Part I – Promoting Healthy Dietary Habits in Children: An Incomplete Approach from National Childhood Nutrition Programs – Abigail O. Isaacson

Childhood Obesity and Food Insecurity in America
Childhood obesity is a growing problem in America. Kids eat more and move less than they did 20 years ago, and childhood obesity has tripled since 1980 (5). Because eating behaviors in childhood are predictive of adult obesity, learning healthy patterns before age 5 can help prevent obesity and related disease in adulthood (20). In 2003–2006, 16.3% of children and adolescents aged 2–19 years were classified as obese (above 95th percentile BMI) according to CDC growth charts (5,20). This increasingly unhealthy behavior stems from a variety of factors, including the availability of cheap, energy-dense foods and popularity of TV and video games.
Most Americans know that obesity increases one’s risk of developing chronic diseases like diabetes, cancer, heart disease and stroke in adulthood, but they know much less about another dietary threat to child and adult health: food insecurity. Increasing in America and around the world, food insecurity occurs when a child or family cannot purchase enough food to enjoy an active and healthy lifestyle (14). The Child Sentinel Nutrition Assessment Program (C-SNAP) reports that 16.7% of American children under age 6 live in a food insecure household (14). Not only are these children more prone to nutrient deficiencies and hospitalization during illnesses, but they also suffer cognitive, motor and behavioral problems that affect their development and school performance.
National approaches to preventing obesity and food insecurity involve multi-level efforts from the United States Department of Agriculture (USDA) Center for Nutrition Policy and Promotion (CNPP), the U.S. Centers for Disease Control (CDC) Division of Nutrition, Physical Activity and Obesity, the National Institutes of Health (NIH) and others. These organizations are well funded and equipped to deliver trusted messages to the mass public and therefore deserve frequent critique. Current childhood health promotions center on breastfeeding, increasing fruit and vegetable consumption and physical activity, and decreasing sugar-drinks, high energy dense foods and TV viewing (10). While such recommendations certainly promote good health and identify what needs to happen to help prevent childhood obesity and disease, they fail to emphasize how such interventions will be made relevant at an integrated level. Specifically, national nutrition promotion programs tend to measure success by individual intention, inconsistently target appropriate decision makers and fail to reflect the realities of diverse sub-populations.
Keeping With Tradition
As with many health interventions, nutrition programs seek evidence from traditional health behavior change models, namely Theory of Reasoned Action, Health Belief Model, Social Cognitive Theory and Transtheoretical Model (12). These theories analyze how people make behavioral choices that produce valuable results by each individual’s judgment (16). Scientists admit to their appeal; for example, the Transtheoretical Model’s brevity, high face validity, and understandability, especially to the non-behavioral scientist, makes it highly appealing to the implementer (16). In terms of strong evidence, however, the model utilizes cross-sectional, observational studies in most cases rather than randomized control trials, which produce stronger results. Traditional behavior models emphasize individual cognitive processes and internal perceptions as determinants of behavior.
The CDC also holds conventional theories in an exemplary fashion: “state-of-the-art nutrition education uses many of the social learning behavioral change techniques used in other health education domains” (10). Critical outcomes include raising the value placed on health, taking responsibility for one's health and increasing confidence in one's ability to make health-enhancing behavioral changes. Similarly, a local nutrition pilot project at Boston Medical Center called Healthy Eating and Activity Today (HEAT) bases its outreach on models like Social Cognitive Theory (20). To elevate self-care in the homes of obese children, it emphasizes building knowledge, skills, reinforcement, rewards, self-awareness, social support, self-efficacy, goal setting, cues to action and modeling (20,21). Even these theories with added environmental-level components still encourage the common perception that individual, psychological factors are the primary forces in decision making. This approach unnecessarily limits the potential role that community and environmental changes could play in encouraging positive behavior change among individuals.
Health behavior research suggests that traditional approaches are out of style. A recent study looking at the relationship between these accepted variables and adult diet adherence found that theoritical factors such as self-efficacy, perceived barriers, positive attitude, goal-setting and social support became improved once patients were successfully adhering to a diet (16). However, none of the variables predicted successful diet adherence as the models suggest they should. Another study analyzing perception and dietary change found that groups who have positive attitudes toward a low fat diet do not necessarily take steps toward reducing fat in their diet, especially if they believe they are already eating a low-fat diet (3). Researchers agree that these models are great predictors of intention and motivation but not actual behavior (2,3). National interventions to prevent childhood obesity and food insecurity have traditionally followed an internal, cognitive approach aimed primarily at changing individual intention and less on external, environmental influences.
Overemphasizing Individual Intention
Current national campaigns fit with traditional models by measuring success according to intention. Following the example of the USDA Fresh Fruit and Vegetable Pilot Program in 2003-4, one Mississippi school distributed free fruits and vegetables among 5th graders to increase their perceptions and consumption of fruits and vegetables (9). The program evaluation cited attitudes toward, preferences for and intentions to eat more fruits and vegetables as indicators of success. Eighth grade students in the district reported increased preferences for and intention to eat more fruits and vegetables, and 5th graders’ preferences decreased (9). No information was reported on whether either group actually adopted healthier eating patterns; instead, judgment of 8th graders’ success and 5th graders’ consequent failure was determined by stated intentions alone.
Another program steered toward individual intentions is the CDC-sponsored “Fruits&Veggies – More Matters” program, which replaces the 5 (to 9) A Day campaign and includes new guidelines set forth by the U.S. Department of Health and Human Services and the USDA (8). More Matters targets children’s healthy eating using traditional behavior change beliefs: raising the value of good health and nutrition, identifying benefits and barriers, promoting physical appearance and capacity for exercise, improving sense of personal independence and control, modeling health eating, giving praise and prizes for successes, analyzing personal eating patterns, etc. (10). It presents interactive and age-specific activities, recipes and healthy recommendations on its website, and information is presented to and left up to the individual to act upon (7,8). Beyond its website and attempts at in-store packaging logos which minimally explain the program to the public, little community-level exposure to program involvement exists.
National efforts put enormous faith in individual intention and ability to consistently conquer emotion, avoid temptation and make good decisions. Left to their own choice and judgment, individuals do not always recognize their weaknesses or available tools to overcome them (2). Rather than being consistently rational beings, humans are prone to procrastination and inconsistency. We are not always capable of keeping logical goals and self-control, especially when it comes to permanent changes in diet and exercise. Forfeiting long-term goals for immediate gratification is common for all ages, especially children, who need external influences to help shape their improved behaviors (2). Most traditional theories of behavior place too little emphasis on the importance and success of such needs.
While national child health behavior campaigns heavily weigh individual cognition and intention, they do not entirely neglect environmental approaches. More Matters mentions policy and environmental change, health disparities, science, partnerships, access, education and research as variables of creating change (10). It includes goals of “enabling students to critically analyze socio-cultural influences, including advertising, on food selection, to resist negative social pressures, and to develop social support for healthy eating” (10). However, individuals remain the ones making the change, and few references to overcome complicated behavior change barriers are easily found. What about dealing with temptation and failure in relapse to previous habits? Emotions associated with eating? Cultural tradition? Lack of healthy food availability? More Matters and school programs need to target relationships between children and their surroundings in order to make behavior change more possible.
Who Really Makes Kids’ Dietary Decisions?
Since free choice is a factor in decision-making, it makes sense that traditional interventions target choosers (3). However, multiple choosers influence life of a child. The health decisions of pre-school aged children are generally made for them, and these early years are formative for healthy behaviors later in life (20). Parents’ involvement in their children’s eating and exercising choices become shared as kids enter elementary school. For example, a parent who is on board with a healthy eating plan at home may be able to prepare healthy lunches for her child to take to school. However, if all the child’s friends are eating in-school lunches because it’s viewed as cool, the child will likely find a way to neglect his healthier home lunch in order to fit in. Unless the school is also ‘on board’ with a healthy eating plan and limits unhealthy options at lunch, the child won’t receive consistent messages about healthy eating. Parents come to rely on school-based programs and community organizations to help shape healthy behavior adaptation.
While national nutrition programs make mention of this key interface, they still tend to target individual children as main influencers of their own health. In a Transtheoretical Model approach, the CDC’s child-focused campaign attempts to adapt nutrition education to children’s levels. Its Food Champs website involves children ages 2-5 with interactive click-and-drag graphics and games (7). Messages such as, “Corn: we like to eat corn on the cob, frozen or canned. It’s even used to make ethanol gas for our cars” are delivered to young children who make it onto the More Matters website. However, introducing ethanol gas to a 2-5-year old and sitting at a computer with him may not be as health-effective or realistic as taking him to the park or helping him taste healthy foods. Food Champs and More Matters must consistently emphasize lifestyle tools for parents or other decision-makers to initiate with their children to help shape their future choices.
The (HEAT) pilot intervention at Boston Medical Center described earlier also targets children as decision-makers through its automated weekly telephone interviews. As part of the data collection, which includes parental responses, the obese child is responsible to report his progress over the phone with a computer prompter (20). This direct, in-home approach values the child’s independence and self-analysis but may not control for emotional responses caused by feelings of failure, shame, embarrassment, or apathy. Involvement of both the pediatrician and the family is noted but limited.
Targeting individual children is not a bad idea when utilized in combination with an emphasis on community influence. In one Colorado elementary school, students are encouraged to ‘purchase’ fruits and vegetables with valuable tokens at a daily produce market setup by staff (11). This construct is praised for encouraging individual student responsibility, analyzing personal diet, and valuing of fruits and vegetables since they ‘cost’ earned tokens. However, the market could also encourage community thought in students by giving them a budget to buy for a proportion of classmates or their family at home for a day. By having them think for others, they might be more understand how others think with and for them.
Environmental change must involve the roles of a wide array of decision makers; parents, school management, grocery stores, and policy makers all determine part of the nutrition and physical activity environment of school children. The USDA's Team Nutrition positively “seeks to gain the support of many sectors of society for improving the diet of young persons by creating innovative public and private partnerships that promote healthy food choices through the media, schools, families, and community” (12). Tangible efforts and evidence of this environmental goal need strengthening. The USDA and partner organizations must implement a clearly defined, multi-level action plan among parents, schools, politicians, community organizations and children to create a framework within which healthy food choices can happen.
Not Everyone Fits Into Traditional Nutrition Intervention Models
Healthy diet promotion programs generally have a standard message catered toward a middle-class population. Communication targets two-parent, working families who spend 30% of their incomes on food (still based on 1964 poverty thresholds), rush to sports practice with their kids and have the ability to prioritize their future health (8,14). Considerations of sub-populations, regional differences, and ethnic purchasing patterns are missing or are supplementary rather than primary considerations, leaving vulnerable populations behind.
Current interventions excel at providing standardized recommendations but fail in providing ethnic or cultural tools to address differences in cultural beliefs. More Matters has created supplemental pamphlets for sub-populations but with little difference in messaging. For example, “Choose Smart, Choose Healthy” publication created for African American Women provides the same food example recommendations that the CDC provides for all populations on its website (8). The message is consistent, but perhaps using healthy foods common to the African American diet would be more helpful. The pamphlet emphasizes control and beauty: “It’s your life. You’re in control” and “Beauty. Inside and Out” are accompanied by pictures of African American women. While the pamphlet does list foods and corresponding nutrients that might be more common to an African American diet, the emphasis is not clear and cultural differences are faint. Instead of conveying a message that African American women can find a manageable way to eat a healthy diet that is still familiar to them, the pamphlet might be communicating that beauty and control are achieved by conforming to a standard diet created largely by white populations.
Instances of families who are setup for failure by these standard designs signify the need for continued development at environmental and social levels. The USDA Thrifty Food Plan gives recommendations that consider issues of disparity, affordability, and opportunity in achieving a healthier diet. However, the 25 million Americans relying on Food Stamp Program, now called Supplemental Nutrition Assistance Program (SNAP), are likely to have difficulty meeting the Thrifty Food Plan’s Healthier Diet Market Basket recommendations (14,17). For example, an average family of four who use Food Stamps would receive a maximum allotment of $497.39 a month for food, but most families receive an allotment far below the maximum (14). In Boston, the average Food Stamp allotment is only $159.95 (far from the maximum); the Thrifty Food Plan costs an average of $524.26 at the grocery store, and Healthier Diet for a Boston family of four costs $645.20 (14). Being able to purchase the recommended foods for such families is not a reality. Even though this federal assistance is meant to supplement other grocery money, many families rely on this as their only food budget.
Giving low-income families a guide on what to put in a ‘healthy food basket’ will not help them if recommended items are not on the shelves at their nearest grocery store or if their monthly wages are eaten up first by rent, childcare, or other pressing needs. Additionally, minority and immigrant families have a different definition of a healthy diet and may see little value in American recommendations based on the Food Pyramid. They may hold differing beliefs about food and its role in health, disease and emotional comfort for different ethnic groups that must be considered. Many families do not have access to health education through national nutrition program websites, lack basic finances even to implement available cost-saving strategies provided by the More Matters program, and are not in a position to prioritize their future health.
Looking Ahead
Children’s individual cognitive processes are certainly involved in choosing a healthy diet, but not to the extent that current programs project. Traditional behavior processes teach kids that they can make decisions independently of the people and influences around them. True human weaknesses complicate the apparent success of intention leading to behavior change, and the involvement of many decision makers is crucial. National nutrition interventions do not give enough recognition to the critical role of community in children’s decision making or to the complexities that culture, poverty and emotion add to standard nutrition approaches. Internal mechanisms continue as the main reliance of these interventions. Unless community environments are structured in a way that helps kids make healthy behavior decisions, we will continue to see childhood obesity and food insecurity, and their social consequences, rise in America.
National nutrition programs are not entirely missing the picture of successful childhood health promotion, but rising rates of childhood obesity and food insecurity demonstrate certain weaknesses in accepted, traditional approaches. A greater emphasis on environmental influences upon children, a more comprehensive strategy that includes all decision-makers, and action plans that consider ethnic and socioeconomic barriers and beliefs will strengthen existing national nutrition interventions.
Part II - Social Science and National Nutrition Program Reform: Improved Methods for Food Insecure and Obese Children and Their Communities – Abigail O. Isaacson

Dominating players of the nutrition world work tirelessly to create relevant and evidence-based diet recommendations for American children. Organizations like the Centers for Disease Control (CDC) and United States Department of Agriculture (USDA) own the resources and expertise to earn public trust when it comes to healthy behavior. Their current child nutrition interventions have focused on individual intention while limiting involvement of external decision-makers. They have also generally presented streamlined, monoculture strategies to instigate positive dietary change in children. With the support of social science theories, national health organizations will better combat childhood obesity and food insecurity by structuring programs at the environmental level, involving a greater variety of decision-makers, and creating regional program variations based on cultural preferences.
“Socialized” Nutrition Programs
The theoretical impetus behind national nutrition interventions has traditionally targeted children’s internal perceptions. Nutrition advocates need not neglect all the factors that theories like Health Belief Model and Social Cognitive Theory identify, but they should elevate certain elements to a community level. A push from intention to action in childhood obesity prevention will require a stronger application of theories based on social sciences to improve outcomes.
Several theories support healthy diet promotion among children. Labeling Theory and, to a greater extent, Stigma Theory, reveal layers of negative social classification inherent in certain program components (32,26). Labeling can create self-fulfilling prophecies among target populations, and federal assistance programs may stigmatize recipients by labeling them as low-income and thus exacerbate their situation. National nutrition interventions need to carefully contemplate their terminology and approach while raising societal value toward obese and food insecure children.
For the development of nutrition strategies, Social Marketing Theory and Framing Theory are helpful. Marketing theory suggests that the continuous emphasis on the tangible marketing of intangible ideas, lifestyle changes and behaviors improve the effectiveness of public health interventions (25). Framing Theory outlines how individuals can shape each others’ perceptions of reality by guiding certain cognitive processes (27). Knowing what food kids value, for example, and then ‘selling’ it back to them, perhaps in a “healthified” version, creates an emotional appeal toward healthy eating habits (24). Social science theories inform national programs to remove stigma and improve desirability of healthy foods to kids and their communities.
Strengthening the Environmental-Level Approach
National child nutrition programs have settled on children’s demonstration of intention to improve dietary behaviors, but additional factors such as acceptance and understanding of a program within the child’s community greatly enhance outcome achievement. The CDC’s More Matters program has designed creative interactions for children of all ages on its website, but they remain locked in a computer screen. Applying online activities at a non-cyber community level will expose more children to learning tools and foster community support of health decisions. To strengthen its approach, the CDC could employ more nutritionists to prepare its ‘food of the month’ in kids’ classrooms for tasting or at community farmers’ markets. The USDA has already sponsored initiatives like these in certain U.S. counties on a small scale, although participation is limited to low-income women and children who qualify for federal assistance (29,31). An enhanced, multi-level approach could omit income requirements (and stigma) and adapt suggestions to the preferences, food availability and cultural beliefs evidenced by community-level research. With Marketing Theory in mind, it could then advertise concepts and materials at local elementary schools to prepare kids for a times of shopping, tasting and learning that are both exciting and realistic.
While broader community support allows more children make the jump from intention to behavior change, barriers still exist. Economic, cultural and ideological variables hinder many kids’ progress toward healthy eating. One idea that incorporates a reduction of these barriers on an environmental level is the development of a healthy food coupon program. Newspaper food coupons often feature foods that are either unhealthy, undesirable, irrelevant to local diet or luxury item from specialty stores. Other coupons are only available online or might require the purchase of some other product first (23). Many coupon systems run the potential of excluding large portions of the populations that need the savings most. A healthy food coupon project would serve as a quasi-continuation of the USDA’s Farmer’s Market Nutrition Program (FMNP), which provides produce coupons at WIC offices in partnership with certain growers at seasonal farmer’s markets, but with added twists (31).
Instead of being available only during market seasons and to low-income women and children, coupons would be available year-round to anyone who wanted them. They could be strategically rotated through different locations where vulnerable populations are more likely to cross, such as day cares, elementary schools, grocery stores, pharmacies and community centers like the YMCA. These coupons would not distinguish participants by race or class or culture. Pilot projects would test the location, regional whole food preferences, local store selection and effectiveness of consistent versus rotating coupon availability.
The project idea is to provide children and their deciders with a set of tools at a community level in order to move past intention to actual adoption of a healthier diet. If children’s schools and home environments are not structured to help them achieve a healthier diet, then intentions alone will unlikely result in positive behavior change. Ideally, users would experience a sense of empowerment, pride, thriftiness and improved health. The CDC, USDA and NIH could collectively contribute resources, communication skills and multi-level support. Coupons would have limits, but they would frame healthy foods in a more attractive light, establish dietary habits that would continue when affordability and access allowed, and foster consistent national and community cohesiveness toward child food security and healthy eating.
A Team of Leaders
While children must maintain some freedom in determining their dietary preferences, community leaders are well positioned to shape kids’ choices toward healthy options as well. External leaders need to take more responsibility for the lives of children who are at risk for obesity and food insecurity. A commanding team of healthy promotion leaders includes parents, guardians, schools, doctors, community nutritionists, day care centers, public libraries grocery stores, advertising agencies, churches and many more. Nationally led support networks of vulnerable and food insecure children can make a huge difference in their success.
At a school level, along with classroom nutritionists preparing foods to expose kids to varieties of new and healthy tastes, students can plant vegetables in school gardens and monitor their progress. They can vote on class snacks, take recipes home to their parents, ‘eat the rainbow’ at farmer’s market visits or practice purchasing adequate fruit and vegetable servings for their family members with a school market budget. Schools would be an important recipient of real produce coupons that kids could take home and give to their parents to take grocery shopping.
Providing children’s decision makers with existing tools at a community level and apart from the Internet will improve accessibility and awareness. More Matters already provides online tools that include food sticker pages and Eat Your Colors worksheets (22). However, families that are not searching for healthy diet resources or lack access to the web or a printer are not going to utilize these tools. Worksheets could be available at participating grocery stores, which could also automatically give produce coupons at checkout if a customer does not purchase a minimum amount of whole foods. Day care centers could implement More Matters Food Champs activities during snack time. Many possibilities and variations exist for improved nutrition program implementation in different community locations, but it will take the involvement of multiple decision makers.
Population Preferences
National health organizations agree that more investigation is needed on environmental variables and their effects on obesity and food insecurity among children (30). They aim to study consumer behavior, but they do not place as much emphasis on cultural differences among these children’s communities. For diet recommendations to be realistically received, they must consider regional dietary beliefs, preferences and food availability. Anthropologists offer additional expertise for determining true community needs assessments: “they immerse themselves in the social life of the setting they seek to understand” (33, p.103). The definition of a healthy diet will differ between communities and among children. For CDC or USDA representatives to involve themselves at such an intimate community level would potentially transform their programs with a wealth of wisdom.
Specifically, research staff or nutritionists in local schools and community sites can talk with children, hold recipe competitions, or work with local chefs to identify preferred healthy foods that will be accepted by various ethnic groups besides Americans of European descent. A coupon project would need to take steps like these to first determine which foods to feature and at what price discounts. Incorporating anthropological tenants into nutrition interventions will alleviate some of the sub-cultural weaknesses of current program approaches.


Child Food Security
National organizations such as the CDC, USDA and NIH have contributed incredible work toward child nutrition, and even methods that are on the right track can still be improved. In their continued aims to reduce childhood obesity and food insecurity, national programs must draw on principles revealed by social science investigation. People enjoy free things, saving money, being independent, and not having to spend a lot of money on food staples (2). A healthy foods coupon project based on the knowledge of these preferences has potential to reach more food insecure and obese children and their families. Population-scale interventions will help nutrition program leaders structure community environments of children in an attractive manner without negative labels. Bringing national nutrition tools to the community-level, involving more decision-makers and considering sup-population preferences will provide more children with a structured environment within which food security is possible.









REFERENCES
1. Adams, W. National Institute of Child Health and Development. IT-Supported Early Treatment of Childhood Overweight, January 2007. http://researchresources.bumc.bu.edu/abstract/5R21HD050939-02.htm.
2. Ariely, D. Predictably Irrational: The Hidden Forces that Shape our Decisions. New York: Harper Collins Publishers, 2008.
3. Brug, et al. Theory, evidence and Intervention Mapping to improve behavior nutrition and physical activity interventions. International Journal of Behavioral Nutrition and Physical Activity, 2005. 2:2. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1087867.
4. Buzby, J, et al. Evaluation of the USDA Fruit and Vegetable Pilot Program: Report to Congress. E-FAN No. (03-006) 31 pp, April 2003. http://www.ers.usda.gov/Publications/EFAN03006/.
5. Centers for Disease Control and Prevention. Chronic Disease Prevention and Health Promotion. Preventing Obesity and Chronic Disease through Good Nutrition and Physical Activity, 2008. http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/obesity.htm.
6. Centers for Disease Control and Prevention. For Health Professionals. About the National Fruit and Vegetable Program, 2008. http://www.fruitsandveggiesmatter.gov/health_professionals/program_guidelines.html.
7. Centers for Disease Control and Prevention. Fruit and Veggies More Matters, Get Kids Involved, 2008. http://www.fruitsandveggiesmorematters.org/?page_id=6.
8. Centers for Disease Control and Prevention. Fruit and Veggies More Matters, 2008. http://www.fruitsandveggiesmorematters.org/.
9. Centers for Disease Control and Prevention. MMWR Weekly. Evaluation of a Fruit and Vegetable Distribution Program --- Mississippi, 2004--05 School Year, September 2006. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5535a1.htm.
10. Centers for Disease Control and Prevention. MMWR Weekly. Guidelines for School Health Programs to Promote Lifelong Healthy Eating, June 1996. http://www.cdc.gov/mmwr/preview/mmwrhtml/00042446.htm.
11. Centers for Disease Control and Prevention. Overweight and Obesity. State Stories, Colorado, 2006. http://www.cdc.gov/nccdphp/dnpa/obesity/state_programs/state_stories/.
12. Centers for Disease Control and Prevention. Physical Activity and Health. A Report of the Surgeon General. Chapter 6: Understanding and Promoting Physical Activity, 1999. http://www.cdc.gov/nccdphp/sgr/chap6.htm.
13. Children’s Sentinel Nutrition Assessment Program (C-SNAP). Frequently Asked Questions, 2007. http://www.c-snap.org/page/ResearchFAQs.
14. Cook, JT., PhD, et al. Children’s Sentinel Nutrition Assessment Program. The Real Cost of a Healthy Diet: Healthful foods are out of reach for low-income families in Boston, MA, August 2005. http://www.c-snap.org/page/ReportsBriefsFactSheets.
15. French, SA; Worsley, T. What is the role of theory in health behavior change interventions? International Journal of Behavioral Nutrition and Physical Activity, 2004;1:9.
16. Jeffery, RW. How can Health Behavior Theory be made more useful for intervention research? International Journal of Behavioral Nutrition and Physical Activity, 2004; 1:10. http://www.ijbnpa.org/content/1/1/10.
17. Thayer, J, MS, MPH, et al. Children’s Sentinel Nutrition Assessment Program. Coming Up Short: High food costs outstrip food stamp benefits, September 2008. http://www.c-snap.org/page/ReportsBriefsFactSheets.
18. United States Department of Agriculture Food and Nutrition Service Newsroom. USDA Readies Fresh Fruit and Vegetable Purchases for Elementary Schools, August 2008. http://www.fns.usda.gov/cga/pressreleases/2008/PR-0208.htmProgram.
19. United States Department of Agriculture. Fresh Fruit and Vegetable Program Handbook, August 2008. http://dpi.wi.gov/fns/ffvp.html.
20. Wright, J, PhD. Boston Medical Center and Boston University School of Medicine. Childhood Obesity: Interventions in Pediatric Primary Care. Powerpoint Presentation, November 2008.
21. Wright, J, PhD. Boston Medical Center and Boston University School of Medicine. Design and Usability Testing of a Telephony-based Care System for Pediatric Obesity. Powerpoint Presentation, November 2008.
22. Centers for Disease Control and Prevention. Take your Child to Supermarket Day, 2008. http://www.fruitsandveggiesmorematters.org/?page_id=1921.
23. Coupon Girls, LLC. Healthy Food Coupons, 2008. www.Healthyfoodcoupons.com.
24. General Mills Eat Better America, 2008. www.Eatbetteramerica.com.
25. Lefebvre, RC and Flora, JA. Social marketing and public health intervention. Health Education Quarterly. Fall 1998; (15): 3 299-315.
26. Link, B and Phelan, J. Stigma and its Public Health Implications. Lancet. 2006; (367): 528-529. http://www.stigmaconference.nih.gov/FinalLinkPaper.html.
27. Sanfilippo, A., et al. Automating Frame Analysis. Social Computing, Behavior Modeling, and Prediction, January 2008; 239-248. http://www.springerlink.com/content/q0754557xk42516r/.
28. Tufts University Friedman School of Nutrition Science and Policy.
Shape Up Sommerville, Eat Smart, Play Hard, 2008. http://nutrition.tufts.edu/1174562918285/Nutrition-Page-nl2w_1179115086248.html.
29. United States Department of Agriculture and Washington State University. Square Foot Nutrition Project, 2008. http://www.pierce.wsu.edu/Nutrition/SFN/index.htm.
30. United States Department of Agriculture Agricultural Research Service, Children’s Nutrition Research Center. Childhood Eating Behaviors: Prevention of Childhood Obesity and other Chronic Diseases. Obesity: Understanding the consumer: studies on consumer behavior, 2004. http://www.ars.usda.gov/research/projects/projects.htm?ACCN_NO=402980.
31. United States Department of Agriculture. Farmer’s Market Nutrition Program (FMNP), 2008. http://www.fns.usda.gov/wic/FMNP/FMNPfaqs.htm.
32. Wikipedia. Labeling Theory, 2008. http://en.wikipedia.org/wiki/Labeling_theory. 33. Hahn, RA. Sickness and Healing: An Anthropological Perspective. Chapter 5: Anthropology and Epidemiology: One Logic or Two? New Haven, CT: Yale University Press, 1995; 99-128.

A Review of the "Balance First" Diet and Exercise Campaign and Recommendations for Improvement – Kristen Binau

Introduction

Diet and exercise make up a large part of physical health and well being. They also are two of the biggest health issues in industrialized countries like the U.S. Poor decisions regarding diet and exercise can lead to many cardiovascular and respiratory problems and can cause obesity (1). Choices about diet and exercise tend to be life long so many public health campaigns concentrate on influencing young people. Ensuring that adolescents have proper diet and adequate exercise may be the key to reducing the incidence of many negative health outcomes (2).

One campaign that focuses on young people is balance first. Balance first is a diet and exercise campaign aimed at adolescents in the sixth, seventh, and eighth grades. The campaign has an overarching theme of personal energy balance. Energy input from food must be proportional to energy output from exercise to maintain health. Balance first takes place within junior high schools and relies on a series of five lesson plans to teach students about diet and exercise. Each lesson requires one to three class periods and consists of several activities. Many of the activities involve engaging the students in discussions regarding diet and exercise and many focus on giving more information on what healthy diet and exercise entail. Along with the lesson plans, a four page magazine is distributed to students with information on diet and exercise and examples of good diet and exercise. At the beginning of the implementation, a letter is also sent home to parents explaining that their child is participating in the program and directing them to several resources to learn more about diet and exercise (3).

Balance first is severely flawed in a few ways. First, the format in which it is implemented is not effective. The campaign is taught to junior high students like any school subject and requires multiple class periods. This is problematic for students in an age group where testing academic authority is popular. Teachers also may not be able to implement the entire program in a tight schedule. The second problem in the campaign involves social factors and personal feelings. The program does not account for the social context of junior high where students can get singled out for being overweight and it also does not engage the families in diet and exercise change to a large extent. Lastly, the balance first campaign assumes that when presented with information on why and how to change, the students will rationally decide to change and then follow through with their decision. Rational behavior and intention leading to change should never be assumed.

Campaign Format

Schools can be very effective environments for public health campaigns to change behavior (4). However, the format of the campaign has to be well thought out. Balance first’s format is designed much like a school subject to be taught to children in lesson plan form. Some of these lessons plans even include the students doing their own research on diet and exercise. Each lesson plan takes between one to three class periods meaning the total class time the program requires is between ten and twelve periods. Balance first is designed for sixth through eighth graders. This age group is often characterized by the transition from children into adults (3).

The format of balance first fails to consider several potential problems. First, the age group of the students could affect the campaign. Students in middle school tend to begin to reject the norms of the school learning format. It is a very important time for students because they are going through puberty and their beliefs about the world are beginning to solidify. They are maturing. While this may seem like a good point in the life cycle to implement a behavior change, it may not be that easy. The students in grades six through eight mature by testing authority. These include school and classroom boundaries. Students may not pay attention to the campaign as an act of rebellion against the norms of school learning. It is important for adolescents to work through this phase of maturing so instead, the campaign should be considered for a different age group. Balance first also should be used within another age group because of the activities themselves. Some activities such as the adapted activity charades game in Lesson Plan 3 could come off as a bit juvenile to middle school students. Certain activities may be more suitable for younger students such as those in elementary school.

The lesson plan setup is another problem. Students in general may not pay attention to the campaign if it is designed like a school subject. Some of the activities in the campaign like the ‘beneath the surface’ activity in Lesson Plan 3 even have the students conducting research. This creates an academic atmosphere for the campaign which may lead the students to treat it as such. They will look at it like they would a math class or English class. This causes the campaign to lose much of its effectiveness because the uniqueness is gone. The campaign also requires between seven and eleven class periods for its five lessons. Teachers may not be able to dedicate this amount of time to the campaign and there is no abridged version to fall back on. They may opt to not participate in the campaign at all rather than try to cut certain activities out themselves. The length could also cause the students to become bored with the topic as the lessons become repetitive. The campaign needs to stand out against the academic backdrop and it can’t do this by a drawn out step by step process.

Social Factors

The balance first campaign tries to include families in its campaign. At the beginning of the program, a letter is sent home to parents about the program. The letter gives facts about problems associated with poor diet and little physical activity. It also goes on to explain what the balance first campaign involves. Finally, it lists a couple of websites that parents can visit to learn more about energy balance and health decisions. Within the program, certain activities are done in a discussion or one on one format. In the third lesson plan, students pair up and discuss their diet and physical activity level. They also create diet plans for each other.

The aspects of balance first listed above leave out the issue of social factors. This is because the campaign has a large basis in the Health Belief model where a person makes decisions based on simply weighing perceived benefits against perceived barriers to behavior change (5). However, no one decides to make a behavior change in a vacuum. The people in that person’s social circle affect how they live and therefore their behavior (6). A major social group that must be considered in the balance first campaign is the family of the student. At the middle school age, young people are still greatly influenced by their parents. This is especially true with diet. For most middle school students, there is no choice when it comes to food. They eat what their parents buy them. This is why it is so important to involve the parents in the behavior change. The campaign cannot rely on the students to teach their parents why and how to change either. Balance first uses a letter sent home with the student at the beginning of the program to get its message to the parents. However the impact the letter will have is small. While the letter does give some statistics about obesity and physical activity level in America, it does not include any particular ways to change behavior. There are no diet or exercise suggestions anywhere in the letter. The only advice given is to visit two websites that have more information. The letter does not even ask the parents to discuss with their children different ways to stay healthy. Because of the lack of useful advice in the letter, most parents will disregard it and make no changes. Those who would like more information need to have an internet connection. This cannot be assumed for all families for a successful campaign. The letter should also be made available in different languages. It is currently only available in English and Spanish.

After parents have read the letter, the ones who have and then use their internet connection may learn important information and advice about diet and exercise. Regrettably, knowing what a healthy diet entails is one thing doesn’t automatically lead to implementing one. For some families, it may just not be possible. Two full time parents or a single full time parent may not have time to cook or even grocery shop. Instead, they may choose to get fast food or pizza. Other families may just not have the financial means to change the family diet. A two liter of Coke is cheaper than a gallon of milk and soft drinks hold little nutritional value. Families that are busy or in a low socio-economic class will not change their behavior because of a newsletter.

Even with a letter full of useful information, parents may not change their food buying choices. Another public health campaign for healthy eating in teens sent home family newsletters to help families change to better food choices. They found that there was not significant change in buying habits of the parents receiving newsletters (7). The family unit is hard to change with only newsletters.

Social factors also come up in the classroom teaching of the program. With many of the activities, students are expected to talk about their diet and exercise habits. This can become a problem with students who do not feel comfortable discussing their habits with peers. Students who are overweight specifically would probably participate in the discussions less than other students. However, these students would probably benefit the most from the discussions. Middle school can be especially hard for students who are different from their peers such as those who are overweight. Overweight children are often treated differently (8).

Subsequently, overweight students may fear taunting by their peers if they speak up in class to talk about what exercise means to them. The program could in fact target the overweight children itself. In one activity, students pair up and discuss how much exercise they get regularly and how much and what they eat (3). An overweight child could be judged by the other students based on what they eat. The students who are overweight may not be honest during the lessons and then as a consequence, reject the behavior change of diet and exercise. Overweight students would not get the best experience from the campaign.

Social circles greatly affect the behavior of a middle school student. Without a campaign that effectively accounts for the social factors that act on students’ decision-making, students will not actively change their habits.

Rational decisions and intention to act

The main focus of balance first is giving students information about diet and exercise. They are given information on the MyPyramid serving of food. They are given information on different forms of acceptable exercise. They are even given some information on why the balance between food intake and exercise output is important. The idea behind all of this information is that when they are given all of the information, they will make the choice to get the appropriate diet and exercise and will proceed to do it. This idea follows the Health Belief model (5). Unfortunately, this way of thinking does not take into account major aspects of the human decision making process. Rational behavior should never be assumed and the intention to change does not always amount to change.

Balance first focuses on giving students facts. Each lesson plan gives students more and more information about keeping diet and exercise in balance. This approach creates a problem though. Listing off the reasons why students should change their behavior and explaining how to change behavior does not necessarily lead to behavior. The campaign assumes that students will take the information they have on the subject and then make the decision to change or not change rationally. This does not happen in real life. Human beings do not always act rationally. Young people in particular will not rationally consider the harmful effects of heart disease to the instant gratification of fast food. Part of this is because they won’t care about health problems they will have when they are fifty. Many of the health problems associated with bad diet and little exercise take time to create. Heart disease and type II diabetes are some of the health problems related to obesity and they don’t usually occur until middle age (9). For students between the ages of twelve and fourteen, that can seem like a far off time. Young people also tend to feel invincible when it comes to health in general.

The campaign also makes another major assumption about decision-making. It trusts that once the student makes the rationalized choice to get more exercise and eat healthier, the student will then just proceed to do it. However, intention does not always lead to action. Many times, a person will decide to make a behavior change but then fails to proceed. This is just another part of human nature that should be considered for a public health campaign.

Conclusion

The balance first campaign created some considerable errors. The format of school learning is flawed because it pushes the students to associate diet and exercise with math class. It also requires too much classroom time for its lessons. The campaign also makes mistakes based on a common public health model. With little regard to social factors, the campaign follows the Health Belief model. This model also makes the mistake of assuming rational behavior and the idea that intention leads to action.

These missteps make much of the campaign ineffective for students. One option they might have considered though for most of the campaign, was the input from students. In the past, student opinions have created very effective campaigns. The Truth campaign in Florida took contributions and ideas from teens about smoking to create an effective anti-smoking ad campaign (10). Input from middle school students would have stopped the campaign from being taught to students in school subject form. They also may have come up with new ways to get the ideas of diet and exercise out to the students and families. In any case, the balance first campaign as is does not give much reassurance that our nation’s children will start becoming more healthy.

Calling for a new diet and exercise campaign

The balance first campaign contains several errors in its planning. First, the format of the campaign is not well thought out. Balance first is implemented in a middle school age setting which is a difficult age group for behavior change. It is also planned out in lengthy lessons which can be boring and too long for the students and teachers. Next, the campaign forgets to account for the social factors that affect a student’s decision making. Parents can have strong effect on behaviors of the family, and school social circles can impact a single student’s feeling and attitudes about behavior change. Finally, the campaign relies completely on rational decision making and follow through. The straight information from the campaign does not necessarily lead to health behavior change. All of these problems can be fixed by redesigning the diet and exercise campaign. The new campaign would need to take into account the format, social factors and decision making and follow through. I propose that a diet and exercise campaign should be redesigned into a one time, comprehensive, learning experience called Family Fun Night.

Family Fun Night

Family Fun Night is a one time per year, after school health fair where parents and students get together to learn more about diet and exercise. It is implemented at an early elementary school age group and focuses on engaging the parents as well as students. The program uses games and activities to teach parents and children health lifestyle activities. Different stations are set up in a school gym or other open space where the parents and children move through the activities one at a time. The stations would include a variety of challenges and activities that the parent-student teams complete. One station might have participants learn how to make some delicious but nutritious snacks. Another station might involve a jump rope tournament. Yet another might involve high school athletes demonstrating different ways to get exercise. All of the activities teach children and parents about healthy lifestyle choices regarding diet and exercise but would not use facts and statistics. Learning happens instead through direct participation in activities. Station leaders lead groups in healthy decision making but don’t push numbers and details. Emphasis is put on learning by doing. Prizes are also given out to participants for completing the activities. These will also encourage healthy lifestyles. Free admission passes to a local, public pool or coupons for healthy snacks would be given out to every participant after each station. These rewards are handed out regardless of how well a parent-student team completes a station. Winning the activity is not important. After the Family Fun Night, parents and students will have new ideas and creative ways to embrace healthy diet and exercise.

Format

The Family Fun Night addresses all of the format problems in balance first. First, the middle school age groups of sixth through eighth graders is changed to a younger audience. The middle school age group is too difficult to implement an effective behavior change campaign. Students at that age might be more set in their lifestyle choices than elementary school children. Elementary school children are very receptive to public health campaigns (11). This age group tends to be more impressionable so the campaign would be more effective. Children at this age group are also still close with their parents. Middle school age students sometimes rebel against their parents and may not want to attend a social function with them.

The other major format issue in balance first was the lengthy, lesson plans. This format would be changed to a one-time event that is after the school day has ended. This shortened time period will make the campaign more interesting for students and keep the campaign’s message in the front of the student’s mind. It will not be treated like any other school subject. The after school event is also helpful for teachers who cannot sacrifice academic time for the campaign. It requires no more classroom time than a brief announcement about the event.

Social Factors

Family Fun Night would also correct the balance first campaign’s ignorance of social factors. The fun night actually implements social networking theory. This theory explains that individuals are directly influenced in behavior change by the social networks surrounding them (12). One of the most important social networks is the immediate family of an individual. Especially for young children, parents are one of the largest influences on behavior (13) and involving them in a diet and exercise campaign can increase effectiveness (14). An example of the influence parents have on a child’s behavior is seen in the purchasing of groceries for a household. Children eat what their parents buy for them. Parents then, are entirely responsible for their young children’s diet and they must be at least partially responsible for their exercise behavior. Because of this, Family Fun Night incorporates parents into the intervention. Parents are actually a main target for the campaign. The idea is that by changing the behaviors and ideas of the parent, the child’s behavior will change also.

The campaign also tackles the social factors among peers of the student. Family Fun Night changes the way children learn about diet and exercise. There is no emphasis on direct communication between the participants. Students don’t have to talk to other students during any of the activities. In fact, the activities are designed to bolster the relationship between parent and child, not among children. The campaign is designed this way because of the effect peers can have on behaviors. Peers have been shown to affect the behavior of an individual. For example, an individual with peers who partake in a risky behavior such as smoking are more likely to partake in that risk also (15). Peers can also affect behavior change in a public health campaign. In balance first, students had to participate in discussions. For some students, this could be a very difficult task. Overweight children could be singled out by their peers for their remarks in discussions. In one study by Blote, Kint, and Westenberg (16) students with social anxiety were met with poor classroom behavior when giving an oral presentation. Students in the classroom did not respect the students with social anxiety. This kind of singling out might lead the socially anxious to not participate in classroom discussions. This example could be applied to overweight children in a discussion of diet and exercise. They may not participate in discussions where their remarks are poorly received. Family Fun Night contains less direct peer interaction. The students participate together but are not required to measure themselves against each other. In fact, Family Fun Night rewards everyone for participating which makes for a more positive environment.

Rational decision making and intention

Finally, Family Fun Night attacks two of the most common problems involved with campaigns based on the Health Belief Model (5). Rational decision making and follow through are pitfalls that the Health Belief Model automatically assumes. Since rational decision making does not work in reality, Family Fun Night instead implements marketing theory. Marketing theory pushes a good or service onto consumers by convincing them that they want or need it (17). It does this by associating the product with something people enjoy. For Family Fun Night, the name alone pushes the idea that children will have fun. The name of the campaign does not mention diet or exercise or anything health related. Elementary school students will think the campaign is actually an event dedicated to fun.

Follow through is one of the most difficult challenges in public health campaigns. Family Fun Night however, tries to promote follow through in two different ways. First, the campaign involves actual exercise and nutrition planning. Participants are already following through to a certain degree and beginning the behavior change in the intervention which may lead to better long term compliance. Family Fun Night also uses rewards that encourage follow through. Admission to a public pool or coupons used towards health foods cause the participants to follow through on the behavior change. This extra push towards the behavior change will help the participants maintain better diet and exercise.

Conclusion

Family Fun Night should be considered as an alternative to balance first. The campaign accounts for the problems that balance first failed to address. The format is changed to a shorter, more action packed event for both students and parents. Social factors regarding parents and peers are explored and then manipulated to promote easier behavior change. Several methods are finally used to convince students and parents to change behavior and follow through on that change. With all of these improvements to the campaign, students and parents will be more likely to change their diet and exercise habits.

References

1. Van Dam, R. M., Li, T., Spiegelman, D., Franco, O. H., Hu, F. B. Combined impact of lifestyle factors on mortality: prospective cohort study in US women. BMJ 2008; 337, a1440.

2. Pan, Y., Pratt, C. A. Metabolic syndrome and its association with diet and physical activity in US adolescents. Journal of American Dietetic Association 2008; 102(2): 276-286.

3. Discovery Education. Balance first: balance what you choose with how you move. Retrieved Nov 17, 2008 from http://school.discoveryeducation.com/balancefirst/

4. Jamelske, E., Bica, L. A., McCarty, D. J., Meinen, A. Preliminary finding from an evaluation of the USDA fresh fruit and vegetable program in Wisconsin schools. Wisconsin Medical Journal 2008; 107(5), 225-230.

5. Rosenstock, I. M. The health belief model and preventive health behavior. Health Education Monograph 1974; p 354-386.

6. DeFluer, M. L., & Ball-Rokeach, S. J. Socialization and theories of indirect influence (pp 203-227). In Theories of Mass Communication. White Plains, NY: Longman Inc., 1989.

7. Lytle, L. A., Kubik, M. Y., Perry, C., Story, M., Birnbaum, A. S., & Murray, D. M. Influencing healthy food choices in school and home environments: Results from the TEENS study. Preventive Medicine 2006; 43, 8-13

8. Brylinsky, J. A., & Moore, J. C. The identification of body build stereotypes in young children. Journal of Research in Personality 1994; 28(2), 170-181

9. Pleis JR, Lethbridge-Çejku M. Summary health statistics for U.S. adults:

National Health Interview Survey, 2006. National Center for Health Statistics. Vital Health Statistics 2007; 10(235).

10. Hicks, J. J. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 3-5.

11. Cardon, G. M., de Clercq, D. L., Geldhof, E. J., Verstraete, S., & de Bourdeaudhuij, I. M. Back education in elementary schoolchildren: The effects of adding a physical activity promotion program to a back care program. European Spine Journal 2007; 16(1): 125-133.

12. Wasserman, S. & Faust, K. Social Network Analysis: Methods and Applications. Cambridge: Cambridge University Press, 1994.

13. Davison, K. K. & Birch, L. L. Childhood overweight: A contextual model and recommendations for future research. Obesity reviews 2001; 2(3): 159-171.

14. Salmon, J., Booth, M. L., Phongsavan, P., Murphy, N., & Timperio, A. Promoting physical activity participation among children and adolescents. Epidemiologic reviews 2007; 29: 144-159.

15. Simons-Morton, B., Haynie, D. L., Crump, A. D., Eitel, P., & Saylor, K. E. Peer and parent influences on smoking and drinking among early adolescents. Health Education & Behavior 2001; 28(1): 95-107.

16. Blote, A. W., Kint, M. J. W., & Westenberg, P. M. Peer behavior toward socially anxious adolescents: Classroom observations. Behaviour Research and Therapy 2007; 45: 2773-2779.

17. Kotler, P & Zaltman, G. Social marketing: An approach to planned social change. J Market 1971; 35: 3-12.

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

Introduction

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

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

Self-Efficacy

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

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

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

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

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

Social Context

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

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

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

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

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

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

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

Labeling

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

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

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

Summary of BMI Report Card Failures

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

Alternate Intervention

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

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

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

How The Alternate Intervention Addresses Self -Efficacy

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

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

How The Alternate Intervention Addresses The Social Level Issues

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

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

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

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

How The Alternate Intervention Addresses Labeling

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

Conclusion

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

References

1. Ebbeling, C., Pawlak D. and Ludwig, D. “Childhood obesity: public-health crisis, common sense cure.” The Lancet. 2002; 360(9331): 473-482

2. Institute of Medicine. “Childhood Obesity in the United States: Facts and Figures.” September 2004. Retrieved 11/12/08 from http://www.iom.edu/Object.File/Master/22/606/FINALfactsandfigures2.pdf

3. Redline Susan et. al. “Risk Factors for Sleep-disordered Breathing in Children.” American Journal of Respiratory and Critical Care Medicine. May 1999; 159(5): 1527-1532

4. Hannon, Tamara S., Rao, Goutham and Arslanian , Silva A. “Childhood Obesity and Type 2 Diabetes Mellitus” Pediatrics. August 2005; 116(2): 473-480

5. Gilliland, Frank D., Berhane, Kiros, Islam, Talat, McConnell, Rob, Gauderman, W. James, Gilliland, Susan S., Avol, Edward and Peters, John M. “Obesity and the Risk of Newly Diagnosed Asthma in School-age Children.” American Journal of Epidemiology. September 2003; 158(5):406-415

6. Sun Guo, Shumei; Wu, Wei; Chumlea ,William Cameron and Roche, Alex F. “Predicting overweight and obesity in adulthood from body mass index values in childhood and adolescence.” American Journal of Clinical Nutrition. September 2002; 76(3): 653-658

7. Batty, G.D. ; Shipley, M.J.; Jarrett R.J. ; Breeze, E.; Marmot, M. G. and Smith, G Davey. “Obesity and overweight in relation to organ-specific cancer mortality in London (UK): findings from the original Whitehall study.” International Journal of Obesity. 2005; 29:1267–1274

8. Zhou, Maigeng et. al. “Body Mass Index, Blood Pressure, and Mortality From Stroke” Stroke. 2008;39:753-759

9. Scheier, L. “School health report cards attempt to address the obesity epidemic.” Journal of the American Dietetic Association. 2004; 104(3): 341-344

10. Ryan, Kevin W.; Card-Higginson, Paula; McCarthy, Suzanne G.; Justus, Michelle B. and Thompson, Joseph W. “Arkansas Fights Fat: Translating Research Into Policy To Combat Childhood And Adolescent Obesity” Health Affairs. 2006; 25(4): 992-1004

11. Wadas-Willingham V. “Six States Get ‘A’ For Work Against Kids’ Obesity.” CNN.com. Jan 31, 2007. Retrieved 11/16/08 from http://www.cnn.com/2007/HEALTH/diet.fitness/01/30/obesity.report/index.html?eref=rss_health

12. Bandura, A. “Social cognitive theory.” In R. Vasta (Ed.). Annals of child development, Six theories of child development 1989. Greenwich, CT: JAI Press: 1-60

13. Callaghan, Donna. “Health-Promoting Self-Care Behaviors, Self-Care Self-Efficacy, and Self-Care Agency” Nursing Science Quarterly. 2003; 16(3): 247-254

14. National Institute of Child Health and Human Development “Study Suggests Schools Lacking in Exercise Programs for Children.” February 10, 2003. Retrieved 11/15/08 from http://www.nichd.nih.gov/news/releases/exercise.cfm

15. Wolfe, W. S.; Campbell, C. C.; Frongillo, E. A; Haas, J.D. and Melnik, T.A. “Overweight schoolchildren in New York State: prevalence and characteristics.” American Journal of Public Health. 1994; 84(5): 807-813

16. Hochbaum GM. “Public Participation in Medical Screening Programs: A Sociopsychologican Study.” Public Health Service publication No. 572. Washington, DC: Government Printing Office; 1958.

17. Fishben M, ed. Readings in Attitude Theory and Measurement. New York: John Wiley and Sons; 1967

18. Magarey, A.M.; Daniels, L.A.; Boulton, T.J.; and Cockington, R.A. “Predicting obesity in early adulthood from childhood and parental obesity” International Journal of Obesity. 2003; 27: 505–513

19. Wasserman, S.; Faust, K. Social Network Analysis. Cambridge: Cambridge University Press; 1994

20. Christakis, Nicholas A.; and Fowler, James H. “The Spread of Obesity in a Large Social Network over 32 Years” The New England Journal of Medicine. July 2007; 357(4): 370-379

21. Ikeda JP, Crawford PB, Woodward-Lopes G. “BMI screening in schools: helpful or harmful.” Health Education Research. 2006;21:761-769

22. Rogers, EM. Diffusion of Innovation. 4th edition. New York: Free Press; 1995

23. Maslow, A. Motivation and Personality. 3^rd ed. New York: Harper; 1987

24. Evans, J. M. M.; Newton, R. W.; Ruta, D. A.; MacDonald, T. M. and Morris, A. D. ”Socio-economic status, obesity and prevalence of Type 1 and Type 2 diabetes mellitus.” Diabetic Medicine. 2000; 17(6); 478-480

25. Wang, Y. and Zhang, Q. “Are American children and adolescents of low socioeconomic status at increased risk of obesity? Changes in the association between overweight and family income between 1971 and 2002.” American Journal of Clinical Nutrition. 2006; 84: 707-716

26. McLaren, Lindsay. “Socioeconomic Status and Obesity.” Epidemiologic Reviews. 2007; 29(1):29-48

27. Whitaker, Robert C. and Orzol, Sean M. “Obesity Among US Urban Preschool Children: Relationships to Race, Ethnicity, and Socioeconomic Status” Archives of Pediatrics & Adolescent Medicine. 2006;160:578-584

28. Hedley, Alion et. al. “Prevalence of Overweight and Obesity Among US Children, Adolescents, and Adults, 1999-2002” JAMA. 2004;291:2847-2850

29. Sheslow, D.; Hassink, S.; Wallace, W.; DeLancey, E. “The relationship between self-esteem and depression in obese children” Annals of the New York Academy of Sciences. 1993; 699: 289-291

30. Weinstein RM. “Labeling theory and the attitudes of mental patients: a review.” Journal of Health and Social Behavior. 1983;24(1):70-84

31. Ackard, Dianne M. ; Neumark-Sztainer, Dianne; Story, Mary and Perry, Cheryl. “Overeating Among Adolescents: Prevalence and Associations With Weight-Related Characteristics and Psychological Health.” Pediatrics. January 2003; 111(1): 67-74

32. Kantor, Jodi. “As Obesity Fight Hits Cafeteria, Many Fear a Note From School.” New York Times. January 8, 2007. Retrieved 11/15/08 from http://query.nytimes.com/gst/fullpage.html?sec=health&res=9801E4DA1530F93BA35752C0A9619C863

33. Gortmaker SL, Must A, Perrin JM, Sobol AM, Dietz WH. “Social and economic consequences of overweight in adolescence and young adulthood.” The New England Journal of Medicine. 1993;399: 1008–12

34. Arkansas Center for Health Improvement “Assessment Of Childhood Obesity and Adolescent Obesity In Arkansas, Year Four (Fall 2006-Spring 2007)” Retrieved 11/15/08 from http://www.achi.net/current_initiatives/BMI_Info/Docs/2007/Results07/ACHI_2007_BMI_Online_State_Report.pdf