Challenging Dogma - Fall 2009

Thursday, December 17, 2009

“Fitness for Life”, A Critique and AmendedProgram for Lincoln University – Shikha Sharma

I. Introduction
Obesity, defined as a BMI of greater than 30, is a rapidly growing epidemic in the Unites States (1). Adults, as well as adolescents, bear the burden of obesity. In 2006, 66% of adults were classified as obese. NHANES stated that 12.4% of adolescents from the ages of 2-5 years, 17% from 6-11 years, and 17.6% from 12-19 years were classified as obese in 2006 (2).
The rate of obesity has also been stratified according to race/ethnicity and region. The prevalence of obesity amongst blacks is 51% and 21% amongst Hispanics when compared to whites (3). The prevalence amongst these ethnicities, as well as whites, is greater in the Southern and Midwestern region of the United States (3).
Obesity trends have increased significantly across the country, specifically in Pennsylvania. States were graded on their efforts to control obesity. Factors such as nutrition standards, BMI, recess, physical education, research, and established programs were taken into account when grading each state. Pennsylvania received an “F” on the ability to pass obesity control measures (4). The only states to receive grades other than a “D” or “F” were Connecticut and Arkansas, with “B’s” (4).
Obesity is affected by behavioral, environmental, and genetic factors. People must balance the intake of calories with the number of calories burnt off (5). Calorie consumption and physical activity comprise the behavioral factor contributing to obesity. Environment is a factor that affects obesity because it may alter the decisions a person makes. For example, a person may not walk to work due to a lack of sidewalks in his neighborhood (5). Genetics have also shown to play a role in obesity; however it may not predict future health (5). Any one of the above factors can impact obesity.
In 2006 Lincoln University, in Pennsylvania, decided to take action against obesity. Lincoln University is in rural Pennsylvania and a historically black college. The university created a program that measured the BMIs of all incoming freshmen beginning in the fall of 2006 (6). Students with a BMI of over 30 were required to complete a fitness course before graduation. The course is a one – credit requirement named “Fitness for Life” (6). Anyone who has a BMI below 30 would place out of the requirement. If the student does not fulfill the one credit requirement, he/she will not graduate. The “Fitness for Life” requirement has come under great scrutiny in the past few months because several members of the fall 2006 freshmen class are not eligible for graduation due to this requirement.
II.Critique of Lincoln University’s “Fitness for Life” Requirement
Lincoln University’s course requirement, “Fitness for Life”, is a flawed public health program. The program is flawed for three reasons. The program labels and attaches a stigma to the people who are being targeted. “Fitness for Life” is an individual approach to attacking obesity in youth and does not account for environmental factors.The final flaw of the program is that is lacks concepts from the marketing paradigm.

A. “Fitness for Life” – Approach Lacks Environmental Factors, Aimed at the Individual
Lincoln University does not require that every incoming freshman complete the one credit requirement, “Fitness for Life”. It is specifically for people who do not place out by possessing a BMI below 30. The program’s goal is to alert students to the potential affects of obesity (7). The program is aimed at each individual student, rather than all students.
Programs that are only aimed at the individual have not been extremely successful (8). By making the individual solely responsible for making a change in the obesity status, the program is ignoring the factors that cause obesity. The CDC states that a person’s environment is one of the three main factors impacting obesity. Lincoln University’s obesity program does not account for environmental factors; which play an integral role in obesity.
The program’s lack of recognition of the environment and the use of an individual approach is a noted issue. Students of Lincoln University have expressed that program contradicts itself (7). Students categorized as obese are required to complete a fitness courses, however “hamburgers and fries and pizza [are served] in the cafeteria” (7). The necessary nutritional adjustments were not made to the cafeteria to promote the objectives of the program. In order to adequately address obesity it is important to address the different facets that result in an impact.
Specifically when making changes to one’s lifestyle, it has been noted that numerous factors influence a person’s behavior. The socio-ecological model illustrates this notion (9). Interpersonal, organizational, community, and public policy factors influence an individual. In order to facilitate change in behavior these factors must be addressed. Lincoln University’s program fails to take these environmental factors into account.

B. “Fitness for Life” –Enhancing Stigma and Labels
“Fitness for Life” has a requirement at Lincoln University that incoming freshmen can place out of if their BMI is below 30. Therefore, the students who must take the one credit course are publically known as the “obese students”. Students are being given the label of obese. The labeling of a person results in bias and discrimination. In an environment such as college, students wish to fit in and conform to what is accepted by others. Being given a label only makes this process more difficult. There is a clear relationship between stigma formation and labeling. A stigma is the result of five different components (10). In the case of obesity, a stigma surrounds the condition. The first component of a stigma is to “identify and label human differences” (10). Lincoln University identifies students at the beginning of their freshmen year by measuring their BMI. A BMI of over 30 is the known definition of obese. These are the students who must complete a one-credit fitness requirement as a result of their BMI status. This labels the human difference according to BMI.
Stereotyping is the second component of stigma. This creates a link between the person who has been labeled and the characteristic identified as undesirable (10). The undesirable characteristic is being obese. Society views obesity as a problem resulting from a lack of self-control, emotional problems, or failure to comply (11). The required gym course is the link between the person being labeled and the characteristic of obesity. Therefore the students in the gym course are now stereotyped as not having self-control, unhealthy, or having emotional problems.
The separation of groups is the third component of stigma (10). Lincoln University only requires those students who have BMIs over 30 to take the fitness course. A schism is created where the obese students have an extra requirement and the skinny students do not. The distinction between these two groups results in the stigma formation. The separation is understood by the two groups and may continue outside of the gym course.
The fourth component states that the people stigmatized experience a loss of status (10). People who are attached to a stigma will experience exclusion and discrimination (10). For example, children in kindergarten are made fun of and excluded in activities when other children sense a difference between them. This still applies in a college setting. Lincoln University is providing the other students with a difference by placing them in a category of obese. The students may be continually excluded from activities as a result of the stigma.
The exercise of power is the final component of stigma (10). In this program the university is exercising their power by creating a mandatory course for people labeled as obese. Students do not have the ability to adequately fight against the university’s power. This is because if the student does not complete the course requirement he/she is in danger of not graduating. By utilizing their power, the university is forcing a stigma onto the students.
Lincoln University’s “Fitness for Life” requirement successfully creates a stigma for students with a specific BMI. Labeling students increases the stigma surrounding obesity. Once students are labeled they are less likely to comply with the program (10).

C. “Fitness for Life” Does Not Utilize the Marketing Paradigm
Two different paradigms can be utilized when implementing a new program. The public health paradigm asks what is the product that people should want. It then sells the product by appealing to the desire for health. The second approach is the marketing paradigm. It asks what do people want. Then it creates and packages the product to fulfill the needs and desires of the people. Lincoln University chose to utilize the public health paradigm rather than the marketing paradigm to implement their program.
In the “Fitness for Life” program, a healthier future was the product that the university was selling. By using the public health paradigm they found that this should be the product that students desire and a physical education requirement was the means of achieving this. They were trying to appeal to a healthier future by selling the idea of health. However, selling health is not successful in implementing a program.
On the other hand, creating a brand and marketing the product can result in a successful and well-implemented program. A brand message is “a strategic communication designed to elicit a particular set of beneficial associations in the mind of the consumer which become linked to the brand’s identity, providing equity or a sense of value” (12). It contributes to the connection a consumer may have with the product (13). The students of Lincoln University were not able to develop a relationship with a healthier future through the “Fitness for Life” program.
In order to create a successful intervention, the target audience must feel connection and “buy-in” to the product being sold. Lincoln University was not able to generate a bond between the students and weight loss. Although, it is globally known that a BMI over 30 indicates potential health issues, it is not enough to have the knowledge when it comes to taking action. This is especially true amongst college students. Any change that one wants them to adopt must be marketed properly. It must tug at their values and beliefs. Important beliefs to college students are acceptance and autonomy (14). Lincoln University’s program was unable to accomplish this.
It is evident that Lincoln University’s program was not based on market research. Market research is the base for understanding what it is people desire. If university officials had conducted market research they would have had a better understanding of what values to target in their population (15). Market research would have also located successfully implemented programs. Various universities have implemented programs to fight obesity and promote a healthier future. These universities have faced less criticism than “Fitness for Life”. Boston University and University of South Carolina are two examples of universities with programs that are well accepted (16).

III. Proposed Changes to Lincoln University’s “Fitness for Life” Program
“Fitness for Life” possessed the potential to succeed as an obesity program. However, its’ ability to flourish was hindered by the presence of the stigma theory. The program also targeted to change only the individual and lacked marketing concepts. Due to its shortcomings, Lincoln University discontinued the program on December 5, 2009 and allowed the students who needed this requirement to graduate to do so without completing the course. If these factors were altered the program could have successfully intervened on obesity in the college setting.
The new approach to obesity amongst students at Lincoln University would promote a fitness course; however it would not be the only facet of the program. A fitness and nutrition course would be required for all students to graduate, but would not focus solely on the obese. All students would have to fulfill a fitness and nutrition requirement. Fitness and nutrition would be mandatory, yet the students would retain the ability to choose which courses they want to take to fulfill the requirements.

A. Socio-ecological Model in “Fitness for Life”
Utilization of the socio-ecological model and a group level approach would strengthen Lincoln University’s program.Individual behavior is largely influenced by environmental factors (9). The socio-ecological model takes into account that there is a relationship between the individual and the environment. The environment may consist offamily, friends, school, or the neighborhood. It is possible for all of these factors to affect the individual. There are barriers present that make achieving healthy behaviors difficult. As the barriers amongst the individual and the environment decrease, the behavior is more achievable (9).
Applying the socio-ecological model, the new intervention would alter the behavior of Lincoln University as well as the student. Previously Lincoln University had implemented the program, but had not created the proper environment for the program to thrive. Assuming an adequate budget for Lincoln University, the food selection in the cafeterias would significantly change. Students had complained of a slim salad bar and nothing but grease as the choices for food (7).By providing students with healthier dietary choices in the cafeteria, the barriers posed by the environment would begin to diminish. According to the socio-ecological model, it is imperative for the barriers posed by the individual’s environment to be eradicated for behavioral to be successful.
The addition of a nutrition requirement enhances the program. Providing the students with healthy food must be accompanied by the knowledge to make healthy dietary decisions. This accompanying course would also be an environmental change. It provides students with the opportunity to learn how to make the best nutritional decisions. Lincoln University’s goal was to promote a healthier future. The course would aid in pursuing the goal.

B. Eradicate the Stigma and Labels from “Fitness for Life”
The new intervention would also attempt to mitigate the stigma and labeling attached to obesity. Only a small portion of the student body is required to complete the “Fitness for Life” requirement for graduation. When a student states he is going to his “Fitness for Life” class, it is understood that this person is attending the class because he has been classified as obese. Expansion of the course requirement to all students who attend Lincoln University would eradicate the separation between the groups; which is what adds to the stigma attached to obesity. If this requirement is made mandatory for all students, regardless of BMI, there is a greater likelihood that students will take part and try to understand the true message behind the program.
The simple act of placing students on a scale to determine if they should take a course during their college career is helping to develop a stigma. The difference in results after measuring the student’s BMI contributes to the distinction made between students. Completely demolishing the measure of BMI as an entrance requirement to Lincoln University will help ease the stigma attached to obesity in the school. Therefore, less anxiety will accompany completing a fitness and nutrition course.

C. The Marketing Paradigm – A Stronger Foundation for “Fitness for Life”
Making this an all student initiative would also apply the marketing paradigm. Tailoring the program based off of what the students want, rather than what they should want, is clear application of a marketing paradigm. This type of change would align with their beliefs. It is essential for college students to feel that they fit in with their peers. Although college students and teenagers strive to be different, they do not want to be alienated from their peers.
Autonomy is essential to college students. Students in their early years of college do not have a great deal of freedom to do what they please, but it is exactly what research has shown they desire (14). Students want a greater sense of autonomy. The “Fitness for Life” program was imposing a requirement that lacked all choices. It stripped students of their independence to choose the courses they wanted to complete prior to graduation. Keeping a nutrition and physical education requirement, but providing options for these requirements speaks to the student’s longing to be able to choose. The right to choose gives the student freedom from the school, but a sense of personal control.
Simply understanding one’s target audience can lead to a more successful program. Conducting market research on college students will provide that understanding. The improved intervention would be based off of what the students want and then tailor the program in response. Also market research will provide insight into what other programs, that were successful, did (15). Market research in the new approach to Lincoln University’s program will provide a stronger foundation and appeal to the target population.

IV. Conclusion
Overall, instilling obesity programs in our universities is essential to teaching students about healthy practices. However, Lincoln University was unable to include numerous factors to allow the program to excel. When making changes in someone’s behavior the environment must be accounted for and properly adjusted. There is a stigma surrounding obesity and singling out students based on BMI only exacerbates that stigma. The use of marketing paradigm will give officials a better understanding regarding what the target population desires. With these amendments “Fitness for Life” is more likely to succeed and be accepted by the Lincoln University community.

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2. Centers for Disease Control and Prevention. Overweight and Obesity: Childhood Overweight and Obesity. Atlanta GA.
3. Centers for Disease Control and Prevention. Overweight and Obesity: US Obesity Trends.Atlanta, GA.
4. Louden, Delroy. Lincoln University. Primary Care Research Network for Treatment of Overweight in Adolescents-Collaborative Effort with Children’s Hosptial of Philadelphia and Geisinger Health Systems. 2006.
5. Centers for Disease Control and Prevention. Overweight and Obesity: Causes and Consequences. Atlanta, GA.
6. Nereim, Vivian. Lincoln University Rescinds Fitness Requirement for Obese Students. In: Pittsburgh Post-Gazette.December 5, 2009.
7. Ruiz, Rebecca R. A University Takes Aim at Obesity. In: The New York Times. November 27, 2009.
8. Faith, Myles S et al. Behavioral Approaches to the Problems of Obesity. Behavior Modification. 2000; 24; 459.
9. Socio-Ecological Model--Looking Beyond the Individual.
10. Link, Bruce G. and Jo C. Phelan. Stigma and Its Public Health Implications. Lancet 2006; 367; 528-29.
11. Obesity Action Coalition. Understanding the Stigma of Obesity and its Consequences. Tampa, FL.
12. Blitstein, Jonathan L. et al. What is a Public Health Brand? In: Evans, W. Douglas and Gerard Hastings Public Health Branding. Oxford, UK 2008.
13. Evans, W. Douglas and Gerard Hastings. Public Health Branding: Recognition, promise, and delivery of healthy lifestyles. In: Evans, W. Douglas and Gerard Hastings Public Health Branding. Oxford, UK 2008.
14. Rock, David. A Sense of Autonomy is a Primary Reward or Threat for the Brain. In: Psychology Today. November 8, 2009.
15. Lefebvre, Craig R and June A Flora. Social Marketing and Public Health Intervention. Health Education Quarterly 1988; 15 (3); 299-315.
16. Epstein, Jennifer. Stopping Short of No More Fries. In: Inside Higher Ed. December 1, 2009.

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