Challenging Dogma - Fall 2008

Thursday, December 18, 2008

Tactful Approach to Childhood Overweight and Obesity Prevention: Implementation of School-Based Programs- Samantha Roy

Suggested Approach to Childhood Overweight and Obesity
A number of childhood obesity prevention programs, promoting healthy weight and lifestyle in children, have been enacted. However, recent statistical analysis on childhood overweight and obesity reveals an increasing trend, indicating the lack of a successful intervention and leaving public health practitioners ardent for a solution (11). One example of an ineffective initiative is the “Fat chance” billboard, endorsed by the MetroWest Community Health Care Foundation in Framingham, Massachusetts.
Firstly, the ad negatively labels and stigmatizes overweight and obese children. Society’s mockery and negative view of obesity exacerbate obese-related behaviors; children eternalize the stigma and adopt the label, augmenting the severe condition of childhood overweight and obesity. Secondly, it fails to consider group-level factors, which contextualize the fundamental factors of obesity. An emphasis on individual-level factors assumes that all individuals behave the same, which is highly inaccurate. Finally, it disregards the influence of social networks. The behavior of overweight and obese children may be greatly influenced by the behavior of their social networks, which may predominantly be obese. The billboard is daunting and humiliating; it hinders its target audience of overweight and obese children from modifying behavior to acquire a healthier lifestyle.
A more practical intervention involves the implementation of school-based programs that, when combined, successfully approach childhood overweight and obesity. Currently, more than 95% of children and adolescents are enrolled in school, demonstrating the potential success of a school-based intervention. According to the Continuing Survey of Food Intakes by Individuals (CSFII) 1994-1996, 1998, 31% of boys aged 6-11 years and 34% of girls aged 6-11 years meet the fat-intake guideline of the U.S. Dietary Guidelines (14). Such findings indicate that the majority of children aged 6-11 years have a fat-intake greater than 35% of total calories from fat (28). Establishing healthy behaviors, such as physical activity and eating habits, at a young age increases the likelihood of proper child growth and development, as well as the possibility that healthy behavior and habits continue in adulthood (12). Implementation of nutrition standards and education, physical activity requirements, and Body Mass Index (BMI) screenings in schools would expose children to nutritious foods and healthy behaviors, and it would inform parents of their child’s likelihood of obesity, a more tactful approach to preventing childhood overweight and obesity
Implementation of Nutrition Standards and Education in Schools
Nutrition standards and education in primary and secondary schools would give to every child the opportunity to develop an understanding of proper eating habits and conscious, healthy behavior. Although the overall upbringing of a child is the parents’ responsibility, schools can utilize the time in class and during lunch period to introduce children to healthy behaviors and foods, which may or may not be present or available at home.
School cafeteria foods should be regulated under the Dietary Guidelines of Americans, jointly published by the United States Department of Agriculture (USDA) and Department of Health and Human Services (HHS) (42). The Dietary Guidelines “provide science-based advice to promote health and to reduce risk for major chronic diseases through diet and physical activity,” (42). During early school hours, cafeterias should provide breakfast options that fulfill “one-fourth of the Recommended Dietary Allowance (RDA) for protein, calcium, iron, Vitamin A, Vitamin C, and calories;” actual food items for all meals are chosen by individual schools, but should include multi-grain/whole-grain breads and cereals, fresh fruit and eggs, non-fat or low-fat milk, and additive free juices (39). Lunch menus must also incorporate USDA guidelines and serve foods that provide one-third of the RDA, such as bread and grains, fresh fruits and vegetables, lean meats and poultry, non-fat or low-fat milk, and additive free juices (35). After school snacks, following USDA guidelines, may also be provided to children in after school programs or extracurricular activities. Most importantly, schools should adhere to appropriate serving sizes and keep prices affordable for all children.
In addition to standardized cafeteria foods, on-campus vending machines must also be regulated to sell healthier options. According to a report by the Government Accountability Office, 83% of elementary schools and 97% of middle schools sell foods out of vending machines, which is why vending machine regulations are in dire need (18). Instead of selling ice cream, candy bars, cookies, fruit cups with syrup, chips, and pop, school vending machines should sell frozen fruit juice bars (with no sugar or high fructose corn syrup), granola bars, peanut butter crackers, low-sodium soups, low-fat yogurts, rice cakes, and 100% fruit juices (40). Changing vending options in schools prevents children from purchasing the unhealthy foods that may contribute to overweight and obesity. Outside of school, children may encounter vending machines that do not follow healthy vending guidelines, established by the USDA; thus, it is ultimately the child’s decision to carryout conscious, healthy behaviors and to consume nutritious foods, which is why an emphasis on healthy foods and nutrition education is imperative.
Nutrition education informs children of the relationship between diet, physical activity, and health, which is necessary to realize at an early age (30). A course on nutrition is as important as the core subjects of reading, math, and science; what a child eats affects his/her health, growth, and ability to learn (33). Children should be taught age-appropriate nutrition concepts, varying from identifying healthy foods, understanding the food pyramid, discussing healthy behaviors, and reading nutritional labels, to identifying USDA guidelines and applying knowledge for a healthier lifestyle (43). Interactive lessons, puzzles, and games can make learning nutrition exciting for children. Classrooms should have fun, colorful posters, diagrams, and images conducive to learning the foods to eat and avoid, the types of physical activities that can be performed, and the benefits of a healthy lifestyle. Teachers should be trained in nutrition to ensure that accurate nutrition information is communicated to children and positive, healthy behaviors are encouraged.
Early involvement in nutrition education and exposure to nutritious foods can instill attitudes and behaviors in children that may continue in adulthood. Requiring nutrition standards and education in schools enables every child the opportunity to eat healthy, fresh foods and acquire healthy behaviors. Most importantly, this approach considers the group-level factor of institutional menus, an improvement from the “Fat chance” billboard, which focuses on individual-level factors. Nutrition standards in schools are a contextual variable; the foods served in schools may be a fundamental cause of childhood overweight and obesity. Wholesome foods and nutrition education should not be a privilege; every child should have the same advantage in accessing fresh foods and learning the role of diet and health in school.
Implementation of Physical Activity Requirements in Schools
Children should be required to participate in physical education and activity to establish an awareness and understanding of the association between healthy diet and exercise. The Office of the Surgeon General (OSG) recommends children to engage in 60 minutes of moderate activity most days of the week; currently, less than 25% of children get at least 30 minutes of any type of physical activity each day (39). Physical education standards, established by the National Association for Sport and Physical Education (NASPE), require that a physically educated individual: demonstrates motor skills, understands movement concepts, principles, and skills, participates in regular physical activity, exhibits responsible, respectful behavior, and “values physical activity for health, enjoyment, challenge, self-expression, and/or social interaction,” (29). Designating time in schools for physical education and activity can increase the rate of physical activity children obtain on a daily basis.
Recently, schools have reduced or eliminated physical education in response to budget concerns and pressures to improve academic test scores (1). Results from the 2006 School Health Policies and Programs Study indicate the need for elementary school improvements: 3.8% of schools offered daily physical education, which entails 150 minutes a week for 36 weeks (as recommended by NAESP), 74% of schools provided regularly scheduled recess, and about 50% of schools offered intramural or physical activity clubs (24). Physical activity requirements, including gym class, recess, and intramural sports, not only positively affect musculoskeletal and cardiovascular health and cholesterol and triglyceride levels, but also reduce anxiety and stress levels, increase self-esteem, and even lay the foundation for regular activity in adulthood (22). Interestingly, children that participate in physical activity show improvements in the classroom (1). A national study conducted in 2006 examined the relationship between physical activity and academic performance: those children who reported participation in physical activity were 20% more likely than their peers to earn an “A” in math or English (1). If children reveal better academic performance in schools with physical education and activity requirements, school systems must consider incorporating physical activity requirements into the school day.
It is crucial to create an environment that prevents negative labeling and the degradation of children. Teachers and school monitors must advocate against peer bullying to ensure that no mocking or humiliation of overweight and obese children occurs. Children should not feel threatened or insecure when participating in physical education or activity. Results, based on Canadian records from the 2001/2002 World Health Organization (WHO) Health Behavior in School-Aged Children Survey, reveal a strong and significant association between relational and overt victimization and overweight and obese children. In addition, some overweight and obese children were more likely to perpetrate bullying than their normal-weight peers (6). Children should not be exposed to negative criticisms at such a young age; bullying behaviors may “hinder the short- and long-term social and psychological development of overweight and obese youth,” (6).
The implementation of physical education and activity in schools is an improvement to the “Fat chance” billboard: children enrolled in schools are given the opportunity to fulfill the recommended physical activity requirements for an improved, healthy life. Regardless of the child’s socio-economic status (SES), school gymnasiums, playgrounds, and athletic fields can offer a safer location to participate in physical activity, which may not be the case for a child in a lower SES (4). Overall, schools must create a positive and supportive learning environment and incorporate academics and physical activity, an approach to reduce the rate of childhood overweight and obesity.

Implementation of BMI Screenings in Schools
Annual school-based BMI screenings would inform parents of their child’s risk for weight-related health problems and notify schools of the health status of its students. BMI is a relatively easy number to calculate from an individual’s height and weight; it is a reliable indicator of body fat and for risk of weight-related health conditions (12). Currently, 10 states have BMI report requirements in effect; some may be state required aggregate reports while others may be individual reports sent to parents (31). A study, which examined recent BMI trends for U.S. children and adolescents from 2003-2006, found that 11.3% of children and adolescents were at or above the 97th percentile, 16.3% were at or above the 95th percentile, and 31.9% were at or above the 85th percentile (9). A child is considered overweight with a BMI between the 85th to less than 95th percentile and obese with a BMI equal to or greater than the 95th percentile (12). With the current rate of childhood overweight and obesity, school-based BMI screening reports address the need for conscious, healthy behavior in children.
BMI reports are not intended to offend children or parents; the goals of BMI reports are to increase awareness of the severity of overweight and obese-related health problems and suggest appropriate, healthy solutions to live a healthier life. It is vital that school-based BMI reports provide parents “a clear and respectful explanation of the BMI results and appropriate follow-up actions” so that parents understand the purpose of BMI reports (22). Parents may not perceive their child as overweight or obese, so providing a clinically standardized children’s BMI scale assures parents of the accuracy of the report. Reports should be mailed to parents to prevent children from feeling stigmatized; most BMI reports are handed to children in class, which creates fear and embarrassment, a current complaint with BMI reports. BMI screenings are similar to additional screenings conducted in schools, such as hearing, vision, and speech tests, so it should not be correlated with an overweight or obese label or stigma (19).
School-based BMI screenings allow schools to gather a general consensus of the health of its student body and apply findings to improve nutrition and physical activity requirements. Every child receives a BMI screening, regardless of weight, so schools do not explicitly differentiate between students. School-based BMI screenings is a better approach to the “Fat chance” billboard: instead of solely informing a child and his/her parents that he/she is overweight or obese, BMI reports provide advice on how to improve health.
A more logical approach to preventing childhood overweight and obesity is the implementation of school-based programs. A successful intervention cannot rely on one single implementation; a multi-based approach is crucial. Nutrition education and standards in schools gives children enrolled in school the opportunity to learn healthy behaviors and to eat nutritious foods. Children from families in a lower SES may not be able to afford fresh foods, so making nutritious foods available in schools increases the likelihood of those children consuming healthy foods. Physical education and activity give children the opportunity to be active, self-expressive, and social, which enhance health and academic performance. Children may not live in a safe neighborhood with recreational parks nearby; providing children a safe location to play can encourage physical activity. Importantly, schools must advocate against peer-bullying so that negative labeling or stigmatization does not occur; peer-bullying victimizes overweight and obese children more than their normal-weight peers. Finally, school-based BMI screenings would inform parents of their child’s current weight-related health; it also would provide straightforward information and advice on BMI results and improving health.
Although parents are responsible for a child’s upbringing and likelihood of acquiring a healthy lifestyle, school systems can play a major role in preventing childhood overweight and obesity. Schools that adhere to this intervention would provide an environment where children can learn healthy attitudes and behaviors from their teachers and peers. It is important to emphasize health and nutrition at a young age so that healthy behaviors become habit in adulthood.

1. Active Living Research. (2007). Active education: Physical education, physical activity and academic performance. [Electronic version.] Retrieved December 3, 2008, from
2. Adams, J. L., Escarce, J. J., Freedman, V. A., Kapur, K., Rogowski, J. A., & Wickstrom, S. L. (2004). Socioeconomic status and medical care expenditures in medicare and managed care. Retrieved November 16, 2008, from
3. Berenson, G. S., Dietz, W. H., Freedman, D. S., Mei, Z., & Srinivasan, S. R. (2007). Cardiovascular risk factors and excess adiposity among overweight children and adolescents: The bogalusa heart study. Journal of Pediatrics. 150(1).
4. Borsboom, G. J. J. M., Bosma, H., Dike van de Mheen, H., & Mackenbach, J. P. (2001). Neighborhood socioeconomic status and all-cause mortality. American Journal of Epidemiology, 153 (4). [Electronic version]. Retrieved November 18, 2008, from 0&hits=&RESULTFORMAT=&fulltext=Neighborhood+socioeconomic+status+ nd+allcause+mortality&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT#S EC2
5. Bower, B. (2007). Weighting for friends: Obesity spreads in social networks. Science News, 172 (4).
6. Boyce, W. F., Craig, W. M., Janssen, I., & Pickett, W. (2004). Associations between overweight and obesity with bullying behaviors in school-aged children. Pediatrics, 113(5). [Electronic version.] Retrieved December 6, 2008, from
7. Braet, C. & Decaluwe, V. (2003). Prevalence of binge-eating disorder in obese children and adolescents seeking weight-loss treatment. International Journal of Obesity, 27.
8. Cacioppo, J. T. (n.d.). Foundations in Social Neuroscience. Retrieved November 17, 2008, from 095& q=socioeconomic+status&ots=rv8Y2PCcap&sig=tx7K-5wO8u- I33Su6ApXxPgW9Q8
9. Carroll, M. D., Flegal, K. M., & Ogden, C. L. (2008). High body mass index for age among US children and adolescents, 2003-2006. [Electronic version.] Retrieved December 2 2008, from http://jama.ama-
10. Casper, R. C. (2000). Eating disturbances and eating disorders in childhood. Psychopharmacology. [Electronic version.] Retrieved November 15, 2008, from
11. Centers for Disease Control and Prevention. (n.d.). Childhood obesity. Retrieved November 16, 2008, from
12. Centers for Disease Control and Prevention. (n.d.). Healthy weight: About BMI for children and teens. Retrieved November 15, 2008, from
13. Centers for Disease Control and Prevention. (n.d.) Healthy youth: Physical activity. Retrieved December 2, 2008, from
14. Center for Disease Control and Prevention. (n.d.). Nutrition: School health guidelines. Retrieved December 6, 2008, from
15. Centers for Disease Control and Prevention. (n.d.). Overweight and obesity. Retrieved November 15, 2008, from
16. Centers for Disease Control and Prevention. (n.d.). Overweight and obesity: Consequences. Retrieved November 15, 2008, from
17. Centers for Disease Control and Prevention. (n.d.). Overweight and obesity: Contributing factors. Retrieved November 15, 2008, from
18. Center for Science in the Public Interest. (2006). Bipartisan support on capitol hill for healthier school foods: Child nutrition promotion and school lunch protection act introduced. Retrieved December 5, 2008, from
19. Chmelynski, C. (2005). States weigh idea of BMI reports as they tackle obesity epidemic. National School Boards Association. Retrieved December 2, 2008, from lthyEating/obesityepidemic.aspx
20. Christakis, N. A. & Fowler, J. H. (2007). The spread of obesity in a large social network over 32 years. The New England Journal of Medicine, 357. [Electronic version]. Retrieved November 16, 2008, from
21. Diez Roux, A. V. (2004). The study of group-level factors in epidemiology: Rethinking variables, study designs, and analytical approaches. Epidemiologic Reviews, 26. [Electronic version]. Retrieved November 17, 2008, from
22. Grummer-Strawn, L., Lee, S. M., McKenna, M., Nihiser, A. J., Odom, E., Reinold, C., Thompson, D., & Wechsler, H. (2007). Body mass index measurement in schools. Journal of School Health, 77. [Electronic version.] Retrieved December 5, 2008, from
23. Kadushin, C. (2004). Basic network concepts: Introduction to social network theory. Retrieved November 16, 2008, from dushin/Txts/Basic%2520Network%2520Concepts.pdf+social+network+theory& hl=en&ct=clnkcd=4&gl=us&client=firefox-a
24. Kahan, D. (2008). Fitting physical activity into the elementary school day: There are many ways to add movement and exercise to classroom instruction. Leadership Compass, 6(1). [Electronic version]. Retrieved December 2, 2008, from .pdf
25. Leppert, J., Nilsson, K. W., & Sjoberg, R. L. (2005). Obesity, shame, and depression in school aged children: A population-based study. Official Journal of the American Academy of Pediatrics, 116.
26. Link, B. G. & Phelan, J. C. (2007). On stigma and its public health implications. Columbia Institute and New York State Psychiatric Institute. Retrieved November 16, 2008, from
27. MetroWest Community Health Care Foundation. (2007). MetroWest kids: Fat chance. Retrieved November 14, 2008, from oard
28. National Agricultural Library. (n.d.). Choose a diet low in fat, saturated fat, and cholesterol. Retrieved December 5, 2008, from
29. National Association for Sport and Physical Education. (n.d.) Moving into the future: National standards for physical education, 2nd edition. Retrieved December 3, 2008, from nationalstandards.html
30. National Center for Education Statistics. (n.d.). Nutrition education in public elementary and secondary schools: Nutrition education in the school curriculum. Retrieved December 3, 2008, from
31. National Conference of State Legislatures (2007). Childhood obesity: 2006 update and overview of policy options. Retrieved December 5, 2008, from
32. National Heart Lung and Blood Institute. (n.d.). How are overweight and obesity diagnosed? Retrieved November 15, 2008, from,
33. Nutrition Explorations. (n.d.). Why teach nutrition? Retrieved December 2, 2008, from
34. Ofei, F. (2005). Obesity: A preventable disease. Ghana Medical Journal, 39 (3). [Electronic version.] Retrieved November 17, 2008, from
35. Pennsylvania Department of Education. (2008). Food and nutrition programs: National school lunch program. Retrieved December 6, 2008, from
36. Physical activity levels among children aged 9-13 years in united states, 2002. (2003). Morbidity and Mortality Weekly Report, 52 (33). Retrieved November 17, 2008, from
37. School Health Policies and Programs Study. (2006). Physical education. [Electronic version.] Retrieved December 3, 2008, from cation_SH PPS2006.pdf
38. The Obesity Society. (n.d.). What is obesity? Retrieved November 15, 2008, from
39. United States Department of Agriculture Food and Nutrition Service. (n.d.). School breakfast program: Fact sheet. Retrieved December 5, 2008, from
40. United States Department of Education. (n.d.) Healthy vending machine. [Electronic version.] Retrieved December 6, 2008, from
41. United States Department of Health and Human Services. (2006). Dietary guidelines. Retrieved December 5, 2008, from
42. United States Department of Health and Human Services and U.S. Department of Agriculture. (2005). Dietary guidelines for americans, 2005. [Electronic version.] Retrieved December 6, 2008, from 005.pdf
43. Utah State Office of Education. (n.d.) Responsible healthy lifestyles nutrition education. Retrieved December 6, 2008, from
44. Wikipedia. (n.d.). Labeling theory. Retrieved November 16, 2008, from

Labels: ,


Post a Comment

Subscribe to Post Comments [Atom]

<< Home