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

Introduction

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

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

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

“Fat Chance!” Fat chance of losing weight?

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

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

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

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

Are some of the options really safe or feasible?

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

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

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

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

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

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

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

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

Introduction

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

Intervention

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

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

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

Self-efficacy and positive reinforcement

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

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

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

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

Safe environment and non-competitive group activities

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

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

Adressing availability and affordability

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

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

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

Conclusion

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

Conclusion:

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

References:

1. Nestle Marion. The Ironic Politics of Obesity. Science; 2/7/2003, Vol. 299 Issue 5608, p781.

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

http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/overwght_child_03.htm

3. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 295:1549-1555. 2006.

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

http://www.metrowestdailynews.com/homepage/8998967371255250943

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

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

7. Edberg M. Essentials of health behavior:Social and behavioral theories in public health. Sudbury, Ma : Jones and Bartlett Publishers.

8. Crocker Jennifer and Major Brenda, Social Stigma and Self-Esteem: The Self-Protective Properties of Stigma. Psychological Review, Vol 96(4), Oct 1989. pp. 608-630

9. Bandura A. Social Foundation of Thoughts and Action. Englewood Cliffs, NJ: Prentice Hall; 1986.

10. Festinger, L. (1954). A theory of social comparison processes. Human Relations, 7,71-82.

11. Tajfel, H., & Turner, J. C. (1986). The social identity theory of intergroup behavior. In W, Austin & S. Worchel (Eds,), The social psychology of intergroup relations (pp. 7-24). Monterey, CA: Brooks/Cole.

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

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

14. Barnes JA. Class and communities in a Norwegian island parish. Human Relations. 1954;7:39-58.

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

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

http://journals.bmj.com/cgi/reprintform

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

Analysis of Boston Public Health Commission’s Boston BestBites Restaurant Program to Fight Obesity – Lindsay Flaherty

Introduction to Obesity and BestBites
As public health practitioners are very aware of, obesity is a major problem in the United States. In Massachusetts, the obesity rate for 2007 was 21.3 percent, which is lower than most states in the country (1). The obesity problem persists in the city of Boston as well, and five years ago, the Boston Public Health Commission created the Boston Steps program to address it, along with diabetes and asthma in eight Boston neighborhoods with the highest prevalence of these conditions. In this focused area including Chinatown, Dorchester, Hyde Park, Jamaica Plain, Mattapan, Roxbury, South Boston, and the South End, 33 percent of residents are overweight, while 20 percent are obese (2). One of the programs created as part of Boston Steps is called the Boston BestBites program.
Boston BestBites is designed to help Bostonians make healthier food options when dining out in the city. With all of the tempting restaurant choices in Boston, it is not surprising that that 40 percent of residents’ food dollars are spent while eating away from home (3). Restaurants that are interested in participating in BestBites submit potentially healthy recipes to nutritionists from Brigham and Women’s Hospital for analysis. The hospital nutrition department has developed guidelines constituting a healthy meal, outlining total calories, saturated fat, trans fat and sodium. Maximum allowances in these categories are outlined for an appetizer, entrée and a dessert. The guidelines fit in with the Dietary Guidelines for Americans 2005, which recommends a 2,000 calorie per day diet for the average American adult (4). Restaurants then work with the nutritionist to meet the guidelines, if they do not pass originally. Once the recipe meets the criteria, participating restaurants are given window decals, coasters, and table tents branded with the BestBites logo and are included in campaign advertising. Healthy menu items are designated in some way so diners know what they are choosing (5).
Boston BestBites launched in August of 2006 with 12 participating restaurants. It sent out 600 packets of information to garner restaurant participation (6). As of April of 2007, there were 21 participating restaurants, spanning some of the targeted neighborhoods, but not all. Information about the program after April of 2007 is difficult to find. It appears as though the program is no longer running, or doing so with minimal support. This could be due to a number of reasons, from lack of funding, to lack of restaurant support, or even poor outcomes.
This approach to fight obesity in restaurants taken by Boston BestBites is not unique. There have been other similar approaches developed. I developed a program that precluded BestBites called The Boston Heart Party Restaurant Program in which we garnered local Boston restaurants to develop heart-smart dishes to complement our free CVD screenings. Some national chain restaurants have created healthier options on their menus for those individuals who are dieting. One example of this was when Applebee’s teamed up with Weight Watchers in 2003 to create a menu that fit the Weight Watchers criteria and was offered alongside other menu choices (7). It is easy to understand the logic of such programs. By providing healthy options on a menu, it allows people to participate in the dining experience of eating out while staying true to their diet. It could even encourage non-dieters to choose healthy, good-tasting options. In reality, the people who have obesity issues may not have the willpower to make the healthy choices when they eat out, or else they may eat and drink other things along with the healthy option that wipe out the positive effects after all.
Critiques of the Intervention
While the Boston BestBites campaign and those like it are innovative and logical, this paper will examine how this program and others like it are flawed for three main reasons. The first is that the campaign as it stands is focused on the individual and does not account for several other options that affect dining choices. Second, it does not take into account social and cultural influences on changes in behavior that can be explained through sociology and anthropology’s influences on the field of public health. Finally, while the campaign had visually appealing collateral materials, it was not supported by a strong communications program, which could have helped to solidify consumer awareness adoption.
Argument #1: Insufficiency in an Individual-Based Model
The Boston BestBites campaign is based on the Health Belief Model (HBM). In the HBM, health behavior is motivated by the following thought processes: perceived susceptibility to an outcome, perceived severity of the outcome, perceived benefits of an action, perceived barriers of taking that action, cues to action and self-efficacy (8-10). When patrons take their seats in a restaurant with a menu to decide what to order, they are presented with an array of choices. They essentially go through the thought processes presented by the HBM as they decide what to eat. Specifically, some of the questions they may consider are:
· Should I choose the lasagna or the baked chicken BestBite option?
· Would the enjoyment of the lasagna be worth breaking my diet for the day?
· If I get the lasagna, will I have time to put in an extra long session at the gym tomorrow?
· Will the BestBite option make me feel good enough to pass up my favorite meal?
Unfortunately, the limitations to the HBM apply to the Boston BestBites campaign as well. One of the main limitations of the HBM is that it is an individual-based model and assumes that people make decisions in a vacuum. However, it is important to consider that other people may be part of the decision-making process and experience of dining in a restaurant. In reality, most people seldom dine out alone. When dining out in a group, people most likely discuss options of what to get with others at their table. Besides engaging others in their decision-making process while eating out, people often share food with others they dine with. Even if they order the healthy dish, they may still be going over their allotted caloric intake for a “healthy” meal because of sharing, sampling, or ordering appetizers and drinks.
Another limitation of the HBM model is that it is based on the assumption that people make rational decisions. The idea of ownership as it relates to rational behavior is discussed by Dan Ariely in his book Predictably Irrational. He uses an example of highly coveted Duke basketball tickets to show that if a person owns something, he puts a higher value on it than a person who does not own it but would like to (11). This concept can be applied to the experience of dining out for new dieters. For people who have been accustomed to unhealthy eating habits, their entire lives, then it will be more difficult for them to give up what they are used to and choose the healthy option. Consider the hypothetical example of a man named Joe. Joe is overweight and grew up in an Italian household that traditionally ate homemade lasagna every Sunday. This lasagna was not a new-fangled version of the dish containing low-fat, soy-based cheese, an abundance of vegetables and whole wheat noodles. Joe is accustomed to gooey, cheesy lasagna with ground beef and sausage loaded into it. Lasagna is comforting and nostalgic to Joe, as well as delicious. When he dines out at an Italian restaurant for the first time and sees the lasagna on the menu next to the BestBites baked chicken, he will think about how enjoyable and comforting lasagna is to him. The decision to choose the chicken would be more difficult for him than someone who has never eaten lasagna before, in the same way that the Duke basketball tickets are more valuable to someone who possesses them. The man in the example will be strongly focused on what he is losing when choosing the chicken over the lasagna, as opposed to the health benefits of the chicken and may act irrationally.
Argument #2: Lack of Consideration for Social and Cultural Influences
Boston neighborhoods are extremely diverse and different from one another. A comparison of the demographic make-up of two of the neighborhoods focused on in the Boston Steps program shows this. According to 2000 Census data, Roxbury has 63 percent black people, 24 percent Hispanic people, and five percent white people. Twenty-two percent of people speak Spanish at home (12). In contrast, South Boston 85 percent white people, 7 percent Hispanic people, and two percent black people. Only six percent of people speak Spanish at home (13). In the Boston BestBites program, a simple solution was applied to a range of ethnic restaurants in neighborhoods with culturally and ethnically diverse backgrounds. But addressing the needs in Boston’s diverse neighborhoods cannot be met by a one size fits all solution.
By considering and applying sociological and anthropological theories and research methods in the development of the BestBites program, a more effective program could have been created. Sociology incorporates a focus on social groups, hierarchies, structures and the nature of social interaction into public health programs. Anthropology emphasizes the role of culture in human behavior and public health problems and takes into account a holistic approach to behavioral decisions (14).
As described above, dining out is highly social and culturally unique. Companions, surrounding, and a person’s background can have a strong influence on the decision-making process at a restaurant and needs to be considered in the BestBites program. Additionally, a person’s cultural background and beliefs might play an important role in how he or she views dining out and what types of dining choices are typical. This must be considered in order to understand how to best influence behavior in a restaurant setting.
It is unclear what, if any, research was done to develop this intervention. Research methods common to sociology and anthropology could have been helpful in developing a successful program. Sociology typically utilizes both qualitative and quantitative research methods, while anthropology focuses mostly on using highly qualitative methods alone. Some of the research tactics that would have been helpful in the development of the program, include surveys, observation, one-on-one interviews, focus groups and experimentation. Data collection could then be used to generate theories about behavior and inform an intervention that could be more effective (15).
Argument #3: Failure to Support Program with Extensive Marketing Program
Finally, the Boston BestBites campaign did not thrive, because it was not supported by strong communications tactics resulting in visibility for the campaign. Even though the campaign had strong collateral materials, they could not serve to hold up the campaign’s success alone. As has been described in this analysis, the BestBites public health intervention is built in a setting that is greatly influenced by social factors. In order to have a greater impact on people’s decision-making, the campaign needs to be accompanied by a higher volume of social marketing, advertising and public relations. When searching for resources about BestBites, there are a couple of pages on the Boston Public Health Commission (BPHC) website, a press release for the launch, a couple of news articles from the launch, and a couple of website commentaries on the program. Other than that, it is impossible to find information about the program before walking in the doors to one of the few participating restaurants.
There are various studies and papers that outline how advertising and marketing can affect people’s actions. One such model is William J. McGuire’s Information Processing Model (IPM) (16). The IPM culminates in a communication/persuasion matrix including the thirteen steps in information processing. They are: exposure, attention, liking, comprehension, cognitive elaboration, skill acquisition, agreement, memory storage, retrieval, decision making, acting on a decision, cognitive consolidation, and proselytizing (16). The IPM model has received criticism that it reduces the decision-making process to a succession of steps which is too orderly. However, it outlines the importance of reaching audiences with messages in various ways and at various times in order to get the consumer through this long list of thirteen steps. The BestBites program is accompanied by clean and practical collateral materials (i.e. table tents and coasters); but if a person has not heard of the program before walking in the door to the restaurant, he or she will most likely not make it past steps one and two (exposure and attention) on the matrix hierarchy. This would most likely not be enough to choose to make a behavior change and order a healthy dining option.
Other communications theories also underscore the effectiveness of using message dissemination as a means to influence consumer thought and opinion. Diffusion of Innovation Theory says that the media can be used to influence and encourage people to help further a message (17). The Agenda-Setting Theory similarly contends that the media can be used to help and direct people on what topics to think about (18). Through better utilization of message distribution by the media and other means, the BestBites program may have been a higher priority in the minds of Bostonians. By hitting audiences with the BestBite messages in various ways – even low budget ones – the campaign could have gained more energy and momentum. This may have helped to influence more people to make the healthy menu item choices and encourage more restaurants to sign on to participate.
Conclusion
In summary, the Boston BestBites program that was developed as part of the Boston Steps program by the BPHC seems like an innovative and catchy idea on the surface. However, by considering the campaign through the lens of a knowledgeable public health practitioner, it is clear that it contains flaws that might limit its effectiveness. Restaurant patrons do not make their decision of what type of food to order while dining out on their own. They are influenced by their companions, surroundings, and cultural background. Such influences need to be taken into consideration in the development of an effective intervention. In addition, a program with flashy collateral materials cannot stand on its own without a full scale communications program to help disseminate messages repeatedly to restaurant patrons so they are more likely to make healthy choices while dining out.
A New Intervention
On the surface, the Boston BestBites program is a fun and innovative way to fight obesity in the Boston neighborhoods with the biggest disparities. In order to create a new and better intervention to help Bostonians make healthier choices while dining out, it will not be necessary to completely overhaul the program. Instead, I propose to renovate it using what we know about more effective – and often unconventional – methods of addressing public health problems. The revamped BestBites program will need to incorporate social and environmental factors into the decision-making process; be constructed based on sound qualitative research so that it will uniquely meet the needs of patrons who live in certain neighborhoods and frequent certain restaurants; and be supported by a strong communications program to not only build awareness, but also supplement the decision-making process.
The revised program will be called Boston BestBites Nites. The campaign will run for a year, and will offer two unique BestBites Nites per month, each at a different restaurant located in one of the neighborhoods targeted in the Boston Steps program. There will be a total of total of 24 “nites.” The restaurant participating at each BestBites Nite will be required to have two appetizers, two entrees and two desserts pass through the nutritional analysis developed by Brigham and Women’s Hospital. In addition to this requirement, restaurants will be given autonomy to add additional elements to their Nite in order to help to customize it to their own patrons. Public health professionals will be available to help develop these ideas based on both traditional and nontraditional models for behavior change. Examples of activities unique to a specific restaurant include offering the meals at a discounted price as a way to entice lower income patrons; a physical activity component such as dancing that is typical in a particular culture and could help garner attendance; or the development of “mocktails” to help teach people how to adopt other healthy lifestyle changes.
All of the Nites will incorporate an educational component as well. The BestBites collateral materials will be expanded to include educational materials. A nutritionist from Brigham and Women’s Hospital Department of Nutrition will be present to answer any questions that patrons have about healthy eating and meal creation. Restaurants will also be free to suggest and develop other educational components based on their customer base. Following a certain restaurant’s BestBites Nite, it will be required to leave at least one of the healthy options on its menu for the future, and continue to distribute educational materials and other campaign literature throughout the duration of the program.
Counter-Argument #1: Moving Beyond an Individual-Based Model
Dining out at a restaurant is not an individual experience, and so an intervention that is based on an individual-based model simply will not have the intended impact. There are several ways that BestBites Nites is more incorporative of social factors. First, the BestBites Nites program is based on the ecological model. This model considers that individual factors are only a small contributor to a person’s behavior. Other factors that affect behavior include social/cultural/group, socioeconomic and structural, political and environmental factors. All of these factors would work together to influence behavior, not work individually (19).
In the BestBites Nites program, the decision-making process shifts from one that is individually focused, to one that is group focused. Family and friends will decide together that they want to attend the BestBites Nite at a certain restaurant, and so one person will not be isolated in trying to choose a healthy menu option amid other temptations and social pressure. Social, cultural, socioeconomic and group factors are already built into the experience. The individual need only decide which of the healthy options he or she wants to eat when after arriving at the event. An evening shaped around healthy restaurant dining and fun removes the pressure from an individual to make a healthy choice while under the influence of environmental surroundings or social pressures. Dancing or entertainment will make the evening more appealing as a group activity. The educational component will arm diners with ideas on how to maintain healthy eating habits in everyday life or while dining out in the future. Since at least one of the healthy menu items will stay on the menu after the BestBites Nite at that location, diners will be more likely to choose it on an individual basis in future visits to that restaurant now that they have experienced it in a group they are comfortable with.
The BestBites Nites also take into account that people do not always make rational decisions. As discussed above, diners know what they are giving up when they choose a healthy meal. For example, patrons at Poppa B’s in Dorchester are accustomed to traditional soul food dishes such as BBQ ribs, fried chicken and sweet potato fries (20). The BestBites Nite at Poppa B’s should not exclude these soul food favorites, but update them into healthier options. Patrons who may be tempted to make an irrational decision will remember how good these items are and not necessarily be satisfied with a menu that does not include them. An example of a renovated, healthy, soul food menu could include BBQ chicken, oven fried chicken and oven baked sweet potato fries. The patrons will not feel like they are giving anything up.
Counter-Argument #2: Strong Consideration for Social and Cultural Influences
As mentioned above, Boston is an extremely diverse city, and it is hardly possible to create a one size fits all obesity intervention that would have an impact on the city’s diverse population. Since BestBites Nites will take place at one location at a time, it will allow the program to be more tailored to accommodate the unique diners who typically frequent those restaurants, based on common characteristics of local residents. In this way, a BestBites Nites held at Poppa B’s in Dorchester will be very different from a BestBites Nites at Centre Street Café in Jamaica Plain.
The public health practitioners who are tasked with development and implementation of the BestBites Nites program will be instrumental in helping restaurants to develop a unique evening at their restaurant that will specifically help to encourage healthy dining among their patrons. By utilizing data collection methods more typical in the fields of sociology and anthropology, a more precise and focused understanding of each restaurant’s customer base can be gathered. Therefore, for each of the 24 restaurants that participate in BestBites Nites, two customer focus groups, at least 200 surveys, and at least five one-on-one interviews will be conducted with restaurants and patrons. Some of the questions that can be posed through these qualitative research methods include:
· Why do you dine at this restaurant?
· What is your favorite menu item at this restaurant, and why do you choose it?
· Who do you typically dine at this restaurant with?
· Do you maintain a healthy diet at home?
· What do you think of when you hear “health food”?
· What does eating a meal with family and friends mean to you?
· How is the food at this restaurant different or similar from the food you eat at home?
· Are there any activities – such as dancing, games, or demonstrations – that you would find entertaining while dining at this restaurant?
The research will be compiled into a report including recommendations for unique tactics to meet those patrons’ needs. The public health professionals will then meet one-on-one with the restaurant owners to design the evening.
Counter-Argument #3: Development of a Strong Communications Program
As mentioned above, Boston BestBites is a creative idea accompanied by a strong base of sharp collateral materials. The campaign’s development of restaurant-friendly items such as coasters and a recognizable logo is an important first step in building recognition of the campaign. However, the program received practically no media attention, has an outdated website, and seems to have fizzled out soon after its inception. In order to drive attendance to BestBite Nites and provide education to people that will hopefully have a longer term impact on people’s dining choices, the campaign will need to be supported by a strong communications program. The existing materials should be used as a basis for this, and additional materials should be developed to build upon and expand them.
The communications program will need to include public relations, advertising and community relations components. It should be creative and wide-reaching. By repeatedly getting the BestBites message in front of residents of target neighborhoods, it should follow that the campaign will have greater adoption based on William J. McGuire’s Information Processing Model (IPM) (21) and the Agenda Setting Model. More specifically, some or all of the following tactics could be included in the communications campaign:
· Advertising in community media publications, such as the Roslindale Transcript, Brighton Tab, South End News, and Jamaica Plain Gazette.
· Hanging flyers at neighborhood libraries, coffee shops, book stores, grocery stores, etc.
· Working with a local healthy food store (such as Trader Joe’s) to have them distribute flyers for BestBites when bagging groceries or giving receipts to customers.
· Generating feature stories in regional, local and community media about participating restaurants.
· Place a news story in Brigham and Women’s weekly newsletter, as well as other Partners institutions – possibly even offering a promotion for all Partners employees.
· Scheduling a “chat” with one of the nutritionists from Brigham and Women’s on Boston.com, where users can write in questions about the program.
· Signing on a campaign “spokesperson” to help educate and influence consumers to eat healthy while eating out with the BestBites program.
In addition to these communications tactics, a strong and up-to-date website should be developed as a core information source of campaign information in addition to collateral materials. A catchy web address can appear on collateral materials, in advertising, or in news articles. When a user visits the website, it will have a detailed schedule and description of upcoming BestBites Nites and participating restaurants. Healthy dining tips and a blog by a Brigham and Women’s nutritionist could also be strong additions to the website. The online communications strategy could even incorporate the use of social media, where appropriate. For example, a Facebook group could be created for BestBites Nites to build buzz. For communities that do not have a high usage of the Internet, extra collateral materials and community relations tactics will be utilized to reach audiences in the most appropriate way.
In conclusion, Boston BestBites is an innovative program with a strong and established base. By tailoring and renovating the program to be more in tune with all of the factors that affect the decision-making process for diners at participating restaurants specifically, the intervention can have a greater impact. An improved intervention that is built around an individual-based decision-making model should also be strongly supported by a highly visible communications campaign that will help to foster a greater participation rate and, with hope, ultimately help improve the health of residents in the Boston neighborhoods facing the most disparaging obesity statistics today.
REFERENCES
1. U.S. Obesity Trends 1985 – 2007 – 2007 Obesity Rates. Centers of Disease Control and Prevention. Accessed on 11/15/08. http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/.
2. About Boston Steps – Boston Steps Project Area. Boston Public Health Commission Website. Accessed on 11/15/08. http://www.bphc.org/programs/initiative.asp?i=314&p=190&b=2&d=17.
3. Boston BestBites. Boston Public Health Commission Website. Accessed on 11/15/08. http://www.bphc.org/programs/initiative.asp?i=260&p=190&b=2&d=.
4. Dietary Guidelines for Americans, 2005. U.S. Department of Health and Human Services. Accessed on 11/15/08. http://www.health.gov/DietaryGuidelines/dga2005/document/default.htm.
5. Boston BestBites. Boston Public Health Commission Website. Accessed on 11/15/08. http://www.bphc.org/programs/initiative.asp?i=260&p=190&b=2&d=.
6. “Mayor Menino, Public Health Officials Kick-off Boston BestBites.” News & Press Releases. August 18, 2006. Accessed on 11/15/08. http://www.cityofboston.gov/news/default.aspx?id=3261.
7. “Applebee’s and Weight Watchers Announce Plans to Co-Develop New Menu.” Business Wire. July 25, 2003. Accessed on 11/15/08. http://www.allbusiness.com/medicine-health/diet-nutrition-fitness-dieting/5742140-1.html.
8. Becker MH, ed. The health belief model and personal health behavior. Health Educ Monogr. 1974; 2: Entire issue.
9. Janz NK, Becker MH. The health belief model: a decade later. Health Educ Q. 1984; 11(1):1-47.
10. Rosenstock IM. Historical origins of the health belief model. Health Educ Monogr. 1974; 2:328-335.
11. Ariely, Dan. Predictably Irrational. Chapter 7, pages 127-138. Harper Collins Publishing. New York, NY. 2008.
12. Roxbury Data Profile. Department of Neighborhood Development, Policy Development and Research Division. US Bureau of the Census. May 1, 2006. www.cityofboston.gov/dnd/pdfs/Profiles/Roxbury_PD_Profile.pdf - 2006-05-01.
13. South Boston Data Profile. Department of Neighborhood Development, Policy Development and Research Division. US Bureau of the Census. May 1, 2006. www.cityofboston.gov/dnd/pdfs/Profiles/South_Boston_PD_Profile.pdf - 2006-05-01.
14. Edberg, Mark. Essentials of Health Behavior. Chapter 3, pages 31-32. Jones and Bartlett Publishers. Sudbury, MA. 2007.
15. Strunim, Lee. Disciplines of Social Sciences. Presentation Given to SB721 on November 6, 2008. Slides 12, 34.
16. McGuire, W. J. (1999). Constructing social psychology: Creative and critical processes. Cambridge: Cambridge University Press.
17. Lazarsfeld, P., Berelson, B., Gaudet, H. (1944) "The People's Choice." New York: Duell, Sloan and Pearce.
18. McCombs, M., & Shaw, D.L. (1972). The agenda-setting function of the mass media. Public Opinion Quarterly, 36, 176-185.
19. Green LW, Kreuter MW, eds. Health Promotion Planning: An Educational and Environmental Approach, 3rd ed. Mountain View, CA: Mayfield Publishing: 1998.
20. Poppa B’s Website. Menu. Accessed on December 9, 2008. http://www.poppab.com/menu.html#ldsides.
21. McGuire, W. J. (1999). Constructing social psychology: Creative and critical processes. Cambridge: Cambridge University Press.

BMI Report Cards in Schools, Critique of a Current Public Health Intervention – Vibe Andersen

Introduction to a Public Health Problem

Public Health professionals need to focus immediate attention on a rapidly growing public health problem encompassing the United States. The prevalence of obese children ages 6-11 has doubled in the past 20 years from 6.5% in 1980 to 17% in 2006, and has tripled in adolescents ages 12-19 from 5% to 17.6% (1). The increasing numbers of obese and overweight children in the U.S. is due to complex interactions of social/environmental/cultural and political/economic factors, that influences the level of physical activity and eating habits of children in the U.S. (2). At least 61% of obese young people have at least one additional risk factor for heart disease, such as high blood pressure or high cholesterol levels. Children who are overweight or obese are more likely to become obese as adults and are therefore at greater risk of heart disease, type 2 diabetes, stroke and several types of cancer (1,3). Obese children also deal with social and psychological problems such as stigmatization, labeling and poor self-esteem (4). Considering the severe consequences of this growing problem, public health interventions must be considered a crucial necessity.

According to the Centers for Disease Control and Prevention (CDC), a child is defined as being obese when his or her Body Mass Index (BMI) is equal to or greater than the 95th percentile of the age-and-gender-specific BMI charts, and termed overweight or at risk when at or above the 85th percentile (5). In recent years, much attention has been focused on BMI measurements programs by schools as an intervention in the battle against childhood obesity. In 2003, the state of Arkansas initiated and implemented a statewide BMI screening and surveillance program (Act 1220 of 2003) and other states have since followed, (Illinois, Maine, New York, Pennsylvania, Tennessee and West Virginia) (6,7). Under the program, schools inform parents of students they have determined either have or are at risk of developing weight problems, by sending home BMI report cards stating the students BMI. All students receive BMI report cards, not just children in the risk group.

The following will be a criticism of why I believe, that the use of BMI report cards in schools can be considered a flawed intervention in the battle against childhood obesity. I will argue, that this intervention does not provide tools for parents to help boost self efficacy in their children. Another argument will be, that the use of BMI report cards includes a high risk of negative labeling and social marginalization of children. Finally, I will make an argument, that using BMI report cards puts too much focus on weight and not enough emphasis on healthy behavior and living, and on that account risks loosing the focus of promoting a healthy lifestyle in families at risk and most importantly in children.

BMI report cards fails to recognize the importance of self-efficacy

An individual’s decision to engage in a behavior, and his or her persistence to stay with the behavior change, is influenced by the individual’s perception as to whether he or she can be successful. According to Albert Banduras social cognitive theory, the concept of self-efficacy, refers to a persons own belief in that he or she can have control over and success with behavioral change. Children with a sense of high self-efficacy are more likely to engage in behavioral changes and be persistence in sticking to these changes (8,9). A child without a strong sense of self-efficacy will be less likely to attempt behavioural change because of fear of failure. In supporting and boosting self-efficacy you can, according to Banduras, support the child’s beliefs that he or she can succeed in changing their behavior (10).

Giving parents of children with an obesity or weight problem a BMI report card does not provide any tools for the parents in order to help and support their child’s sense of self-efficacy. The BMI report cards provide a number to the parents, that places their child on a scale of being either under, normal or overweight or obese. Some states do also include some information and guidelines for a healthier diet from the American Academy of Pediatrics suggestions for healthy lifestyle, but do not offer counselling or follow-up to the parents (6). Parents are left to make sense of a number on a report card, and just information on healthy lifestyle provided to them by the schools, is not enough to make anyone change behavior and does not boost self-efficacy. Self-efficacy plays a key role, and ways of boosting children’s belief in that they can succeed in changing diet and exercise regime, and in that way influence their BMI, is crucial for the rate of success in any intervention battling obesity. Quite a few parents receiving the BMI report cards for the first time reacted with anger and disregard (11). A qualitative study in the U.K. showed, that parents would like a medical interpretation of whether their child is at healthy weight and also that parents found BMI a difficult concept to understand (12). A more effective way of informing and supporting the families, might be counseling sessions at the schools, which is a more personal setting and may turn out to be a better way of helping the parents find tools to offer to their child.

One could also argue, that without true support within the school environment such as increasing the amount of physical activity scheduled into the school day, and serving a healthier diet in the school cafeteria, the intervention does not have much chance of success (7). Parents and children need to feel that their choice of a healthier lifestyle is being supported in schools where children spend a good part of their week. Schools have a huge responsibility to promote self-efficacy, by providing an environment where modeling from other students and encouragements from teachers and peers is encouraged.

BMI report cards and the risk of negative labeling

By using the term “report card” in the intervention some children could feel as if they are getting graded on the way they look. The risk of children feeling as if they have been officially labeled as “fat” is very high. According to labeling theory, behavior by the individual is influenced by the way the individual is judged by society, and the label he or she thereby gets (13). Labeling theory has roots in sociology and according to social psychologist George Herbert Mead, as an individual you are aware of how you are judged by others from your perception of the role you play in social interactions. There are different rules in different social settings, and varying social and moral norms plays a role in behavior and labeling of individuals (13). The use of BMI report cards focus on the individual, and poses a significant risk of labeling overweight children as being “fat” in the eyes of their peers. Labeling can directly lead to negative behavior in the way that individuals can be seen to accept to the label they are given, in that way enabling the label to work in a self-fulfilling way. The group of children being branded as “fat”, may resign themselves to this being their social role, and may loose any motivation they had to strive for healthier behavior. Some children may start overeating and avoid physical activity because they feel that is what is expected from being “fat” (13,14).

Another negative outcome of BMI report cards could be an increase in taunting and bullying of overweight children, a problem already reported as existing (15). Overweight children are more likely to be teased about their weight and less likely to form friendships than their non-overweight peers (16). Studies conducted on adolescents being teased about their weight showing that they are at high risk for low self-esteem, depression and suicidal attempts (17,18).

Also labeling can have a significant effect on the group of children not characterized as overweight. The fear of being labeled as “fat”, a label this group sees as socially less accepted, can be so severe in this group that unhealthy dieting could become a big problem, resulting in eating disorders and serious body image issues (11,16). So the use of BMI report cards in schools could have negative consequences in both the groups of overweight children and in the group of children being at healthy weight (19).

BMI report cards: too much emphasis on weight not enough emphasis on healthy behavior

The use of BMI report cards risks putting too much emphasis on children’s weight and not enough on healthy behavior and lifestyle. Focusing only on body size, without looking at the big picture, puts the health of children at normal weight at high risk of being neglected. They may have a normal BMI, but eat an unhealthy diet and have sedentary behavior that could lead to health problems later on in life (20). Many problems associated with weight are consequences of poor diet, genetic factors, ethnicity, level of physical activity and spending too much time engaged in sedentary activities, such as watching TV and playing videogames. Parents inactivity and high consumption of energy dense food are also risk factors associated with childhood obesity (12).

The National Health and Nutrition Examination Surveys (NHANES) 1999-2004 found that 23.5% of normal-weight adults were cardiometabolically abnormal, while 51.3% of overweight adults and 31.7% of obese adults were cardiometabolically healthy (17). The long-term health risk might in fact be higher for some of the children defined as normal-weight, and BMI measurement might not be accurate predictor of unhealthy behavior (21). One could argue, that the intervention using BMI report cards does not focus at all on promoting a healthy behavioral change. With BMI report cards, children and parents in the group of “normal” children may be lulled into thinking that they do not need to consider healthier alternatives to change their habits.

BMI is practical, easy to obtain and reliable, but arguments are, that entire states are adopting a policy that has not yet been tested (22). Little is known about the outcome of BMI measurement programs, including effect on weight-related knowledge, attitudes and behavior of children and their families. Kipping et.al.. in a clinical review of obesity in children, argue that as long as we do not have an effective intervention available to follow up on the population that gets a high BMI score, screening school children for weight problems is hard to justify (11,23).

Conclusion

The problem of the increasing numbers of obese and overweight children in the U.S. is, as mentioned in the introduction, a diverse and complex social and environmental problem and it is a collective responsibility that requires individual, family, community, corporate and governmental commitments. Using BMI report cards in schools is one amongst many interventions designed to try to address the growing problem. I would, with my arguments state, that the use of BMI report cards in schools, as an intervention addressing childhood obesity, is flawed in its lack of including important factors, such as self-efficacy, risk of negative labelling of children and lack of emphasis on healthy behavior and living. The effectiveness of this intervention is highly questionable and may actually have directly negative consequences, as the outcome of the intervention has yet to be evaluated. It leaves parents with a number on a report card and no tools to promote self-efficacy, and offers no solution to reverse the course. The significant risk of negative labelling children as being “fat” and in that way directly increasing the risk of further unhealthy behavior in obese and overweight children, as they see the label as their social role, must be seen as another flaw in the intervention. BMI report cards could also promote unhealthy weight behavior in the group of “normal” children, as they fear of being labelled “fat” could lead this group in the direction of eating disorders and serious body image issues. The intervention does not emphasize healthy lifestyle. By this focus on body size (BMI) rather than healthy diet, a positive exercise regime and healthy life style, the intervention overlooks a large group of children who have a normal BMI but might lead a very unhealthy life. BMI levels within the normal range may as a consequence lure families into staying with an unhealthy lifestyle. To date the effect of the BMI screening program on childhood obesity has yet to be scientifically evaluated.

Counter-Proposal to a Current Public Health Intervention

Obesity is a consequence of choices and lifestyle. These lifestyle issues need to be addressed individually and collectively as a society in order to change the path of the rising numbers of overweight and obese children in the U.S. The focus need to be moved away from body size and towards behavior and environmental factors. Instead of using BMI report cards in schools, that indeed focus on body size, I will argue that a focus on healthier lifestyle for all children, no matter what BMI level they are at, is a better approach in order to avoid the flaws pointed out in assignment #3, and also why I find this proposal superior to the original intervention on the specific flaws that I articulated in assignment #3.

Self-efficacy, a key component in behavioral change

Ways of boosting children’s belief in that they can succeed in changing diet and exercise regime is crucial for the rate of success in any intervention battling childhood obesity in the U.S. Children with a sense of high self-efficacy are more likely to engage in behavioral changes, and be persistence in sticking to these changes (8,9). The use of social cognitive theory as part of a frame for an intervention would be a good approach, as a key element in this theory is self-efficacy, social modelling and learning by observing. According to social cognitive theory, children model what they see, and learn from what others do, so if the social norm is healthy lifestyle with healthy food and exercise, there is a good chance that children will model that (10,25). Also studies have shown, that peers and siblings attitude towards eating and food consumption significantly influences children’s behavior (26,27).

Ways of boosting self-efficacy would be to give the children responsibility in their own life and health, make realistic goals for and with the children. In praxis introducing cooking classes in schools, where children get hands on experience in preparing healthy meals, would be one way of boosting the children’s belief in possible behavioral change, and at the same time teach nutrition. Another way of boosting self-efficacy in children, would be focusing more on including or building in physical activity into everyday life for children; walk/bicycle to school, make class projects exploring new ways of exercising daily in a new and fun way. Making the children feel, that they are a part of a group with a common mission. Make children feel they belong and in achieving their goals, boosting their feeling of success.

Changing the social norm is hard and very challenging, families need more practical advise in being able to choose a healthier lifestyle and finding tools to boost self-efficacy (25). Counseling sessions at the school would be a more personal setting than merely a report card sent home. In this way, by giving parents tools to boost children’s self-efficacy through counseling, you move away from the flawed approach by BMI report cards only stating a number. Schools have a huge responsibility in promoting self-efficacy, by providing an environment where modeling from other students and encouragements from teachers and peers is encouraged (7). But not only schools have responsibility, the whole community needs to come together in a multilevel approach where different sections work together to find a solution (home, schools, physicians, state, government).

Reducing the risk of negative labeling

Schools should be a safe and supportive environment for students of all sizes, and implement strategies to promote physical activity and healthy eating. The risk of children feeling as if they have been officially labeled as “fat” is very high by using the term “report cards”, as the BMI report card intervention does. To decrease the risk of negative labeling, you would have to address the way society judge individuals (13). A significant flaw by using BMI report cards in schools, is the risk of self-fulfilling behavior in children with high BMI score. The risk of acceptance and resigning to a social role and the de-motivation this could course for these children, leading to lack of interests in physical activity sometimes combined with overeating (13,14). The question is what type of health related communication, instead of sending home a “report card” from the school to the family, is most likely to bring positive results, and at the same time dismiss the chance of labeling some children. One different approach in schools could be making an assessment of quality of diet, eating habits, physical activity and time spent in sedentary behavior. On top of this you would make an assessment of the child’s body image and relationship with food, and making this assessment part of every child’s school year, the risk of just pointing out some children and hereby risk negative labeling is decreased (7,28).

In addressing the negative effect BMI report cards have on the risk of increasing weight teasing and bullying, schools have a serious responsibility in boosting children’s self-esteem. Working away from a school system with report cards on weight will also be beneficial for the likelihood of overweight and obese children’s risk of teasing and bullying (14,16). The fear of being labeled fat that can lead some children within the normal range of weight to unhealthy dieting and other eating disorders needs to also be addressed (18). Eating and exercise habits are shaped by social and cultural structures and norms, and building an approach that includes these elements would stand a better chance of successfully taking up the battle against childhood obesity (25,93-111).

Emphasis on healthy behavior, environment and lifestyle -not body size

The focus on body size by stating children’s BMI score on report cards puts the health of children of normal weight at risk. BMI report cards focus mainly on overweight and obese children, hereby totally overlooking the risks involved in leading an unhealthy lifestyle but still being within the normal BMI range (17,20,21). A more appropriate approach would focus on positively promoting healthy living, healthy eating habits, exercise for all children, not only for those that, by using BMI report cards, are being labelled obese.

In today’s society and eating environment, good nutrition is something that sadly must be learned. We need to ensure, that the school policies and the whole school environment encourage physical activity, and ensure students meals in pleasant sociable environments as well as providing psychosocial support (23). In my opinion, by making unhealthy food less accessible in schools cafeterias by simply taking it off the menu, not only adding healthier choices, but removing unhealthy choices, you would be able to influence healthier eating behavior. True support within the school environment such as increasing the amount of physical activity scheduled into the school day, and serving a healthier diet in the school cafeteria is needed now (19,23). Parents and children have to feel that their choice of a healthier lifestyle is being supported in schools, where children spend a good part of their childhood hours. Parents need to understand, that they are teachers too, children models what they see, not what they are told and the society needs to build support and awareness for parents (28).

There will always be a political/economic context that will affect what people do, and especially what they can or cannot do (25). The food environment we live in is toxic, the influences of the food industry is massive in the obesity epidemic that is currently a reality in the U.S. (24). One of the problems public health advocates faces in the U.S. is the highly individualistic mentality in the society, and as a result of that, individuals are assumed to have sole responsibility for their choices. The level of individualism is why so many people object to proposals to changes in the food environment, i.e cafeteria lunches, and children’s access to unhealthy food in vending machines, they do not like to be told what they can or cannot eat (24,27). But changes in the food environment are necessary to influence lifestyle changes.

Conclusion

There is very modest effectiveness of programs aimed at individual behavioral change to prevent childhood obesity, which is why a paradigm shift at societal and political/governmental level is needed, in order to see any significant changes towards lifestyle changes. On governmental level politicians needs to realize that changes in the food environment is necessary. Public health workers have to be realistic in their planning of interventions and create a realistic frame for the work. Select from different factors and decide what to focus on in the light of resources, as public health does not have unlimited resources or time, so you have to pick your battles. The battle against childhood obesity is a complicated multi factual battle that will need a multilevel approach. Not only schools have responsibility, but parents, family physicians, community and government all have to contribute. Intervention using BMI report cards in schools is flawed in different ways. An approach focusing on providing tools to help boosting children’s self-efficacy, decrease the risk of negative labeling, and support healthy lifestyle by moving focus away from body size, is in my opinion a superior approach. By the use of social cognitive theory as part of a frame of an approach, you would be able to focus on self-efficacy as a key component, and reduce the risk of leaving parents without tools to support their children. By focusing on a healthier life style for all, you would reduce the risk of labelling some children as fat. By assessing all children, and meet with all families to offer counselling in healthy lifestyle and possible behavioral changes, you would create a possibility not only for overweight children at risk, but all children equally. It is my strong belief that the mindset of thinking convenient, easy, automatic, effortless and free “the American way of life” needs to be challenged and changed if any intervention shall stand any chance in the battle against childhood obesity in the U.S.

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15. The Center For Consumer Freedom. BMI Report Cards: The “F” is For “Futility”. Feb. 28 2006. http://www.consumerfreedom.com/news_detail.cfm/headline/2980 .

16. Strauss RS, Pollack HA. Social Marginalization of Overweight Children. Arch Pediatr Adolesc Med. 2003:157:746-752.

17. Mitka M. Experts Weigh Pros and Cons on Screening and Treatment for Childhood Obesity JAMA. 2008;300(12) :1401-1402

18. Neumark-Sztainer D, Falkner N, Story M, Perry C, Hannan PJ, Mulert S. Weight-teasing among adolescents: correlations with weight status and disordered eating behaviors. International Journal of Obesity 2002;26:123-131

19. Crawford PB, Woodward-Lopez G, Ikeda JP. Weighing the risk and benefits of BMI reporting in the school setting. Center for Weight and Health 2006.

20. Parson Tj, Power C, Logan S, Summerbell CD. Childhood predictors of adult obesity: a systematic review. Int J Obes Relat Metab Disord 1999;23 (suppl 8):S1-107.

21. Moyer VA, Klein JD, Ockene JK, Teutsch SM, Johnson MS, Allan JD. Childhood Obesity Working Group, US Preventive Task Force. Screening for overweight in child and ado: where is the evidence? A commentary by the childhood obesity working group of the US Preventive Task Force. Pediatrics. 116(1):235-8, July 2005.

22. Agency for Healthcare Research and Quality. Screening and Interventions for Overweight in Children and Adolescents, July 2005. http://www.ahrq.gov/clinic/uspstf/uspsobch.htm

23. Kipping RR, Jago R, Lawlor DA. Obesity in children. Part 2: Prevention and management. BMJ 2008; 337:a1848

24. Brownell, K, Horgen KB. Food Fight: The Inside Story of The Food Industry, America’s Obesity Cricis, and What We Can Do About It. 2004, New York: McGraw-Hill/Contemporary Books.

25. Edberg M. Essentials of Health Behavior, Social and Behavioral Theory in Public Health. 2007 Jones and Bartlett Publishers, Inc. Sudbury, MA.

26. Salvy SJ, Vartanian LR, Coelho JS, Jarvin D, Pliner PP. The role of familiarity on modelling of eating and food consumption in children. Appetite. 50 (2-3); 514-8, 2008 Mar-May.

27. Vartarian LR, Herman CP, Wansink B. Are we aware of the external factors that influence our food intake? Health Psychology 27 issue 5, (533-538) 2008.

28. The Rudd Center for Food Policy and Obesity http://ruddsoundbites.typepad.com/rudd_sound_bites/2008/10/index.html

Failing Grade: The Ineffectiveness of BMI Report Cards--Kaitie Feloney

Over the past decade it has become painfully clear that childhood obesity is an epidemic within the United States. Once only a condition for the few, obesity is now the status quo for the majority of American children. Whereas only 6.5% of children ages 6-11 were classified as obese in 1980, that figure has climbed to 17.0% in 2006 (1). Defined by a child being at or above the 95^th percentile of the body mass index (BMI) scale, obesity has recently become a main focus of public health advocacy groups. One recent public health intervention that is designed to fight childhood obesity is displaying a child’s BMI on her report card so that her parents know if the child’s weight is getting too high. While this intervention was designed with good intentions, its lack of several key features caused it to be destined for failure. The BMI-report card program did not provide perceived benefits of weight loss, and did not address the self-efficacy, or social norms associated with childhood obesity.

Childhood obesity has negative consequences for nearly every system in the human body, including joint problems, and higher rates of reactive airway disease and insulin resistance (2). In addition to clinical problems, obese children often face taunting and bullying from their peers, actions that can cause psychological damage over time. Obese children are more likely to be the target for relational (withdrawing friendship or spreading lies) and overt (kicking or pushing) victimization as well, which means that obesity can negatively affect a child’s life in more than one way (3). Many factors can contribute to childhood obesity and it is not the exact same mix that causes the condition in every child, but generally genetics, level of physical activity, diet and familiar factors are all contributors (4). Of note is the fact that most of these factors exist outside of normal school hours, with the exception of lunch and gym class.

BMI Report Cards Do Not Illustrate the Benefits of a Healthy Weight

There are currently seven states that require that a child’s BMI be reported on his or her report card: Arkansas, California, Illinois, New York, Pennsylvania, Tennessee and West Virginia (5). While the specific layout of each report card is different, all list the child’s BMI as well as a classification of normal, overweight, or obese. One problem with these report cards, though, is that not every state uses a format that clearly explains what the number means. In addition, there are not always tips listed for how to encourage physical activity or healthier eating, so parents can be left with a bad grade in their child’s weight and no suggestions as to how they should fix it. Another key piece of information that these report cards lack is an explanation of the benefits of staying at a healthy weight, getting physical activity and eating nutritiously. Children (and parents) often know that overweight and obesity are not healthy, but they may not know specific reasons why it is healthier to be within the normal weight range. Providing the potential health benefits, such as sleeping better and being able to run faster in gym, could give the children and parents tangible reasons why they want to improve, versus not knowing why their lifestyle should change. This is especially significant for parents to see, as they are usually the ones directing the child’s diet and level of physical activity.

While the lack of an explanation of how to reach or sustain a healthy weight is problematic for overweight or obese children, the lack of attention to an overall healthy lifestyle also negatively affects children at a healthy weight. Some children may lead an extremely unhealthy lifestyle, with little to no physical activity, a lack of nutritious foods and no parental guidance on healthy life choices, yet these children might still have a BMI within the normal guidelines. Research studies have shown that there is a positive link between the hours of television viewed per week and fatness in children, so while a child might not be overweight at the point the report card is issued, he or she might already have established unhealthy behaviors that could lead to health problems (6). In this case, it is important to list ways to lead a healthier lifestyle so as to prevent the child from becoming overweight or obese in the future. Focusing solely upon the BMI number prevents a large number of children from receiving information about a healthy lifestyle.

BMI Report Cards Do Not Address Self-Efficacy

The concept of self-efficacy is central to social cognitive theory, and it is the idea that an individual’s belief in their own ability to complete an action and meet a set goal shapes the decision of whether or not to engage in the action, as well as their perseverance in completing the action (7). While self-efficacy is a measure of a person’s confidence in her ability to complete an action, self-efficacy is also influenced by other aspects, namely that individual’s physiological factors, vicarious experience, social persuasions, and mastery experience. A person’s physiological factors are defined as her response to stress, and vicarious experience is how an individual interprets other people’s responses and models her own behavior accordingly. Social persuasions are whether the people surrounding an individual encourage or discourage a particular behavior, and mastery experience is how successful the individual has been at performing historically (8). In regards to an emotionally-charged subject like weight, self-efficacy is extremely important to address. If a child and her parents know that she is overweight but feel that they cannot complete the necessary steps to bring her to a healthy weight, it is much less likely that they will even attempt to make changes in the first place. The mix of factors that can lead to a child becoming overweight is especially linked to self-efficacy, because feeling that one is able to eat a few more fruits and vegetables, cut down on soda, or get a little more physical activity can all have a significant impact upon health. Studies have found that only slightly decreasing the amount of time that children are sedentary can greatly decrease their chance of becoming overweight (9). When only a small modification in behavior is necessary to create a significant change, a person’s conception of self-efficacy is vital to success. BMI report cards fail at encouraging self-efficacy because they do not suggest healthful behaviors or provide encouragement to the child. As a result, many recipients of the report cards who have a classification of overweight may feel that they do not know how to confront this problem, may lose confidence in their ability to resolve the situation, and in the end will not make any lifestyle changes.

BMI Report Cards Do Not Address Subjective Norms

One of the key features of the theory of reasoned action is that an individual takes subjective norms into account before making a health behavior decision. Ajzen and Fishbein state that subjective norms stem from a person’s beliefs about how others in their social group will react to a behavior, and their personal motivation to conform to these social norms (10). This means that if an individual is greatly affected by subjective norms, they might not undertake a health behavior for fear that their peers will disapprove of the behavior. The United States has a very conflicted culture regarding body weight, as the majority of Americans are overweight or obese, and yet television and marketing almost exclusively portray very thin women and very muscular men. This trend has led to women having many insecurities about weight, which trickles down to young girls. Several studies have found that the weight-control practices utilized by girls in a social group can affect how the other girls view body image and their own risk of practicing unhealthy weight-loss behaviors (11).

Since BMI report cards are handed out to children (who are supposed to give them to parents but will inevitably read them first), it is extremely important to take subjective norms into account when designing an intervention that targets school-age children. There is a great deal of pressure upon girls especially to remain thin, and a BMI rating of “overweight” could result in teasing, bullying and a great deal of stress for the student. Sending home a document that has such socially-significant phrases on it is a failure on the part of the designers of the BMI report card. A better approach would have been to schedule a parent-school nurse conference, either in person or over the phone, to help avoid embarrassment in front of their peers for overweight children.

Another way to improve subjective norms is to change the culture of the school so that the culture of individual social groups might also change. The physical education and nutrition teachers at schools could plan school-wide initiatives to help children believe that healthy eating and physical activity are fun and enjoyable. In addition, it should be taught that all children should adhere to these behaviors, not just children with weight problems. It has been found that physical activity helps to stave off cardiovascular disease amongst all children, normal and underweight included, so these behaviors should be touted for all (12). These actions could help to make behaviors like healthy eating and increased physical activity more accepted within all social groups, so that overweight children will not be the only individuals subjected to these behaviors.

Additionally, the promotion of the health benefits of a healthy weight could help to convince children that if unhealthy behaviors are the norm, conforming to that norm might not be the best decision. In this sense explaining the health benefits of weight loss could work together with establishing positive subjective norms to help increase the chance that children and parents will be successful. The lack of attention that BMI report cards give to the potential health benefits of weight loss and addressing subjective norms is ineffective separately, but the combination of these two blunders can result in an even lower chance of children undertaking more healthful behaviors. There are many flawed parts to the planning and design of BMI report cards, but this combination in particular can result in little to no change.

Conclusion

BMI report cards have a number of shortcomings, but the intention behind the intervention was good. It is true that the problem of childhood obesity is a pressing issue in the United States, and public health interventions need to be designed and implemented as soon as possible to prevent this epidemic from affecting even more children. That being said, this intervention was flawed for a number of reasons, which is a common occurrence when a new public health problem is identified and the first interventions are set into action. The lack of information about the potential health benefits of maintaining a normal weight, the failure to address or promote self-efficacy and the lack of attention given to subjective norms are all aspects of this intervention that are poorly designed and cause BMI report cards to be ineffective.

While there are many problems with the current design of the BMI report card intervention, certain changes could be made that would result in the program being more effective. Restructuring the report cards to provide a detailed explanation of each classification, i.e. normal, overweight, etc., would help parents and children to better understand the significance of a BMI. In addition, suggesting healthy behaviors such as consuming more fruits and vegetables and increasing physical activity will help parents and children improve their sense of self-efficacy, as well as remind normal weight children how to maintain a healthy weight. Finally, promoting healthy behaviors for all children within the school will help to create a culture of positive subjective norms towards healthful behaviors. In doing so, the school will help take attention away from overweight children trying to make better health behavior decisions and instead focus upon the overall health of the school community. BMI report cards have the potential to help stabilize the number of children who become classified as overweight every year, and then potentially reduce that number by alerting parents to children who are at risk of becoming overweight, but this will only happen if several changes are made to the program. In its current state, though, the intervention of BMI report cards is lacking in several key areas and is ineffective as a public health intervention.

Health Reporting—A Fresh Approach in the Fight Against Childhood Obesity-Kaitie Feloney

The BMI report card has recently become the focus of a great deal of media attention. Some news coverage points to the report cards as an innovative approach to fighting obesity in the United States, while other news reports vilify the schools for possibly hurting the feelings of overweight children. While neither assessment is accurate, it is certain that BMI report cards in their current format represent an ineffective public health intervention. In order to become an effective and worthwhile tool, the report cards must explain the perceived benefits of a healthy weight, address self-efficacy as related to weight loss, and take into account the social norms associated with childhood obesity.

BMI report cards are an intervention that has been attempted in seven states (13). Under the current framework, a child’s body mass index (BMI) is included on the normal report card with a designation of underweight, normal, overweight, or obese. The idea behind the report cards is that parents who might otherwise be unaware of a child’s weight problem can be made aware of the situation, and that the parent will then take steps to address the issue. This methodology has several problems, namely that the report cards do not explain the perceived benefits of a healthy weight, address self-efficacy or the social norms of childhood obesity. With a few minor changes, however, an overall health reporting system could become an effective tool to help fight childhood obesity in the United States. A more effective intervention would be to link BMI reporting to parent-teacher conferences. Instead of receiving a piece of paper with a number and little to no explanation, parents could receive a print-out explaining the BMI and the child’s classification, as well as direct counseling from the school nurse or health teacher. In addition, the print-out could address several aspects of health, such as days absent from school due to illness, performance in gym class, and performance in health class. Doing so would take the focus off weight and place more emphasis on a healthy lifestyle, so that all children could have a goal to work towards instead of singling out overweight or obese children.

Health Reporting Will Explain the Perceived Benefits of a Healthy Weight

The health belief model operates under a number of assumptions, one of which is that an individual weighs the perceived benefits of a health behavior before undertaking it (14). With the old approach of BMI report cards the perceived benefits of a healthy weight were not explained. Under this new intervention, the benefits of a healthy weight will be explained directly to parents at the conferences, as well as to children during health education class. Doing so will help to convince parents that measures should be taken to help their children maintain a healthy weight, as well as explain to children why these behaviors are important. The theory of reasoned behavior also addresses the idea that a person’s belief about what will happen if they undertake a particular behavior affects his attitude towards that behavior (15). Research has found that maintaining a normal weight and the behaviors that lead to this (such as regular physical activity and nutritious meals) can help prevent chronic diseases later in life, such as type II diabetes and cardiovascular disease, as well as joint problems, sleep apnea, and hypertension (16). Explaining these potential benefits to parents will help educate them as to which behaviors lead to a healthy weight, as well as help minimize any defensive feelings the parent may have. Telling a parent that her beloved child is overweight can easily result in anger, but framing the conversation as one about overall health, of which weight is only one part, may help to lessen angry feelings.

Health reporting will address self-efficacy as related to weight loss

As noted previously, social cognitive theory explains the concept of self-efficacy as the idea that an individual’s belief in her ability to complete an action affects the decision of whether or not to engage in the action and the perseverance in completing the action (17). A person’s concept of self-efficacy is also affected by other aspects, like that individual’s psychological factors, social persuasions, mastery experience and vicarious experience. One of the main failings of BMI report cards is that they did not address self-efficacy as it relates to weight loss, leaving children and parents feeling helpless. The ability to complete physical activity and eat nutritiously is greatly impacted by a person’s self-efficacy, so in order to ensure that health reporting will be effective, self-efficacy will be buoyed on a regular basis.

One way that health reporting will promote improved feelings of self-efficacy is through the print-outs given to parents as part of parent-teacher conferences. The informational sheets can suggest ways to add physical activity into daily life, as well as examples of nutritious meals and snacks. Parents and children can read through the sheets and get ideas for how to move towards a healthier lifestyle, and these tips can be helpful for normal weight children as well. For example, the informational sheet could use uplifting language and images to help children feel confident about their ability to maintain a healthy lifestyle. The nutritional section could note that drinking soda instead of water or milk is a good choice, and that drinking less soda is linked to a lower average caloric intake (18). Health and physical education teachers should also put forth a positive attitude in class, and running a school-wide challenge to improve one’s health could result in improved feelings of self-efficacy school-wide.

Health reporting will take into account the social norms related to childhood obesity

While the lack of focus upon self-efficacy was a serious shortcoming of BMI report cards, a more severe failure of the program was its inadequacy in addressing the social norms associated with childhood obesity. The theory of reasoned action states that an individual considers the subjective norms of a health behavior before choosing to engage in it. These subjective norms emerge from an individual’s belief of how others in his social group will react to a particular behavior, as well as the individual’s desire to conform to these social norms (19). For a topic as emotionally-charged as childhood obesity addressing social norms can greatly impact the success of a program. Overweight and obese children are more likely to endure bullying from classmates, as well as experience feelings of shame and depression, and it is clear that various social stigmas of being overweight have developed among school-age children (20). Delivering health information about the child at parent-teacher conferences avoids the potentially embarrassing situation of being handed a BMI report card that reads “overweight,” which other children could see and taunt. In addition, the health and physical education teachers should try to cultivate an environment of respect and acceptance so that children of all sizes will feel comfortable in gym class and ultimately in all settings. Creating this open culture will help to shift the social norms of the school towards an environment in which healthy behaviors are looked upon favorably, and where children who are trying to improve their health status are celebrated.

Conclusion

The BMI report card program that was initialized in several states earlier this year was designed with good intentions, but it ultimately fell short in its accomplishments due to several glaring omissions. The program as designed did not provide children and parents with the perceived health benefits of a healthy weight, and did not address self-efficacy or social norms as they relate to childhood obesity. A health reporting intervention that focuses upon communicating information directly to parents alongside a health print-out would provide more information, and a school-wide health improvement initiative would help to increase a child’s sense of self-efficacy as well as improve the social norms associated with childhood obesity, and this program could potentially help to fight the ongoing epidemic of childhood obesity in the United States.

References

1.) http://www.cdc.gov/HealthyYouth/obesity/index.htm

2.) A. Must and R.S. Strauss. “Risks and consequences of childhood and adolescent obesity.” International Journal of Obesity (1999), 23, Suppl. 2.

3.) I. Janssen, W. Craig, W. Boyce, W. Pickett. “Associations between overweight and obesity with bullying behaviors in school-aged children,” Pediatrics (2004), Vol. 113 No. 5, pp. 1187-1194.

4.) C. Ebbeling, D. Pawlak, D. Ludwug. “”Childhood obesity: public-health crisis, common sense cure,” The Lancet (2002), Vol. 360 No. 9331, pp. 473-82.

5.) http://www.cnn.com/2007/HEALTH/diet.fitness/01/30/obesity.report/index.html

6.) A. Grund, H. Krause, M. Siewers, H. Rieckert, MJ Muller. “Is TV viewing an index of physical activity and fitness in overweight and normal weight children?,” Public Health Nutrition (2001), Vol. 4, pp. 1245-51.

7.) MK Salazar. “Comparison of four behavioural models,” AAOHN (1991), Vol. 39, pp. 128-135.

8.) Ibid.

9.) LH Epstein, AM Valoski, LS Vara. “Effects of decreasing sedentary behavior and increasing activity on weight chance in obese children,” Health Psychology (1995), Vol. 14, Issue 2, pp. 109-15.

10.) I. Azjen, M. Fishbein. Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ: Prentice Hall; 1980.

11.) M. Eisenberg, D. Neumark-Sztainer, M. Story, C. Perry. “The role of social norms and friends’ influences on unhealthy weight-control behaviors among adolescent girls,” Social Science and Medicine (2005), Vol. 60 Issue 6, pp. 1165-1173.

12.) O. Raitakan, K. Porkka, S. Taimela, R. Telama. “ Effects of persistent physical activity and inactivity on coronary risk factors in children and young adults,” American Journal of Epidemiology (1994), Vol. 140, No. 3, pp. 195-205.

3.) http://www.cnn.com/2007/HEALTH/diet.fitness/01/30/obesity.report/index.html

14.) Becker MH, ed. “The health belief model and personal health behavior.” Health Educ Monogr. 1974;2:Entire issue.

15.) Azjen I, Fishbein M. Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ: Prentice Hall; 1980.

16.) Sothern MS, Loftin M. “The health benefits of physical activity in children and adolescents: implications for chronic disease prevention.” European Journal of Pediatrics (1999), Vol. 158 No. 4, 271-74.

17.) MK Salazar. “Comparison of four behavioural models,” AAOHN (1991), Vol. 39, 128-136.

18.) Harnack L, Stang. “Soft Drink Consumption Among US Children and Adolescents Nutritional Consequences,” Journal of the American Dietetic Association (1999), Vol. 99 No. 4, 436-41.

19.) Azjen I, Fishbein M. Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ: Prentice Hall; 1980.

20.) Sjoberg R, Nilsson K, Leppert J. “Obesity, Shame and Depression in School-aged Children: A population based study,” Pediatrics (2005), Vol. 116 No. 3, e389-92.