Fat-Shaming, An Ineffective Way of Motivating People to Lose Weight: A Critique of the Strong4Life Campaign - Alicia Zonenshine

Introduction

Over the past two decades, obesity has made its way to the forefront of our nation’s health issues.  This is not only an issue for the adult population, given that it is estimated that 16.9% of American children between the ages of 2 and 19 years old are obese (1).  There are a number of social consequences of childhood obesity which include increased risk of depression, lower self-esteem, lower self-acceptance, and lower life satisfaction (2). In addition, there are also increased risks for cardiovascular disease and all-cause mortality in those that are overweight during their childhood years (3).  It is well known that an effective intervention is necessary to slow the increasing number of children that are overweight and obese.  A number of interventions have been implemented, yet positive results have yet to be seen. 

            One such intervention that has been implemented in Georgia is called Strong4Life (4).  The focus of this campaign is to “stop sugarcoating,” and be blunt with the people of Georgia to get them to make a positive change and stop childhood obesity.  The campaign includes billboards with pictures of overweight children and sayings such as “Fat prevention begins at home.  And the buffet line,” and “It’s hard to be a little girl if you’re not.” (5)  These billboards have stirred up quite the commotion amongst residents of the Atlanta, Georgia community.  Many feel that such a frank campaign will not be effective in stimulating a constructive change, but instead will further stigmatize the children that are overweight and obese (5).  This may also not be the most effective way to motivate children and their parents to adopt a healthy lifestyle. 

            There are obviously a number of people that believe that this is the most effective way to approach the problem of childhood obesity.  Linda Matzigkeit, vice president of Children’s Healthcare of Atlanta, says, “It has to be harsh.  If it’s not, nobody’s going to listen.” (6)  On the surface, this might seem to be a logical explanation.  However, there is a large body of research that suggests that this is not the most effective mechanism of motivating these youngsters and their parents.  There are a few inherent flaws that are detrimental to the design of this intervention, which include the stigmatization of overweight youth, the use of low self-efficacy messages, and the use of fear as a motivation to get people to do something.  Looking at these more in depth will show the ineffectiveness that this intervention is bound to experience.

Flaw 1: Stigmatizing overweight youth

            The Strong4Life campaign is very centralized on the theory of the Health Belief Model.  The Health Belief Model is based on the thought that there are four motivating factors to a person's actions: perceived susceptibility, perceived severity, perceived benefits of an action, and perceived barriers to taking that action (7).  While in theory this seems to make sense from a health perspective, there are a number of reasons why this limits the scope of the Strong4Life campaign.  This model does not apply well to long-term interventions; it is only really effective when it is a one-time thing that you are trying to motivate people to do (8).  This obviously is not promising when applied to a program where the main intended outcome is weight loss.  This model also assumes that the person is in a vacuum and is not influenced by other people, and that people’s actions are reasoned and planned.  In addition, a major assumption that is made is that people value their health more than other things.  This assumption is made in the Strong4Life campaign, and it is definitely one of the bigger flaws of the program (8).  With this program, they are assuming that the parents, who are the intended audience, care more about the health of their children than the freedom to live as they want.  Even though many of the parents of overweight and obese children obviously do care about the health of their children, threatening to take away their freedom to eat and live as they want is more frightening than taking away their health.

            In addition to utilizing the Health Belief Model, the ads and commercials used for the Strong4Life campaign show images of overweight and obese children in a negative semblance.  The billboard ads in particular consist of pictures of overweight youth written over with a bold red “WARNING” label with things such as “Chubby kids may not outlive their parents” written underneath (5).  Overweight and obese youths and adults already deal with so much negative energy in other aspects of their lives that this is only distressing them more.  In a study by Sutin and Terracciano, it was shown that weight discrimination is associated with factors that can cause obesity, including excessive caloric intake and lack of physical activity (2).  They found that for the participants that were not obese at baseline, those that were exposed to weight discrimination were 2.5 times more likely to become obese by follow-up, which was 4 years later (2).  This demonstrates how negative language such as the words “fat” and “chubby” are only further demoralizing these children and their parents.  Not only are these ads stigmatizing overweight and obese children, they are causing more anxiety and perpetuating the problems that these kids are already having to deal with.  Other studies have shown that stigmatizing weight may worsen such medical conditions as hypertension, cortisol reactivity and also the risk for hypertension (9).  By branding these children with words such as "fat," these ads are likely promoting the risk for further psychological and physical health problems.

Flaw #2: Lack of self-efficacy-inducing motivation

            The negativity that these ads bring about not only defames those that are supposed to be helped by them, but also they do not allow for any self-efficacy to be shaped.  How effective can a campaign truly be when it is not motivating and instead is giving its target audience the feeling that they have already lost their battle?  The messages that these ads embody go against the Social Cognitive Theory, which focuses on self-efficacy, or the belief that you are able to do something (10).  This theory explains the fact that self-efficacy has a large impact on both motivation and action (10).  The negativity that these ads put forth does not allow the children and parents that see these ads to achieve a feeling of self-efficacy.  They are essentially knocking these children down and telling them that they have already failed.  If these children believe that they have already failed and that being healthy and losing weight are out of their reach, they are not going to be motivated to change and try to achieve these things.  They will not believe that they can lose weight, join a sports team, or even live a healthy life.  Social Cognitive Theory also takes into account that the environment, individual and the behavior can all influence one another (11).  With that being said, if the environment that is being created is so negative and puts these children down, that is not going to influence the individual or the behavior in a positive manner.  Most likely, the behavior will be viewed negatively, and the individual will not feel as if they are capable to, nor will they want to, do the behavior that the ads are trying to induce.

            The lack of self-efficacy created by these ads goes past merely affecting the children that are being targeted.  These ads are also placing blame on the parents of these overweight and obese children.  One ad in particular features a child that is overweight, with the wording, "He has his father's eyes, his laugh, and maybe even his diabetes." (12)  Not only does this ad make the parents feel as if they have failed their child, but also it is sending a message to the child that it is his or her parent's fault that he or she is overweight.  Thinking about this in the terms of the Social Cognitive Theory, this is creating the same negative environment for the parents, who are supposed to be the intended audience of these ads.  Blaming the parents is inherently saying that they have done something wrong and that they are "bad" parents for letting their children get to the unhealthy state that they are in.  This most likely is going to create a sense of defensiveness for the parents, causing them to not want to listen to these ads.  Overall, these ads have the same effect as they do on the children, not allowing for self-efficacy or the feeling that losing weight and living a healthier lifestyle is achievable. 

Flaw #3: Trying to scare the fat out of people

The frame that this campaign is using is centered around the health consequences of being overweight.  Despite the fact that for most people health is extremely important, as was mentioned before people are known to not make decisions rationally.  As with the Health Belief Model, this is an assumption that many other models used by public health campaigns make (8).  Because people are inherently irrational in their decision making, using a frame that is focused on health is not always the strongest motivator.  Moreover, the way in which this campaign is framed is very negative.  It is presenting the issue in terms of the loss of health that these children are encountering.  Presenting an issue with what there is to lose is going to be far less effective than if it is presented in the form of what there is to be obtained.  It is also known that although in some situations fear may be a good motivator, it is not always so (13).  As reported in a meta-analysis by Witte and Allen, if a campaign is using fear as a motivational tactic, it should be used in conjunction with a high-efficacy message.  If fear is used alongside a low-efficacy message, such as is used by the Strong4Life campaign, there is a higher chance that the response is going to be more defensive and do the opposite of what is intended (13).  Although fear can be an effective way of motivating people to do something, the use of fear needs to be used properly in order get the desired effects.

The fear devices that the Strong4Life campaign uses can also be related to the Psychological Reactance Theory.  This theory states that if certain behaviors are threatened with eradication, the person affected will be motivated to fight for that freedom by however they feel fit (14).  This generally results in the person clinging even more strongly to the threatened belief (15).  In this case, by creating such a shocking ad and threatening the freedom of choice that every American citizen values, the ads are really generating a reactance that will cause the viewers to hold on to that freedom.  Most likely this will manifest in the form of continuing with the lifestyle choices that they are currently making.  This therefore compounds the effect of using stigmatizing and low self-efficacy messages.  Essentially, these ads have potential to do the exact opposite of what the campaign has set out to do. 

            It is fairly clear that using a scare technique in the Strong4Life campaign has its downfalls, yet there is another obstacle related to this that is not addressed by the ads and commercials.  This is the fact that the majority of parents of overweight and obese children do not recognize that their child is at an unhealthy weight (16).  There are a few hypotheses as to why parents do not recognize when their child's weight is an issue, including ethnicity, the gender of the child, and the weight status of the parents (17).  This may also be related to the Law of Optimism Bias, which states that people tend to underestimate their personal risk of something happening to them even when they overestimate the risk of that event happening to the general public (18).  The combination of parents not recognizing that their child is overweight and believing that their child is not at a high risk for developing the negative health outcomes outlined in the ads and commercials makes for an unsuccessful intervention.

Alternative Intervention

            In taking a closer look at the Strong4Life campaign, it has become obvious that there are a number of innate flaws that need to be addressed.  In order to do this, a new program should be put into place.  It would be easiest to start over, reframing the message and painting the picture in a more positive style.  The specifics of this proposed intervention are outlined in the following sections.

Positivity matters

            A big problem with the Strong4Life campaign which was outlined above is that it stigmatizes the overweight youth that it targets.  For this new proposed intervention, billboards will be used but instead of showing one overweight child they will feature a number of different people.  There will be some showing families, including those who are overweight or obese, spending time together.  All of the people in the ad will be happy and smiling.  Other ads will feature groups of children playing sports together or even just being outside together, but also having a good time doing so.  The purpose of these ads will be to get the children to join the movement to become healthier.  To do this, there will be messages written at the bottom of the billboards such as, "Join in the movement!" and "Let's move together!"  By having groups of children or families on the billboards, this takes away the stigmatizing factor of having just one overweight child on the billboard covered with negative words.  These new billboards will create a sense of community and they will target both the parents and children.  This will make joining the movement more like joining a group, making the participants feel as if they are a part of something positive.  There will be a website listed on the ads as well, so that those who want to become a part of the change will have resources that will help them to do so.  On this website, participants will also have the option to get certain merchandise.  Having things such as t-shirts or bracelets with the movement logo on it will allow those involved to feel even more a part of the group.  This can create a sense of ownership, which in this case would be the feeling that one owns the idea of being healthy (19).  One successful anti-smoking campaign that has used this technique is The 8ighty 4our, which targets youth that do not smoke and has essentially created a community of people that are proud of not smoking (20).  Using this approach for losing weight and getting healthy can create a feeling of attachment to the idea of being healthy, and should motivate people to not only work hard at achieving that goal but to also hold it closer with the more work that they put towards living a healthy lifestyle (19).  Presenting eating healthy and exercising more in this manner will allow the children and their parents to see these ads and respond to them in a more positive fashion.  

Induce self-efficacy

            Along with creating a more positive message for the youth and their parents that are the target audience of this new proposed campaign, using messages that more strongly promote self-efficacy will be employed.  The billboards that target more of the youth audience should still feature children that are overweight or obese so that those viewing the ads will be able to relate to them.  However the messages will be things such as a group of kids playing a sport, for instance basketball.  This will show the viewers that they are capable of being athletic and that they should not be afraid to join a sports team.  A child that sees this ad and is motivated to try a sport that they were previously too intimidated to try may be able to become more active and gain more self-esteem, which are positive changes all around.  In order to also target the parents through this campaign, some billboards should feature pictures of families engaging in physical activity together, or even cooking with healthy foods together.  This should have the same effect of promoting self-efficacy for the parents, showing them that it is possible to make positive changes for their families and that it is important to work together to achieve these goals.  In doing this, it is also allowing for both the parents and children to feel a sense of responsibility, instead of placing blame on the parents for causing their children to be unhealthy.

Re-framing the message

            Rather than using scare tactics to motivate people to get healthy, it would be beneficial for this new proposed campaign to focus on something different than merely health.  A more effective way to frame this message would be to use freedom as a core value.  This can be used by framing being healthy and active as a way to express one’s freedom and ability to do whatever he or she aspires to do.  This is related to the ads inducing self-efficacy; they should make people inspired and make them desire to live their lives as the people depicted in the billboards do.   Moreover, by reframing the intervention in order to entice people to join the movement, the fear tactics need not be used.  As was discussed, using fear as a motivator does not always work, and has to be used with higher self-efficacy messages (13).  This new ad campaign will eliminate the need for the use of fear as a motivator, focusing solely on the positive that can come from adopting healthy behaviors. 

            Another approach that will be used to target both parents and children is to use people that are overweight or obese in the billboards, but to present them more positively.  It has been shown that people are more likely to be swayed by someone that is similar to them rather than someone who is different (21).  By using adults that are overweight, the intended audience of the parents will be more likely to agree with the message and be encouraged to join the movement.  The same goes for the children if kids that are overweight are featured in the billboards, the targeted audience of overweight and obese kids will be more likely to listen to the message that the ad is putting forth.  In addition, by presenting this demographic in a more positive way, there will hopefully be less social stigma around weight.  This could potentially help to ease some of the social and psychological anxiety that many overweight and obese children experience.

Conclusion

            It has become increasingly evident that childhood obesity is an enormous problem in the United States and around the world.  Developing an appropriate intervention to help stop the increasing numbers of overweight and obese children throughout the world is extremely important.  Obese children are known to have an increased risk of cardiovascular disease and all-cause mortality than those children that are of normal weight (3).  In addition to these physical health risks, overweight and obese children have a higher risk of psychological issues such as depression, low self-esteem and self-acceptance as well as lower life satisfaction in general (2).  If something is not done to successfully slow and eventually stop this trend, the entire planet will be dealing with excessive health problems that we may not necessarily be equipped to deal with.

            Many interventions have been attempted in vain, including the Strong4Life campaign.  The flaws of this campaign were highlighted in this critique and were based on a number of different behavioral and social theories.  Specifically, those used to analyze the Strong4Life campaign were the Health Belief Model, Social Cognitive Theory, Framing Theory, Psychological Reactance Theory and the Law of Optimism Bias.  By using these different theories, it was determined that the Strong4Life campaign, which includes billboard ads and a few commercials featuring similar messages, is inherently flawed based on a few different reasons.  These flaws were centered on the stigmatization of overweight youth, the use of low self-efficacy messages, and the use of scare tactics.  In determining these flaws, a new intervention has been proposed which is based on the very theories that prove the Strong4Life campaign is unsound.  This new intervention will feature billboard ads that display messages such as “Join in the movement!” over pictures of kids playing sports together, or families cooking healthy meals together.  There will be no negative images of any person, child or adult, and there will be no blaming of any particular person.  Further information will be available at the website provided on the billboard where a person will be able to get further information on how to get healthy, as well as purchase items such as t-shirts or bracelets that exhibit the movement logo.  By being positive and showing kids and parents that they are capable of achieving a healthy lifestyle, this crusade will embody higher self-efficacy, a sense of ownership and commitment, as well as a sense of community.  These different methods, when used in conjunction, will hopefully aid in the fight against childhood obesity.

 References

1.                Ogden C, Carroll M.  Prevalence of obesity among children and adolescents: United States, Trends 1963-1965 through 2007-2008.  Health E-stat. 2010; 1-5.

2.               Sutin AR, Terracciano A.  Perceived weight discrimination and obesity.  PLoS One 8(7): e70048.

3.               Must A, Strauss RS.  Risks and consequences of childhood and adolescent obesity.  International Journal of Obesity.  1999;23:s2-s11.

4.               Children’s Healthcare of Atlanta.  Strong4Life. Atlanta, GA: Children’s Healthcare of Atlanta.  http://www.strong4life.com/default.aspx.

5.               ABC News.  ‘Stop sugarcoating’ child obesity ads draw controversy.  Atlanta, GA: ABC News. http://abcnews.go.com/Health/Wellness/stop-sugarcoating-child-obesity-ads-draw-controversy/story?id=15273638

6.               NPR.  Controversy swirls around harsh anti-obesity ads.  NPR: http://www.npr.org/2012/01/09/144799538/controversy-swirls-around-harsh-anti-obesity-ads

7.               Edberg M. Individual health behavior theories (pp. 35-49).  In: Edberg M. Essentials of Health Behavior.  Sudbury, MA.  Jones and Bartlett Publishers, 2007.

8.               Seigel M.  Social and behavioral sciences for public health. Boston University.  October 10, 2013 Lecture.

9.               Puhl RM, Latner JD. Stigma, obesity and the health of the nation's children. Psychological Bulletin. 2007;133(4):557-580.

10.            Bandura A.  Social cognitive theory of self-regulation. Organizational Behavior and Human Decision Processes. 1991;50(2):248-287.

11.             Seigel M.  Social and behavioral sciences for public health. Boston University.  October 17, 2013 Lecture.

12.            About-face.  Georgia's Strong4Life campaign relies heavily on fat-shaming.  http://www.about-face.org/georgias-strong4life-campaign-relies-heavily-on-fat-shaming/

13.            Witte K, Allen M. A meta-analysis of fear appeals: Implications for public health campaigns. Health Education and Behavior. 2000;27(5):591-615.

14.            Brehm JW. A theory of psychological reactance (pp. 377-390).  In: Burke WW, Lake DG, Waymire JP. Organization change. San Francisco, CA.  John Wiley & Sons, Inc, 2009.  

15.            Seigel M.  Social and behavioral sciences for public health. Boston University.  November 21, 2013 Lecture.

16.            Etelson D, Brand DA, Patrick PA, Shirali A. Childhood obesity: do parents recognize this health risk? Obesity Research.  2003;11(11):1362-8.

17.            He M. Are parents aware that their children are overweight or obese? Do they care? Canadian Family Physician. 2007;53(9):1493-1499.

18.            Ariely D. The high price of ownership; why we overvalue what we have (pp. 167-182). In: Ariely D. Predictably Irrational.  New York, NY. HarperCollins Publisher, 2010.

19.            Seigel M.  Social and behavioral sciences for public health. Boston University.  December 5, 2013 Lecture.

20.           The 8ighty 4our. Youth fighting for a tobacco-free generation in Massachusetts. http://the84.org/

21.            Roskos-Ewoldsen D, Fazio RH. The accessibility of source likability as a determinant of persuasion.  Personality and Social Psychology Bulletin. 1992;18(1):19-25.

The Fallacy of Fat Letters: Why the Health Belief Model Does Not Work- Katherine Ulrich

The prevalence of overweight and obesity amongst children is climbing nationwide (5, 10). Childhood obesity is problematic from a public health standpoint obesity in childhood is linked  to many adverse health outcomes later in life, as well as obesity in adulthood (1, 2, 3). In fact, “for children and adolescents with BMI above the 95^th percentile at any age during childhood, the probability of being obese at age thirty-five years ranged from 15 to 99 percent (3). Such adverse outcomes include hypertension, insulin resistance, metabolic syndrome, type 2 diabetes, asthma, obstructive sleep apnea, nonalcoholic fatty liver disease, and depression (1, 3).In many states the answer to this epidemic of childhood obesity is calculating BMI in schools and reporting the information in letters home to parents. In Massachusetts BMI reporting became a very controversial topic.

BMI reporting first became mandatory in Massachusetts public schools for 1^st, 4^th, 7^th, and 10^th grade students in 2009. The recording and reporting of individual students’ BMI information was to be confidential and reported only to their parents or guardians; nurses also reported aggregate data on all students was to the Massachusetts Department of Public Health by school nurses. School nurses were also carrying out the BMI screenings and calculations. Parents received BMI data regarding their individual children via mail or “secure internet portal” (7). Parents also had the option of opting out of having their child’s BMI calculated in school at any point. Healthy weight was defined as BMI from the “5^th percentile to less than the 85^th percentile”, underweight as BMI “[l]ess than the 5^th percentile”, overweight as BMI from the “85^th [percentile] to less than the 95^th percentile, and obese as BMI “[e]qual or greater than the 95^th percentile” (7). The results of BMI screenings from the 2010-2011 school year in Massachusetts showed that of children in grades 1, 4, 7, and 10 (n=205,975) 16.7% of students were overweight and 15.7% were obese. Prevalence of and obesity was also slightly higher in males (17.3%) than females (14.0%) (7).

            We can attribute the failure of BMI reporting in large part to its reliance on the Health Belief Model as a means of effecting change in health behavior. It is important to note that in the case of BMI reporting—in this context—the actors are the parents rather than the children. The Health Belief Model operates on the assumption that people will take “health-related action” because of (a) a specific health problem or concern that makes taking action important, (b) the idea of “perceived threat”, and (c) the conviction that adhering to a health behavior recommendation will reduce said “threat” or have some benefit (6). The use of the health behavior model as a method of framing BMI reporting proved deadly for the program and this is why.

Rationalization of Risk

            While data and literature support the reality that rates of overweight and obesity in children are on the rise in the United States—and Massachusetts specifically—this does not guarantee parents’ support for programs such as BMI reporting. The Health belief model posits that when people realize that their behavior or actions negatively impacts their health—or in this case the health of their children—they will cease these deleterious behaviors or actions (6). However, this assumption is based on the belief that human behavior is rational, a belief that is inherently flawed. Research demonstrates that parents often underreport their children’s weight despite the fact that they might be overweight or obese (9, 10). The reality that parents underreport their children’s weight points to the irrationality of the human thought process because despite the fact that they are aware of their children’s appearance they still do not register their weight as a potential health problem. This achieved ignorance highlights one reason that intervention based on BMI score reporting may not be the best option for effecting change in health outcomes.

            BMI reporting seeks to place irrefutable, concrete evidence of possible overweight or obesity in the hands of parents. However, the argument over the efficacy of BMI as a screening measure allows parents to rationalize the risk posed by ignoring BMI reports as the first sign of danger. As BMI reporting became a hot button issue in the media claims about the unreliability of BMI as a screening measure amplified parents’ feelings that BMI scores in percentiles denoting overweight or obese were not as much of a problem as schools and public health officials were making them out to be (12).        

            In only appealing to rational thought processes and rational evaluations of risk, public health professional made a grave error when rolling out BMI reporting programs in Massachusetts public schools. The health of their children is very important to parents and the assertion that they have done something wrong—or something that impacts their child’s health negatively—in their parenting is the message that BMI reporting sent as it played out in the media. This message activates a protective factor in parents—for both themselves and their child. Unfortunately, the best way to counteract this message that their parenting has fallen short in some way is to discredit BMI as a means of assessing their children’s health. Essentially, in the media portrayal of BMI reporting itself became the threat rather than obesity (6, 12).

The Danger of Victim Blaming

            In addition to overvaluing the place of rational thought in decision-making, the health belief model takes dangerous steps into the arena of victim blaming (6). The risk of overweight and obesity is much higher for children from socioeconomically disadvantaged backgrounds (1, 11). Because public health as a discipline has a stake in social justice in relation to health disparities, addressing health inequity such as disproportionate rates of overweight and obesity in socioeconomically disadvantaged populations is very important.

            Health belief model on the other hand assumes “that one can successfully execute the behavior required to produce the outcomes”, in this case referring to achieving BMI scores between the 5^th and 85^th percentile (6, 7). The assumption that everyone has the tools to “successfully execute” behaviors that will lead to positive health outcomes is erroneous. In the case of childhood overweight and obesity socioeconomic status is a social determinant, that has a great deal of influence over the increased vulnerability of a child to overweight and obesity. Health belief model has no allowances for social determinants however, which leads to the idea that all parents—regardless of circumstance—should be able to ensure that their children maintain a healthy body weight because they know that overweight and obesity increase the likelihood of negative health outcomes (6, 11).

            The implementation of a standardized measure of BMI reporting also fails to take into account the impact of social determinants that disparately affect specific populations more than others. This also has the potential to blame certain populations for being affected by these risk factors, which is incorrect as well as counterproductive. The best way to remedy this problematic standardization of programs is to implement specific, culturally competent interventions in populations and communities with increased risk for childhood overweight and obesity due to social determinants such as socioeconomic status (11). These interventions in high-risk populations should be carried out in addition to or in place of interventions implemented in populations that are not high risk.

The Crisis of Core Values

            Core values are extremely important in framing the way that public health interventions are implemented and perceived. In the case of BMI reporting in Massachusetts public schools public health officials unfortunately chose to frame this intervention around the core value of health. The Massachusetts Department of Public Health represented BMI reporting as a way of protecting the future health of children (7). There are two distinct ways in which selling the idea of BMI reporting as protective of children’s future health is flawed. First, people are less interested in modifying health behaviors when adverse health outcomes relating to their behaviors are years down the road. Second, this campaign for BMI reporting in public schools is based around health, which as a core value rarely inspires immediate action; even less so when the threat of adverse health outcomes is not immediate.

Because health in this case is refers to the health of children—for whom protection is a vested interest of parents—this frame of health is stronger than it is typically. However, the frame of health is still not strong enough. Rather than choosing health as a core value for BMI reporting as an intervention targeting reduction in overweight in obesity, public health professionals would have been much better served by choosing core values such as autonomy or family unity and basing interventions around these values.

How Can We Create a Culturally Competent Intervention?

            While BMI reporting was not necessarily a poor intervention in Massachusetts public schools in and of itself, the way it was carried out—following assumptions made by the health belief model—predicted its downfall earlier this year. Rather than trying to tweak BMI reporting, or reframing based in more competent public health theories I will propose an entirely new intervention.

            Historically, many public health interventions targeting children have been school-based because it allows for a more equitable and further reaching intervention, under the assumption that the vast majority of children in the United States are attending public schools. School based interventions also allow for a more equitable spread of interventions across populations, demographics, and communities (11). This is why housing interventions addressing childhood overweight and obesity in public schools seems the best and most equitable means of reaching the largest amount of children. School-based interventions are then also the best way of reaching populations of children in the United States who are at higher risk for overweight and obesity—such as children from socioeconomically disadvantaged backgrounds (8).

            Keeping all of this in mind, I propose a two-pronged approach targeting two different populations of children within and intervention addressing rates of overweight and obesity in Massachusetts. First a widespread intervention in public schools integrating health and gym classes with an after school program that focuses on making physical activity fun (8). Second a program providing realistic nutritional advice to lower-income families and communities.

 In health and gym classes, a curriculum pertaining to nutrition and healthy eating will be integrated with the current curriculums in place. Building on this foundation of nutrition and healthy eating afterschool physical activities will place emphasis on giving children agency in making decisions about how and in which kind of activity they would like to participate (11). In making decisions as a group about what will constitute physical activity that day, children are empowered to make positive decisions about their health. The nutrition and afterschool programs focusing on physical activity would have to be both integrative and interactive to ensure these goals. It is also important to begin these interventions early on to facilitate the formation of healthy habits among young children, increasing their likelihood of maintaining healthy habits later on. I hope that these programs would be at least partially staffed by community volunteers (both members of the community as well as dedicated community volunteers such as AmeriCorps service members) as well as college or professional students studying relevant areas.

            This intervention would need to be available to all children in order to make it effective. It is important to note however, that for higher-risk populations more focused intervention would be necessary. Research shows that rates of overweight and obesity disproportionately affect children from socioeconomically disadvantaged backgrounds (4). In order to address this dedicated community involvement would be necessary. An online learning module as well as phone interviews and training would be cost and time effective in disseminating community and parental learning curriculums based around what constitutes proper nutrition as well as ways that proper nutrition can be maintained through economic hardship (i.e. how to make healthier food choices). These interventions seek to address both the complicated needs of diverse populations as well as the weaknesses of the BMI reporting intervention.

Risk Identification

            These two interventions mitigate the miscalculation of the risks of childhood overweight and obesity that plagued BMI reporting. By dedicating time and resources to provide culturally competent services and education to parents and communities these interventions do not leave parents feeling ineffective in the face of hard line statistics--such as BMI scores—and without realistic options regarding how to improve their children’s health. The intervention in schools also gives children a sense of agency and ownership in their own health, making it more likely that they will maintain healthy behaviors.

Empowering Communities

            Rather than blaming communities or populations for their increased risk of overweight or obesity, these interventions empower them to change them (1). More importantly, the interventions also give them tools by which they can effect this change in the health of their children. Children learn how to make healthy choices in the context of their circumstances. We cannot chastise them for not choosing a healthy option, when one is not realistically available to them. In the same way, parents are empowered to learn how to make healthier decisions for their family, again within the context of their circumstances. In fighting childhood overweight and obesity, it is important to set realistic expectations for populations that are affected disparately by factors such as finances, access to food, and access to places where physical activity is safe. This is one reason that schools are an ideal setting for after school programs dedicated to fun, rather than competitive, physical activity. For some children schools represent the only space in their built environment that being physically active is safe.

Enhancing Core Values

            While both of these interventions a based around improving children’s health outcomes and influencing positive health behavior, health is no longer the core value. Instead of health, we use empowerment as a way to frame both interventions. In changing the core value and the framing of the interventions, the interventions challenge parents’ authority roles in their children’s lives less. Rather than telling them that there is some deficit in their care for their children, because their child has a BMI score that qualifies them as overweight or obese, we are giving both parents and children tools to empower them in making healthy decisions and maintaining healthy physical activity. Rather than passing a mathematical judgment, we are providing a service.

References

1. Anderson P., Butcher K. Childhood Obesity: Trends and Potential Causes (pp 19-45). In: The Future of Children. Princeton, NJ: Princeton University, 2006.

2. Caprio, S Treating Childhood Obesity and Associated Medical Conditions (pp. 209-224). In: The Future of Children. Princeton, NJ: Princeton University, 2006.

3. Daniels S. The Consequences of Childhood Overweight and Obesity (pp 47-67). In: The Future of Children. Princeton, NJ: Princeton University, 2006.

4. Economos C., Hyatt R., Goldberg J., Must A., Naumova E., Collins J., Nelson M. A Community Intervention Reduces BMI z-score in Children: Shape Up Somerville First Year Results (pp 47-67). In: Obesity. 2007.

5. Paxson C., Donahue E., Orleans C., Grisso J. Introducing the Issue (pp 3-17). In: The Future of Children. Princeton, NJ: Princeton University, 2006.

6. Rosenstock I., Strecher V., Becker M. Social Learning Theory and the Health Belief Model. In: Health Education Quarterly. John Wiley & Sons, 1988.

7. School Health Unit Bureau of Community Health and Prevention, Massachusetts Department of Public Health. The Status of Childhood Weight in Massachusetts, 2011: Preliminary Results from Body Mass Index Screening in Massachusetts Public School Districts, 2009-2011. Massachusetts Department of Public Health, 2012.

8. Story M., Kaphingst K., French S. The Role of Schools in Obesity Prevention (pp.109-142) In: The Future of Children. Princeton, NJ: Princeton University, 2006.

9. Childhood Obesity Underreported by Parents (pp 3). In: Journal of Physical Education, Recreation & Dance. Taylor & Francis Ltd., 2011.

10. Tschamler J., Conn K., Cook S., Halterman J. Underestimation of Children’s weight Status: Views of Parents in an Urban Community (pp 470-476). Clin Pediatr. 2010

11. Pinard C., Hart M., Hodgkins Y., Serrano E., McFerren M., Estabrooks P. Smart Choices for Health Families: A Pilot Study for the Treatment of Childhood Obesity in Low-Income Families (pp 433-445). In: Health Education & Behavior. 2012.

12. Miller T. Massachusetts Mulls Doing Away With “Fat Letters” That Report Schoolkids’ BMI to Parents. In: NY Daily News. 2013.

Strong4Life - Mariale Renna

Introduction

            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”.

Conclusions

            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.

References

1. Centers for Disease Control and Prevention. Childhood Obesity Statistics. Atlanta, GA: Centers for Disease Control and Prevention. 2013. http://www.cdc.gov/healthyyouth/obesity/facts.htm

2. Ungar R. Obesity Now Costs Americans More in Healthcare Than Smoking. Forbes. Published 30 April 2012. Accessed 4 December 2013.http://www.forbes.com/sites/rickungar/2012/04/30/obesity-now-costs-americans-more-in-healthcare-costs-than-smoking/

3. Strong for Life. We Have a Problem in the Peach State. Children’s Healthcare of Atlanta. 2013. http://www.strong4life.com/pages/about/TheIssue.aspx?

4. Teens Health for Nemours. Emotional Eating. The Nemours Foundation 2013. http://kidshealth.org/teen/your_mind/emotions/emotional_eating.html

5. Sung J, Lee K, Song YM. Relationshop of eating behavior to long term weight change and body mass index: the Healthy Twin study. Eat Weight Disord 14: 2-3, 98-105. 2009.

6. Chelser BE. Emotional eating: a virtually untreated risk factor for outcome following bariatric surgery. ScientificWorldJournal. 2012.

7. Braet C, Van Strien T. Assessment of emotional, externally induces and restrained eating behavior in nine to twelve year old obese and non obese children. Behavior Research and Therapy 35(9): 1997.

8. Individual health behavior sciences (ch 4) in Edberg M. Essentials of Health and Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007, pp35-49.

9. National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice Part 2. Bethesda MD: National Cancer Institute, 2005, pp9-21.

10. Carleton College. Self-Efficacy: Helping Students Believe in Themselves. Updated 7 December 2013. Accessed 5 December 2013. http://serc.carleton.edu/NAGTWorkshops/affective/efficacy.html

11. Shin H, Shin J, Liu PY, Dutton GR, Abood DA, Ilich JZ. Self-efficacy improves weight loss in overweight/ obese post menopausal women during a 6 month weight loss intervention. Nutr Res 31(11):822-828. 2011.

12. Roach JB, Yadrick MK, Johnson JT, Bordeaux J, Forsythe WA, Billon W. Using self-efficacy to predict weight loss amoung young adults. J of the Am Dietetic Asc 103(10): 1357-1359. 2003.

13. Simons JA, Irwin DB, Drinnien BA. “Abraham Maslow” from Psychology- The Search for Understanding. New York, NY: West Publishing Company, 1987.

14. Wikipedia. Maslow’s Hierarchy of Needs. Wikipedia Foundation. Updated 11 December 2013. http://en.wikipedia.org/wiki/Maslow's_hierarchy_of_needs

15. French SA, Story M, Perry CL. Self Esteem and obesity in children and adolescents: a literature review. Obesity Research 3(5): 6. 479-490. Sept 2012.

16. Strauss RS. Childhood obesity and self-esteem. Pediatrics Online 105(1): 15. 1 January 2000

17. Heneghan HM, Heinberg L, Windover A, Rogula T, Schauer PR. Weighing the evidence for an association between obesity and suicide risk. Surgery for Obesity and Related Disease 8(1):  98-107. 2012.

18. Seals D, Young J. Bullying and victimization: prevalence and relationship to gender, grade level, ethnicity, self-esteem, and depression. Adolescense 38(152): 735-747. 2003.

19. Myers A, Rosen JC. Obesity stigmatization and coping: relation to mental health symptoms, body image, and self esteem. J of the Int Asc for the Study of Obesity 23(3): 221-230. 1999.

20. Baranowski T, Cullen KW, Nicklas T, Thompson D, Baranowski J. Are current health behavioral change models helpful in guiding prevention of weight gain efforts? Obesity Research 11: 2003.

21. Hicks JJ. The strategy behind Florida’s truth campaign. Tobacco Control 10:3-5. 2001.

22. Wallerstein NB, Duran B. Using community based participatory research to address health disparities. Health Promot Pract 7(3): 312-323. 2006.

23. Weijzen PLG, Graaf C, Dijksterhuis. Predictors of consistency between healthy snack choice intentions and actual behavior. Food Quality and Preference 20:110-119. 2009.