc. These activities are not only disruptive to the parents but may also result in the kids hurting themselves. Another suggestion was to get off the bus a few stops before the destination which could prove to be dangerous in a high crime neighborhood; it also may lead to vehicular accidents if the kids are not cautious enough while crossing the road.

The intervention fails to bring about a change in the social norms, or target groups and social networks and does not take into account group dynamics and herd mentality. Behavior of most kids and adolescents today is influenced by the very factors that the intervention fails to address, according to the social expectations theory(7,13) and the social network theory(7,14) respectively.

What is MetroWest Kids doing to help with the real issues of environment, availability and affordability?

Additionally, the intervention does nothing about the environment and practical roadblocks such as lack of availability and affordability of healthy food and/or safe as well as affordable places to do physical activities like riding bikes or walking. The locations for parks and recreational areas provided on the website are few and far away from most places like Boston, Dorchester, Roxbury, Quincy etc. For most people these might be the only places where they can go for physical activities due to constraints such as living in an unsafe neighborhood or inability to afford the high membership fees for gyms, especially in these difficult economic times.

Also, processed and fast foods are cheaper and more easily available than healthy foods. Wherever we go, we are surrounded by vending machines and franchises like Dunkin Donuts, McDonald’s, Wendy’s, etc., which provide cheaper and tastier alternatives to the expensive salads. Also, most salads available at these places contain cheese or some kind of creamy dressing. According to the SCT another major factor affecting individual behavior is the environment surrounding them.(7,9) Additionally, the low-socioeconomic areas have fewer and costlier grocery stores compared to the high socio-economic areas and suburbs where most of the relatively cheaper chain stores are located. The intervention fails to take any measures that address these problems.(15)

According to a study, conducted in 2000, the quality of the food served, easy access to non nutritious snacks, limited time for lunch period are the major factors affecting the food choices made by high school kids. Many of the students and staff members complained that the cafeteria food was too greasy. Moreover, they felt that presence of snack carts and vending machines influenced students’ food choices. It was noted by many of the staff members that students are less likely to select nutritious foods for lunch in the presence of these other attractive non nutritious options in their environment.(6) One of the students made a very interesting statement which emphasizes the role that the environment surrounding an individual plays in their decisions. She said, "How Can We Stay Healthy when you’re Throwing All of this in Front of Us?" with reference to the food choices available at their high school.(6) Although high school cafeterias have begun to offer some healthier foods, many continue to sell sodas and fries. If you were an average American teenager, given a choice between fries or salad and soda or milk, what would you choose? Besides, the intervention does nothing to provide positive reinforcement to consume healthy foods, which according to SCT is an important aspect in enabling positive health behavior change. (7,9)


Childhood obesity is a serious issue and requires a multilevel intervention that targets the environment of the kids on the whole, including their home, school and social environment. It should provide them with the confidence, self-efficacy and positive reinforcement required to enable them to make the necessary lifestyle modification in order to combat obesity.(7,9) According to The Social Expectation Theory(SET), behavior change occurs in groups and an individual’s behavior is largely dependent on the social norms that dictate the social environment.(7,13) It is important to understand that intention may not lead to behavior changes unless individuals also have a positive environment and access to healthy and affordable food and a safe place to exercise.


Most of the requirements needed to fight the battle against childhood obesity can be met by schools. Schools can provide a safe environment for the kids to stay active in by arranging non-competitive after-school activities like aerobics, yoga, dance, and martial arts. They should make it mandatory for every student to be enrolled in at least one of these activities, regardless of whether or not they are obese so as to avoid stigma to obesity. To make sure that the obese kids do not get teased or bullied, they should start with the basics and go at a pace everyone can keep up with.

Schools could organize discussion sessions for parents and kids together, as well as just for kids, where they can promote self efficacy and provide positive reinforcement for these kids. Another purpose of these meetings would be to encourage parents to bond among themselves and exchange ideas on how to support their kids and provide their kids with appealing healthy food at home. In addition, the school can organize a monthly talk given by a formerly obese, now well balanced and successful peer or role model followed by an interactive discussion session. The school should encourage the students to host a social event that serves only healthy food and has fun activities, at the end of each semester. Instead of vending machines with junk food and sodas, they could have, carrot sticks, cherry tomatoes, apples, grapes, bananas and juices at an affordable price. School cafeterias and social events should have healthy food, too.

The intervention that I propose is based mainly on Bandura’s SCT and also derives support from the Social Expectation Theory and some published articles.

Self-efficacy and positive reinforcement

The above intervention promotes self-efficacy and provides positive reinforcement, which are key factors affecting behavior change in an individual according to Bandura’s Social Cognitive Theory.(7,9)

The after-school activities promote self-efficacy by showing the students that they are capable of doing these activities despite obesity. Also, being able to successfully learn these activities enhances their sense of ‘self’. On the other hand, competitiveness negatively affects physical activity.(16) Thus it is essential to keep the activities non-competitive to avoid bullying and make the activities non-stressful and fun. The monthly talks are aimed at promoting self-efficacy and providing positive reinforcement using modeling (behavior of others) and vicarious learning (consequences of others’ behavior), as suggested by SCT.(7,9)

The end of the semester social also raises self-efficacy by giving students the confidence that comes from successfully organizing the event, and it makes them aware of their behavioral capabilities, which is one of the individual-level factors influencing behavior change according to the SCT.(7,9)That self-efficacy is an important factor affecting behavior change is supported by Dr Gordon Cochrane, a registered psychologist. (12)

The weekly parent meetings educate parents on how to support their kids emotionally and help them build confidence, self efficacy and provide positive reinforcement, which are key factors influencing behavior change according to SCT.(7,9)

Safe environment and non-competitive group activities

Unlike the Metrowestkids campaign, which focused on individual-level activities and did not provide practical options for activities, this intervention provides a safe environment for the kids to come together and participate in non-competitive, fun activities and to host group discussions. The Metowestkids campaign suggested that the kids walk to school, which could be dangerous for them. For example, Bauer, Yang and Austin reported that various staff members of a school observed and were worried about incidents in which students were approached by strangers while walking to school. As a result, the administrators discouraged parents from letting their kids walk to school. They said the high density of car traffic further compromised the safety of these kids.(6,16) Since the activities suggested by the current intervention happen at school, after school, students are spared the risk and expenses of travelling and trying to find a safe place to carry out these activities.

According to the Social Expectation Theory, individual behavior is driven by each person’s desire to conform to social norms. (7,13) Norms may be established and/or changed over time. This process can occur in three ways: “top-down influences, including official edicts and role models; bottom-up influences in which local customs and practices coalesce into norms; and lateral influences in which established norms from one type of interaction are transferred to related types of interactions.”(17) All the kids are required to participate in these activities, and physical activities are promoted by the role-models during the monthly discussion sessions (top-down influence), and it is an established norm that rules are followed (lateral influence). Additionally, some kids might be interested in these activities and will encourage their friends also to get involved in all these activities (bottoms-up influence). Hence, it is only a matter of time before being active becomes a social norm.

Adressing availability and affordability

The most important roadblock in fighting the battle against obesity is the lack of availability and affordability of healthy food and a safe place for physical activities. Also, the presence of unhealthy temptations all around us prevents us from making healthy choices easily and quickly. (6,16) This is especially the case for kids who are less aware of the serious consequences of these choices.

Replacing the unhealthy options in school vending machines with healthier affordable options takes away the temptation and increases the availability of healthy food. A study published by the Society of Public Health Education quoted some students as saying that “if the cafeteria offered fruits and vegetables in greater quantity and quality, they would choose to eat them instead of the less nutritious entrees or snack foods”(6). Providing healthy choices at school ensures that students have at least one healthy meal a day, regardless of what is available at their individual homes. Additionally, the weekly meetings for parents are aimed at encouraging healthy food choices at home and educating parents on what is healthy. Having kids present at these meetings could give them a chance to express their opinion in these matters too, and help them communicate their suggestions and choices.

The after school activities also provide a safe non-expensive place and environment for the kids to stay active and bond and explore options that would otherwise not be available or affordable, like yoga and aerobics. This is especially important in these difficult economic times.


The suggested intervention is based partly on the SCT and SET, and provides a feasible way to combat childhood obesity. The habits we develop during the formative childhood years last us a long time. If we make sure that this generation of kids develops healthy habits at an early stage and incorporates these habits of eating healthy and staying active into the social norms, we are on our way to winning the battle against obesity.


The MetroWest Kids Campaign, like most other Public health campaign fails to rise above the individual level factors influencing behavior. Even while addressing only individual level factors they fail to address important individual level factors like self-efficacy and positive reinforcement. They do not take into account that an individual is affected by, the social norms and the environment surrounding them. It does nothing to increase the availability of healthy food. It also fails to address the issue of affordability, of both healthy food and a safe place to exercise, especially in these difficult economic times.


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2. CDC’s National Centre for Health Statistics. Prevalence of Overweight among Children and Adolescents: United States, 2003-2004.

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4. Manuse Andrew J. Obesity billboard idea yanked. The MetroWest Daily News. Posted Jan 31, 2007 at 12:38 AM. Last update Jan 31, 2007 at 04:47 PM

5. Reuell Peter. MetroWest 'fat' ads attract the ire of national obesity tolerance outfit. The MetroWest Daily News. Posted Feb 13, 2007 at 11:23 PM. Last update Feb 14, 2007 at 11:48 AM.

6. Bauer Katherine W., Yang Wendy Y. and Austin Bryn S. "How Can We Stay Healthy when you’re Throwing All of this in Front of Us?" Findings from Focus Groups and Interviews in Middle Schools on Environmental Influences on Nutrition and Physical Activity. Health Education and Behavior. 2004; 31; 34.

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12. Cochrane Gordon. Role for a sense of self-worth in weight-loss treatments: Helping patients develop self-efficacy. College of Family Physicians of Canada. Can Fam Physician. 2008 April; 54(4): 543–547.

13. Hornick, Robert. Alternative Models of Behavior Change. Annenburg School for Communication, Working Paper 131, 1990, p 5/6

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15. Chung C., Myers, S. Do the poor pay more for food? An analysis of grocery store availability and food price disparities. The Journal Of Consumer Affairs.(1999)Pg 276.

16. Olga López de Dicastillo. Promotion of physical activity and healthy food quality food, easy access to non-nutritious food, and choices was hampered by competitiveness, lack of time constraints. Evid. Based Nurs. 2004;7;123

17. Edited by Durlauf Steven N., Blume Lawrence E. New Palgrave Dictionary of Economics, Second Edition.

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