Challenging Dogma - Spring 2011

Monday, May 23, 2011

Critique of the Eat Smart Play Hard Campaign to Prevent Childhood Obesity-Gauri Apte

Overweight and obesity are significant public health problems in the United States (US). [1] The number of overweight adolescents has tripled in the last years and prevalence among younger children has more than doubled (See figure 1). [2,3,4] Not only has the proportion of overweight individuals increased but the heaviest children in a recent National Health and Nutrition Examination (NHANES) survey were markedly heavier than those in previous surveys. [2,3]
Being overweight during childhood and adolescence increases the risk of developing high cholesterol, hypertension, respiratory ailments, orthopedic problems, depression and type 2 diabetes as a youth.[5] It also has a large number of long-term adverse health outcomes. Overweight adolescents have a 70 percent chance of becoming overweight or obese adults, which increases to 80 percent if one or more parent is overweight or obese. [6] Obesity in adulthood increases the risk of diabetes, high blood pressure, high cholesterol, asthma, arthritis, and a general poor health status [7].
Understanding the causes of childhood obesity can provide the opportunity to focus resources, interventions and research in directions that would be most beneficial in addressing the problem. The causes of childhood obesity are multi-factorial. Excess weight in children and adolescents is generally caused by a lack of physical activity, unhealthy eating patterns resulting in excess energy intake, or a combination of the two. Genetics and social factors, such as socio-economic status, race/ethnicity, media and marketing, and the physical environment – also influence energy consumption and expenditure. Most factors leading to being overweight and obese do not work in isolation and solely targeting one factor may not going to make a significant impact on the growing problem. [8] Specific causes for the increase in prevalence of childhood obesity are not clear and establishing causality is difficult since it involves research which must employ long study times to see if there is an interaction of factors leading to an increase in the prevalence or the prevention of obesity during childhood and adolescence. Under-reporting total food intake, misreporting of what was eaten, and over reporting physical activity are all likely potential biases that may affect the outcomes of studies in this area.[9]
This paper briefly describes the current intervention for prevention of childhood obesity and proposes a new modified intervention. It presents three critiques of this current intervention and then defends the new intervention as a tool to overcome these critiques. In the end it gives a conclusion derived from this exercise.

Current Interventions: The Eat Smart, Play Hard Campaign (ESPH)
This campaign is a part of the U.S Department of Health and Human Service's 'Childhood Obesity Prevention' program [10] and is funded by the U.S Department of Agriculture (USDA). This campaign is a national nutrition education and promotion campaign designed by USDA's Food and Nutrition Service (FNS) to convey science-based, behavior-focused and motivational messages about healthy eating and physical activity. [11]
Messages developed for the campaign are based on the most recent edition of the Dietary Guidelines for Americans [12] and the Food Guide Pyramid. [13]
The initial campaign messages focus on four basic themes: breakfast, snacks, balance and physical activity. The program is designed to: 1) Encourage families to adopt behaviors that are consistent with the Dietary Guidelines for Americans and the Food Guide Pyramid; 2) Communicate behavioral and motivational nutrition education and physical activity messages to children and caregivers; and 3) Foster positive behavior change to promote nutrition and health, and reduce the risk for obesity and chronic diseases.
The target audience for this campaign is the diverse population of children (ages 2 to 18 years) and their caregivers including include parents, guardians, child care providers, after school providers, and teachers. The campaign is designed to reach the target group where they live, work, learn and play using multiple communication vehicles, approaches and channels. The campaign has a spokes-character- the Power Panther and his nephew Slurp to promote healthy eating and to encourage physical activity in children and their families. Power Panther encourages children to eat healthy foods and get more exercise.

Proposed Intervention:
For an intervention for prevention of childhood obesity to be successful, it has to be community-based, involving a community or a social group of people and has to involve social marketing and advertising. [26] However a well recognized potential downside of the community-based programs and social marketing campaigns targeting obesity is their promotion; the social desirability of thinness, which is exacerbated by the media.[27,28,29] Given the uncertainty of the balance between 'benefit' and harm associated with community-based programs and social marketing campaigns, approach to controlling the increasing prevalence of this condition should focus on the benefits of a healthy diet and physical activity rather than on obesity per se. This promotion of a healthy diet and increased physical activity would be expected to lead to the achievement of weight control in current generations, and the prevention of weight gain in future generations. [30]
The proposed intervention will make use of social networks and groups that children and adolescents are a part of in order to communicate healthy behaviors. These networks will involve peers who influence and can be influenced by one another in a way more effective than being influenced by parent, teachers and caregivers. [31] The intervention will also make use of media such as the internet and social networking website which form a large part of the lifestyle of today's children and adolescents. Along with use of social networks, the intervention will use TV advertisements and internet videos to communicate health message to the target audience, who spend a considerable amount of time watching TV and online videos. [32]
In addition to promoting healthy eating and exercise habits, the campaign will also make available fruits and vegetables at more affordable prices to schools who take part in the campaign as well as to families that have children and adolescents. It will involve education of parents and caregivers especially in the lower socio-economic families where healthy eating habits and physical activity are not a part of the household. Along with children, their parents and caregivers will be encouraged to adopt these health practices so that it will be easier for these children and adolescents to Eat Smart and Play Hard.

Critique 1: Psychological Reactance Generated Makes Campaign Ineffective
The ESPH Campaign involves getting children and adolescents to eat healthier and take part in more physical activity. The Campaign does this by telling children what healthy food are and that they must eat these foods. For example telling children to eat more fruits and vegetables, asking them not to drink sweetened drinks, not eat fried foods, etc. In order to improve physical activity i.e making children play hard, the campaign recommends restriction of screen time. This means that parents have to set restrictions for the amount of time spend in front of the TV, computer, video games, etc. [15]
The Psychological Reactance theory proposed by Brehm, states that if a person's behavioral freedom is reduced or threatened with reduction, the person will become motivationally aroused. This arousal would presumably be directed against any further loss of freedom, and it would also be directed towards re-establishment of whatever freedom has already been lost or threatened. This hypothetical state of motivational arousal is know as Psychological Reactance. [16,17] The variables affecting the degree of reactance include, strength of a threat, presence of a freedom, importance of the freedom, proportion of the freedom threatened, and implication for future threat . [18] The effects of this psychological reactance can adversely affect the ESPH campaign. When children and adolescents are told what they must and must not eat, their freedom to select the food of their choice is threatened. They can react to it by intentionally picking so-called the forbidden food. The success of a public health campaign in avoiding reactance, depends on its explicitness, dominance and reason. [19] The ESPH campaign does not explicitly explain to the target audience why they must eat healthier foods. One of the tools is replacing unhealthy foods in the cafeteria with healthier options, but in doing so, there is no consideration given to reasoning with the children and adolescents as to why this change has been brought about. This will result in increased reactance among the children and decrease the chances of changing health behavior. Similarly, with regards to the play hard part of the campaign, if children are made to exercise by enforcing screen time restrictions they will see it as a threat to their freedom. This will increase reactance and they will be prompted to do the exact opposite and not exercise in order to gain back control. [20]

Intervention Defense 1: Using the Social Cognitive Theory/Social Network Theory to Combat Psychological Reactance.
One of the ways to overcome psychological reactance is to make the campaign message delivery as similar to the target audience as possible. This is less threatening to their freedom and they will willingly want to bring about the behavior change. Similarity increases the positive force towards compliance by increasing liking. [33,34] A good way to do this is to have a communicator who is as similar to the children and adolescents. Thus using peers to convey the message of healthy eating habits and increased physical activity will be more widely accepted by these children than a similar message by parents, caregivers, schools, etc. This can be done by building a model based on the Social Cognitive Theory which states that change is behavior is influenced by the environment, self-efficacy and modelling of observed behavior. [35]
In schools, a committee of students can be formed, who will communicate the message of eating healthy and increasing physical activity. The initial group of students can be selected based on general model social behavior, peer influence and leadership potential. This group of students can communicate the message directly to their fellow students and also communicate to the teachers and school management about what children and adolescents like to eat, the physical activities that they would enjoy taking part in, etc. The students can be involved with the school in deciding healthier options to replace junk foods in the cafeterias. This will help schools have foods that are healthy and more liked by children. Also knowing that their peers had a say in deciding the cafeteria menu will reduce reactance among the children and adolescents and they will be more willing to try these new healthier options. Also knowing that the more popular and influential kids eat healthy foods, will make many other children model similar behavior and this will encourage healthy eating habits.
In order to improve physical activity, a similar group of students can be used to help the educators come up with innovative and interesting activities that will be attractive to the students. Team activities can also be started using the selected students as leaders of different teams. There can be healthy competition which will encourage the students to engage in more physical activity without it being boring or seeming like a task. At home this can also be done by encouraging older siblings to first modify and adapt healthier eating habits by explaining to them the importance of these health behaviors. Being explicit and open about healthy eating habits will reduce reactance amongst the older children. [19] They should be told about the influence they have on their younger siblings and that they can act as helpers to the parents. This will evoke a sense of responsibility among the older sibling and will improve health behavior in younger siblings through modeling of sibling eating habits.
In addition to this, the Social Network theory can also be used to improve eating habits and physical activity among children and adolescents. Network phenomena appear to be relevant to the biologic and behavioral trait of obesity, and obesity appears to spread through social ties. [37] This knowledge can be used for prevention of Childhood Obesity. According to the Social Network theory , the factor that most affects a person's behavior is the behavior of persons in their social network, such as family, extended family or non-kin -church or work groups, friends or neighbors who regularly socialize and clubs and sporting teams. [38] This can be done by positively using various social networking websites where children and adolescents are a part of. Groups can be formed on these sites that encourage healthy eating habits and increased physical activity. The campaign can be propagated as a movement, being a part of which, can be considered trendy or 'cool' by the target group. This can again be done by initially involving a select group of students and including them as part of the campaign. They can then spread the message to their network of friends via these websites and these friends will pass it on to others, thus creating a large movement which will spread through the social network. [39] This social network can then also be used to create and organize events that will encourage healthy eating habits and involve physical activities games, among others and targeted toward different age groups keeping in mind their interests and current trends. Various other online contests such as one for healthy innovative recipes that children and adolescents can come up with, games involving physical activity, etc can also be held. Thus social networks can be used to bring about health behavior change.

Critique 2: Use of An Animated Mascot/Spokesperson to Communicate Behavior Messages
The ESPH Campaign uses animated spokes-character, the Power Panther and his nephew Slurp, to communicate messages to children and adolescents and their care givers. The Campaign provides three scripts to help communicate these messages. [21] Eat Smart. Play Hard. With MyPyramid: It is a script for community events and introduces parents, kids and community groups to the Power Panther and the food guide pyramid. It provides an optional physical activity- Power up Moves.
Power Panther takes Eat Smart, Play Hard to Schools: This is an interactive session where school-age children are introduced to Power Panther who encourages them to embrace healthy eating and physical activity behaviors. Power Panther also conveys the importance of eating breakfast. Learn to Eat Smart, Play Hard with Power Panther: Interactive session where children and care givers are introduced to the campaign
Along with these scripts, there is also a Power Panther song encouraging children and adolescents to follow healthy eating habits and physical activity.
The target audience of this campaign is children and adolescents from 2 to 18 yrs of age. While use of an animated character as a spokesperson may be an effective means to communicate with younger children, it may have an adverse effect on adolescents. Adolescents do not like to be treated like children. They are at a stage when they begin to consider themselves close to being adults and prefer to addresses similarly. Often reckless and irresponsible behavior seen in teenagers is a way of declaring their adulthood. If they are treated as adults by caregivers, teachers, etc., they almost immediately rise to the challenge and can bring about effective behavior change. [22]
The ESPH campaign mainly uses tools such as activity sheets, bookmarks, comic stickers to encourage children to indulge in healthy behaviors. They also use brochures, posters and handouts. Though attractive to younger children, these tools may not be an age-appropriate method to communicate with adolescents. Adolescents are less likely to take these methods seriously and may in turn mock them or form spoofs to gain peer popularity. This deters the goal of the campaign. Also adolescents are at a stage where they tend to look up to their peers and gain recognition from them and are less likely to be influenced by a spokes-character like the Power Panther which they might consider too childish for them. [23] In order to gain prestige some teens use general sociability and good reputation while some others do it by being the class clown. [24] In attempting to be popular among peers these teens might resort to mocking the seemingly juvenile posters, stickers, etc.
This can result in others following similar behaviors due to peer influence and not taking the campaign and its message seriously. [25] For the campaign to be successful, it needs to be conveyed via a more effective vehicle that is likely to be effective for all of the target audience.

Intervention Defense 2- Use of Advertising and Marketing Theory for Better Compliance.
An important cause of increased childhood obesity is in the increase in junk food TV commercials. [39 ] These commercials are based on the three main principles of the Advertising theory. They are:
Promise: Every advertisement makes a promise to a certain desirable outcome to the consumer if he/she buys the product
Support: Evidence that the product can support the promise
Core Values: There are a certain set of core values that have universal appeal.
Some of these are family, love, freedom, youth, rebelliousness, power and, acceptance. If an advertisement can appeal to these values in an individual, it is more likely than not to be successful.
These same principles can be used to create advertisements which encourage healthy eating habits and physical activities in children and adolescents.
Advertisements can use young celebrities who can communicate the Eat Smart, Play Hard message. These celebrities are usually looked up to by children and adolescents and have high model prestige. If they encourage a certain health behavior, more youth will want to model their behavior and indulge in healthy eating and exercise habits. The advertisements can be as simple as the celebrity choosing a fruit or a vegetable over a bag of chips. They can be targeted towards appealing to the core value of 'power' where children will believe that it is indeed in their hands to make a change about their own behavior and whether or not they choose a healthy lifestyle is up to them. This will also minimize psychological reactance and bring about voluntary change in health behavior.
In addition to using celebrities, children and adolescents from the same age group as the target audience can be used to create advertisements that promise a healthy life style. For example, an advertisement can show a group of teens, including a mix of different type of kids that most children can identify with. These teens can be shown to make simple choices such as picking health food at the cafeteria, choosing to bike to school or even the mall as opposed to being dropped off, choosing to play a group sport as opposed to a video game and doing so with a lot of ease and enthusiasm. Each of the advertisements can have the catch phrase 'I/We Choose', followed by different endings such as 'eat healthy', 'stay fit', 'go green'. These will appeal to a number of core values such as freedom, power, rebelliousness, acceptance just by demonstrating that children and adolescents have the power 'to choose' the right health behavior. Media, in the form of, attractive visuals and catchy music can be used to appeal to these youth along with using the factor of peer influence. [31] This will create a public health brand that will seek to change eating and physical activity habits.
Social Marketing employs commercial marketing principles and tactics to influence voluntary human behavior for societal benefit rather than commercial profit. [42] According to this marketing theory, there is a need to research what consumers want and modify the campaign so that the product trying to be sold fulfills those wants. These ads will market 'Fun and Freedom' in order to promote good health. The advertisements will make the promise of a healthy yet fun and interesting lifestyle appealing to various core values in youth. In order to follow up and provide support to this promise, we can have healthier options in cafeterias, more time allocated to physical activities in schools, providing parking for bikes at schools, malls etc. In addition to having advertisements on TV, the videos can also be posted online. The internet is one of the major sources of entertainment and learning for today's youth. Children and adolescents spend a good amount of time surfing the internet. [42] Thus putting these videos online can increase their viewership in children and adolescents.
The internet can also be used to create various competitions under the 'We Choose' campaign where children can send in videos and photographs of their friends and peers and how they chose to make a healthier food or exercise choose. This can be done through social networking sites as well as online videos announcing these competitions. Winners will be chosen from each category on a monthly basis and winning videos and photos can be posted online and at the end of 6 months one chosen video can be used as a part of a TV advertisement. This will create healthy competition as well as provide an opportunity to do something creative, all while keeping the ultimate goal of healthy eating and exercise habits.

Critique 3: Reliance on the Theory of Reasoned Action Fails the Campaign at a Community Level
Like a lot of other public health interventions, the ESPH Campaign relies on the Theory of Reasoned Action. According to this theory, a person's behavior depends on [43]:
Attitude: A persons belief about what will happen if he or she performs the behavior and a person's judgment about whether the expected outcome is good or bad.
Subjective Norms: A person's belief's about what other people in his or her social group will think about the behavior and a person's motivation to conform to these perceived norms.
Behavioral intention: A person's intention to perform behavior.
This theory however has its weaknesses. To begin with, it is an individual level model, which assumes that intention leads to behavior which may not be true. It also uses social norms as a determinant for behavior change. However social norms are not universal and defer based on culture, society, etc.
The ESPH campaign involves use of charts, posters, worksheets etc to explain to children and adolescents the importance of healthy eating and physical activity. Through the use of its spokes-character it encourages adoption of such health behaviors. However, the theory makes an assumption that if children know the health benefits of healthy eating and exercise they will want to change their habits and this in turn will prevent obesity and bring good health. However there are various other factors that may be barriers to adoption of healthy behaviors even if children and adolescents intend to do so. One of the ways the campaign plans to promote healthy eating is providing healthier options in the cafeterias. However it does not take into account the fact that often these healthier foods such as fruits, vegetable or salads are more expensive than the unhealthy options, such as a bag of chips or French fries. [44] Though some children may be able to afford these more expensive food items, there are many that may not be able to do so and therefore their intention to eat healthy may not actually turn into reality.
Another problem would be eating habits of children after school. Many children come from families that do not themselves practice health eating and exercise habits at home. For these children the unhealthy habits are a part of their lifestyle and they view them as norms. Since they think this is normal behavior, it is harder to them to bring about a change in their behavior. Also often children and adolescents come from poorer families who cannot afford to buy healthier foods. There are also children whose parents themselves are not aware of the changes that can be brought about with addition and healthy food and exercise behaviors and unhealthy habits for such children is often learned behavior. The Campaign however assumes that parents would actively take part in bringing about change to their households with the use of tools provided through the campaign. The campaign does not take into account these norms that affect the child's behavior and does not involve active education of parents and caregivers.

Intervention Defense 3: Overcoming Assumptions of the Theory of Reasoned Action.
In order to enable children and adolescents to adopt healthy behaviors, the campaign will provide affordable healthy foods. The Campaign will match prices of foods such as fruits, vegetables, salads, etc to those of unhealthier options like fried and fatty foods. This will enable children to make a choice without having to worry about the costs involved in choosing healthy foods. This can be done by partnering with produce companies and buying in bulk so that affordability of these foods can be maintained. In addition to this, the healthier foods can be displayed more attractively and accessibly so that young people who have the intention to change their health behaviors will get a push forward in the direction towards making that healthy choice.
Another barrier to adoption of healthy eating and exercise habits is the after school environment of kids which differs from person to person. The Campaign will undertake education of parents and caregivers by conducting community level programs and workshops. In these workshops the parents and caregiver will be taught about the ill effects of obesity during childhood and its affects on future life as adults. Benefits of healthy eating habits and regular physical activity will be explained to them and they will be given various methods to help bring about this health change in their wards. They will be given various easy healthy recipe options and encouraged to incorporate these into their diet. They will also be told not to ask a certain behavior of their children in order to avoid reactance but instead to provide healthy options to the children and encourage them to make the right choice. For families who come from lower socio economic backgrounds, healthy foods such as fruits and vegetables will be provided at subsidized rates within the community and incentives will be provided to families that adopt healthier eating habits.
To encourage regular physical activities, parents and caregivers themselves will be encouraged to take part in such activities and use some such fun physical activity as a good bonding experience for the entire family. Adults will be encouraged to adopt healthier lifestyles and lead by example by cutting down on screen time themselves. This will help create an environment which will prompt children to take up more physical activity. [45] Parents will also be educated to encourage their children to walk and use bicycles to go to school and other accessible places rather than dropping them there. The campaign will organize community events where families can take part in activities such as races and other games involving physical activity, workshops for parents and kids to learn simple and healthy recipes, etc. These will help bring about effective health change in children and adolescents.

Current interventions for prevention of Childhood obesity include the Eat Smart, Play Hard Campaign which is targeted at children and adolescents between 2-19yrs of age. It makes use of tools such as worksheets, charts, posters, spokes-character, etc to encourage children and adolescents to adopt healthy eating habits and physical activity. This campaign however, does not take into the account the psychological reactance that it cause in youth, does not use enough and appropriate mass media to propagate its message and does not take into account the various barriers to adoption of the suggested health behaviors.
The new campaign that this paper proposes, plans to overcome the drawbacks to the ESPH Campaign to create an improved childhood obesity prevention program. The new campaign makes use of celebrities and peers to communicate the health messages in order to minimize reactance. It makes use of the power of social networks in influencing youth and uses them to bring about behavior change. It uses TV and online advertisements which appeal to core values of the youth and gives them the power to choose to adopt the target health behavior thus prompting informed change and promoting the adoption of a healthier lifestyle. The campaign also makes an effort to overcome economic and social barriers that may limit children from eating healthy and taking up more exercises. It does this through parent and caregiver education and provision of healthy foods at subsidized rates to participating schools and families with children and adolescents.
Child Obesity is one of the leading public health problems in the US today. It has serious short-term consequences such as increased risk of developing high cholesterol, hypertension, respiratory ailments, orthopedic problems, depression and type 2 diabetes as a youth [46]and long term consequences such as increased risk of diabetes, high blood pressure, high cholesterol, asthma, arthritis, and a general poor health status. [47] Prevention of Childhood obesity should therefore be a public health priority. The new campaign proposed, aims to prevent childhood obesity by a using more effective vehicles to promote health behavior change and if well implemented will help bring the obesity epidemic under control.

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