The Smallstep Campaign against obesity and its Small Effect- Navid Shams

Introduction

In the past 30 years we have witnesses the obesity problem in this country develop into a major epidemic and a predominant issue in public health. Just in the first 20 years, the percentage of obese adults doubled from 15% to 30%. In a similar time period the prevalence of overweight children increased from 5% to 17.4%. [i] Now about 64% of the US population is either overweight of obese. [ii] This striking progression also brings with it direct and indirect costs that are estimated to be as high as $117 billion dollar annually. [iii] These costs are so high due to the fact that being overweight or obese has been shown to increase the risk for a series of diseases, including osteoarthritis, Type 2 diabetes, coronary heart disease, stroke, gallbladder disease, sleep apnea, respiratory problems, and even breast and colon cancer. ⁱ

The steady and significantly increase in the prevalence of obesity as well as the associated costs have pushed the government to act. In November of 2005, the US Department of Health and Human Services in conjunction with the Advertising Council mounted a $1.5 million a year media-based campaign called smallstep. Its goal is to “increase awareness, change behavior and promote healthier lifestyles among the millions of Americans who are currently unhealthy and overweight and at risk for obesity and long-term chronic diseases.” ^xvi A series of professionally produced television, magazine, and radio public service advertisements get people’s attention by using humorous visual images and then refer them to the companion website so they can learn about more than 100 small steps that can lead to a healthier lifestyle. The small steps are thought to be manageable enough to fit into a busy schedule without requiring drastic changes and therefore should promote long-term, sustained weight control and good health.

In conjunction with this campaign, a sub-campaign, smallstep kids, has recently been added to encourage children to eat healthier and be more active. It uses similar media outlets to portray healthy fruits and vegetable as fun foods that can be used as fuel for play. It also utilizes NFL players, LPGA golfers, and Shrek characters to promote the “Play 60” and “Be A Player” concepts that urge children to get out and play everyday.

The smallstep campaign uses a novel approach to obesity problem. It integrates healthier eating and a more activity into the typical American’s life in a reasonable manner. It even incorporates a non-traditional model by using advertising theory. However, it still doesn’t seem to be effective enough to produce positive health outcomes. In the following analysis, I provide an evidenced-based criticism that illuminates why this public health campaign is not succeeding.

Argument 1: Dependence on the HBM does not account for the impact of social networks on behavior change.

The smallstep campaign uses the Health Belief Model (HBM), which is an individual-level, value-expectancy model that posits that people will engage in healthy behavior when they intend to do so because they value the outcome and believe it will result from their behavior. [iv] In their campaign report, the smallstep developers emphasize how the program promotes self-efficacy, a trademark of the HBM. [v] They highlight the idea that having to complete only a few simple and small steps (i.e. take the stairs instead of the escalator, get off the bus a stop early and walk, try smaller sized items when snacking or eating out) will boost confidence in one’s ability to perform the behaviors.

Although this tactic makes the tasks seem more manageable, it is counterproductive to give each step a number. The actual numbers associated with each “step” on the main webpage make it seem like one’s goal should be to complete each one as if it is a task. Also, mentioning that there are over 100 of them makes it seem less manageable and can be intimidating for people, especially those who are already not very hopeful about their ability to eat right and exercise regularly.

Besides not considering the previously explained challenges facing individuals in vulnerable economic situations, the select use of the HBM also doesn’t permit the developers to address the influence of social networks on predicting behavior. Social Networking Theory tells us that the relationships with a person’s peers, teachers, teammates, friends, neighbors, and family are of great importance and can significantly affect a person’s decisions. This effect depends on the nature of the relationship, which involves reciprocity, frequency and complexity of interactions, and the setting. [vi] This theory is especially important to consider because the “network phenomena appear to be relevant to the biologic and behavioral trait of obesity.” [vii] By focusing on individuals, the smallstep campaign neglects research that suggests the obesity tends to “spread” through social ties and develop in clusters.

For instance, being friends with an obese person increases one’s risk of becoming obese by 57% and having a sibling who becomes obese increases it by 40%. [viii] Although the smallstep kids advertisements do promote activity that involves friends and peers, the smallstep adult and teen section doesn’t recognize that an individual’s social network plays a role in determining actions related to health, the health information one is exposed to, and the social support people have available to them. Only one of the exercise related tips even addresses the idea of involving another person in your physical activity: Tip # 44 states “Ask a friend to exercise with you). Most of the activities are very individual-based, such as the use of a step tracker, which includes an online component that promotes setting activity goals and tracking progress using an interactive calendar.

A lack of consideration of Social Network Theory (SNT) is apparent in the discord between the adult/teen and kids sections. The developers should have considered the relationship between parent’s obesity status and its effect on their children. Children are known to adopt parent’s diet and health related behavior due to daily exposure. [ix] Children with 2 obese parents have an 80% chance of becoming obese in their lifetime, while those with one obese parent have a 40% chance and those with no obese parents have only a 7% chance. [x] Considering that part of this is related to the social-norms established by parents, the developers should have taken more steps to link the kids and adult sections of their campaign.

Lastly, a person who has overweight/obese social contacts has a different perception of the acceptability of being overweight/obese. It may even be a social-norm for them. This partially explains why weight gain by same-sex friends and siblings had such a large impact on the risk of the individual becoming obese. ^xvi Approaching the public with more group level smallstep interventions could be more effective at instituting long lasting behavior change.

It is important to link appropriate individual and population-based theories when designing interventions. This produces a richer intervention because, after all, we are all
individuals but we are also enmeshed in social networks. The specific importance of social networks in the obesity problem warrants using a group-based theory like SNT to combat the limitations from HBM. Neglecting this aspect leads to a smallstep campaign that does not have a strong multi-level intervention.

Argument 2: Poor Use of Advertising Theory

The inclusion of the Ad Council in this public health intervention was a good decision because it allows for the use of multiple media outlets (TV, internet, newspapers) that have a large audience. Also, it allowed for the addition of aspects of the intervention that are based on Advertising Theory. This theory involves two essential components: a promise and its support.

The support aspect can be implicit and even laughable, but should include compelling visual images, music, etc. In the case of the smallstep ads, the support has drawn confrontation and is being laughed at instead of being laughable. As Michael Jacobson of the Center for Science in the Public Interest says, it so “namby-pamby [that] I think people will shrug it off.” [xi] This is a criticism of the commercials that show people finding love handles, double chins, and other fatty and unwanted pieces of flesh in public places because they have lost them due to simple exercise (e.g. taking the stairs, walking to the office).

We know that “viewers pay more attention to ads that evoke feelings of personal loss, sadness, anger, disgust or fear [and] tend to remember such ads longer,” ^xvii so it’s unfortunate that the developers didn’t use more vivid, dramatic effects to get their point across. They even admit that research showed the ads to be humorous, instead of evoking any of the above feelings. Even the “lost” fat isn’t particularly disgusting, or as disgusting as it could be. This also applies to the magazine ads that are supposed to look like lost cat type signs, but lack attention-getting colors. These ads are poorly designed and do not evoke the right emotions from the audience, which is critical to their success.

The promise aspect of an advertisement is of critical importance and must be researched thoroughly so as to identify what exactly it is that your target population most aspires to at a core level. Unfortunately, the text that delivers the promise on the print ads is also impossible to read as it is very small, not colorful, and written vertically. In addition, framing theory tells us that the ads would be more effective if they identified core values. Unfortunately, only a couple of them do this reasonably well: “Now runs the risk of being mobbed by female admirers.” Most of them miss the mark: “No longer dependant on wearing vertical stripped shirts.” Also, the use of humor continues in these ads: “fights urge to run on the soccer field and play forward.” So, even if you manage to read the promise, it may not even be effective.

It is surprising to me that the Ad Council didn’t come up with more promising material and leads me to be suspicious of the partnership with the “Coalition for Healthy Children,” which includes Coca Cola, Pepsi, Hershey, and the National Confectioners Association. Their products are serious contributors to obesity, yet there is no mention of them. There could be conflict of interest issues that led to the absence of candy and soft drinks in the advertisements.

The smallstep kids advertisements are also flawed, especially in regards to the “brand name” they developed. The “Play 60” and “Be A Player” show groups of kids having fun and playing easy outdoor games like tag, 4-square, football, kickball, cheerleading. Respectively, they include well known professional football players and LPGA golfers, and Shrek characters that are involved in the kid’s activities. The impressive recruiting the developers did is counteracted by the use of “brand names” that emphasize the wrong idea. Play 60 advertisements specifically tell the kids to play for 60 minutes every day and suggest that this should be their goal. However, research tells us that kids would be more responsive if values like improved appearance or social standing were addressed. [xii] [xiii] The well respected athletes could have been used more effectively in this way.

On the other hand, the Shrek characters, although they are certainly popular are not exactly the most athletic group that could have been used to promote physical activity. However, that is exactly the point: you don’t have to be an athlete to enjoy and benefit from physical activity. This raises issues around the effectiveness of the message delivered by the advertisement and the coordinated online system, which gives health tips based on personal exercise and health statistics. Shrek isn’t focused on physical activity but instead on improving health, which we know is not a core value for children. [xiv] We know that the kids watching these are already displaying sedentary behavior, so the smallstep kids developers need to be sure to dissuade the inactivity while they have the children’s attention. [xv]

Argument 3: Developers Overlook the Sociological Perspective

When designing a public health intervention, it is critical to know the traits of the problem. However, the designers of the smallstep campaign have overlooked the socio-demographic characteristics that are an important part of the obesity problem. In the US, we have seen the prevalence of obesity rise more than twice as fast among minority groups compared with white groups. [xvi] Moreover, we know that black and Latino children are as twice as likely of being overweight compared with white children. [xvii] Among adult women, obesity prevalence varies significantly by ethnic group: 31% among whites, 40% among Mexicans, and 52% among African Americans. In terms of obesity, the concepts of race/ethnicity and SES are interlinked. [xviii] Namely, the highest rates of obesity occur among populations with the highest poverty rates, and poverty disproportionately affects minorities. [xix] Keeping this connection in mind there are a couple of reasons why overlooking socioeconomic status, specifically, is a major flaw of the smallstep campaign.

The idea of a family’s socioeconomic status (SES) is a key factor that influences food options. People from lower SES backgrounds are more likely to become overweight due to limited access to health-related stores and local food shops with available fresh and healthy foods. [xx] So, even if people want to eat the healthy, fresh fruits and vegetables that smallstep suggests, they are not readily available and can be prohibitively expensive. [xxi] A related factor is the lack of reliable transportation. Also, there are there are fewer supermarkets with fresh, affordable produce and many more small independent grocers that provide low cost, high-energy foods in low-income areas. This leads to the purchasing of cheaper meals and snacks that are convenient but offer little nutritional value. [xxii] These are factors that will certainly impede the effectiveness of the “Can your food do that?” aspect of the smallstep kids campaign, which is well designed enough that is can succeed at getting children to want to eat fruits and vegetables. Unfortunately, when it succeeds and the children want those foods, they may not have access to them.

SES can also restrain physical activity. Lower income neighborhoods can have more crime and street violence. This does not allow children to safely use parks and open spaces; children in lower income neighborhoods get less physical activity when compared to children in safer, wealthier neighborhoods. [xxiii] Besides the safety concerns, the built environment itself can impact physical activity. Geographic areas occupied by low SES and minority populations are known to have less availability of physical activity facilities than those occupied by higher SES populations. [xxiv] Studies have shown a correlation between the accessibility to sidewalks, gyms, gardens, and parks and increased physical activity. [xxv] Understandably, areas with more facilities have been associated with lower rates of overweight and obese people. So, although the “Shrek” and “NFL Play 60” ads [xxvi] can get kid’s attention because of the presence of popular football players and movie characters, the fun they have playing in seemingly safe, sizable parks and well equipped and maintained sports facilities is not possible for many of the more vulnerable children. It is especially unrealistic for those in urban areas.

Conclusion

The US Department of Health and Human Services’ smallstep campaign has tackled the complex obesity problem with a media-based approach that certainly has possibilities. It focuses on perceived barriers to individual behavior in a novel and worthwhile manner. However, this epidemic requires multi-level interventions that address the underlying causes of obesity from various dimensions. The individual’s behavior must be viewed in relation to the social network and also social environment. Its failure to do this is common among public health interventions, but is still unforgivable. The use of creative solutions based on Social Network Theory, coupled with a better use of Advertising Theory is warranted.

Counter-Proposal

Introduction

The US Department of Health and Human Services’ smallstep campaign has tackled the complex obesity problem with a media-based approach that certainly has possibilities. It focuses on perceived barriers to individual behavior while integrating healthier eating and a more activity into the typical American’s life. Their approach is novel and worthwhile. However, it still isn’t effective enough to produce positive health outcomes because this epidemic requires multi-level interventions that address the underlying causes of obesity from various dimensions. The individual’s behavior must be viewed in relation to the social network and also social environment. The use of creative solutions based on the sociological perspective and Social Networking Theory, coupled with a better use of Advertising Theory is warranted. In the following proposal, I present an intervention that builds upon the smallstep campaign by capitalizing on its strengths and addressing its weaknesses.

Step I: Accounting for the impact of social networks on behavior change.

A major strength of the smallstep campaign is its unique approach to addressing self-efficacy by providing simple and small steps. This tactic does, in fact, make the tasks seem more manageable and will be effective once the numbering of steps is removed. Because each step is independent (i.e. take the stairs instead of the escalator, try smaller sized items when snacking or eating out) they can be effectively understood and implemented no matter what order they are used in. Not using numbers also adds to their self-efficacy by removing the intimidation brought on by knowing that there are over 100 possible small steps.

Along with the Health Belief Model (HBM), Social Networking Theory (SNT) will be utilized. The new campaign should recognize that obesity tends to “spread” through social ties and develop in clusters. It should promote individual’s involvement in their social networks so that they can give and get support and health information from them. The tips that are given to adults and teenagers should specifically address the inclusion of others. This can be done by referring to general characters in a person’s life. For instance, “Make a pact with a coworker to use the stairs.” We could even modify the step tracker program so that it allows for teams of people to join online and have inter-departmental competitions.

Along with promoting the inclusion of coworkers and friends, the new campaign will consider the parent’s obesity status and its effect on their children. Because the effect is related to the social-norms that are established by parents, it can be used to have a more positive effect on the child as well. We will take more steps to link the kids and adult sections of the campaign so that each group is addressed separately and also as one social unit. For instance, the children could be asked to make a grocery list after using the interactive “Can your food do that?” interface. It could recommend that they discuss it with their parents, which would expose the parents to the campaign and perhaps promote the purchase of those healthy foods. On the other end, suggesting that the parents walk their kids to school or to activities would get the children to view that activity as more normal.

This part of the new campaign links appropriate individual and population-based theories and ultimately results in a richer, multi-level intervention.

Step II: Effective Use of Advertising Theory

The use of multiple media outlets (TV, internet, newspapers) and the inclusion of the Ad Council is another major strength of the campaign. However, just because a larger audience is exposed to an intervention, does not necessarily mean that it will have better results. A better understanding and use of advertising theory will increase the new campaign’s effectiveness.

First, we will adjust the emotions that the images evoke. Instead of laughter, we will aim for disgust, which is known to cause viewers to remember an ad longer. This will be accomplished by using attention-getting colors on the magazine ads and vivid, dramatic effects in the commercials. For instance, in portraying the “lost” love handles, double chins, and other fatty and unwanted pieces of flesh, a “surgeon’s view” of fat will be used in place of the simple looking plastic objects that were used in the previous set of advertisements. Adding this type of drama to the ads will make sure that the “support” that advertisements are using isn’t just being viewed, but noticed and having an impact.

Concurrently, the “promise” aspect of the new advertisements will be enhanced. First, the text that conveys this on the magazine ads will be large, colorful, and horizontal so that it is easy to read. Using framing theory, we will create more effective ads that identify core values (i.e. “having to buy that new bikini” and “leaving work early because you are the captain of the soccer team”).

Lastly, this new campaign will recognize the importance of having a captivating “brand name.” This is especially critical in the aspects that target kids and teens. These groups have been shown to be quite responsive to brand names that address values like improved appearance and social standing. The VERB campaign that the CDC ran until 2006 can be incorporated into this campaign. Using this model, we can successfully increase and maintain physical activity by getting kids to find, take ownership of, and integrate their own verb into their personal lives. In this way, the campaign isn’t focused on improving health, which we know is not a core value for children, but instead on physical activity.

This new brand name, coupled with the well known professional football players, LPGA golfers, and Shrek characters that were part of the previous advertisements will make for an innovative approach that will likely be popular and catchy enough to spread through communities. Along these lines, it can address social networks by having parents, teachers, doctors and coaches also targeted by using advertisements that expose them to the slogan “it’s what you do” and have them utilize it in their interactions with the kids.

By using a provocative brand name with effective, theory based, advertisements in a mass communication medium this new campaign makes some warranted improvements.

Step III: Including the Sociological Perspective

The designers of the smallstep campaign overlooked the socio-demographic characteristics that are an extremely important part of the obesity problem. The new campaign will take into account the interlinked concepts of race/ethnicity and SES and adjust the intervention to specifically target the social and ethnic communities that suffer the most from the epidemic.

Because of the large audience that this intervention reaches and engages, it has the awesome possibility for meaningful health education. The online portion of the campaign can be especially useful to introduce viewers to programs like Women, Infants, and Children (WIC), which are in place to provide food, nutritional counseling, and access to health services for low-income families. Because few families recognize that programs like this exist, having links to their website or even including them among the tips can have lasting effects for those at highest risk. Although there are certainly still challenges, like dependable transportation, these programs can at certainly decrease the number of factors that stand in the parents way.

This type of community health education can be expanded from only addressing access to healthy foods to encouraging local programs that promote the use of safe outdoor space. This campaign can’t change the built environment, but it can identify the local programs and give people information about them in region specific ways via the website. Also, the new campaign will replace the safe, sizable parks and well equipped sports facilities that were in the previous advertisements with settings that are more realistic for those living in low income and urban areas.

Conclusion

The US Department of Health and Human Services’ smallstep campaign is attempting to address an obesity epidemic that is 30 years in the making. The media-based framework of the approach has great utility in promoting long-term, sustained weight control and good health. However, we must recognize that obesity has been a predominant issue in public health for this long because no one theory or intervention is going to address each important dimension. In light of this, the intervention I have presented capitalizes on the strengths and properly addresses the weaknesses of a previous program in hopes of creating a well enhanced program. It involves creative solutions based on the sociological perspective, Social Networking Theory, and Advertising Theory. Even so, it understands that it is dependant on other programs and factors to achieve the positive health outcomes that it seeks.

References

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[i] CDC National Center for Health Statistics. Health E-Stat. NHANES data on the Prevalence of Overweight Among Children and Adolescents: United States, 2003–2004. 28 Mar. 2008.

[ii] Flegal K, Carroll D, Ogden L, Johnson L. (2002) Prevalence trends in obesity among U.S. adults, 1999-2000. JAMA, 288(14), 1723-1727.

[iii] U.S. Department of Health and Human Service (2001). The surgeon generals call to action to prevent and decrease overweight and obesity. Rockville MD: US Department of Health and Human Service, Office of the Surgeon General.

[iv] Becker MH, ed. The health belief model and personal health behavior. Health Educ Monogr. 1974;2:Entire Issue.

[v] Ad Coucil/Healthy Lifestyles and Disease Prevention Media Campaign Report. March 2004

[vi] Edberg M. Essentials of Health Behaviors: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.

[vii] Moffitt T. Adolescence-limited and life-course-persistent antisocial behavior: A developmental taxonomy. Psychology Review. 1993; 100:674-701.

[viii] Christakis NA. Fowler JH. The spread of obesity in a large social network over 32 years. New England Journal of Medicine. 357(4):370-9, 2007 Jul 26.

[ix] Birch LL, Fisher JO. Development of Eating Behaviors Among Children and Adolescents. Pediatrics 1998; 101:539-49.

[x] Whitaker RC, Wright JA, et al. Predicting obesity in young adulthood from childhood and parental obesity. New England Journal of Medicine 1997;337:869.

[xi] Stobbe, M. Critics say ads on obesity lack punch: Call ‘Small Steps’ spot too tame. The Boston Globe. October 23, 2007

[xii] Strauss RS, Rodzilsky D, Burack G, Colin M. Psychosocial correlates of physical activity in health children. Archives of Pediatric and Adolescent Medicine 2001:155:897-902

[xiii] Sothern M, Gordon S. Prevention of obesity in young children. Clinical Pediatrics 2003;42:101.

[xiv] Ward-Begnoche W, Speaker S. Overweight youth: Changing behaviors that are barriers to health. Practical advice for dealing with the family, the child, and socioeconomic environment. Journal of Family Practice 2006; 55(11):957-963.

[xv] Standford Prevention Research Center. Building “Generation Play:” Addressing the crisis of inactivity among America’s children. Stanford, CA. Stanford University School of Medicine, 2007.

[xvi] Ebbeling CB, et al. Childhood obesity: public-health crisis, common sense cure. Lancet. 2002, 360: 473-82.

[xvii] Haas JS, et al. The Association of Race, Socioeconomic Status, and Health Insurance Status With the Prevalence of Overweight Among Children and Adolescents. American Journal of Public Health. 2003; 93: 2105-2110.

[xviii] U.S. Census Bureau. Current Population Survey (CPS). Annual Social and Economic (ASEC) Supplement. Income Distribution Measures, by Definitions of Income: 2006. (INC RD-AEI 1).

[xix] Drewnowski A., Specter SE. Poverty and Obesity: The Role of Energy Density and Energy Costs. American Journal of Clinical Nutrition January 2004; Vol. 79, No. 1, 6-16.

[xx] Stafford, M. et al. Pathways to obesity: Identifying local, modifiable determinants of physical activity and diet. Social Science and Medicine 2007, 65, 1882-1897.

[xxi] Ard, J.D., et al. Informing Cancer Prevention Strategies for African Americans: The Relationship of African American Acculturation to Fruit, Vegetable, and Fat Intake. Journal of Behavioral Medicine, Volume 28, Pages 239-247.

[xxii] Cummins, Steven & Sally Macintyre. Food Environments and Obesity –
Neighborhood or Nation? International Journal of Epidemiology, 2006. 35(1): 100-104

[xxiii] Lumeng, J.C., Appugliese, D., Cabral, H.J., Bradley, R.H., & Zuckerman, B. (2006). Neighborhood safety and overweight status in children. Archives of Pediatric & Adolescent Medicine, 160(1), 25-31.

[xxiv] World Health Organization. Global Strategy On Diet, Physical Activity And Health. 28 Mar. 2008.

[xxv] Duncan MJ, Spence JC, Mummery WK. Perceived environment and physical activity: a meta-analysis of selected environmental characteristics. Int J Behav Nutr Phys Act 2005; 2:11.

[xxvi] U.S. Department of Health and Human Services. Washington, D.C. SmallStep Kids. http://smallstep.gov/kids/flash/index.html

Why the BMI Report Card is not an effective intervention for the childhood obesity epidemic and an alternative intervention- Emma Wicker

Introduction

Childhood obesity is at epidemic levels and is a major public health concern(1). Results from the 1999-2002 National Health and Nutrition Examination Survey (NHANES), indicate that an estimated 16% of children and adolescents between the ages of 6 and 19 are overweight. What is even more troubling is the fact that this represents a 45% increase from the 1988-1994 NHANES which estimated that 11% of children were overweight. In real numbers this means that approximately nine million children over the age of 6 years are obese(2). This is of major concern because overweight children face a variety of health risks both while they are children and later when they become adults. Children that are overweight are at risk for developing Type II diabetes, sleep apnea, and asthma(3-5). Overweight children are much more prone to becoming overweight adults and as obese adults their health problems are likely to become exacerbated(6). On top of the health issues previously mentioned, overweight adults battle health problems such as cardiovascular disease, cancer and stroke(7-8).

Given that childhood obesity is a major health concern, several public health interventions have been attempted to address this issue. This paper will examine one such intervention, a Body Mass Index (BMI) report card for children that is sent home from school(9). The idea behind the BMI report card is if parents know that their child’s BMI is too high they will be motivated to initiate steps to address the issue. The report card is designed to focus parent’s attention on the issue of childhood obesity. The first school district to role out this program was Arkansas in 2003 and later California, Illinois, New York, Pennsylvania, Tennessee and West Virginia all sent home BMI report cards(10-11). While the BMI report card was designed with the best of intentions, it has several failings. These failings include the fact that the BMI report cards fail to promote self-efficacy, it does not recognize that behaviors occur in a social context and finally it has the potential for negative labeling.

Self-Efficacy

The first step in evaluating the effectiveness of the BMI report card is to evaluate its ability to promote children’s self efficacy. The social cognitive theory developed by Albert Bandura lays out the concept of self efficacy(12). According to this model, perceived self-efficacy plays a very influential role in personal motivation. People who harbor doubts about their capabilities to perform a healthy behavior are easily dissuaded by failure. In contrast, people who have a strong sense of self efficacy intensify their efforts when they fail to achieve their goals. People with strong self efficacy will persist in the behavior until they succeed in achieving their goals. If self efficacy is important for a child to be able to successfully undertake a healthy behavior that will address their obesity, then the BMI report will not be a successful intervention.

The BMI report card is a very simple tool. All it has on it is the child’s BMI and what weight category the child falls into based on their BMI. The categories are ‘underweight’, ‘normal weight’, ‘at risk for becoming overweight’ and ‘overweight’. There is no information provided on the report card on how to promote the child’s self efficacy in the home setting. If the child does not believe that they will be successful in executing healthy behaviors, simply knowing that they are overweight will not solve the problem. The best way to promote self efficacy is through mastery of experiences. What this means is if a person is successful in performing a behavior, then those successes will build a strong belief in one's personal efficacy(13).

To effectively promote a child’s self efficacy there needs to be many avenues where the child can be successful in performing healthy behaviors both at home and at school. If the school sends home a report card that says that the child’s BMI is too high, they also need provide opportunities for the child to eat healthy foods at school or to exercise. Unfortunately, not only do the schools not provide information on how self efficacy can be promoted at home, but they also do not provide avenues in which to promote a child’s self efficacy at school.

According to a study published in 2003 by the National Institute of Child Health and Human Development, children may not be getting enough exercise through their schools' physical education programs. The study specifically looked at third grade children and found that these children only received an average of twenty five minutes per week in school of moderate to vigorous activity(14). In contrast, the recommended amount of exercise that children should get is thirty to sixty minutes of moderate to vigorous activity every day.

The school can also impact childhood obesity with the food that they serve to the children. There have also been some studies that suggest that children who eat the school lunches are in fact more likely to be obese than those who eat food prepared from home(15). If the school is not going to provide an avenue for children to perform healthy behaviors, the children will not end up with a strong sense of self efficacy and therefore their ability to be successful in performing healthy behaviors will be substantially diminished.

Social Context

Many public health interventions are individual level models. The Health Belief Model and the Theory of Reasoned Action are just two of the many models used by public health professionals that focus on behavior at an individual level and do not take into account the social context that the person lives in(16-17). These models do not recognize that healthy behaviors do not occur in a vacuum. There are many issues that may arise if the context of childhood obesity is ignored. One way this is evidenced is by the fact that children with obese parents are more than twice as likely to be obese themselves(18). This is consistent with the ideas put forth by the Social Network Theory which posits that what determines an individual’s behavior is the behavior of other people in their social network(19). The Social Network Theory indicated that it is not individual characteristics, but the relationship between individuals that is important in influencing health beliefs and behaviors. Research shows that network phenomena are very important to the biologic and behavioral trait of obesity, and obesity appears to spread through social ties(20).

If a child’s social network is a powerful influencer on their behavior, then the BMI is not a successful tool in addressing the problem. Some of the report cards offer no suggestions at all on how a child or the family can do something to address the BMI. A few of the BMI report cards offer a few simple suggestions such as watching less than 2 hours of TV, getting 1 hour physical activity and eating 5 servings of fruits and vegetables(21). However, none of these suggestions offer tools on how the entire family can participate in healthy behaviors.

Getting an entire group of people to change a behavior can be seen in the Diffusion of Innovation Theory(22). The Diffusion of Innovation Theory has its roots in sociology and it is concerned with the mechanism by which an innovation makes its way through certain channels until it is communicated to all the members of a social system. If the social network is important, than any intervention to combat childhood obesity needs to be designed to effectively diffuse the innovation through the social network. The way the BMI report card is set up offers no way to diffuse healthy behavior through the child’s social network.

The other problem is that the report card does not recognize that the healthy behavior happens in context of many other behaviors. Parents have many concerns to worry themselves with and health may not be at the top of the list. According to Maslow's Hierarchy of Needs, basic needs such as food and shelter much be met before one can worry about a chronic illness such as obesity(23). If the parent is concerned about paying the rent or just getting some kind of food on the table they are not going to be worried about providing their children with 5 fruits and vegetables a day or giving them ample opportunity to exercise.

This intervention assumes that once the parents are informed about their child’s obesity, first, they will decide to do something about it and second, that they will have the resources to undertake the desired action. As mentioned earlier in terms of Maslow’s Hierarch of Needs, just because the parents have the information does not mean that they will chose to act on it. The second issue is that just because someone may have the intention to undertake an action does not mean that they will have the resources available to undertake those actions.

Research has shown that there is a significant relationship between socioeconomic status, race, and geographic location with childhood obesity(24-26). Some studies suggest that certain populations such as children in low socioeconomic status families and children in the country's southern region tend to have higher rates of obesity than the rest of the population. The increased risk of obesity is especially evident among African-American and Hispanic children(27). These two minority groups have upwards of 24% of their children above the 95th percentile in terms of weight. If the two genders are separated it can be seen that among males, the highest prevalence of obesity is observed in Hispanics and among females, the highest prevalence of obesity is observed in African Americans(28). The BMI report card does not offer any suggestions for healthy behavior that recognize ethnic and SES differences. If parents are not provided with the appropriate tools to help their children, then they will not be able to provide the children with the opportunity to engage in healthy behavior.

Children also have many worries that may prevent them from participating in healthy behaviors. One of the steps on Maslow’s Hierarchy of Needs is self esteem and the respect that children are receiving from others. Children who are overweight struggle with their self esteem and may find themselves marginalized by their peers(29). If children are struggling with these issues they may not be able to implement the healthy behaviors necessary to address their obesity. The BMI report card offers no skills to help the child feel better about themselves. In fact, the report card may have the opposite effect and lower the child’s self esteem as they feel they are being labeled as ‘fat’.

Labeling

The BMI report card has one final flaw which is the fact that the BMI report card puts the children into one of four categories which could cause a problem no matter what category the child falls into. Labeling Theory postulates that the labels that are applied to people influence their behavior, particularly the application of negative or stigmatizing labels. This can then become a self fulfilling prophecy as the person believes that they have no choice but to conform to the label(30). If a child falls into the ‘overweight’ BMI category or even the ‘at risk for becoming overweight’ category the child may feel that they have been labeled as ‘fat’. This label may leave them feeling powerless to do anything about the issue. This may mean that children would ignore any possible opportunities to engage in healthy behavior that are presented to them. Being labeled as fat also may have a deleterious effect on the child’s self esteem and may encourage them to engage in unhealthy behaviors. Children who are already overweight and suffer from low self esteem are more likely to over-eat which will further exacerbate their obesity(31).

Children may also not fully understand what the BMI index means. Children as young as six are receiving these BMI report cards, and the BMI report card does not offer an explanation of what a high BMI means in terms that a six year old could understand. Children who do not understand whet the BMI index really is may feel that they are being chastised for being overweight as the BMI report comes home in the form of a report card. This may lead the children to drastically and dangerously cut down on their caloric intake or to stop eating all together(32).

The BMI index may also cause children who are categorized as ‘normal weight’ or ‘underweight’ to engage in unhealthy behaviors. Children are aware that there is a social bias against ‘fat’ people and they may do whatever they think is necessary to avoid being labeled as ‘fat’(33). This may encourage children who are not overweight to engage in unhealthy weight control behavior in order to avoid a ‘bad’ report card.

Summary of BMI Report Card Failures

While the BMI Report card was designed with the best of intentions, it does not provide tools for the child to address their weight issues. In 2007 Arkansas released its fourth annual report that discussed its program to address childhood obesity which included the BMI report card. This report showed that since 2003, the program has had no effect on reducing childhood obesity as there has been no change in the percentage of children whose BMIs fell into the ‘overweight’ or ‘at-risk-for-overweight’(34). In 2003 when the program began, about 20% of Arkansas children were classified as ‘overweight’ and 17% as ‘at-risk-for-overweight’, and those percentages remained the same in 2007. By not providing tools that promote self efficacy or address the social context that the child is in, the BMI report card will not be able to successfully address childhood obesity. In fact, by sending home the report card, the intervention may have a negative impact on the health of both normal weight and overweight children as the fat label is not conducive to performing the desired healthy behaviors. For the BMI report card to be successful it will need to address these issues.

Alternate Intervention

The BMI report card has many issues that makes it ineffective at addressing the childhood obesity epidemic. For an alternate intervention to be effective it will need to address all of the failings of the BMI report card. When developing an effective intervention it will need to address self efficacy, the social environment of the child and labeling in order for the intervention reach its intended goal of having children engage in healthy behaviors.

Since a child spends time both at school and at home, both of these environments need to support the child in their healthy behaviors. If the school were to offer a program that both the children and the parents attended then the parents would be involved in the behavior which is important for the child’s success in executing the behaviors. Schools have parent teacher conferences, usually during the fall and spring semester, and during that time the school should also have a panel of health professionals available to speak with both the children and the parents. The professionals should include a nutritionist, an exercise professional, a psychiatrist and a public health professional available who can tell the families what support program there are in their local community, such as programs that will help them get healthy food, where they can exercise and other publicly funded programs that will help them lead healthy lives. Each family will sit down with the panel on a one on one basis so that the panel can address the specific needs of each family. The family will also be provided with information that they can take home with them. Given that many parents work, the conference needs to take place not only during the day, but there needs to be an evening and weekend option as well. Each panel will also need to be trained so as to be able to appropriately address the needs of the different communities that each school is located in. The children who go to schools in upper class neighborhoods will have different experiences than the children who live in inner city neighborhoods and each panel needs to be trained as to recognize and work with those differences. With the wealth of information both the parents and the children will be able to work together to support the child’s healthy habits.

This information will also allow the child to make healthy decisions when not at home, like how to choose healthy food at school. As part of this intervention the school needs to provide the children with avenues in which they can use their new knowledge to generate positive results. As part of this program the school should design its school lunch menu and physical education so that healthy food options are offered at lunch and so that the children have multiple opportunities to exercise.

How The Alternate Intervention Addresses Self -Efficacy

According to the Social Cognitive theory, perceived self-efficacy plays a very influential role in personal motivation (12). People who believe that can execute a behavior are more likely to be successful in doing so. This belief is strengthened when the child is given the opportunity to gain mastery of experience. The reason that the alternate intervention is an improvement is that it offers the child tools so that they can execute healthy behaviors and gain mastery of experience. After attending the panel the child will know how to make the right food choices and how to find ways to exercise based on their own individual experiences. When they are able to make those decisions they will feel empowered and then will be more likely to make those decisions again in the future.

The new intervention also will provide the parents will the tools to help support the child’s self efficacy. If the parents are able to support the child’s healthy decisions the child will be more likely to be successful which, again, will support the child’s self efficacy. The school will also provide avenue that will promote the child’s self efficacy as by having healthy food to choose from and effective physical education programs the child will be successful in executing the healthy behavior at school which will also boost their mastery of experience and therefore their self efficacy. With both the home environment and the school environment supporting the child’s self efficacy the child is much more likely to be successful.

How The Alternate Intervention Addresses The Social Level Issues

Another problem with the BMI report card is that it is an individual level model and does not take into consideration the child’s environment. The alternate model is an improvement as it incorporates the child’s family in the intervention. As indicated by the Social Network theory, what determines an individual’s behavior is the behavior of other people in their social network (19). What this means is, that if the parents are acting in a healthy manner, it is more likely the child will do the same. If the family is involved in the intervention and given the tools to engage in healthy behaviors then it is much more likely that the child will do the same. This intervention provides the family with the tools to engage in healthy behaviors which will have a positive influence on the child’s behavior.

One of the main problems with the BMI report card is that it does not recognize that healthy behaviors happen in the context of many other behaviors. On Maslow's Hierarchy of Needs health is a higher level need than other needs such as shelter (23). If the lower level needs are not met then it will not be possible to meet the higher level needs. As the panel will include a public health professional to assist the family with finding programs that will help them address the lower level needs it will be a more successful intervention than the BMI report card. This professional can help the family find inexpensive housing and other public assistance program that may be available to them. With this information it will be easier to meet the needs lower on the hierarchy and when those needs are met they will be able to address higher needs on the hierarchy, such as health.

Children also have many worries that may prevent them from participating in healthy behaviors. One of the steps on Maslow’s Hierarchy of Needs is self esteem and overweight children can struggle with their self esteem which would make it harder for them to attend to higher level needs such health. The problem with the BMI report card is that it offers no skills to help the child feel better about themselves, which is one of the reasons that it is not a successful intervention. The school based health panel will have a psychiatrist on it that will help the child address any self esteem issue that they may have. If the child feels better about themselves they will be more likely to engage in healthy behaviors which will also help to boost their self esteem.

Another problem with the BMI report card is that it does not recognize ethnic and SES differences. Children may face unique challenges based on their SES or ethnic profile and the BMI report card does not offer any tools to address these challenges. The advantage if this alternate intervention will try to address theses challenges. The health panel will be trained to help families navigate their SES environment and be trained to be culturally sensitive. As each family will meet with the panel one on one, the family can be given tools that specifically address their SES and ethnic needs.

How The Alternate Intervention Addresses Labeling

According to Labeling theory the labels that are applied to people influence their behavior, in particular the application of negative or stigmatizing labels (30). The problem with the BMI report card is that it gives a label to each child. If the child believes that there is nothing they can do after they have been labeled ‘fat’ then they will not engage in healthy behaviors which may help address the problem. On the other end of the scale, a child who has not been labeled as ‘fat’ could be so worried about being labeled ‘fat’ that they engage in unhealthy behaviors to avoid becoming labeled ‘fat’. The alternate intervention is an improvement because when the family meets with the panel they will not be labeling the child, just offering tools to live a healthy life style. All children will meet with the panel no matter what their weight so there will not be a negative stigma associated with going to the panel. If the child is not labeled then it can not negatively influence the child’s behavior.

Conclusion

The BMI report card is not sufficient for addressing the growing epidemic of childhood obesity. This alternate intervention does not have the failing of the BMI report card and therefore would likely realize greater success. This new model addresses self efficacy, the social environment and labeling theory and by doing so will help the child execute healthy behaviors so the child can live a healthier life.

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