The
Problem
The rising prevalence of childhood
obesity negatively impacts society’s health and well being. The Centers for Disease Control and Prevention
(CDC) classifies overweight and obese children using the Body Mass Index (BMI)
calculation. A child’s BMI within the 85th to 95th percentile is considered
overweight and greater than the 95th percentile obese, when compared
to children of the same age and sex (1). According to the CDC’s 2010 U.S. data, greater
than one-third of children are overweight or obese (2).
Obesity prevalence varies across the US.
The Southern region reports the highest prevalence of childhood obesity (3).
For example, children residing in Georgia are 14.8% overweight and 12% obese
and adolescents are 15.8% overweight and 13.5% obese (4). According to the Youth Risk Behavior Survey,
8.3% of Georgia’s adolescents reported not eating vegetables and 14.3% reported
not eating fruits (5). Lastly, 58% of adolescents participating in this survey
reported being active for at least 60 minutes 5 days a week (5). Interventions addressing education, food
security, and the importance of physical activity will intend to improve statistics
and health outcomes.
Obesity prevalence also varies by family
income level. Children from low-income households are at increased risks of
becoming overweight or obese, as unhealthy non-nutritive highly processed foods
tend to be more affordable and/or accessible. According to the National Initiative for
Children’s Healthcare Quality, 50.4% individuals have incomes <100% Federal
Poverty Level (FPL) and are categorized as overweight or obese in Georgia.
However, compared to 21.0% have incomes > 400% FPL (6). Thus, place of
residence and socioeconomic factors strongly influence nutritional status.
America’s current environment contains an
abundance of highly processed foods and beverages full of sugar, fat, and
salt. Thus, overconsumption of such
nutrients can attribute to excess weight gain and adverse health effects.
Unhealthy choices along with sedentary behaviors, increased screen time and
decreased playtime, have contributed to America’s rising prevalence of obesity
(1,2,3). Therefore, overweight and obese
children and adolescents impose a public health concern as immediate health
effects can result including: high cholesterol, high blood pressure,
pre-diabetes, bone and joint problems, sleep apnea, and psychological problems
such as stigmatization and poor self-esteem (2). Secondly, obese children are at risk to
become obese adolescents and adults, leading to long-term health effects such
as heart disease, type 2 diabetes, stroke, and cancer (2).
The Harvard School of Public Health
address two costs associated with obesity and obesity related conditions:
indirect and direct. Direct costs include: lab and radiology tests, drug therapy,
and outpatient/inpatient health services (7). Indirect costs include: days
missed from work, higher insurance premiums, decreased wages, and lower
household income (7). Exceeding $147 billion
annually, obesity related costs place a huge financial burden to the U.S.
health system (7).
Georgia’s Efforts
Due to the rising prevalence, adverse
health outcomes, and financial burden of obesity, public health officials
developed various interventions across the U.S. including soda bans, increasing taxes of
unhealthy items, and healthier school lunches are current interventions
implemented.
The
Children’s Healthcare of Atlanta Georgia Pediatric Hospital (CHOA) created a 5
year $ 25 million dollar program known as Strong4Live (8). Their mission is to reduce childhood obesity
in Georgia by launching a media campaign titled ‘Stop Childhood Obesity’ (8). Black and white billboards and TV ads featuring
images and video clips of overweight and obese children were displayed across metro
Atlanta (9). CHOA ads intended to raise
awareness of this epidemic and alert caregivers, parents, and children (10). CHOA
utilizes a “Tough Love” approach disseminating slogans such as: “Fat kids
become fat adults”, “Stop sugarcoating it Georgia ”, “Warning: Being fat takes
the fun out of being a kid”, "My doctor says I have
something called hypertension," she says. "I'm really scared", and "75
percent of Georgia parents with overweight kids don't recognize the problem"
(8,9,10,11). Linda Matzigkeit, vice president of CHOA, explained that this
campaign “has to be harsh” as parents are in denial and their children are
developing conditions prevalent in adults (8). In contrast others question CHOA’s strategy,
raising concern as negative connotations toward the target population exist (8). Although Georgia’s campaign alerted viewers,
it fails to combat the issue of childhood obesity as the following flaws are
present:
1. promotes stigmatization, 2. leads to victim
blaming, and 3. lacks self-efficacy
and plan of action.
Critique 1: Promotes
Stigmatization
Though CHOA’s ads are aimed to increase
awareness of Georgia’s health crisis of childhood obesity, their messages
increase the presence of social stigma. Rather than encouraging children to
develop healthy habits, a variety of health experts and parents agree that
CHOA’s campaign ads will make overweight and obese children feel ashamed of
their bodies, exhibiting stigmatization (physical bullying, verbal teasing, and
relational victimization are several components of stigmatization) (12). Overweight and obese youth are at risk
for facing social stigma, which may lead to serious consequences for emotional
and physical health (12). Associated with depression, low self-esteem, body
dissatisfaction, and difficulty developing personal relationships, stigmatizing
youth can negatively impact their health status (12). One study examined how obesity results in a
negative sense of self and a complex relationship with food (13). Study
participants used adjectives such as ugly, blob, freak, and disgusting to
describe their identity. They highlighted food’s association with emotional
regulation, social behavior, and an addiction (13). Even though stigma may
promote behavioral change among some individuals, this study concluded that
predominately stigmatization exacerbates the problem of obesity (13).
CHOA’s ads fail to recognize the
importance of self-esteem in children’s hierarchy of needs. Abraham Maslow’s
Hierarchy of Needs acknowledges different stages of human needs and how such
needs effect motivation and behavior (14). The main five components include:
physiological (breathing, food, water, sex, sleep), safety (security of body,
employment, resources, family, health), love/belonging (friendship, family,
sexual intimacy), esteem (self esteem, achievement, respect of others), self-
actualization (mortality, creativity, problem solving, acceptance of facts) (14).
In order for one to tackle higher levels, prior unmet needs must be achieved. Children
and adolescents will not be able to sufficiently address healthful diet and
exercise behaviors if their basic need for self-esteem is unmet. Failing to address the issue of self-esteem
and decrease overall stigmatization, interventions to combat childhood obesity
will likely lack effectiveness in motivating and changing behavior.
Critique 2: Leads to Victim
Blaming
Another flaw of the ‘Stop Childhood
Obesity’ campaign is the use of victim blaming. One major disadvantage of the
Health Belief Model (HBM), utilized in this campaign, is victim blaming. Two components
of the HBM include: perceived perceptibility and perceived severity. The main reasoning strategy for one to take
action includes: 1. susceptibility, 2. severity, 3. assess discomfort, 4. asses
if severity or susceptibility way more heavily, and finally make a decision
(15). Strong4Life’s ‘Stop Childhood
Obesity’ campaign utilizes the HBM, assuming by informing a child he/she is
susceptible or is overweight or obese, motivation will occur and behavior will
change. CHOA’s ads manipulate feelings of fear and guilt and by telling an
individual: “Chubby isn't cute if it leads to type two diabetes"; “My Doctor
says I have something called hypertension and I’m scared and "Being fat
takes the fun out of being a kid" (8,9,10,11). When
such emotions are present, the child believes he/she is doing something wrong
and being overweight or obese is their own fault as something is wrong with
their beliefs, in turn leading to victim blaming. Victim blaming leads to viewing
behavior as being in control of the individual. Given the large range of
factors contributing to obesity (genetics, environment, poor dietary choices,
physical inactivity) it is clear that this is not an individual issue (16). Thus, if caregivers simply just tell their
patients they are overweight or obese and this is bad or puts you at risk for a
number of conditions, motivation and behavior change is less likely to result,
as blaming the victim is not an effective approach.
Critique 3: Lacks self-
efficacy and a Plan of Action
According to the American Psychological
Association: self-efficacy is ones belief in his/her ability to perform and
have control over their motivation, behavior, and social environment (17). CHOA’s ads do not promote a message that
transmits self-efficacy. None of the ads offer a plan of action to follow,
instead they are asked to ‘Stop Sugarcoating It.’ The black and white ads
portray a feeling of hopelessness among the worried looking children. For
example, as stated in CHOA’s ads: “My Doctor says I have hypertension and I’m
scared” or “Mom why am I fat?” lacks a solution or plan (8,9,10,11). Also one
video ad titled “Video Games” stars a young African American boy, who enjoys
playing video games by himself so he is not around people who make fun of him.
Children are just expected to be motivated to change their behavior after
viewing CHOA’s ads, however when negativity and unanswered question arise,
change is unlikely to occur. As stated
previously, 75% of parents do not recognize their child as being overweight or
obese, even after viewing CHOA’s ads, they may still not recognize them as
having this condition as a plan of action is absent. Although these ads depict
a picture of concern to alert caregivers and parents, the lack of a model to
follow can lead irrational decision-making and ineffectiveness. If overweight
and obese children lack the confidence to motivate themselves to set attainable
goals and change their behavior, the desired outcome to ‘Stop Childhood
Obesity’ is less likely to be achieved.
Conclusion
Public health interventions aimed to
combat childhood obesity are critically important. However, such interventions
need to be created and framed in a way to positively impact their audience.
Displaying video and billboard ads of overweight and obese children, in a black
and white somber manner, enforcing stigma and victim blaming as well as lacking
self-efficacy and a model to follow, Strong4Life’s ‘Stop Childhood Obesity
campaign is unlikely to empower viewers to change behavior. By reframing this issue in a way to positively
impact children and parents and provide an opportunity to set goals for a
healthier lifestyle, will result in a more effective campaign.
Proposed Intervention
The ‘Stop Childhood Obesity’ campaign was
effective in alerting caregivers, children, and parents as well as gaining
exposure of childhood obesity. However, several flaws are present in the above
campaign as noted. Successful public health interventions impact individual as
well as society levels (18). Therefore, relying on children and their parents
to overcome this multi-factorial health condition can be overwhelming and
ineffective. The proposed campaign will
have the same goal as Strong4Life’s initial campaign, to address the issue of
childhood obesity. Reducing stigmatization and victim blaming and promoting
self-efficacy along with a plan of action are the proposed interventions
addressed below. In order to plan an effective intervention where childhood
obesity rates are prevalent, as in Georgia, the aforementioned components will
be implemented in a positive manner.
Intervention 1: Reduce
Stigmatization
Unfortunately, the presence of
stigmatization may always be present in the lives of overweight and obese
children; however reducing this issue when able is imperative. Incorporating
the Social Cognitive Theory (SCT) will address the stigmatization issue present
in Strong4Life’s current campaign. Self-efficacy is a key component to the SCT.
Three factors that effect one’s behavior in SCT include: interaction with the
environment, the behavior witnessed, and the individual themselves (19). Alienating obese and overweight children, as
depicted in CHOA’s ads, leads to such individuals being frowned upon. CHOA’s
ads single out overweight and obese children by failing to address children at
risk who may have a normal BMI but practice unhealthy behaviors. Various health
conditions may develop later on in life from sedentary and unhealthy manners applied
in childhood. Therefore such ads neglect a large population of children who are
at risk and focus on shaming overweight and obese youth. Authors suggested that
if society increases its acceptance and decreases negative attitudes and
behaviors toward obese children, stigmatization would decrease (20).
The Obesity Action Coalition combats
weight bias and stigma by educating the general public by acknowledging such
discrimination exits (21). Discussing
obesity in an open compassionate manner may not be able to change how people
feel but how they act (21). “Society shapes what is acceptable and what is not.
We have the ability to change how we conduct ourselves, if not totally then
partially” (21). It is our turn to act
as leaders and step up, changing the way overweight and obese individuals are
accepted in society.
The proposed campaign
will showcase advertisements of normal weight and overweight and obese children
under a headline stating, “Join Us On A Path to Set Goals and Make Healthier
Choices, We Wont Let Junk Food and Soda Get in Our Way”. By promoting a positive interaction
between overweight/obese children and their peers, utilizing colorful and
lively billboards and video ads, will in turn decrease the discrimination faced
by overweight and obese children. Displaying
ads of all children in various weight categories eating healthy or
participating in sports will reduce weight stigmas as an encouraging message is
being sent to society. As explained in the SCT, by one person modifying a
behavior, he/she is changing the environment that can be modeled if other
people follow (19). Thus, by accepting overweight and obese children into
society and then showcasing an interaction of all children (disregarding their
weight status), others may incorporate such model into their lifestyle.
Research suggests that sharing beliefs builds emotional
support, acceptance, and security in social groups (22). Demonstrating pictures and videos of distinct
children creating a bond, all children can act together to stop childhood
obesity by changing their perception about nutrition and physical activity. Acknowledging
that everyone needs to make beneficial dietary choices and everyone needs to be
active to live a longer healthy no matter how much you weigh, weight stigmas
may reduce. A campaign initiated in NC,
Peer Power, develops positive health behavior change by training high school
students to be educators and mentors t0 their younger counterparts (22). Peer involvement in public health campaigns
can truly make a difference, as one’s behavior may be willing to change by
having support from not only their parents or doctors, but also their
peers. Therefore, increasing
self-awareness, changing society’s behavior toward individuals affected by obesity,
and implementing the SCT are imperative components to apply in Strong4Life’s
campaign so overweight and obese children can gain self-esteem and motivation
to change their behaviors.
Intervention 2: Minimize Victim Blaming and Build Community Awareness
Towards Childhood Obesity
Overweight
and obese children deserve the same medical attention, compassion, and interest
as others diagnosed with chronic conditions (20). Genetics and metabolism play
a huge role in weight gain. Thinner individuals may consume the same amount of
soda or junk food as their overweight/obese counterparts and not even gain a
pound. Blaming children and their parents for letting
weight get out of control is ridiculous. This fast-paced society, with both
parents or single parents working, may rely on convenience highly process
foods, in turn leading to weight gain and/or unhealthy behaviors. If families
lack the education, money, or support to help develop a healthier lifestyle,
they shall not be blamed for a health crisis such as childhood obesity. Rather
than placing blame on the individual or his/her family, the following should be
addressed: food security, safe play grounds, foods/beverages allowed on food
stamps, and current policies in school. As described in Intervention 1 above,
once weight stigma is reduced a relationship between overweight and normal
children will most likely form. Once a relationship is formed, the parents and
caregivers can get on board to build community awareness, in turn reducing
victim blaming and incorporating the SCT to address this epidemic. CHOA’s should depict confident and happy
looking kids of all sizes to show society a sense of community that all
children should make healthy choices and stay active quoting “ Join Us!” The
proposed intervention does not emphasize a number on a scale or threatening
kids they will be diagnosed with various conditions later on in life, instead a
more positive message is delivered supported by a community awareness model.
Intervention 3: Promote Self-efficacy and a model to follow
Rather than creating an image of
hopelessness, the advertisements will emphasize positive ways to boost
self-esteem and encouragement by promoting self-efficacy. Self-efficacy is present in several
behavioral change models, therefore if this is created, it is likely behavior
will change. Thus, public health
campaigns must implement easy steps and tools to follow for both children and
parents to understand and apply to their lifestyles. Ways to Enhance Children’s Activity &
Nutrition (We Can!), a public health campaign, aims to achieve self-efficacy
among children and their families. This national education program provides
tools and fun activities to increase physical activity, encourage healthy
eating, and reduce screen time (23). Campaigns
such as We Can! sets the stage for the implementation of future effective
public health campaigns.
CHOA will work with policy and lawmakers
in Atlanta to create an environment to help combat the obesity crisis and learn
strategies and ideas from other public health campaigns such as We Can! Overweight and obese children will understand
and see for their own eyes that change is possible. By incorporating the SCT
and having diverse children in the ads acting healthy and active, obese and
overweight individuals will feel less alienated. For example, by observing
actions and behaviors of others, individuals are more likely to change their
behavior by witnessing others participate in such behavior. CHOA’s billboards will
help build a model to follow by providing miles to the closet farmers market, a
sample grocery list, and fun ways to be active. One study demonstrated that
cooking with children improved children’s fruit and vegetable consumption along
with increasing self-efficacy (24).
While the color vibrant aids are aimed
toward parents, children, and caregivers, a separate model will be needed for
parents to follow. Providing a link with smart snacking, alternative beverages,
step-by-step recipes, family fun activities, etc. are resources parents can
utilize. Many parents do not know how to
help their children, instead of blaming them, CHOA’s will provide information
on how to support their children and move on to build a healthier lifestyle.
Conclusion
Although addressing the issue of
childhood obesity is imperative, doing so in a negative manner: inducing victim
blaming, lacking self-efficacy, and the absence of a model to follow will
unlikely change viewers behaviors. The
Children’s Healthcare of Atlanta Pediatric Hospital can progress to a more
effective campaign if the proposed interventions are considered. The main goal
of the proposed interventions is to adapt a healthier lifestyle by reducing the
stigma, enhancing self-esteem, diminishing blaming, boosting self-efficacy, and
providing a model to follow. Implementing this campaign is just the
beginning, an abundant amount of educational resources shall be available for
parents and children in the near future. Proposing vibrant CHOA’s ads with
diverse children: “Join Us On A Path to Set Goals and Make Healthier Choices, We Won’t Let
Junk Food and Soda Get in Our Way” will empower children, parents, and
caregivers in a positive manner to motivate and change their behavior by
introducing or continuing a healthy lifestyle.
References
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