Challenging Dogma - Fall 2008

Thursday, December 18, 2008

The Prevalence of Unhealthy Bodies: A critique on addressing childhood obesity in the Primary Care Setting-Krishna Chokshi


Recently, the problem of unhealthy bodies has almost become an epidemic in America. Overweight adults seem to be a big public health concern since this group has a considerably increased risk of diseases such as diabetes, and even cancer (13). To address this issue, some researchers planned interventions to decrease childhood obesity within the primary care setting. Researchers believed that taking a “preventive” approach would be effective, since the probability of an obese child becoming an obese adult is 50% after the age of 6 (13). Though addressing a relevant issue, this approach has many flaws. Many interventions taking this approach did not succeed in achieving their desired outcome. Evidence from researchers, the social sciences, as well as the effectiveness of different behavior change models provide us with evidence as to why these interventions were not effective. First, these interventions were largely based on individual level models. Parts of the interventions were aimed at parents, and not children, or vice versa. Individual behavior within social networks was not given consideration. Second of all, these interventions failed to take into consideration environmental factors that could influence a child’s health. Finally, these interventions failed because they did not sell to kids what they want. Instead, what was being sold was mainly the doctor’s interest.

Individual level models are not effective

Behavior change models that target individuals instead of that individual’s social network tend not to be effective. Many traditional behavior change models are based on the individual level. Some examples of these include the Health Belief Model, the Theory of Reasoned Action, and the Theory of Planned Behavior (2, 4, 6). The interventions aimed at addressing childhood obesity within the primary care setting mirror one or more of these models.

For instance, in a study done by Schwartz, Hamre, Dietz et al in 2007, physicians attempted to deliver obesity prevention intervention using motivational interviewing strategies. Their study group was a group of 91 children within the ages of 3-7 who were overweight or at risk. In addition to talking with the children about diet and exercise, they physicians provided the children with tips from the CDC on healthy eating and activity. The researchers observed no significant differences in BMI at the end of the study. In fact, the control group did better than the intervention group on healthy snacking, and loss to follow up was high. This intervention was similar to the Health Belief Model in that the doctors tried to persuade the children that unhealthy eating habits would cost them in the long run and that there were benefits to their health in changing their behavior (13).

In another study done by Kubik, Story et al in 2008, researchers chose a group of 117 parents of 5-10 year olds to test whether counseling them would be effective in changing their children’s eating habits. The researchers found that in general, parents did not regard take-home messages they received from counseling about weight, physical activity and eating practices as relevant. This intervention was also somewhat based on the Health Belief Model, except that it was even more indirect. The physicians hoped that if the parents could see the perceived benefits of having their children eat healthy and exercise, they might be able to influence their kids. They did not succeed (13).

The main argument against these traditional behavior change models is that they emphasize individual behavior change process and pay little attention to other influences on behavior. Models based on individual behavior change cannot be effective when that individual is a part of a larger social network. Social Sciences say that the most effective interventions occur on multiple levels. Intrapersonal as well as interpersonal and group factors must be considered when developing an effective model of behavior change. These interventions that simultaneously influence multiple levels may be expected to lead to greater and longer lasting changes as well as maintenance of health promoting habits (5).

In contrast to some traditional models of behavior change, social network theory argues that what dictates a person’s behavior depends on the behavior of the social network (1). Social network theory views social relationships in terms of nodes and ties. Nodes are the individual actors within the networks, and ties are the relationships between the actors. In contrast to traditional theories, social network theory says that attributed views of individuals are less important than their relationships and ties with other actors in the network. This approach has been useful in explaining many real world phenomena.

Further evidence in the social sciences suggests that behavior which appears to be individual may be viewed as social behavior. Individual behavior is largely the result of the expectations of others (6). This social scientist proposes that in creating an intervention, we have to ask ourselves “how do groups change their behavior?” rather than “how do individuals change their behavior?”

Consequently, we see that unless we take entire social networks into account, interventions aimed at producing behavior change in the individual will not be effective. Persuading children to eat nutritiously or convincing parents that their kids should be more active will not produce healthier children. Instead, there has to be an analysis of the social networks these children make decisions in order for interventions to be effective.

Failure to Consider Environmental Factors

Another big flaw of these interventions is that they fail to account for societal and community factors that could influence kid’s health. In the studies done by Schwartz, Hamre, Dietz et al as well as Kubik, Story et al, individuals were counseled as to how much and what types of foods the kids should eat, and what type of physical activity was necessary. These counseling methods were not effective because there are a variety of other variables which could influence a child or parent’s ability to follow these guidelines.

It is very possible that parents did not have access to or did not know how to cook the foods the physicians suggested were appropriate for their kids. In fact, other studies confirm the fact that some parents simply do not know how cook and sometimes part of a more effective intervention requires them to be taught how to (13). It is also possible that eating habits and types of foods can vary amongst cultures. “Leafy greens,” as prescribed by many of these interventions, is not a staple part of every culture’s diet.

Another environmental factor these interventions fail to account for is socioeconomic status. As we found through class activities, socioeconomic status is closely linked with the kinds of foods available as well as the opportunities to engage in physical activity. Those in lower socioeconomic status groups do not always have access to the wholesome, organic foods as those in higher socioeconomic areas. People in lower income neighborhoods cannot always afford gym memberships and cannot always rely on the safety of a local park for physical exercise.

One study done by Yeong Sook Yoon actually tested the relationship between socioeconomic status and obesity. Adjusting for confounders, they concluded that there was a statistically significant relationship between low income and obesity in the population of Korean men they studied (14.). In anther report published in the Sage journal, researchers found that low-income populations have an elevated risk of obesity as well as chronic diseases. Environmental factors influence health behaviors that contribute to obesity. These researchers propose that in order to address the issue of obesity in these neighborhoods, specific interventions must be designed to help these communities make use of the specific resources available to them (ex. produce stands, walking trails, etc.). Overly generalized interventions encouraging children to engage in physical activity are not effective without considering these factors (7).

The school environment was also left out of these intervention models. Children spend a significant time at school, and the environment of the school can have a significant impact on their daily food intake as well as their physical activity. As an example, in a study in Vienna, researchers found that 60% of the snacks available in vending machines were unhealthy. Also, 75% of the schools had at least one food facility in the direct neighborhood of the school. These researchers recognized the importance of developing an integrated multisectoral approach and policy to address children’s eating habits. They discussed that a child is a part of the environment and that effective interventions must include different sectors: local authorities, schools, community, as well as parents. They say that if we are to move forward in preventing obesity, there must be a more balanced food selection at school, not just at home (11).

There is also scientific evidence why effective interventions must take into account environmental factors. A neural network in our bodies has been identified s the control system for the regulation of food intake. However, another extensive neural system that processes appetite and rewarding aspects of food intake is mainly interacting with the external world. This system is constantly attacked by signals from the environment, ultimately resulting in increased energy intake. Because of this, these scientists recognize that the changing environment and its associated lifestyle are primary causes of obesity in the large majority of the population (3).

Another environmental factor these interventions in the primary care setting failed to address is the fact that kids are easily influenced by the advertisements of unhealthy foods and snacks. Research conducted by psychologists with expertise in child development, cognitive psychology, and social psychology shows that children under the age of eight are unable to critically comprehend messages they see on television and are more prone to accept them as truthful, accurate, and unbiased. This can led to unhealthy eating habits as evidenced by our obesity epidemic in young people today. Some psychologists even suggest that advertising targeted at children under the age of eight be restricted. The Task Force, appointed by the American Psychologists Association, conducted a lengthy review of the literature in area of advertising media. Advertisers spend more that $12 billion a year on advertising messaged aimed at the youth market. Additionally, the average child watches more than 40,000 television commercials per year (8).

Interventions are not giving kids what they want

Perhaps the most essential reason as to why these interventions aimed at curbing childhood obesity within the primary care setting failed is because these physicians and researchers were not selling to kids what they really wanted. If kids were not getting what they wanted or what they found appealing out of these interventions, they were bound to fail.

Since these interventions were based on some traditional public health models, the importance of the “consumer’s wants” was not taken into account. However, recent theories emphasize the importance and effectiveness of getting an audience to believe that what they are buying into is actually extremely appealing. Marketing theory is one technique used by public health organizations to get people to change behavior. These organizations first ask themselves “what do the people want?” They take the answer to this question and try to sell it back to their audience instead of asking themselves “what do we want them to do and how are we going to get them to do it?” Instead of directly trying to sell their product, they sell an “idea” that people like. The reason why marketing theory is so effective is because it uses the “5 Ps.” These include 1.Product 2. Price 3. Place 4. Promotion and 5. Positioning. The product refers to the behavior or the idea that is being sold. The price of the product refers to the monetary as well as the non-monetary cost of a product. These can include psychological, social, or convenience costs. The place refers to the site where the product is distributed. Promotion refers to the way in which the audience is made aware of the product. Positioning refers to the psychological "image" of the product (10).

In the interventions at the primary care setting, kids were advised to eat certain foods like “whole grains, fruits, and vegetables.” Plainly seeing these items listed on paper were neither appealing nor what kids wanted. Children were encouraged to watch less television, and to get physical activity. This method did not work because the “product” (losing weight) was not something these kids absolutely wanted in the first place. It came with a price since it meant they had to watch less TV, cut down on the foods they liked, and eat more vegetables. The kids received counseling sessions at their doctor’s offices, and so the “place” was not one they associate with having fun at all. Though the physicians may have tried to promote healthy eating, it was not done in a way that the kids found appealing, nor was it associated with something that was enjoyable or “cool.”

Kids are obviously influenced by what they see on TV. If it is marketed to them in the right way, they are likely to buy into what they have to do. Advertising theory is another effective, less traditional public health method used to homogenously control a group of consumers at the same time. Advertisers sell their product by making consumers a promise and supporting that promise through visual images (9). As affirmed by Kunkel, kids tend to believe what they see. These interventions in primary care did not advertise healthy eating habits in way that is proven to work effectively on children. Instead, they tried to talk to kids and gave them pamphlets and guidelines as to how they were to change their behavior. These methods were not effective. They did not assure kids with a “promise” of something they wanted, nor did they support their intervention with images that were visually appealing to them. Psychologists have done extensive research in what methods are effective in creating behavior change in children. Simply talking to kids and proving them with papers are not effective methods.

Finally, the creators of these interventions clearly did not have in mind what the kids actually wanted because they did not give kids a reason to stay with the program. Kids want to have fun, be with friends, and do the things they are used to doing. Instead, the basic premise of these studies was to target children who were already categorized as “obese.” The primary goal of these studies was not to produce happy, active children, but instead to specifically reduce their BMI. Instead of giving children a way to enjoy being active in a more natural, assuring way, they automatically stigmatized them as “overweight.” Stigma theory says that when people are labeled, once they self-identify with that label, they become that label (15). Kids who were picked to participate in this study automatically had this label put on them. Already, their self-esteem was lowered, and they may not have been happy to be a part of this program. Furthermore, since the investigators’ goal was to specifically reduce BMI in overweight children, they gave other children who were not categorized as “overweight” no reason to be active and eat healthier. The investigator’s methods were flawed because in failing to see what would attract kids to be healthier, they set themselves up for poor compliance, loss to follow up, and disinterest in the study all together.

A New Approach

These interventions aimed at reducing childhood obesity through the primary care setting have many flaws. They are largely based on the individual level, fail to account for environmental factors, and do not sell to kids what they wanted. With this in mind, I am proposing an intervention in which the US Department of Agriculture (USDA), with its “My Pyramid” dietary and activity guideline would provide kids with an incentive to be healthy. Through an online site, the USDA would allow kids, in teams, to document points they earn by participating in various healthy habits (outlined below). When the team earns a certain amount of points, it will win a gift certificate to Old Country Buffet. Through this program, the USDA would encourage parents, schools, as well as the community to get involved in kids’ health. To promote the program, the USDA would air commercials during television programs kids between the ages of 6-11 normally watch. In this new approach, there is a large emphasis on social networks as well as environmental factors that influence a child’s behavior. This new method also keeps the children’s interests in mind and provides a fun way for them to make healthy decisions.

Social Networks: Involving Parents and Friends

The interventions aimed at reducing childhood obesity through the primary care setting did not focus on the child-parent relationship nor did they account for the fact that children make decisions with their friends. Social scientists say that in order for longer lasting changes as well as maintenance of health promoting habits, an effective intervention must occur on multiple levels and consider group factors (5.) Social network theory argues that what dictates a person’s behavior depends on the behavior of the social network (1) and that individual behavior is largely the result of the expectations of others (6). Therefore, in creating this new intervention, we ask ourselves “how do groups change their behavior” instead of “how do individuals change their behavior?”

To answer this, we must first get children’s most important social network, their families, on the same page. By involving parents, the aim is to ensure that kids receive uniform messages and encouragement as to how to be healthy. Children will be able to log points for things like accompanying their parents to the super-market, assisting them with preparing a meal, and engaging in 30 minutes of daily physical activity. To validate these points, parents must sign off on their children’s daily logs (parents can sign on to their kids’ logs with their own passwords). This way, parents are forced to learn more about healthy habits and stay very involved in their children’s daily activities.

Kids also tend to make decisions based on their friends’ behavior. In this new intervention, children pick 3 friends to join their team. Instead of individually working towards a goal, the kids in the team pool their points towards the prize. Through this method, kids do not feel like they are the only ones participating in the program. Furthermore, working in teams helps friends encourage each other to do what will earn them the most points.

Accounting for Environmental Factors: Schools and the Community

Another substantial flaw in the interventions aimed at curbing childhood obesity in the primary care setting was that they failed to take environmental factors into account. Previous studies prove that there are strong ties between low income and obesity (14) Scientific evidence also shows that our brains are constantly attacked with signals from the outside world which often encourage people to consume more food than they should (3). One way researchers propose to keep lower income families from being at risk of obesity is to encourage them to become familiar with the recourses available in their particular communities (7).

To address this issue, a main focus of this intervention will be to encourage families to learn more about and make use of the resources in their neighborhoods. Another way for kids to earn points is to go with their parents to “discover health” in their community. If kids accompany their parents and discover a new grocery store, stall, or stand where fresh produce is available to them, they can document this online. Kids can also get points by finding a new bike path, walking trail, or park in their community. Of course, the kids will then receive points for making use of these recourses.

Another issue that some of these interventions through the primary care setting failed to account for was that not all people eat the same foods. The investigators in those interventions may have been under the impression that giving examples of certain “green” foods (like fruits and skim milk which the kids should eat “lots” of) and “red” foods (like cream cheese, soda, and potato chips that the kids should limit) would make it easy for the kids to follow dietary guidelines. However, these foods may not be common in every child’s diet. This new intervention will use “My Pyramid” instead as a guideline for how much food from the different food groups kids should include in their diet. “My Pyramid” guidelines are more adaptable to families who eat and cook different foods. Instead of generalizing which kinds of foods kids should eat and not eat, kids receive their own “My Pyramid Plan” based on their age, height, weight, and activity levels. Kids will earn points if they meet the requirements of their individual “My Pyramid Plan” daily (16).

Researchers also say that if we are to move forward in preventing obesity, there must be a more balanced food selection at school, not just at home (11). In order to make sure kids can keep their “My Pyramid Plan” in mind while at school, schools can help kids by labeling the cafeteria’s different food choices according to which food group(s) they fall under. This way, instead of unrealistically forcing schools to only offer “healthy” food choices, kids might be more likely to choose foods wisely depending on their individual plans. The kids can save the labels from the food they eat at school to make it easier to document when they get home.

Another environmental factor these interventions in the primary care setting failed to address is the fact that kids watch and are easily influenced by how foods are advertised on television (8). The USDA can make it a point to work with advertisers to also tell kids which food group(s) their products fall under. Again, it is not realistic that this new intervention will stop advertising of “unhealthy” foods. However, if kids discuss with their parents and are aware of what types of foods fit into their own “My Pyramid Plans”, they will be more conscious of which foods they eat so as to earn more points for themselves as well as their team.

Selling Kids What they Want

Finally, interventions aimed at preventing childhood obesity at the primary care level did not sell kids what they want. First of all, kids do not want to be stigmatized as “obese” (15) This new intervention sells a message to all kids that this program is something fun for everyone. This is crucial because it is important for all kids to know that a healthy lifestyle is not only something for people while they are trying to lose weight. Here, our end goal is not to reduce children’s BMI, but rather to get all kids to start making healthy choices. This will make kids more likely to join and less likely to drop out. There is no “limit” to being healthy, whereas a goal like reducing BMI can only work for certain kids, and only to a certain point.

Using media theory and its 5 Ps: Product, Price, Place, Promotion, and Positioning, this intervention sells a product that kids want: a fun “game” with a prize at the end (10). Kids like working in teams and being with their friends. They enjoy working hard earning points with an incentive in mind. Giving kids an incentive to engage in healthy behavior motivates them as well as reinforces the idea that its ok to go out and enjoy a meal with their family and friends once in a while. Being healthy does not mean going to one extreme or another, but being able to make good choices. Other than what the child’s family may already spend on purchasing groceries, the kids can obtain this “product” at virtually no cost. There is also no limit as to the place where kids can participate in this program. In fact, they are encouraged to get involved within their families, friends, schools, as well as their communities. A way in which this intervention can be promoted is through popular actors and actresses that the kids recognize. In between television shows that kids normally watch, young actors and actresses can advertise this new program in a way in which kids feel it is easy, fun, and socially accepted. Through this method, kids will have a positive “image” of the program and will add to effective positioning of the product. We know that kids watch a lot of TV and are influenced by what they see. Advertising theory focuses on making consumers a promise and supporting that promise through visual images (9). Through using the TV as a medium to market this product, we can effectively get a message across to kids while they are doing something they already enjoy doing.

Finally, kids recently enjoy spending a lot of time online. Kids are more likely to keep up with their “My Pyramid Plans” and document their points if they are doing so through a fun, interactive site online rather than on a separate piece of paper or in a book. They can also share their status with their teammates online. Recognizing that all children may not have access to televisions or computers at home, it is crucial that schools cooperate with the USDA to make children aware of this program and help them participate.


In developing effective interventions to address the problem of unhealthy bodies, we must at the very least take social networks and environmental factors into account. Furthermore, unless we present an intervention in an appealing method, kids are unlikely to follow any program. This new intervention addresses these flaws and offers an inventive approach to being healthy. With approaches like this, we can successfully convey the message that living a healthy lifestyle is for all people.


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9.) Marshfield, David. “Advertising Theory.”

10.) Meischke, Hendrika “Social Marketing Theory.”

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diet, physical activity and overweight in secondary schools.” National Institute for Public Health and the Environment.”

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13.) Wright, Julie. PhD. Slides and Interview on “Childhood Obesity and the Primary Care Setting” Including Studies by Schwartz, Hamre, Dietz et al and Kubik, Story et al

14.) Yoon, Yeong Sook et al. “Socioeconomic Status in Relation to Obesity and Abdominal Obesity in Korean Adults: A Focus on Sex Differences. (2006) The Obesity Journal. 14, 909–919; doi: 10.1038/oby.2006.105

15.) Link, Bruce. “Stigma as a Barrier to Recovery: The Consequences of Stigma for the Self-Esteem of People With Mental Illnesses.” Psychiatric Services 52:1621-1626, December 2001 © 2001 American Psychiatric Association

16.) My United States Department of Agriculture Home.

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