Challenging Dogma - Spring 2011

Sunday, May 15, 2011

Tipping the Scales on Childhood Obesity: Why School-Based Interventions Need Fixing – Benjamin Spozio


Rates of overweight and obese children have risen to alarming proportions both in the United States and worldwide. According to the Centers for Disease Control and Prevention (CDC), in the United States alone, approximately 12.5 million (17%) of children and adolescents aged 2-19 years are obese. This represents a tripling in prevalence since 1980 (1). Healthy People 2010, an initiative of the Department of Health and Human Services to improve our nation’s health by 2010, identified overweight and obesity as one of ten leading markers of health (2). While it has been known for some time that obesity poses a threat to the health of both adults and children, little has been accomplished in the United States in terms of reversing the trend. Results from the 2007-2008 National Health and Nutrition examination Survey show that obesity rates among preschool children aged 2-5, obesity increased from 5.0% to 10.4% between 1976-1980 and 2007-2008. Among children aged 6-11 rates increased 6.5% to 19.6%, and among adolescents obesity increased from 5.0% to 18.1% during this period (2). Obesity rates among adults in the U.S. have also increased markedly over the past decades. The number of obese adults in the U.S. has increased by over 50% since the 1970s, affecting all segments of the population (3).

Overweight and obesity are not issues being solely dealt with here in the United States. Worldwide, there are over one billion overweight individuals with approximately 30% of them being obese (4). Given the distressing tendencies amongst adults, it is logical that intervention strategies for obesity target children so that unhealthy behaviors can be quelled at an early age. Globally, around 10% of school-aged children are overweight, which puts the magnitude of the problem facing American public health officials in perspective (4). Despite major efforts to combat obesity and promote weight reduction, physicians and researchers have labeled obesity in children as a worldwide epidemic.

Historically, a fat child indicated a healthy child. While being fat, in the past, increased a child’s likelihood of surviving the rigors malnourishment and disease, it has now become one of the primary health complications in children (5). With obesity being associated with increased morbidity and mortality, overweight children face elevated risks for health complications in both childhood and adulthood. Long-term follow-up of obese children indicates that, as adults, they experience increased rates of morbidity and mortality. Alarmingly, these increased rates of morbidity and mortality are present regardless of the individual’s weight at adulthood (6). This illustrates the long-term consequences that overweight and obese children are put in risk for. High Body Mass Index (BMI) in children has been linked to immediate consequences such as elevated lipid concentrations and blood pressure (7). Obesity in childhood has also been linked to chronic inflammation, increased blood clotting tendency, endothelial dysfunction, and hyperinsulinemia. These cardiovascular disease risk factors, collectively known as insulin resistance syndrome, have been seen in children as young as five and have demonstrated a two-fold increase in the risk of death from heart disease in adulthood (5). Childhood overweight and obesity are also associated with a number of additional long-term consequences such as type 2 diabetes, stroke, fatty liver, arthritis, sleep apnea, gall bladder disease, and bronchial asthma. There have also been a number of psychological issues linked to overweight and obese children, such as depression, discrimination, and low self-esteem (4). Arguably, overweight and obese children are also subject to many negative stereotypes such as being socially inept, unhygienic, and lazy.

Sizing up Obesity

There have been a number of factors implicated in the growing obesity epidemic. A wide range of genetic, sociological, socioeconomic, and environmental influences have been connected by researchers to the prevalence of obesity. Looking at obesity from its most basic roots, it can simply be defined as a combination of taking in more calories than are consumed by the body through physical activity. Unhealthy eating habits, and lack of physical activity, can be established at very young ages and persist into adulthood.

Efforts to alleviate and control the growing epidemic have largely focused on school-based intervention programs. The idea is that by targeting individuals at an early age, poor nutritional and behavioral habits can be changed before long-term consequences can occur. Children spend many hours in school, therefore making schools important channels through which behavioral changes to reduce obesity can be addressed (4). Given the general implication of insufficient physical activity and poor-nutrition, due to the prevalence and availability of calorie-rich foods, it is not surprising that both of these factors are the primary emphases of prevention and intervention campaigns. Many school-based programs encourage physical activity, increasing the consumption of fruits and vegetables, controlling the size of portions, and limiting the intake of unhealthy foods. The CDC has even issued its own guidelines and recommendations for healthy eating and physical activity programs for school programs. These guidelines include curriculums, instructions for students, nutrition education, and staff training (8).

The idea, however, of aiming policy and prevention efforts at nutrition and activity are nothing new to the public health toolset. School-based dietary and physical activity programs have the potential to make a significant impact on the health and behaviors of children. In a 2005 analysis of 5200 fifth-grade elementary school students exposed to obesity-prevention programs, Veugelers and Fitzgerald concluded that despite insignificant results, school-based programs may enhance health education; enhance health during critical periods of development; lower the risk of chronic diseases in adulthood; and help to establish life-long healthy habits (8). It is important to recognize that Veugelers and Fitzgerald’s conclusion is one of optimism, because as mentioned above, rates of overweight children and obesity have yet to show desired levels of improvement despite the implementation of many school-based interventions.

A Flawed Curriculum

The application of intervention programs that rely on imparting strategies and information onto a hopefully susceptible population of children are fundamentally flawed in their approach. From both the point of view of the social sciences, and simple achievability, these programs fail to address major factors in the development of children’s behaviors. It can be shown on three separate levels where these programs fail to address the underlying issues at hand in rising obesity rates. Fortunately, however, the existing shortcomings that will be described can all be addressed through a restructuring of school-based campaigns.

School-based obesity prevention programs that rely on creating behavioral change through imparting knowledge are weakened by the assumptions they make regarding their target audience. These types of interventions are fashioned under the premises put forth in the social science theory known as the Health Belief Model. Since the 1950s, when it was first proposed by psychologists Hochbaum, Rosenstock, and Kegels working in the U.S. Public Health Service, the Health Belief Model has been one of the most widely used frameworks for research into health behaviors. It was originally developed in an effort to explain and predict health behaviors, particularly why certain programs designed to prevent and detect disease failed to attract participation (9). The Health Belief Model thus contained several predictions to why people will or will not take action to prevent or screen for disease. These constructs include perceived susceptibility; perceived severity; perceived benefits; perceived barriers; cues to action; and self-efficacy (10). Perceived susceptibility refers to how likely an individual feels it is that they will acquire a certain disease or outcome. Perceived severity refers to the feelings about the seriousness of contracting an illness or the consequences of leaving it untreated. Perceived susceptibility and perceived severity combine to construct an individual’s perceived threat. The construct of perceived benefits holds that even if a person perceives susceptibility to a serious health condition, that person will only commit to a behavior change if they believe in the benefits offered by making such a change. However, the potential drawback in undertaking a certain health action is subject to an individual’s perceived barriers. Under this construct individuals perform a cost-benefit analysis of the expected benefits relative to the perceived barriers. ‘Cues to action’ is a construct proposed by Hochbaum that held that an individual’s readiness to take part in some action could only be instigated by a proper external cue. This construct has proven interesting in theory, but difficult for researchers to study. The final construct is termed ‘self-efficacy’. This construct refers to the belief one has in oneself to successfully make a change for their benefit (10).

School-based obesity prevention programs, that solely present information and strategies to children, make several critical assumptions using the constructs of the Health Belief Model. This form of intervention assumes that an informed child will make the rational decision to adopt a healthy lifestyle if simply presented with the facts. It is taken for granted that at-risk children will be able to fully and correctly perceive their own susceptibility to the consequences of obesity and subsequently conclude that the benefits of making a change outweigh any barriers they may be facing. This strategy for intervention not only trivializes whatever barriers may exist for children that are at-risk, but more importantly, it completely ignores other influences in a child’s life. The decisions we make as human beings are often not made following a conscious cost-benefit analysis of risks and benefits. Strategies targeting obesity that ignore the effects of social motivators such, namely a child’s peers and parents, are unlikely to produce any significant long-term results. It is for this same reason that other public health campaigns that have confronted issues such as smoking, but used the same underlying philosophy, have also failed to produce results.

The failure to recognize the influence and role of individuals within a child’s social sphere is a second area in which nutrition and activity-driven obesity interventions collapse. While these interventions falsely rely on one social science theory, the Health Belief Model, they completely ignore the implications of another: social norms theory. Social norms theory states that a person’s behavior is heavily influenced by their perception of how others behave, and how they perceive others would want them to behave. The fact that we are by nature influenced by those around us has great implications on how to approach preventative programs aimed at obesity. As stated by Anderson, “policies aimed at individuals are doomed to fail” (3). Social norms theory would suggest that weight gain in an individual may be influenced by the weight of those around him. In particular, there are at least three distinct reasons to why weight may be affected by social norms: individuals choose friends based on weight; individuals adjust their behaviors because of perceived influences; and individuals alter their eating habits and physical activities as their friends and influences do (3). Anderson’s 2009 study looked at the effect that relative BMI can have on the perception of weight and weight goals within schools, and made several important conclusions relevant to the implementation of a successful intervention.

It was concluded that an increase in the average weight of individuals within a student’s own school can have drastic effects on how they perceive their own weight and weight goals. A school or society with a strong trend towards obesity will undergo a shift in the social norms surrounding weight. Individuals perceive their weight as lower due to the changing norm and change their eating behaviors as a consequence. It is rational to argue that individuals with a lower perception of their own weight will increase their unhealthy eating habits. Changing norms in this manner can lead to an increase in average weight and simply aggravate the obesity epidemic as children perceive themselves as thinner and are mess motivated to lose weight (3). It is important to acknowledge that the social influences that a child is exposed to extend beyond just school. The effect of parents can also play a formative role in how children’s social norms are created. Bad habits observed both at home and at school can combine to compound the problem of obesity. Consequently, preventative programs aimed at obesity that neglect the competing influence of both peers and parents are fundamentally flawed in their methodology.

There is a third matter in which obesity-targeted programs, as described, demonstrate a notable oversight. This involves a general failure to acknowledge the influence of mass media and marketing in the decision-making surrounding both eating habits and physical activity. According to data compiled in 2010 by the University of Michigan Health System, television viewing among children is at an eight-year high. On average, children ages 2-5 spend 32 hours a week in front of a television, while children ages 6-11 spend 28 hours a week. 71% of 8-18 year olds have a television in their bedroom, and advances in media technology and accessibility have provided considerably more mediums by which children are being exposed to the influences of mass marketing while increasing the amount of time they are spending inactive (11). A 2002 article from Pediatrics concluded that while certain factors such as genetics may predispose an individual to develop obesity, the increasing prevalence among children is more likely attributable to both changes in lifestyle and environment. Namely, time spent watching television was found to be directly correlated with increased BMI measures (12). Interestingly, the amount of time children spent watching television was potentially influenced by several demographic factors, such as race and socioeconomic status.

In addition to contributing to a sedentary lifestyle, television and advertising threaten to pose a challenge to efforts at improving children’s nutrition. It is widely known that nutrition during childhood and adolescence is vital for proper growth and development. Heightening the importance of appropriate dietary habits is the fact that habits that form in childhood generally tend to transition over into adulthood. With children watching an estimated 20,000 to 40,000 commercials a year and about 95% of U.S. fast-food restaurants advertising budgets allocated to television, it is of little surprise that marketing demands considerable attention in combating the obesity epidemic in children (13). To put the significance of media’s role in what children are eating consider the following facts: food is the most frequently advertised product during programming for children, accounting for over 50% of all ads targeted at children; children view an average of one food commercial for every five minutes of television viewing; and that during Saturday morning programming aimed at children, 11 of 19 commercial per hour were for food, with 44% of these promoting foods from the fats and sweets group (13).

The threat of marketing to children and adolescence is compounded by the numerous channels available to marketers. While effective school-based interventions have the potential to bring down overweight and obesity rates in children, they are forced to compete with some rather alarming trends. In the past fifteen years, U.S. marketing companies have developed strategies to focus on schools. Cover Concepts®, a division of Marvel Entertainment, promotes itself on its website as having provided “FREE materials to over half the nation’s schools since 1989 [working] in tandem with administrators and teachers to distribute sponsored materials such as book cover, educational comics, teacher’s guides, posters, bookmarks, and specialty packs”. Cover Concepts® is able to do this because the materials it distributes are branded with company logos and sponsorship. Cover Concepts® does well to present the nobility of its work, providing teacher testimonials and pictures of understandably grateful children, but fails to mention several of its associated partners: McDonalds, Pepsi, Gatorade, Frito Lay, General Mills, Hershey, Keebler, Kellogg’s, M&Ms, Mars, Kraft/Nabisco, Wrigley, and State Fair Corn Dogs (13).

An additional point of concern for any program looking to combat the rise in childhood obesity comes from the fact that there had been a growing trend of fast food vendors in schools in the middle of the past decade, with about one in every 5 U.S. high schools offering brand-name fast-foods. The relatively recent passing of the Healthy Hunger-Free Kids Act of 2010, strongly championed by First Lady Michelle Obama, provides $4.5 billion over the next ten years to support school cafeterias in introducing a higher standard of food (14). This contemporary piece of legislation may provide a unique opportunity for novel intervention campaigns to have a markedly more profound impact on obesity trends in children.

Fixing the Problem

The described flaws, and formidable obstacles, that plague obesity and overweigh programs aimed at children in the U.S. present a unique opportunity for meaningful changes to be made. The depicted interventions that simply emphasis imparting knowledge to children so that they may make the best decisions for themselves are clearly ineffective. This is made evident by how obesity rates have risen over the past few decades. An effective model for change would have to properly address the aforementioned flaws. This model would have to distance itself away from the impractical recommendations of the Health Belief Model, and entrench itself in recognizing the enormity of the influence that a child’s peers, parents, and media spheres have. The approach to creating and implementing an effective model for obesity prevention would ideally incorporate the findings of the social norms theory by acknowledging the effects of peers on children’s behaviors, comprehend that an effective intervention would have to also address the attitudes and behaviors of parents, and realistically concentrate on minimizing the sway that marketing campaigns, often present in television, can have on the lifestyle decision-making of children.

To begin, programs that simply assume that providing children an instruction manual on how to construct a healthy life, without the necessary tools to put it together, need to be either dropped or drastically overhauled. Presuming that children, or anyone, can naturally and effortlessly weigh the logic of two choices, and come to the correct conclusion, without controlling for the effect of outside influences is far too simplistic an approach to be effective. At the same time that a preventative program needs to address the social norms created by children, a main focus of the intervention has to also be placed on changing parents’ understanding of their unique role in shaping the behaviors and norms of their children. Considering that parents can actively influence the family environment by exposing family members to particular foods, by both encouraging and discouraging certain foods, and by promoting physical activity and, to a certain extent, exposure to media, a truly effective strategy must begin at home. Previous studies have shown that in the treatment of childhood obesity, clear benefits have arisen from parental involvement (15). A 1998 study published in the American Journal of Clinical Nutrition tested two separate intervention strategies. One strategy used the standard approach of promoting weight loss by directly targeting children and their behaviors, while the experimental strategy left children out of the intervention and instead focused on the behaviors of the parents. The results demonstrated that the approach of treating parents as the agents of change was significantly more effective than the conventional approach, with a 15% decrease in the amount of overweight children in the index group compared to an 8% decrease in the reference group (16).

So our improved intervention strategy would begin by initially attempting to reconstruct a child’s social norms at home. School-based programs would need change into home and school-based campaigns. Ideally, parents would actively participate in learning about what constitutes healthy diet and behavior educational sessions with a dietician. Realistically, this sort of endeavor would depend on a substantial amount of finances if the goal is to provide each family with face-to-face counseling. However, an approach that could prove to be useful is the implementation of web-based seminars and social networks, similar to such online programs as Second Life, which is currently being tested for its efficacy in promoting lifestyle changes in individuals with diabetes in the Boston area. In this sort of environment, individuals, or groups of individuals can meet online, in a fully interactive virtual world, with physicians, dieticians, or nutritionists in order to learn new healthy lifestyle strategies. Perhaps a first step in promoting behavioral changes at home could begin with implementing these types of online resources. As mentioned earlier, the increase of technology’s integration into our daily lives can be a cause for concern. Especially when one considers the constant stream of advertising we are continually exposed to, at seemingly younger and younger ages. With all likelihood, technology will continue to further integrate itself into our lives, and the idea of there being passed some form of legislation to censor what our children are exposed to on television and online does not seem all that realistic an approach to dealing with contemporary challenges to fighting obesity. So perhaps there does exist a way for technology to become a tool for the benefit of our children’s health. With interest in the potential for online interventions coming from both the pharmaceutical industry and institutions such as the National Institute of Health, it might be realistic to think that funding could be available to support community-wide online intervention programs that are promoted through local schools and run by both area universities and hospitals.

This proposal for combating the prevalence of obesity in children tries to attack the three flaws pointed out in some of our current interventions by arguing that the most effective change can be accomplished by altering the way families as a whole, and not just children, think. In doing so, however, it does make some rather serious assumptions. Firstly, it assumes that enough interest in this type of intervention will exist to secure adequate funding. Secondly, it assumes that parents are going to willingly participate in a rather unorthodox type of intervention strategy. For this type of program to work, it must avoid making it sound as if parents are doing an inept job of raising their children. It must be presented in a way that makes parents feel that they are helping to contribute not only to a better understanding of present health issues in children, but would be helping to pave a way to healthier lives for future generations. Additionally, it assumes that since a given proportion of parents either will choose not participate, or not have the chance to, that newly developed social norms in a proportion of children will diffuse into the social constructs of other children. It also acknowledges that decreasing the exposure to marketing of unhealthy foods through advertising mediums such as television is rather unlikely apart from some form of government legislation. Trying to censor the marketing of unhealthy foods, however, may not the best way to go about making long-term changes to behavior. It is arguably in our better interest to change the way in which families and children understand what makes healthy foods important, rather than just what foods are bad. Given that advertising is likely to persist, and that significant steps have begun to be taken down the path towards decreasing obesity rates, it might be the right time to give an old problem a novel solution.


(1) Centers for Disease Control and Prevention. Division of Nutrition, Physical

Activity andObesity. Atlanta, GA. Center for Chronic Disease Prevention and Health Promotion, 2011.

(2) Ogden, C. and M. Carroll. “Prevalence of Obesity Among Children and

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(12) Dennison, B.A., Erb, T.A. and P.L. Jenkins. “Television Viewing and Television in Bedroom Associated with Overweight Risk Among Low-Income Preschool Children”. Pediatrics 2002; 109; 1028-1035.

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(14) Let’s Move. Child Nutrition Reauthorization Healthy, Hunger-Free Kids Act of 2010. Washington, D.C. Child Nutrition Fact Sheet, 2010.

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(16) Apter, A., Golan, M., Weizman, A. and M. Fainaru. “Parents as the Exclusive Agents of Change”. American Journal of Clinical Nutrition 1998; 67; 1130-1135.

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