Is America Sicker or Overmedicated? The Public's Abandoment by the Health Sector—Zhandra Ferreira-Cesar

The Issue-

It is true that many drugs help people live longer and better lives. However, others may hurt patients in ways they do not know about. Everyday people place their full trust and lives in the hands of doctors, public health practitioners and pharmaceutical companies who advertise their mission to be an increase in the quality of life and the eradication of diseases. However, what happens when those same professionals whom the public trusts to educate and create the safest medications are also the same individuals who regularly treat the creation of drugs as a billion dollar industry that can be manipulated to enhance profits regardless of what this means for the population? Pharmaceutical and supplement manufacturers have to increase sales and profits, as all businesses must, and they do so in part by developing drugs to treat disease and also by convincing people they need medications to prevent disease or lessen the perceived risk of future illness. Is America sicker or just overmedicated? While the number of people with disease is not growing, the number of adult Americans taking medication is increasing. According to J. Douglas Bremner, MD 50% of Americans take prescriptions drugs and 81% take at least one pill everyday [3]. This problem can be attributed to the increase in the number of advertisements used by the pharmaceutical companies who have moved from the area of sick people, to individuals who look well but may have some genetic marker that makes them more susceptible to disease [9]. Thus the era of disease prevention starts in the medical world. At the end of the day, however, rather than increasing awareness about the key diseases affecting the public, public health practitioners have lost control of the efforts and joined in a billion dollar industry dedicated to treating people who are not sick.

Healthcare or business-

Throughout history people have regarded medical professionals as compassionate, selfless, devoted individuals who dedicate their lives to saving others. This image however has been tarnished with the latest movement to get new pills off the shelves and into the mouth of the American public. This frenzy began when government deregulation and an earnest attempt to help HIV/AIDS patients get easier access to crucial life extending drugs collided. A need for faster approval of drugs to serve patients coupled with an understaffed FDA dealt the leading hand to the pharmaceutical companies [3]. In order to speed drug patenting, the FDA had to develop a system that would provide it with the necessary funds to operate. In a response to this need, Congress passed a law mandating that pharmaceutical companies pay a fee every time a drug patent is requested in an attempt to offset the bureaucratic cost of the FDA [8]. However, this fee implementation did not obtain the necessary funds, and thus the funding for surveillance and research of approved drugs was drastically diminished. This initial budget cut initiated the snowballing effect of a hungry industry to make money and forget the focus of its initial humanitarian purpose—the well being of individuals [3].

Another interesting event came as a result of the change in law: the limits and boundaries between pharmaceutical companies, the FDA, and doctors became increasingly vague. In some cases, individuals that worked for the FDA acquired jobs with drug companies; therefore making their relationships with the FDA a major priority for the success of their careers [3]. These same FDA officials who approve a drug are also in charge of monitoring it after it enters the market, which means that these people have no incentives to admit an error and say that the drugs that they previously categorized as safe are now unsafe, even if it means that those patients making use of these drugs may be at risk [2]. Finally, it is noteworthy to mention that the FDA gets most of its input from a panel of doctors who are experts in their fields [8]. However, it is not accurate to say that these doctors are unbiased when analyzing the data presented to them since most of these doctors receive payment as consultants, or are given research grants and support for travel to conferences from drug companies [1]. All these incentives deter physicians from fully acknowledging all side effects of the drugs being presented for approval, thus increasing the chances that they will be patented and reach the public to cause harm and leave behind catastrophic death rates, like the arthritis medication Vioxx did by increasing the incidence of heart disease [3]. The cooperation between the FDA, drug companies, and doctors therefore, actually presents itself as a conflict of interest that completely disregards the initial job of the healthcare system, which is to care for, treat and educate individuals about pertinent health issues [4].

Take for example, USA Today reported on October 16th, 2004 in the article “Cholesterol Guidelines Become a Morality Play” that nine of the doctors that sat on the committee for the production of cholesterol guidelines were also making money from the companies that developed drugs to lower cholesterol, which were urging Americans to take these drugs via the media [3]. This exemplifies the heavy influence that drug companies have upon physicians, which leads to the conclusion that not even family physicians have the power to control the treatment for their patients. Ultimately, the drug companies have the power to dictate which drugs are being consumed and which diseases will emerge by means of carefully framing and delivering their desired message through the media. This is mainly because only so much information reaches physicians, and the information that does reach doctors is carefully selected and presented as the ultimate truth in the medical world [12]. Dr. Curt D. Furberg, a former head of clinical trials at the National Heart, Lung and Blood Institute describes the way in which information reaches physicians as published on the Los Angeles Times on December 22nd, 2004, “The National Institutes of Health: Public Servant or Private Marketer?” saying, “The company reps tell the doctors,’ you should follow these guidelines’ implying that you’re not a good doctor if you don’t follow these guidelines” [9].

One point that should be made on behalf of the doctors, however, is that these physicians do not have the time to be reading every journal and study that is released. Thus, it is only natural that they place their trust in the drug companies who claim to have the same interests as they do [6]. This is clearly not true as pharmaceutical companies often ignore obvious signs that a drug is failing in order to make extra earning regardless of how many individuals are being affected.

The media and pharmaceutical companies-

People have inherent trust in medical professionals due to the social acceptance and glorification that has been established over time. Surveys conducted of the general population show that Americans trust pharmaceutical companies to advertise the adequate and proper information regarding the side effects of drugs and their advantages [2]. However, is the purpose of drug advertisement really to increase awareness and educate the mass public about the positive and negative effects of new drugs or is their main purpose to make profits?

The first clue that the pharmaceutical market has turned its back on the sick population is displayed in the creation and expansion of a new market that is composed of healthy individuals as the target for preventive medicine, which has become a multibillion-dollar business. In order to promote this market shift, pharmaceutical companies have initiated educational programs, which they claim are meant to identify those individuals who are at risk of developing the targeted conditions. Some examples of these are hypertension, heart disease, and osteoporosis [11]. These programs are usually put on by making large donations to the organizations that research and support the various diseases, and in return these organizations “spread the word” about these newly invented drugs that promise to prevent undiagnosed and underdeveloped diseases [2]. This increases awareness and the number of screenings and with that also the number of individuals who can potentially take the medication. This is fine for individuals who have not been diagnosed with high blood pressure or for those at the early stages of cancer; however, these campaigns are not created to be completely altruistic and educational. Most of these campaigns are directly linked to the pharmaceutical companies’ media campaigns, whose only intentions are to convince the average American that they need a pill to prevent any possible disease [8].

Another factor that has increased the use of prescription drugs in America took place in 1997 when the FDA lifted the ban on direct consumer advertising. In addition, the law that requires every possible side effect to be listed was also removed [3]. The effect of this change is displayed strongly on the various television advertisements that target the emotional state of viewers rather than identifying the problem and effect of the drugs being advertised. This change in legislation allowed drug companies to attack Americans with a mass amount of media and news telling Americans to go and “ask [their] doctor for a specific drug [8]. In fact, America is the only country where you can turn on the TV, open the newspaper or a magazine and be told to go ask your doctor for a specific drug and brand [6]. However, what is more alarming is that doctors will prescribe medications to their patients if they ask for them even if they do not entirely need it. Dr. Marcia Angell author of “The Truth about Drug Companies” says that studies show that 54% of the time physicians will prescribe a brand of medication if the patient asks for it [3].

The prime example of this medical fraud that has let America down and destroyed the public’s trust involves ADHD medications. The creation of ADHD as a disease is one example of a series of conditions that has given the pharmaceutical companies an open door into the market of healthy people to promote long-term drug consumption [2]. The media has emphasized ADHD as a serious behavioral disorder that must be controlled with medication. However, it has failed to inform the public that in fact there is very little known about ADHD aside from the very broad hyperactive behavior, which many argue is just a characteristic of childhood [10]. Therefore, rather than informing the public of the serious side effects of ADHD medications, which some doctors have compared to the effects of cocaine, the drug companies, physicians, and public health practitioners have increased the use of ADHD medication by 369% in the past three years [9]. In the case of ADHD medication, rather than increasing awareness of the disease and promoting various modes of treatment, health professionals have increased drug use among American youth [12]. Rather than improving their quality of life, the use of ADHD medications has added a new dimension to their lives, which includes increased social isolation and cognitive toxicity [1]. Cognitive toxicity refers to the power of drugs to superficially create focus and increase simple analysis, while inhibiting more complex cognitive behavior and function [10]. Side effects such as these and the rapid increase of youth drug use are clear evidence that the alternative model of advertising and marketing, in the case of drug treatment awareness has failed, and rather than aiding American society it has opened the doors to a lucrative industry that is more interested in making money than helping the public [4].

The drug deregulations and the obvious favoring that occurs on behalf of the drug companies by removing the educational component of advertising campaigns leaves people wondering if in fact the well being of society is the priority of the FDA. It is obvious however that what lies at the top of the priority list for the FDA includes the protection of profit for pharmaceutical companies.

Modern medicine and American society:

Culture has a lot to do with the effectiveness of the various advertising attempts made by the business sector. In essence, the media cannot succeed if they do not know the beliefs and customs of the target population. However, what is even more complicated is that these beliefs and sentiments are often established by the media themselves and just accepted and adopted by society [8]. This leads one to the conclusion: that in order to increase awareness and establish a desired pattern of behavior, the media is the right means by which to do this [3]. It is clear that health practitioners have already discovered this, and as a result of this also discovered the tremendous opportunity to make money at the expense of people’s trust and health.

Health practitioners constantly express their regard and concern for the health of Americans; however, if these are genuine then the question persists—why is America still sick? There is no doubt that America has a prescription drug problem. The United States spends twice as much money on drugs and intakes twice as many drugs than other countries and yet still continues to have worse health than other industrialized countries [5].

It is no accident that throughout time America has become obsessed with health and the infinite number of pills available to cure so-called diseases. The purpose here is not to discredit all medications, or to say that drugs do not ever successfully treat diseases. However, the fact of the matter is that the health field has lost perspective of their mission and become greedy. John Abramson, M.D. author of Overdosed America: The broken Promise of American Medicine explains that America is pouring money into expensive drugs and outrageous medical devices, and in the process has left behind the best type of preventive treatment, which includes diet modification and exercise [3]. In order to refocus and alter the current beliefs of society, there needs to be a massive media movement that will push America away from the medication frenzy that has driven this society to the overconsumption and long-term addiction to the various drugs created by the industry that claims to have the public’s interest in mind.

Implications for the public health field-

Public health practitioners have as their focus and goal to improve the physical, mental and social health of Americans. As a result of this, they have joined with the various groups on the medical field to increase awareness and health screenings across America. However, this cooperation with medical sectors such as pharmaceutical companies has proclaimed this mission of awareness and goals of better health and opportunities as a failure.

Detox for an Overmedicated America-

Health professionals have throughout time been given the responsibility of taking care of the welfare of the public. This trust has been given without any hesitation and with the full confidence that these well-intentioned and trained individuals possess the ability, moral and ethical obligation to improve the overall health of the public. However, it is clear that they have failed to reach their publicized goal of educating and increasing awareness of the most common diseases attacking the American public and the prescription drugs available for use. Instead they have created a multibillion-dollar industry that survives and flourishes rapidly at the expense of the American people’s trust and health. It is clear that the health professionals’ attempt at increasing awareness and educating the public regarding the various health threats attacking them have been a complete failure that has resulted in an overmedicated America that finds relief and comfort in the hands of pharmaceutical companies. Therefore, the means by which the field initiated intervention to increase awareness and education need to be reevaluated and reinvented so that the goal of helping the public can be refocused and accomplished. The reinvention of the initial efforts to increase awareness on medical screening and the threats common diseases pose upon people must include the cooperation of government agencies, the education department, health professionals and the media.

The initial step that needs to be taken in order to achieve the initial goal of increasing awareness and education regarding disease prevention involves the government of the United States of America. This government was founded with the idea that it is “a government by the people for the people.” This statement, however, does not seem to be supported any longer as government organizations such as the FDA, seem to love the profit being generated by direct-to-consumer advertising so much that they have made it even easier for the drug companies to advertise their products by not requiring that all side effects be listed during commercials and by being able to run direct ads through the television and printed news scripts [5]. Therefore, it is time that the FDA rearranges its priorities and puts the welfare of people at the top rather than pharmaceutical profits. It is crucial that limits are set for these companies and that rather than advertising a brand by invoking overall positive emotions, their true effects and ability to help individuals is advertised [12]. The introduction of a new set of advertising guidelines put forth by the FDA for pharmaceutical companies will then reverse the standing effect of simply selling drugs for profit to a more focused idea that involves helping the public understand the proper use of prescription drugs and their side effects and other potential risks.

The next step to the successful intervention on the use of prescription drugs and their potential side effects involves the full cooperation of health professionals at all levels. The problem of overmedicating in America is due to the notion that a pill can solve every symptom of discomfort. This erroneous belief needs to be fixed at its root and this can only be accomplished by encouraging all health professionals to start taking the time with their patients to explain alternative preventive methods, such as an increase in exercise and a change in diet, in order to prevent a large majority of these diseases such as hypertension and diabetes that are affecting the American public at alarming rates [4]. In addition, physicians need to be reminded that their number one priority is the well being of people and that as public servants they must first and foremost fulfill this duty. If these physicians do no fulfill their duty they are in fact violating their medical oath and ought to be reminded of their priority. However, it would be illogical to place the responsibility of changing existing social trends entirely on physicians. Therefore, public health practitioners must also reassess the techniques being used to alter existing destructive behaviors and societal beliefs. In order to accomplish a successful intervention, it is crucial that they work in cooperation with physicians and social workers in order to introduce this new way of thinking into mainstream America and to assure that it is accepted and implemented at all societal levels. Once health professionals at all levels have reached a consensus on the best and most efficient way to educate and implement alternatives methods of preventive medicine, they can then take a step forward in an attempt to reverse the negative effects that a media-drug-driven America have had on its members.

Once the missions of the FDA, health professionals and pharmaceutical companies have been reevaluated and focused, an effective intervention should work to target and teach educators the importance of a balanced diet and exercise. In addition, teachers should be asked to join the team and provided with the necessary and proper diagnostic and observational tools that can help them to accurately distinguish a child that is in fact suffering from a behavioral disorder from one that is just simply acting according to their age. Such important and convenient tools can drastically reduce the number of misdiagnosed ADHD cases, a disorder that has claimed millions of children as slaves of Ritalin [1]. This addition to the education department has the ability to reset the American standards of medical treatment and therefore raise a generation that is not drug dependent and that amidst this fast progressing society is able to find health by means of the traditional treatment of a healthy lifestyle, awareness, education and alternative methods of preventive medicine. Even though a new method of treatment and means of implementation can be designed and deemed appropriate and ethical, in the 21st century whatever intervention designed will not be successful if the most powerful form of introduction and acceptance of new ideas in this society is not brought aboard to cooperate and make this issue the utmost important matter affecting the nation currently

The problem of overmedicating in America already exists and abolishing this already accepted way of thinking is one of the hardest goals to accomplish. Regardless of how well teachers and doctors are trained to teach and advertise the importance of understanding the use of prescription drugs and alternative methods of preventive medicine, the bottom line is that America is a society of consumers that relies on the media to be told what is ok to do, what it is that one needs, and the various things one should purchase. It is because of this that the number one factor that could help save America from overdosing is ironically the same instrument that brought it to the alarming high consumption of drugs at which it stands today. In order to reverse the beliefs of this industrialized society in addition to the full cooperation of government, medical professionals and educators, the ultimate intervention to limit the use of unnecessary drugs in America and the development of preventable diseases can only be successful if the media places this issue at the top of its agenda. They, in addition, must award the time, framing and present it with a degree of urgency that deserves to be spoken about daily until the American public realizes that a change in lifestyle and their current medical treatment options need to be changed. Furthermore, the prioritization of this issue by the media should also teach Americans to seek other options other than the easy way out and attempt to treat their various symptoms at the root rather than superficially with the use of pharmaceutical medications.

After educating the different levels of professionals regarding the changes that must be made in order to bring the alarming use of drugs in America to a halt, an advertising plan needs to be created in order to change the awareness, knowledge, and attitude of consumers towards a specific change being discussed. These changes take place all throughout the buying, a decision-making pattern that results in a change of behavior and standard beliefs. The first step in this intervention would involve the introduction of awareness. Past interventions have shown that the simple introduction of the importance of exercise and a balanced diet is not successful due to their lack of understanding of the average American lifestyle, which is fast paced and constantly being bombarded by economic hardships. Therefore, it is imperative that this campaign works to show first the alarming effects of overmedicating and the detrimental effects it can have on any one person. Once the negative aspects and acknowledgement of the problem is introduced the intervention moves into the next stage of consideration. In order for consideration to occur a solution to this alarming problem must be introduced with careful consideration of the various social and environmental factors that are affecting Americans today. It is at this point that the intervention seeks to make a connection with the consumer. Highlighting the costs of the various unnecessary medications being consumed and the money that pharmaceutical companies are wasting on advertising rather than investing on research are truly affecting the American society and the world can help make this connection. This approach on the economic effect is sure to receive attention especially due to the economic hardships that America is confronting today. It is at this point that alternative “cheaper” methods of preventive medicine can be introduced and the name of health professionals advertised as large pools of information at the disposal of the public.

The third stage of this intervention involves reaffirmation. At this stage of the advertising campaign the public reassesses the product or idea being introduced and attempts to find a place for it in their lives thus determining how convenient and appropriate it is for them. It is at this point that the importance of paying a visit to their physician is important and that a change in lifestyle that is characterized by an increase in exercise and a balanced diet can be stressed. However, the stress placed on these changes should be made in a different manner than in the past. They should be marketed with alternatives methods such as the addition of easy enjoyable exercises that can be done at home or outside or even ones that can be integrated during the workday. In an effort to obtain and retain a large audience these changes that need to be made must be attached with the idea that consumers will be saving money when opting for this option rather than spending thousands of dollars on unnecessary medications. This approach will certainly catch the attention of consumers during this time of recession.

The last couple of stages of this intervention all happen quite quickly as action tends to take place once the behavior is introduced enough times into the life of the individuals targeted. This is then reinforced by the constant repetition of the issue and its recommended solutions by the media who use the trusted physicians and other health care professionals in order to submit the desired behavior as a social standard and therefore into mainstream culture [12].

In conclusion the intervention used in order to assess the overmedicating problem in America needs to start with the cooperation from all levels of the health sector in this country. Once this cooperation has been reached, an advertising campaign displaying the negative effects of overmedicating and the various affordable solutions available to avoid future spending due to unnecessary problems can be used to grab the attention of an America that is overwhelmingly concerned with the ongoing recession.

References:

1-Are Children being given too many Drugs? Norwich Evening News 24, August 2006.

2-Bergin, Sue 2005. Stoning Young America: Over Prescribing Harmful Stimulants as a Treatment for Children with ADHD. Brigham Young University.

3-Bremner, Douglas J. 2006. Why do Americans take so many Prescription Drugs? Prescription drugs Review.

4-Healy, Melissa 2007. The Push to label many drugs isn’t well studied in children Revise standards, critics say. Los Angeles Times, Health.

5- Jensen, Peter S. MD; Kettle, Lori BS; R, Margeret T. MS; Sloan, Michael T. BA; Dulcan, Mina K. MD; Hoven, Cristina Dr PH; Bird, Hector. MD; Bauermeister, Jose J. PhD; Payne, Jennifer D, 1999. Are Stimulants Overprescribed? Treatment of ADHD in Four U.S. Communities. Child and Adolescent Psychiatry.

6-National Center for Health Statistics and Centers for Disease Control and Prevention. Health, United States, 2007. Department of Health and Human Services.

7-Null, Gary, PhD; Dean, Carolyn MD, ND; and Feldman, Martin, MD. 2006. Overmedication Seniors. LE Magazine.

8-Overmedicating of America. CBS News, Health. 2000.

9-Rados, Carol. 2004. Truth in Advertising: Rx Drug Ads Come of Age. FDA Consumer Magazine.

10-Rowland, Rhonda 2001. Ritalin Debate: Are we Over-medicating? CNN Health, CNN Medical Unit.

11-Salaman, Maureen Kennedy 2006. The Medicating of America. National Health Federation News.

12- Sighn, Llina, 2004. Doing their jobs: mothering with Ritalin in a culture of mother-blame. Faculty of Social and Political Sciences, Center for Family Research, University of Cambridge, Cambridge, UK.

13-Standish, Maude, 2008. Too many drugs? American Academy of Pediatrics News. Vol. 29 No. 9, p. 28.

14-Too many Drugs “Not Child Tested.” BBC News, Health. 2006.

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

Introduction

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

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

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

“Fat Chance!” Fat chance of losing weight?

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

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

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

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

Are some of the options really safe or feasible?

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

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

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

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

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

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

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

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

Introduction

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

Intervention

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

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

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

Self-efficacy and positive reinforcement

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

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

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

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

Safe environment and non-competitive group activities

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

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

Adressing availability and affordability

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

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

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

Conclusion

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

Conclusion:

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

References:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Shifting the Paradigm to No Where: How the American College Health Association Failed Primary Prevention – Erin Williston

United States college students are increasingly threatened with violence on campus. One of the most pervasive forms of violence happens in a place students rarely anticipate. National studies have consistently found approximately 32% of college students experience domestic/ relationship violence (1). The overwhelming prevalence of violence against women on college campuses is well documented nationally. Women ages 16-24 are at the highest risk for rape and other forms of intimate partner violence (2). While the statistics are omnipresent, higher education has neglected to set their sights higher than simply responding to incidents of violence, a form of public health called tertiary prevention.

In April 2007, the American College Health Association stepped out with their, “Position Statement on Preventing Sexual Violence on College and University Campuses”. What followed was a document with a mission to “provide facts, ideas, strategies, conversation starters and resources to everyone on campus who cares about prevention of sexual violence” – the ACHA toolkit, Shifting the Paradigm: Primary Prevention of Sexual Violence. Primary prevention is a public health approach using environmental and system-level strategies, policies, and actions that prevent sexual violence from initially occurring. The problem with Shifting the Paradigm surrounds not its idea to use primary prevention to address the issue – but in the theories and interventions it encourages its audience to use. The interventions presented are deficient, archaic, and fail to speak the language of higher education as an organization.

Promoting a Deficient Tool – Opening Pandora’s Box

Shifting the Paradigm authors encourage screening for sexual violence in college health and wellness services. This tool could help identify survivors of sexual assault, provide client centered services in the health care setting and encourage reporting. While screening is widely debated and mildly supported in medical-based literature, it is not primary prevention (11).

What is most interesting in this proposed intervention is the missing critical piece. There is no mention on training medical care providers to ask the questions proposed in this intervention! There isn’t even an analysis of student health centers and their ability to train and implement an effective screening tool. The classic study Opening Pandora’s Box helps explain why it is vital to deliver training to providers who will implement these screening tools.

An analysis of interviews with physicians found exploring domestic violence in the clinical setting analogous to "opening Pandora's box." Their issues included lack of comfort, fear of offending, powerlessness, loss of control, and time constraints. This study revealed several barriers that physicians perceived as preventing them from comfortably intervening with domestic violence victims. These issues need to be addressed in training programs (3).

Student health centers are not equipped to respond to the answers these questions will bring. Questions such as:

• “Has someone ever touched you in a sexual manner against your will or without your consent?”
• “Have you ever recognized you had ‘unwanted’ sex while drunk or using drugs?”
• “Do you feel that you have control over your sexual relationships and your partner will respect your wishes if you say no to specific sexual activities?”

These questions don’t fit in to the 15 minute appointment providers have with students in a clinical setting; especially if the training or programs to support these questions doesn’t exist (3). Shifting the Paradigm misses the mark by calling this primary prevention and proposing it without mention of proper training for providers.

Revisiting Individual Models

Shifting the Paradigm makes several attempts to provide tangible primary prevention exercises for college health educators to use with their students. One of the first interventions is “[to] facilitate conversations about sex that focus on individual choices along the continuum of sexual activity… [to] identify and popularize healthy sexuality that respects gender, sexual orientation, and gender identity.” Another intervention encourages educators to distribute “10 ways young men can prevent sexual violence” to fraternities and other male dominated organizations on campus.

These are both classic examples of the Health Belief Model – an individualized public health model that assumes no social interaction, and demands rational behavior (4-5). This model and proposed intervention fails to understand one important issue in human behavior: people are not rational; they do not make decisions in silos and are easily influenced by unconscious factors.

Dan Ariely helps make this clear in his book Predictably Irrational: The Hidden Forces That Shape Our Decisions. Dr. Ariely conducted a study with Berkeley undergraduate students who underwent a variety of sessions in different orders answering questions about sexual and moral decisions. In one session students predicted their sexual and moral decisions while in a cold, dispassionate state. In another, they did the same but while in a hot, aroused state.

“In every case, our bright young participants answered the questions very differently when they were aroused from when they were in a ‘cold’ state….when participants were aroused they predicted that their desire to engage in a variety of somewhat odd sexual activities would be nearly twice as high as they had predicted when they were ‘cold’.” (6)

The results go on to demonstrate how in a cold, rational state, the men involved in this study respected women. They thought they understood themselves, their preferences and what actions they were capable of. These men, like many young college students, underestimated their reactions to arousal and the outside environment. It does not make these participants social deviants; it proves that human behavior is irrational.

This study is critical to understanding that college students do not make decisions in a vacuum; they are highly influenced in their vulnerable state of transition from high school to higher education. While Shifting the Paradigm encourages discussion about respecting gender and being aware of pop-cultures messages, the reality is college students are having good, bad and ugly sex without the influence of these conversations in the bedroom.

Could We Get a Little Buy In?

Contributing authors to Shifting the Paradigm express their hopes for primary prevention in the preface: “[primary prevention] must reach the same level of efficacy and adoptions as programs that respond to its consequences.”

Shifting the Paradigm authors makes 2 assumptions with this statement: 1. it assumes the reader is on a campus that is effectively responding to consequences of violence and 2. The reader understands the levels of public health prevention and the concept of moving upstream. These are erroneous assumptions considering many campuses are failing to make the basic responses to victimization work on campus. According to a 2005 National Institute of Justice report, of the nations institutions of higher education less than half listed a contact phone number for students who have been sexually assaulted that was accessible after “normal” business hours – when most assaults happen (7).

This demonstrates the lack of understanding Shifting the Paradigm authors have in regard to higher education organizations. If the authors had followed organizational development theory, they would have understood that one of the keys to mobilizing an organization is to know your community priorities. For example, by pairing a health issue with other priority issues you can maximize the potential for community action (8).

Shifting the Paradigm fails to speak the language of higher education and answer the questions critical to administrators in the organization. Administrators hold the keys to what college health professionals need – support from the institution: both financially and politically. Why should higher education administration care about sexual violence? How does it impact the organization and the students we serve? How much money will it save us if we invest in these programs? College health educators need to make the connection between health and academic success in order to speak the language of our stakeholders (9). Without this connection, administrators will fail to see the value in sexual violence prevention.

Moving Past Shifting the Paradigm

The authors and consultants for the ACHA toolkit neglected to produce a sound document for their intended audience. They sent out a grab bag of deficient, archaic and inconsistent tools for overburdened campus professionals to toss out at the end of the day. It is unfortunate that this opportunity to speak to higher education about primary prevention was wasted with the promotion of such tools as “discussion starters” and “screening interventions”. The lack of outcry from ACHA members isn’t surprising; many of them lost value in the document before reading it. In an effort to move forward and adopt a primary prevention approach to sexual violence, new theories must be brought to the table.

Smedley and Syme explain in their article Promoting Health: Intervention Strategies from Social and Behavioral Research, “It is unreasonable to expect that people will change their behavior easily when so many forces in the social, cultural and physical environment conspire against such change.” Smedley and Syme, along with many others in this field support the need for a social and behavioral approach to violence prevention (6,12-18). Shifting the Paradigm could benefit from considering two specific social science theories: Organizational Development (OD) and Fostering Healthy Norms (Norming) (8, 16-18, 20-21,). The finale of this post will provide empirical data and examples in support of using OD and Norming to address primary prevention of sexual violence on a college campus. It is vital to know these methods lend themselves concurrently however; creating an environment open to change from the top down should be the first step.

Stimulating Change

Community mobilization around a specific issue can be challenging. It requires much from the agent of change in order to move an organization toward a new behavior (16). ACHA members fit into the role of ‘agent of change’ and learning to speak the same language is a gateway to common ground. ACHA members would benefit by cultivating relationships with professional leaders on campus; one great approach is to appeal to the individual’s self-interest, showing how their participation in your cause can aid in achieving their own goals and objectives (23). Utilizing OD theory to foster shared goals and motivation among members of the institution will aid in the change process (16-18). Organizational Development theory encourages community and organizational change while taking into account the culture, organizational climate and capacity (16). Systematizing an institutional change utilizing the culture, climate and capacity is critical to avoid simply replicating what other schools do without evidence of an effective intervention.

To mobilize an institution to address sexual violence through primary prevention, three key issues should be addressed (17).

1. Define the community: Develop an understanding of the chain of command within the institution. Set up individual interviews with key players and learn who the movers and shakers behind decisions made on campus might be.
2. Assess and work with the community’s capacity for mobilization: Are their experienced professionals on campus who are researching or addressing sexual violence currently? What is the history of task forces or committees to address sexual violence appointed by upper administration? Look for current action within the institution and work with those players to assess the ability to move upstream in addressing sexual violence.
3. Understand the community agenda and select the right issue: ACHA members should look at the mission of the institution and assess how sexual violence might impact that mission. This could be done by reviewing national and local data regarding sexual violence. Sources may include the ACHA National College Health Assessment, Jeanne Clery Act Reports, local police and prosecutor’s office data and qualitative data from local organizations that work in the area of sexual violence. The impact sexual violence has on matriculation, retention, and graduation could be a critical piece of information for upper administration. Successfully selling primary prevention of sexual violence can be achieved if you pair the institution’s goals and objectives with your topic area goals and objectives.

Fostering Healthy Norms

There are 5 damaging norms that impact attitudes and beliefs about sexual violence (12). These norms are:

1. Women: limited roles for and objectification and oppression of women

2. Power: value placed on claiming and maintaining power (manifested in power over)

3. Violence: tolerance of aggression and attribution of blame to victims

4. Masculinity: traditional constructs of manhood, including domination, control and risk-taking

5. Privacy: notions of individual and family privacy that foster secrecy and silence.

ACHA members can address these norms by strategically promoting normalizing messages about positive female roles, egalitarian relationships, men standing up to aggression, downplaying negative risk-taking, and engaging citizens. The social norms approach provides tools for increasing perceived support to take action to address health and violence behaviors (20). The key is to create and sustain healthy norms within the institution and surrounding community (12).

We know that one of the critical places students’ receive and trust messages is from health care providers (26). A mandatory training with continuing education credit for all health care professionals on campus (in the student health center and otherwise) could help foster norms at an individual level. This curriculum would consist of trust building, using positive sexuality language and sharing healthy relationship guidance in a clinical setting (12-13). Providers would be expected to use the tools learned in this curriculum with patients to build trust and promote the health center as a safe, positive place to receive information and services. In order to implement this type of care, health care providers will need more time with patients. A critical role for ACHA members will be advocating for longer visits with providers and promoting efficiency in scheduling visits (3, 12).

The second component to this ‘Fostering Healthy Norms’ approach is to develop a marketing campaign that is interactive and promotes positive environmental change. Studies suggest that the social norms approach to sexual assault prevention is a promising practice that is worthy of further attention and research to determine its effectiveness (20). For example, at James Madison University a campaign designed to change men’s intimate behavior towards women was implemented. Data demonstrated significant increase in the percentage of men who indicated “stop the first time a date says no to sexual activity” and a significant decrease in the percentage of men who said “when I want to touch someone sexually, I try and see how they react.” (20). Other campaigns have demonstrated similar findings, making social norms marketing campaigns a promising practice in prevention of sexual violence.

No Substitute for Planning

The American College Health Association’s toolkit, Shifting the Paradigm: Primary Prevention of Sexual Violence would be a greater resource if the role of health and its impact in higher education was all ready established. However, without this critical collaboration, no campus is ready to implement tools that have not been grounded in research. The interventions fail to speak the language of higher education as an organization or foster change in the current climate.

In an effort to design a replicable toolkit, ACHA would have done well to offer planning and evaluation tools for primary prevention of sexual violence on college campuses. Saltz and DeJong’s comment in ‘In Reducing Alcohol Problems on Campus: A Guide to Planning and Evaluation’, “Simply replicating what other schools are doing is not a substitute for sound planning.” Utilizing Organizational Development theory to stimulate change from the top down, followed by a comprehensive implementation of Fostering Healthy Norms allows flexibility to accommodate the institution’s individuality and take research to practice.

References

1. Feminist Majority Foundation. Violence Against Women on College Campuses. 2005

2. Gross A.M., Winslett A., Roberts M., and Gohm C.L. An Examination of Sexual Violence Against College Women. Violence Against Women 2006; 12(3): 288.
3. Sugg NK, Inui T. Primary care physicians' response to domestic violence. Opening Pandora's Box. JAMA 1992; 267(23):3157-60.
4. Becker MH, ed. The health belief model and personal health behavior. Health Educ Monogr 1974; 2: Entire issue.

5. Janz NK, Becker MH. The health belief model: a decade later. Health Educ Q 1984; 11(1): 1-47

6. Ariely, D. The Influence of Arousal (pp. 89-108). In: Ariely, D. Predictably Irrational: The Hidden Forces That Shape Our Decisions. Harper Collins 2008

7. Kariane H.M., Fisher B. S., Cullen F. T. Sexual Assault on Campus: What Colleges and Universities Are Doing About It, U.S. Department of Justice Office of Justice Programs, December 2005, National Institute of Justice www.ojp.usdoj.gov/nij

8. Cummings, Worley. Organization Development and Change, 6^th ed. Boston, MA: South-Western; 1997

9. McNeil M., Grizzel J. Linking Student Health with Academic Success: American College Health Association Annual Meeting 2006.

10. American College Health Association. Shifting the Paradigm: Primary Prevention of Sexual Violence. www.acha.org/SexualViolence August 2008

11. PREVENT Program at University of North Carolina Injury Prevention Research Center. Prevent Provider Toolkit Module 1. January 2007

12. Davis R., Fujie-Parks L., Cohen L. Sexual Violence and the Spectrum of Prevention: Towards a Community Solution. National Sexual Violence Resource Center 2006.

13. Cohen L, Swift S. The spectrum of prevention: developing a comprehensive approach to injury prevention. Inj Prev. 1999; 5:203-207.

14. Smedley BD, Syme SL, A social environmental approach to health and health interventions. In: Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, D.C. National Academy Press 2000:4.

15. Banyard, V.L.; Plante, E.; and Moynihan, M. M. Bystander Education: Bringing a Broader Community Perspective to Sexual Violence Prevention. Journal of Community Psychology 2004 32: 61-79.

16. Steckler A., Goodman RM, Kogler MC. Mobilizing organizations for health enhancement: theories of organizational change. In: Glanz K, Rimer BK, Lewis FM, eds. Health Behavior and Health Education: Theory, Research and Practice, 3^rd ed. San Francisco, CA: Jossey-Bass; 2002.

17. Freire P. Pedagogy of the Oppressed. New York: Seabury Press; 1970.
18. Wendell L French; Cecil Bell (1973). Organization development: behavioral science interventions for organization improvement. Englewood Cliffs, N.J.: Prentice-Hall. chapter 8.
19. 
    
20. Berkowitz, A. Fostering Healthy Norms to Prevent Violence and Abuse: The Social Norms Approach. Preventing Sexual Violence and Exploitation: A Sourcebook. Wood and Barnes Publishers, 2007.

21. Berkowitz, A.; Jaffe, P.; Peacock, D.; Rosenbluth, B.; and Sousa, C. Young Men as Allies in Preventing Violence and Abuse: Building Effective Partnerships with Schools. San Francisco: The Family Violence Prevention Fund, undated. http://new.vawnet.org/Assoc_Files_VAWnet/YoungMenAllies.pdf

22. Morrison, S.; Hardison, J.; Anita Mathew, A.; and O’Neil, J. An Evidence-Based Review of Sexual Assault Preventive Intervention Programs. Research Triangle Park, N.C.: RTI International, 2004. http://www.ncjrs.gov/pdffiles1/nij/grants/207262.pdf

23. Langford L., DeJong W., Strategic Planning for Prevention Professionals on Campus, U.S. Department of Education, Office of Safe and Drug-Free Schools, Higher Education Center for Alcohol and Other Drug Abuse and Violence Prevention, Washington, D.C., 2008.

24. Bachar, K.J., and Koss, M.P. From Prevalence to Prevention: Closing the Gap Between What We Know About Rape and What We Do. In: Renzetti, C. M.; Bergen R. K.; and Edelson, J. L. eds Sourcebook on Violence Against Women, Thousand Oaks, Calif.: Sage Publications 2000.

25. Bartholomew, L.K.; Parcel, G.S.; Kok, G; and Gottlieb, N.H. Planning Health Promotion Programs: An Intervention Mapping Approach. 2^nd ed. San Francisco: Jossey-Bass, 2006.

26. American College Health Association. Publications and Reports. Baltimore, MD: American College Health Association. http://www.acha-ncha.org/pubs_rpts.html

27. Population Council. Yaari Dosti: A Training Manual. New Delhi, India. Population Council. , 2006.

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

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


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
















REFERENCES
1. Active Living Research. (2007). Active education: Physical education, physical activity and academic performance. [Electronic version.] Retrieved December 3, 2008, from http://www.activelivingresearch.org/alr/alr/files/Active_Ed.pdf
2. Adams, J. L., Escarce, J. J., Freedman, V. A., Kapur, K., Rogowski, J. A., & Wickstrom, S. L. (2004). Socioeconomic status and medical care expenditures in medicare and managed care. Retrieved November 16, 2008, from http://www.rand.org/pubs/working_papers/2005/RAND_WR216.pdf
3. Berenson, G. S., Dietz, W. H., Freedman, D. S., Mei, Z., & Srinivasan, S. R. (2007). Cardiovascular risk factors and excess adiposity among overweight children and adolescents: The bogalusa heart study. Journal of Pediatrics. 150(1).
4. Borsboom, G. J. J. M., Bosma, H., Dike van de Mheen, H., & Mackenbach, J. P. (2001). Neighborhood socioeconomic status and all-cause mortality. American Journal of Epidemiology, 153 (4). [Electronic version]. Retrieved November 18, 2008, from http://aje.oxfordjournals.org/cgi/content/full/153/4/363?maxtoshow=&HITS= 0&hits=&RESULTFORMAT=&fulltext=Neighborhood+socioeconomic+status+ nd+allcause+mortality&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT#S EC2
5. Bower, B. (2007). Weighting for friends: Obesity spreads in social networks. Science News, 172 (4).
6. Boyce, W. F., Craig, W. M., Janssen, I., & Pickett, W. (2004). Associations between overweight and obesity with bullying behaviors in school-aged children. Pediatrics, 113(5). [Electronic version.] Retrieved December 6, 2008, from http://pediatrics.aappublications.org/cgi/reprint/113/5/1187
7. Braet, C. & Decaluwe, V. (2003). Prevalence of binge-eating disorder in obese children and adolescents seeking weight-loss treatment. International Journal of Obesity, 27.
8. Cacioppo, J. T. (n.d.). Foundations in Social Neuroscience. Retrieved November 17, 2008, from http://books.google.com/books?hl=en&lr=&id=nQk5Pv9kfYC&oi=fnd&pg=PA1 095& q=socioeconomic+status&ots=rv8Y2PCcap&sig=tx7K-5wO8u- I33Su6ApXxPgW9Q8
9. Carroll, M. D., Flegal, K. M., & Ogden, C. L. (2008). High body mass index for age among US children and adolescents, 2003-2006. [Electronic version.] Retrieved December 2 2008, from http://jama.ama- assn.org/cgi/content/full/299/20/2401
10. Casper, R. C. (2000). Eating disturbances and eating disorders in childhood. Psychopharmacology. [Electronic version.] Retrieved November 15, 2008, from http://www.acnp.org/g4/GN401000162/CH.html
11. Centers for Disease Control and Prevention. (n.d.). Childhood obesity. Retrieved November 16, 2008, from http://www.cdc.gov/HealthyYouth/obesity/index.htm
12. Centers for Disease Control and Prevention. (n.d.). Healthy weight: About BMI for children and teens. Retrieved November 15, 2008, from
http://www.cdc.gov/nccdphp/dnpa/healthyweight/assessing/bmi/childrens_BMI/about_childrens_BMI.htm
13. Centers for Disease Control and Prevention. (n.d.) Healthy youth: Physical activity. Retrieved December 2, 2008, from http://www.cdc.gov/HealthyYouth/physicalActivity/
14. Center for Disease Control and Prevention. (n.d.). Nutrition: School health guidelines. Retrieved December 6, 2008, from http://www.cdc.gov/healthyYouth/nutrition/guidelines/summary.htm
15. Centers for Disease Control and Prevention. (n.d.). Overweight and obesity. Retrieved November 15, 2008, from http://www.cdc.gov/nccdphp/dnpa/obesity/
16. Centers for Disease Control and Prevention. (n.d.). Overweight and obesity: Consequences. Retrieved November 15, 2008, from
http://cdc.gov/nccdphp/dnpa/obesity/childhood/consequences.htm
17. Centers for Disease Control and Prevention. (n.d.). Overweight and obesity: Contributing factors. Retrieved November 15, 2008, from http://www.cdc.gov/nccdphp/dnpa/obesity/contributing_factors.htm
18. Center for Science in the Public Interest. (2006). Bipartisan support on capitol hill for healthier school foods: Child nutrition promotion and school lunch protection act introduced. Retrieved December 5, 2008, from http://www.cspinet.org/new/200604052.html
19. Chmelynski, C. (2005). States weigh idea of BMI reports as they tackle obesity epidemic. National School Boards Association. Retrieved December 2, 2008, from http://www.nsba.org/MainMenu/SchoolHealth/SelectedNSBAPublications/Hea lthyEating/obesityepidemic.aspx
20. Christakis, N. A. & Fowler, J. H. (2007). The spread of obesity in a large social network over 32 years. The New England Journal of Medicine, 357. [Electronic version]. Retrieved November 16, 2008, from http://content.nejm.org/cgi/reprint/357/4/370.pdf
21. Diez Roux, A. V. (2004). The study of group-level factors in epidemiology: Rethinking variables, study designs, and analytical approaches. Epidemiologic Reviews, 26. [Electronic version]. Retrieved November 17, 2008, from http://epirev.oxfordjournals.org/cgi/content/full/26/1/104
22. Grummer-Strawn, L., Lee, S. M., McKenna, M., Nihiser, A. J., Odom, E., Reinold, C., Thompson, D., & Wechsler, H. (2007). Body mass index measurement in schools. Journal of School Health, 77. [Electronic version.] Retrieved December 5, 2008, from http://www.cdc.gov/HealthyYouth/obesity/BMI/pdf/BMI_execsumm.pdf
23. Kadushin, C. (2004). Basic network concepts: Introduction to social network theory. Retrieved November 16, 2008, from http://64.233.169.132/search?q=cache:48ThleuKviMJ:home.earthlink.net/~cka dushin/Txts/Basic%2520Network%2520Concepts.pdf+social+network+theory& hl=en&ct=clnkcd=4&gl=us&client=firefox-a
24. Kahan, D. (2008). Fitting physical activity into the elementary school day: There are many ways to add movement and exercise to classroom instruction. Leadership Compass, 6(1). [Electronic version]. Retrieved December 2, 2008, from http://www.naesp.org/resources/2/Leadership_Compass/2008/LC2008v6n1a4 .pdf
25. Leppert, J., Nilsson, K. W., & Sjoberg, R. L. (2005). Obesity, shame, and depression in school aged children: A population-based study. Official Journal of the American Academy of Pediatrics, 116.
26. Link, B. G. & Phelan, J. C. (2007). On stigma and its public health implications. Columbia Institute and New York State Psychiatric Institute. Retrieved November 16, 2008, from http://www.stigmaconference.nih.gov/FinalLinkPaper.html
27. MetroWest Community Health Care Foundation. (2007). MetroWest kids: Fat chance. Retrieved November 14, 2008, from http://www.metrowestkids.org/mediaroom/mediaresults.php?search_fd1=Billb oard
28. National Agricultural Library. (n.d.). Choose a diet low in fat, saturated fat, and cholesterol. Retrieved December 5, 2008, from http://www.nal.usda.gov/fnic/dga/dga95/lowfat.html
29. National Association for Sport and Physical Education. (n.d.) Moving into the future: National standards for physical education, 2nd edition. Retrieved December 3, 2008, from http://www.aahperd.org/naspe/template.cfm?template=publications- nationalstandards.html
30. National Center for Education Statistics. (n.d.). Nutrition education in public elementary and secondary schools: Nutrition education in the school curriculum. Retrieved December 3, 2008, from http://nces.ed.gov/surveys/frss/publications/96852/index.asp?sectionid=3
31. National Conference of State Legislatures (2007). Childhood obesity: 2006 update and overview of policy options. Retrieved December 5, 2008, from http://www.ncsl.org/programs/health/ChildhoodObesity-2006.htm#body
32. National Heart Lung and Blood Institute. (n.d.). How are overweight and obesity diagnosed? Retrieved November 15, 2008, from, http://www.nhlbi.nih.gov/health/dci/Diseases/obe/obe_diagnosis.html
33. Nutrition Explorations. (n.d.). Why teach nutrition? Retrieved December 2, 2008, from http://www.nutritionexplorations.org/educators/whyteach.asp)
34. Ofei, F. (2005). Obesity: A preventable disease. Ghana Medical Journal, 39 (3). [Electronic version.] Retrieved November 17, 2008, from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1790820
35. Pennsylvania Department of Education. (2008). Food and nutrition programs: National school lunch program. Retrieved December 6, 2008, from http://www.able.state.pa.us/food_nutrition/cwp/view.asp?a=5&Q=45622
36. Physical activity levels among children aged 9-13 years in united states, 2002. (2003). Morbidity and Mortality Weekly Report, 52 (33). Retrieved November 17, 2008, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5233a1.htm
37. School Health Policies and Programs Study. (2006). Physical education. [Electronic version.] Retrieved December 3, 2008, from http://www.cdc.gov/HealthyYouth/shpps/2006/factsheets/pdf/FS_PhysicalEdu cation_SH PPS2006.pdf
38. The Obesity Society. (n.d.). What is obesity? Retrieved November 15, 2008, from http://www.obesity.org/information/what_is_obesity.asp
39. United States Department of Agriculture Food and Nutrition Service. (n.d.). School breakfast program: Fact sheet. Retrieved December 5, 2008, from http://www.fns.usda.gov/cnd/breakfast/AboutBFast/bfastfacts.htm
40. United States Department of Education. (n.d.) Healthy vending machine. [Electronic version.] Retrieved December 6, 2008, from http://doe.sd.gov/oess/cans/training/docs/healthyvendingmachine.pdf
41. United States Department of Health and Human Services. (2006). Dietary guidelines. Retrieved December 5, 2008, from http://www.health.gov/DietaryGuidelines/
42. United States Department of Health and Human Services and U.S. Department of Agriculture. (2005). Dietary guidelines for americans, 2005. [Electronic version.] Retrieved December 6, 2008, from http://www.health.gov/DIETARYGUIDELINES/dga2005/document/pdf/DGA2 005.pdf
43. Utah State Office of Education. (n.d.) Responsible healthy lifestyles nutrition education. Retrieved December 6, 2008, from http://www.uen.org/utahlink/lp_res/nutri001.html
44. Wikipedia. (n.d.). Labeling theory. Retrieved November 16, 2008, from http://en.wikipedia.org/wiki/Labeling_theory