Challenging Dogma - Fall 2008

Wednesday, December 17, 2008

Tackling Childhood Obesity in Schools: The Failures of the Social Expectations Theory and How to Overcome Them– Akshar Patel

In America, childhood obesity is an increasingly growing concern and is proven by the fact that currently 16-18% of children and adolescents are obese and 34% are at risk, this is an 11% increase from the 1970’s (1,2). Obesity in children becomes ever challenging as those afflicted grow up to become obese adults. Cardiovascular disease, high blood pressure, and Diabetes Type II are all problems which arise due to obesity in adults and have been documented to be present in children who suffer from obesity (3). The United States has started to realize that obesity is rapidly becoming a problem in adults and especially in children and as a direct result, a variety of school based interventions have been created; BMI report cards, increasing physical activity, and changing the food available inside of public schools are just a few of the interventions which have been performed. These intervention share one main thing in common, they will all fail, or as discovered, children will go into remission once the intervention has been completed (4).

Due to the fact that they encompass a wide range of groups and are recognized to be a microcosm of the larger world around them, primary and middle schools have been established as a pivotal place to base interventions. The two types of obesity interventions that have designed are: primary, which try to prevent or lessen the effect of obesity, and secondary, which strive in helping maintain weight for obese children (5). Primary schools do not face many problems as the student body is not as deeply fragmented as the middle schools; here the dominating jocks, cheerleaders, and lowly geeks interact together and form a small social community whose actions are interconnected and influenced by factors such as puberty. I will be arguing the obvious, that the numerous interventions that have been proposed and conducted try and incorporate the social expectations theory but fall short in living up its’ definition. Social expectations theory states that individuals will act based on what the social norms prescribe as the acceptable way to act (6). Current interventions of changing foods, increasing physical activity, and promoting parental interaction (7,8) are modeled with the social norms of adults in mind, children and teenagers might share some of the norms, but they act by trying to associate the action with it’s acceptability to their peers.

Eating right does not mean being right

Kids do not have healthy eating on their minds, and let’s face the facts, nor do most adults. At risk kids, ages 6-13, are concerned about having fun or are in the center of teenage life and not thinking about what they will be having for dinner, for that is a problem best left to parents who have enough problems to deal with which will be discussed later. The norms of educated adults and dieticians call for heavily regulating what children are eating so that obesity can either be prevented or maintained. Schools were the chosen point because norms can be tried to be altered on a large scale. Grown ups typically have a method of going about doing things and often it is exactly like the lineage before them: we simply dictate what we want children to do. In a perfect world, this would work out completely fine, but kids have their own social norms, and one of them is to not always listen to what is directed towards them. This can create a problem if schools have lectures and classes about healthier eating habits, students will be less apt to pay attention or retain any information being conveyed, because teenagers hate being told what to do.

The removal of soda and food vending machines from hallways has already been implemented or is currently underway in most schools. This intervention was developed with the hope that throngs of students would be forced to buy healthier drinks, or single serving food packets (5,7) as they found an increasingly amount of less junk food available in the lunch lines. However, even though this intervention was shown to slightly decrease the consumption of unhealthy foods; many children were still bringing the products from home. By trying to rid of vending machines we are simply trying to change the social norms of teenagers into making them believe that it is ok to eat healthier foods. An idea which is unfathomable for school kids everywhere. The average student eats one to two meals supplied by schools; lunch is guaranteed, unless brought from home and thus unregulated and breakfast which can be healthy but is often served with sugary cereals (9). By supplying one healthy meal we are implementing a diet upon the kids since the dinner portion is not controlled by schools; studies have been conducted to test the effectiveness of such interventions, and have found inconclusive evidence of healthy eating interventions lowering obesity rates in children and some studies have even shown to promote weight gain from enforcing a diet (8,10).

This method of trying to change the social norms of eating habits in school kids was not implemented in the best way and is reflected with the inconclusive results. This failure can be attributed to two reasons: incorrect use of the Social Expectations Theory and overlooking a powerful factor. This factor is a lot more powerful than policy making and it is the power that the media holds. The media, if utilized properly, can be used to implement Marketing, Advertising, and Agenda Setting Theory at one time and quickly change social norms held by any group of people. This is exactly what the fast food industry has done. The commercials they have in the mainstream are more appealing than looking at the menu in a cafeteria. After school is dismissed, kids are left on their own until dinner time. At home, elementary school children might have snacks that may or may not be healthy. The situation is different for at risk middle schoolers, who with freedom and their allowance money can easily act on their cravings (11). Instead of eating a healthy meal at school, more and more teenagers are opting for the delicious but deadly Big Mac, items such as these are marketed to an extent (12) where children’s norms have been changed to promote eating at fast food restaurants; thus contributing to the rising problem of obesity and also unraveling the school based food program. The fast food industry has easily been able to change the social norm of children, for them fast food is the like advertising Gatorade, very easy. Fast food is quick, cheap, and delicious; there is no regard for the calorie count or the health effects of obesity simply because kids feel that it is not a problem that they have to worry about (11).

Physical Activity: Not just for athletes

Recess is the highlight for most children in primary school, and with good reason. As a kid, after a stressful morning of class all you want to do is run around outside and let off some pre-teen stress. For those in middle school, this is easier said than done. Middle schools do not have recess; instead they have replaced recess with Physical Education (PE), or recess in a structured environment.

As the obesity epidemic affects more children, schools are following a study (13) that provided inconclusive data for extending PE and weight loss. As an idea, extending PE looks to be well thought out; after all, what kid does not want to play games and hang out instead of sitting in class? The answer is simple, take a look into the bleachers and you will be easily able to spot them. It is one thing to appeal to the social norms of playing sports and having fun in teenagers, however when you try to mandate and get every student to participate, it is bound to fail. Those that can be found sitting in the bleachers are often the afflicted and the target of the intervention. The reason that they are sitting and not participating in the sport of the week is for the simple and small fact of not having developed the skills of playing sports, and instead of embarrassing themselves have opted to sit and take a mediocre grade. Although we can mandate physical activity and playing sports along with being active may completely be within the social norms, kids can not be forced into actually partaking in the exercise, especially obese children who have developed norms different then their peers. Interventions increasing requirements for physical activity do not take this into account and can fail (13,14). However, for the individuals that do participate in the activity, small effects can be observed as long as they keep up the exercise.

The beauty of school based physical activity is that it can be expanded out of the confines of the four walls of school. Students are encouraged to join school or city sport teams. This offers another way for kids who have developed athletic skills to keep exercising, and those who have not to try and get involved; although most often they tend to avoid these sport teams as well. One of the other factors that affect the success of this intervention is the neighborhood children come from. Low-income families typically live in the darker side of the city, and it might not always be safe for kids to cross the street and play a game of basketball, instead a safer alternative can be playing sports on the new Xbox 360 or watching TV (15). In conclusion, although intervening and increasing the amount of physical activity taking place in school using the Social Expectations Theory, we have completely disregarded the fact that athleticism is a developed talent and part of growing up is becoming absorbed into a clique where playing sports is just not the social norm. We have targeted the wrong social norm.

We’re in this together: the need for increased parental influence and involvement

Children can be compared to trees, as both need roots to survive. Without roots, trees will die off and in children values and knowledge will fail to be imparted. Due to this, parents are very important in determining the outcome of an obesity intervention. Studies have shown that if the grandparents and parents of children under 10 are obese, then the chances of obesity in the children is doubled when compared to non obese families (16,17) According to the social norms of parenting, parents should be present to take care of their children; this as we will see is not always the case, especially in low income families.

School based interventions, which are striving to change many norms that children currently have, relied heavily on parental involvement. Schools can only be held responsible for a small fraction of a child’s health and it is parents who hold the majority stake in the investment so they must be active in their child’s upbringing and health. However, this social norm is sometimes unattainable for some families located low on the socio-economic ladder. These parents are not able to feed their kids healthy foods everyday, most are working multiple jobs to help clothe, keep their children healthy, and put any food on the table (15). Most times when parents choose to work over dinnertime, fast food or ordering pizza becomes more of a decision. This applies not just too low income families but those that are in the middle class as well. The stigma of fast food as fast and filling, as also been established within the mindset of adults, and is attributed to adult obesity. In the context of this analysis, if parents are working longer hours everyday and do not have time to prepare healthy food, fast food becomes a viable alternative and unravels any forward process attained by school based interventions.

Looking ahead

Social Expectations Theory tells us that individuals act as a cohesive group, and will base their actions and thoughts around if their peers will find it acceptable. The loss of incorporating this teaching into a real world setting and forgetting children and adults have different norms has led to and will lead to a failure of school based interventions to stop and prevent childhood obesity. We in the public health field have tried to push our thoughts and norms onto kids that are not concerned about the same problems; the strategy of simply filling cafeterias and vending machines is a short term approach and completely disregards what kids eat after they leave the confines of the building.

A successful approach should not mirror present approaches, trying to change the social norms of pre-teens and teenagers to reflect what educated adults this is not right. Interventions should be addressed similarly to the “Truth” campaign in Florida, what the fast food industry is currently doing, and keeping the idea that parental involvement is crucial to the success of studies. The Florida and industry campaigns successfully utilized Marketing, Advertising, and Agenda Setting Theories; if these were applied to childhood obesity correctly, there would be a significant increase in success.

New interventions to fix past mistakes

The first steps that must be undertaken if we are to slow down and reverse the rate of childhood obesity, is to change the way children and adults view and act within their respective norms. Children can no longer be led to believe that junk food is the easier alternative to healthy eating, adults must not be allowed to dictate their views upon the younger generation, doing so only increases the rate of failure. Using the ideas and foundations of Social Expectations Theory in order to address the effects of obesity has so far, for the most part led to failure.

One way to address the failures of the theory in terms of childhood obesity is to patch up and strengthen the weakness mentioned earlier. A second method is to incorporate Marketing, Advertising, and Agenda Setting Theory to the same extent that fast food companies have done in order to ‘serve billions worldwide’, as McDonalds puts it. Children have been exploited through the use of these theories and it is time that we use the same weapons in order to protect them from further harm. The way these theories work are by determining what the consumer wants and then packaging and advertising the item (in our case fast food) back to the population (18). Once this happens, the issue that is always advertised and displayed in the media is the problem or item in question (19). Decreasing the growth of childhood obesity will save millions of dollars in the future for treating illnesses such as hypertension, cardiovascular problems, and Type II Diabetes (3).

The majority of interventions must focus on primary and middle school education. It is at these levels that children are most susceptible to the media, and also for forming bad habits such as unhealthy eating (20). By the time children reach high school, the majority of the damage has been done, and habits that were formed will continue into adulthood. Younger children are more likely to be affected by adult interventions, as they have not fully developed the need to rebel against the parental and authoritative adults.

Keeping kids healthy: a balance between dictatorship and friendship

Schools are the perfect place to conduct obesity interventions. The small community of children function as a smaller part of the adult world, and different models of interventions can be made for each subgroup of the population. These institutions are set up as a dictatorship, the principal and teachers dictate what the students should do; something that carries into every interaction a teacher and pupil have. This carries over into lectures that are given to middle school students about healthy eating; instead of learning about how to eat healthy, the students are simply told why it is good for them and told what to eat.

If interventions are meant to succeed, teachers need to become friendlier when addressing problems such as obesity in the classroom. Instead of lecturing to middle school pre-teens about what they should eat, more emphasis should be placed on not just the nutrition behind healthy eating and why it is important, but the lessons should become hands on. Students can be placed into groups, or ‘families’ and each are in charge of preparing a recipe of healthy meals. In this way, not only do the students learn about why healthy eating is beneficial, but they began to learn more about what healthy meals should consist of.

One of the biggest issues mentioned earlier is the removal of vending machines from schools. The machines were removed from schools to help lower the consumption rate and lower obesity as a result of buying the unhealthy products. A better method to go about this process would have been to allow both types of healthy and unhealthy vending machines to exist, but charge a much lower rate for the goods in a healthier machine. This method allows for children to somewhat make their own choices, however if the product is much more than one is willing to pay, the runner up looks even better. In this way, instead of boycotts of unwanted machines occurring, students would slowly develop a liking to the cheaper healthier foods.

Only six to seven hours of one day is spent inside the confines of school, the rest is spent at home, where the television is always on. This invention is one of the greatest culprits of childhood obesity. The commercials by the fast food industry are more numerous and appealing due to the new types of burgers, and the inclusion of a toy. One way to reverse this trend of commercials on the air is to have public service announcements in the form of the Truth campaign. The issue should link fast food companies and tobacco companies together, and talk about how fast food companies, are getting children addicted slowly and affecting health over a longer period of time. Another example on how to use Advertising and Marketing theory is to have short clips on making healthy snacks using the same ingredients that can be used to make junk food.

Physical Activity: making sure it’s done right

Recess is everyone’s favorite memory of early schooling. It was a chance to run around in the fresh air, not having to worry about class or the fact that you forgot your homework at home. During those early years, physical activity and fitness are not on a kid’s mind, however recess allows for excess energy and calories to be burned off and fights weight gain.

Once middle school came, recess was snatched away and replaced with a period called Physical Education (PE). It became known as structured recess with the catch being that you had to play the game of the week, and be graded on participation. Teams were decided on not how much you wanted to play, but what your peers thought of your athletic skills and how likely you were to help the captain win. Instead of being put through the humiliation of being picked last, one is more likely to skip PE or do something requiring less activity. This is not something we need in America, where the average person is told to exercise for 30-60 minutes three to five times a week (21).

There are two options that we can choose from. Option one brings back the dream of recess; in this version, PE is eliminated and everyone is allowed to play from many games. This allows for groups to decide on what they want to play and activities that are based on ones talents can be decided to be played. The second option is to allow PE to exist but in a manner which helps build up athletic skill. Those that often skip out on PE lack the skills that are required to play many of the sport games. Furthermore, teams should not be decided by a captain, but instead arranged so that individuals who are athletic are teamed up with those that are not.

Outside of schools, physical activity can take place in neighborhoods. Children have the option of joining city teams outside of school; others might want to play in the local park but are hindered by the lack of safety surrounding parks. In lower income neighborhoods; parks and recreation areas are places where gangs and other unsafe practices may congregate. This creates an atmosphere that parents do not want their children to experience and will not allow their children to go outside. If these areas have better lighting and more is done to ensure that the neighborhoods are safe; parents would be more willing to allow their children to play in the park. This would increase the amount and duration of activity that every child has a chance to partake in.

Teamwork: getting parents involved

One of the major reasons for the failure of current interventions is the lack of parental commitment. As stated earlier, low income parents often work at more than one job or multiple shifts. As a result, children are left with money for fast food. Barring large amounts of money being handed to low-income families; there is not much that can be done about the fact that parents have to work.

There are two things that can be done to help promote healthy eating at home in low and middle income families, the first is to send pamphlets and videos home to parents to view on healthy eating. The second, and more effective method, would be to encourage parents to cook meals in advance. Cooking meals in advance allows for healthier eating, because instead of eating fast food, children or parents can come home and warm up the prepared food.

…And that’s a Wrap

In conclusion, although primary and secondary school based interventions are being conducted; more often then not, they will fail. The failure is partly due to the fact that differences in norms of children and adults, nor the fact that parents may not always be a good mediator of keeping up the intervention at home, are not taken into account. Adults often dictate and do not think as a child, this alienates interventions from addressing the issues that would help enhance the chance of success of the specific intervention. By addressing these simple issues, and following the ideas that were suggested, the goal of curbing the rate of childhood obesity can be greatly enhanced.


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