Monday, December 23, 2013

Strong4Life - Mariale Renna

            Rates of childhood obesity have risen dramatically and obesity is now considered an epidemic. Obesity has more than doubled in children and tripled in adolescents (1). As of 2010, one in three children were considered obese. Additionally, these children are at no less risk for comorbid conditions than adults, and many experience conditions such as Type 2 Diabetes, hypertension, and dyslipidemia (1). This is especially relevant as obese children are more likely to become obese adults (2). Additionally, annual spending for an obese person may cost around $3200 per year versus a non-obese person’s $512, resulting in significant strain on the healthcare system (2). Aggressive prevention efforts were made in order to reduce the growing problem of childhood obesity. However, many interventions were only somewhat successful, forcing public health officials to look to new strategies to keep childhood obesity at bay.
            In order to increase awareness of childhood obesity, the group Strong4Life released a series of ads targeted at obese children and their families. This campaign began in Atlanta, Georgia, where health advocates noted that over 1 million children were overweight or obese yet 75% of parents did not recognize the issue (3). These ads featured photos of overweight children with a large, red “warning” and a tag line stamped over their bellies. Tag lines were often offensive, shaming children for their weight, and the ads received serious backlash within the Atlanta community (3). While the tactic to stop sugar coating the truths about childhood obesity may have been effective, the campaign failed to recognize the importance of eating behaviors, self-esteem, and strong core values in order to entice people to change. Additionally, the campaign did not provide any tools to increase self- efficacy and allow people to feel confident that changes could be made towards a healthier lifestyle.
Health Belief Model
The Strong4Life Ads Wrongly Assume All Eating Decisions are Rational
            Our bodies use our food as fuel. Food is broken down and metabolized into essential components for energy, health, and body maintenance. Hunger occurs to signal the need for energy and continue these necessary processes. However, many people do not only eat when they are hungry. Emotional eating is when one consumes food in order deal with feelings but not satisfy hunger (4). This can be problematic as emotional eating can affect overall weight and health status, as many do not connect feelings to food consumption.
            Every individual has his or her own unique comfort foods, which are foods one turns to during emotional eating. These foods may be sweet, like ice cream, or savory, like steak and potatoes, and serve to soothe negative emotions or reward positive ones. However, comfort foods are traditionally high in fat and have an addictive quality, making one repeatedly reach for that food when emotions peak. This is especially troublesome as excess eating may contribute to weight gain other health complications. One study by Sung et al found that emotional eating was positively associated with weight gain (5). Another study by Chelser et al found emotional eating had a significant effect on weight lost in bariatric patients. Patients who did not receive behavioral therapy prior to surgery lost approximately 53% of excess body weight in comparison to an 84% loss in patients who received therapy (6). While weight loss was expected in both groups due to the surgery, greater weight loss was seen in the therapy group because potentially detrimental eating behaviors were reduced, thereby decreasing total caloric intake and increasing weight loss (6).
            The crux of emotional eating is that it is not rational; people do not think if they are experiencing physical or emotional hunger before reaching for their favorite foods. Here is where the Strong4Life campaign fails. It’s assumed that simply by feeling guilty about their weight, children will begin to make rational food choices. This is not the case. Emotional eating scales can be used to score the degree to which one emotionally eats, and obese children tend to score higher than their non-obese counterparts (7). Moreover, feeling physical inadequate can strongly correlate to and increase in emotional eating (7,8). This shows that obese children are no less likely to emotionally eat than other children; in fact, the obese population may at even greater risk. The effect of these ads has been the opposite of what they intended to do. If viewers feel shame, depression, guilt, and anxiety after exposure to the ads, they may emotionally eat in order to suppress the negative thoughts about their weight (7, 4).
            It is extremely difficult to “unteach” emotional eating. It is, however, possible. It starts with awareness of what emotional eating is and what may trigger it. Ideas for strategies on how to deal with the triggers are also necessary. The Strong4Life ads do not provide any information to children or parents on emotional eating. Additionally, the campaign’s website does not provide any tricks to minimize emotional eating. As emotional eating is multifactorial and unique to the individual, providing hotlines, group counseling sessions, or other emotional outlets may be a better a better alternative.
The Strong4Life Fliers Lack Tools to Support Self- Efficacy
            While lifestyle changes may be necessary, one’s ability to make modifications may be affected by their lack of belief that they can effectively implement and sustain the changes. Self- efficacy is defined as a person’s belief in his or her ability to take action (8).  Those who have high levels of self- efficacy are more likely to challenge themselves, be intrinsically motivated, and attribute shortcomings to themselves instead of blaming external factors. However, those with low self- efficacy believe they cannot be successful and thus may put less effort towards making a change (8). This affects weight loss and healthy eating because those who are not confident in their ability to lead a healthy lifestyle will not be able to effectively do so.
            Research supports higher self- efficacy can increase weight loss and healthy lifestyle habits. Shin et al studied the relationship between self-efficacy and subsequent weight loss in overweight and obese women. The study showed that participants with a high level of self- efficacy had a significantly greater chance of losing 5% or more of initial body weight in comparison to those with low self- efficacy. The researchers concluded that promoting self- efficacy may boost people’s confidence towards curbing negative eating habits, which helps increase weight loss (11). A similar study by Roach et al aimed to see if attitude changes could improve healthy lifestyle behaviors. They found that as self- efficacy improved, positive eating habits and weight loss were also improved than in those with lower self-efficacy (12). This research shows how one’s belief in their own abilities can affect their final health outcomes (11,12).
            However, self-efficacy can be taught and encouraged. Setting specific, short term goals challenges people while enabling them to meet their goals because the goals are not viewed as unobtainable. Additionally, providing successful role models can help people learn positive habits. Allowing people to make their own decisions, encouraging accurate objectives, and providing frequent, focused feedback can help to increase self-efficacy (8) by promoting more positive attitudes about one ’s self and potential achievements.
            The research showed that higher self- efficacy can help encourage lifestyle changes. This is one area in which the Strong4Life ads are strongly flawed. The ad labels children as obese and tries to shame them to lose weight. However, no tools are provided to make these changes. While these families may have financial, social, and emotional support, they will not reach their goals without the appropriate tools (10,11,12). Furthermore, communicating the need to change may also be difficult with a sensitive topic. Parents may not recognize potential health dangers of an overweight child and may feel the fliers are bullying or discriminating against heavier children. Providing parents with suitable tools will help them implement changes in their homes without feeling like they are hurting their child. However, it is not enough to just provide example and resources (10). Families (particularly parents) need to feel as though they can actually integrate the changes into their lives. This can be done through group workshops, such as grocery store interventions or nutrition classes, as well as private counseling. This can provide families with the education and resources they need to make healthy changes and reduce destructive behaviors.
            By the Health Belief Model, the Strong4Life campaign is flawed for multiple reasons. First, the campaign assumes eating behaviors are rational and making children feel negatively about their weight will spur them to make healthier choices. This may not be the case as negative emotions may actually increase emotional and irrational eating, leading to weight gain. Second, the campaign fails to provide tools that increase self-efficacy towards making healthier decisions and changing habits that may lead to weight gain, such as emotional eating. Ultimately, children experience self- destructive thoughts and continue the behaviors that contribute to these thoughts, while feeling helpless and unable to fix these problems. Thus, improving self- efficacy in order to encourage healthy eating and behavioral habits is absolutely essential.
The Strong4Life Ads Disregard Essential Components in Maslow’s Hierarchy of Needs
            People have the ability to make lifestyle changes, but complex decision making only happens if basic needs are met. Maslow’s Hierarchy of Needs Theory is commonly used for explaining personality differences and decision choices. This theory states that humans strive to become a fully functioning, self-actualized person by the movement through five stages of needs (13). This theory is presented as a pyramid, with the most fundamental needs (food, breathing, homeostasis) at the bottom and with self-actualization at the top (14). The needs below self-actualization are referred to as deficiency needs, and in order to become self- actualized, these needs must be satisfied (13). If not, the person will feel dissonance and will not be able to fully satisfy the next higher stage.
            Obesity may affect various stages in the Hierarchy of Needs, thus making it more difficult for this population to become self-actualized and make complex decisions. The one deficiency need that may be most affected is “Esteem.” People have a need to feel respected and accomplished and low self- esteem may hinder one’s ability to become self-actualized. Research shows that the obese often have significantly lower self- esteem than their non-obese counterparts (15). This may lead to amplified feelings of sadness and loneliness and increased rates of drinking and smoking in obese children (16). Additionally, the obese may be more likely to commit suicide or have suicidal ideations (17).
               Here is where the Strong4Life campaigns are flawed. These ads shame children for being overweight, which may further decrease their self- esteem. With low self- esteem, these children will not become self-actualized and properly address the complex decisions and potential struggles associated with weight loss and lifestyle modifications (13, 14). Additionally, if these ads target overweight youth and make their bodies out to be shameful or grotesque, then these children may be subject to bullying and obesity stigmatization, which will further decrease self-esteem (18). As this may lead to increased obesity or failed weight loss attempts, these ads may do the opposite of their intended purpose (19). In order for these children to become self-actualized, self-esteem must be raised. This can be done through group activities which focus on a child’s attributes other than their bodies. Additionally, awareness and education may help to create a more favorable climate for the obese population.
Social Marketing and Advertising Theory
The Strong4Life Ads Fail to Consider Core Values Other Than Health
            The foundation of the social marketing theory is to make an item appeal to an entire population based on core values other than health. A core value is the root motivator or supporter behind a particular action; it is typically tied to strong emotions and basic rights. Health alone is not a strong core value because it can be emotionally overridden by stronger values, such as acceptance or liberty (20). Additionally, social marketing theory provides the target audience with a “package” of benefits that is targeted at this audience’s deeper desires (20). For example, research shows that almost all teenagers are aware that smoking can kill and lead to other health consequences. Yet, the incidence of smoking has increased (21). This is not due to ignorance of health consequences; it is, however, caused by a teenagers need to rebel and feel accepted. Many youth feel that smoking, similar to piercings and dyed hair, signals that they are in control of their own life decisions (21). Thus, the motivator for smoking is a stronger, deeper value than the reason not to smoke (health). Independent of its addicting nature, this is another reason that makes smoking cessation difficult: it fills a deep emotional need that is more powerful than the potential health consequences (20, 21).
            In this case, the Strong4Life campaign is strongly flawed. The core value that is the center of their campaign is health, as seen by the fat shaming which is not a strong enough motivator to change. Additionally, the campaign does not help children to find their own core value that serves as their inner desire to change. More importantly, the Strong4Life campaign does not promote change by appealing to the audience’s deepest desires nor does it provide any meals to reducing barriers that may prevent them from achieving these desires (3,20). For example, the ads could’ve shown a picture of a child in a clothing store, starting longingly at the clothes on the mannequin. This would appeal to the child’s desire to fit in through clothes, and may encourage children to change as materialistic items (such as clothes) are important to teens. The current campaign does not support self- interest and will not encourage children to make changes and fails as a social marketing campaign.
The Proposed Intervention: The “I CAN” Campaign
            While the idea behind the Strong4Life fliers was well intended, the end result ultimately was ineffective. No dramatic weight loss was seen in Georgia’s youth as a result of these ads. Thus, I feel the campaign can be improved with some changes. I propose changing the campaign from a nameless fat-bashing ad to the “I CAN” campaign. The “I CAN” campaign is not just a series of fliers but a movement designed to help improve the health of Georgia’s youth. Community based movements have been found to be more successful in altering behaviors than shock campaigns or individual interventions (22).  The campaign would help to improve youth health through interactive, community- based classes with trained staff and mentor figures. The campaign, therefore, does not focus on weight loss but creating a healthier individual on all accounts.
Intervention #1:
The “I CAN” Campaign and Self- Esteem/ Self-Efficacy
            The first change I propose would be to resolve the major issues of self-efficacy and self -esteem.  In terms of self- esteem, The Strong4Life ads actually harm a child’s self- esteem by labeling them as fat. A label of obesity is often associated with other negative adjectives, such as lazy and lack of self -control. These negative labels can exacerbate the stigma against obese people, thus lowering self- esteem.  Additionally, according to Maslow’s Hierarchy of Needs, low self-esteem may prevent children from tackling the complex decisions often associated with losing weight (13,14). Thus, raising self-esteem is absolutely and essential component for the child’s success.
            The “I CAN” campaign would raise the self-esteem of overweight and obese children by creating an accepting and non-judgmental environment. This is due to the idea that if an overweight child is pointed out of the crowd, they may feel embarrassed or shamed. However, if they were part of a crowd who accepted them, then these kids should not feel embarrassed to do activities and may be more likely to push themselves because there is peer support. Unlike the Strong4Life campaign, the “I CAN” campaign provides a sense of community and belonging for obese children and their families. This ultimately will help to raise self- esteem, which 
            Self-efficacy also plays an essential role in the implementation of healthy life changes. However, the Strong4Life campaign provides no tools to increase self- efficacy to either children or their families. While the ads provided links to the main campaign website, the information is generally useless if the families do not understand it or feel they cannot make the necessary changes. More importantly, simply providing information or pictures of people performing healthy activities is not enough. Self-efficacy can be increased through hands on-activities to reinforce learning, as well as making small but achievable steps towards the goal (10).
            In order to address this issue, the “I CAN” campaign will hold interactive group classes aimed to teach basic nutrition skills. The classes will be run by a dietitian in a community location (such as a town meeting hall, high school kitchen, etc) and will be geared towards both children and their families. Classes will feature basic nutrition education on topics such as healthy snack choices, nutrient density, and label reading. Cooking demos and grocery store trips may be used to reinforce the family’s learning and show them that small changes are not impossible.  All lessons will be recorded and posted online for those families who cannot attend. Additionally, group exercise sessions, such as a walking club or weekend hikes, will allow youth to try new activities without feeling embarrassed because of their weight.
             Finally, the slogan for this campaign is set up to address both self-esteem and both self-efficacy. The “I CAN” campaign is centered on the slogan “I Can Because I Am…” This slogan is intended to empower children and their families with the idea that they can make changes and raise self- esteem by praising the kids for who they already are. For example, a child may choose to fill in the “I Am” portion with the word “Smart”. This raises the child’s self –esteem because it emphasizes that they are smart, which is an attribute they should be proud of and focus on instead of their weight. Additionally, this labels the child with a positive label, such as smart, strong, or creative, instead of the negative terms generally associated with obesity. This also increases self-efficacy by reminding the child that they can achieve their goals, and they have an attribute (independent of their weight) which will allow them to succeed (15, 16).
Intervention #2:
The “I CAN” Campaign and Rational Eating Behaviors
            Furthermore, the Strong4Life ads failed because they assumed all eating decisions are rational and did not consider emotional eating as an important yet complex factor in obesity. The ads labeled children as obese and shamed them for their weight, but did not address the issues behind their weight gain. This is essential as negative emotions can actually increase irrational eating behaviors, thus exacerbating the disease. Obesity is a multifactorial disease and simply pointing out one’s weight status will not alter factors behind their abnormal eating (4,7).
            The “I CAN” campaign hopes to address the factors behind a family’s eating habits through workshops and forums. The topic of emotional eating will be mentioned in many of the group settings because families may not even be aware of what emotional eating is. Once identified, the families can then work with campaign staff on ways to reduce it. Some research has identified that up to 25% of people could continue to make unhealthy snack choices, even when they pre-selected a healthier snack (23). This shows how important it is to help these children cope with emotional eating. Methods to solve emotional eating may be addressed during group sessions. For example, the dietitian could discuss the difference between physical and emotional hunger and make suggestions such as drinking water or chewing gum when one thinks they may be experiencing emotional hunger. More importantly, the campaign provides healthy alternatives to emotional eating, such as outdoor activities, music, and cooking class. These activities may serve as an outlet for the children and teach them other ways to deal with emotions (4). Finally, peers and staff members can serve as channels for the children when they may be experiencing emotional trouble (4).
Intervention #3:
The “I CAN” Campaign and Core Values Beyond Health
            Another essential component to the campaign’s success is appealing to a core value beyond health. This is important because if the core value were to serve as a motivator to change, then a weak core value may not entice people to alter their habits. The Strong4Life ads only had a core value of health, which is not strong. The value of health may not motivate families to change when another core value, such as freedom to make their own choices, opposes the desired action. However, the “I CAN” campaign hopes to address this lack of a strong motivating core value. The slogan of “I Can Because I Am…” hopes to provide children and their families with a stronger reason to change their habits. The children will identify with their label (smart, funny, nice, etc) and potentially realize that their weight does not fit this label. For example, if someone writes “Nice”, they may feel that their weight is impeding new friendships. Thus, they will change their habits on the core value of “acceptance” which is a much stronger motivator over “health”.
            Childhood obesity has become a growing and more concerning issue, as obese children are at the same risk for the development of comorbid conditions as adults (1). Has many prevention efforts have been unsuccessful, the Strong4Life campaign published a series of ads in order to stop sugarcoating the truths of childhood obesity. However, these ads were met with resistance and did not provide the intended results. This is because these fat shaming ads fail to ignore the importance of self-esteem, a critical component in Maslow’s Hierarchy of Needs Theory, as well as self-esteem and core values that are stronger than health. Additionally, the campaign fails to acknowledge that many eating decisions are not rational. In order to account for these key components behind childhood obesity, the Strong4Life ads should become a community-based movement in which children’s self confidence and self-esteem are increased while learning about healthy eating behaviors. The community/ movement design will allow for peer support and outlets for negative emotions in a nurturing environment. This kind of movement hopefully will tackle many of the difficulties behind obesity that health promotion ads struggle to solve.

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