Monday, December 23, 2013

A Critique of Georgia’s Campaign to ‘Stop Childhood Obesity’ – Samantha Budwit

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.

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.

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.


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