Challenging Dogma - Fall 2009

Tuesday, December 15, 2009

The Healthy Kids Act: The Need to Address More Than What Children Are Exposed To On Television - Melissa Jeffers

I. Introduction
A. Childhood Obesity and Children’s Television Habits
Obesity among children is a serious health concern in the United States today. Data from the NHANES survey have shown that the prevalence of obesity among children aged 2-5 was approximately 12.4% in 2006, a very drastic increase from the prevalence of 5.0% in 1980. The prevalence of obesity in children aged 6-11 also increased dramatically from 6.5% to 17.0% during the same time period. For children aged 12-19, the prevalence increased from 5.0% to 17.6% (1). Overall, currently 32% of children in the United States are overweight, 16% are obese, and 11% are extremely obese (2,3).
There are many serious problems that can result from being overweight or obese. Youth who are overweight or obese have a much greater likelihood of having cardiovascular risk factors such as high cholesterol, high blood pressure, and abnormal glucose tolerance. Obese children are more likely to become obese adults and are likely to be at risk for diseases such as asthma, sleep apnea Type 2 diabetes, coronary artery disease and other heart conditions, and stroke. Other non-physical risks include psychological risks such as alienation from peers, which can lead to low self-esteem (1). All of these problems associated with the obesity epidemic and the increase in the number of obese children put us at the point where childhood obesity is a serious problem in the United States and needs to be addressed.
Television watching is a primary activity for many American children and adolescents currently. Almost half of children aged 8-16 watch more than two hours of television per day and there is a positive correlation between the potential of being obese and number of hours of television watched (4). Thus, television is an important way to reach youth and adolescents, while also being a factor that contributes to being overweight and obese in this same population.
There are many factors that have led to the increase in overweight and obese children in the United States. There is the problem of increased food intake, the problem of limited physical activity, and the problem of increased sedentary behavior among children in recent years (1). All of these problems must be addressed before there will begin to be a decrease in the childhood overweight and obesity rate in the United States.
B. Healthy Kids Act 2009
Introduced by Jim Moran and Bill Pascrell, both Democrats in the United States’ House of Representatives, this bill was designed to help control the obesity epidemic in children in the United States by controlling the amount of “junk food” commercials that may be aired during children’s television programs (2). Moran and Pascrell believe that the passing of this bill will lead to decreased levels of obesity in American children, which will lead to decreased expenses by the United States on treatment of problems associated with obesity (2). Overall, they believe it will increase the health and wellbeing of American residents.
The bill proposes that a food tier system will be designed to organize foods into three categories: healthful foods and beverages for which consumption is encouraged, foods and beverages which do not exceed levels of total, saturated, and trans fat, sugars, and sodiums that are acceptable in a healthful diet, and foods and beverages that are not healthful and consumption of which is discouraged (2). Tier 3 foods would be eliminated from commercials that can be shown during any children’s television programs. Tier 2 foods would be limited to two minutes per hour on weekends and three minutes per hour on weekdays. Only Tier 1 foods would be freely advertised during children’s television programs. The Federal Communications Commission would also be given the authority to ban certain advertisements and limit some for unhealthy sodas and snacks (2).
The laws proposed in this bill would be applicable to all network television stations broadcasting anywhere within the United States. This law would go above and beyond the Children’s Television Act, which was implemented in 1990 and stated that there were certain commercial matters that could only be aired for 10 ½ minutes per hour during the weekends and 12 minutes per hour during weekdays (5).
II. Critique of the Healthy Kids Act
This section will discuss several reasons why the Healthy Kids Act alone will not be enough to combat childhood obesity and how some changes must be made in order for it to fully address the problem. The Healthy Kids Act only addresses one issue associated with obesity: the idea that watching commercials with unhealthy foods in them leads to increased consumption of these unhealthy foods. There has not been a strong causal link found for this idea and many studies show that “there is little evidence to show whether the influence of food promotion on children's food behaviour and diet is greater or lesser than other factors” (6,7). The bill also does not address the fundamental characteristics that that change behaviors in people.
A. The Healthy Kids Act Does Not Give Children the Tools to Change Their Eating/Physical Behaviors Associated with Overweight/Obesity
There are several problems associated with the Healthy Kids Act. With “junk food” advertising being limited to children, they are not being given their own opportunity to make choices regarding their dietary behaviors. They are not being given any information about the issue and therefore, are unable to make their own decisions regarding it. They cannot make a conscious decision regarding what they are and are not willing to eat because they are not being given all potential dietary options.
Another issue is that children and adolescents are not being given all of the options to limit their likelihood of becoming obese when the sole intervention is to reduce the number of commercials they see that contain unhealthy food advertisements. They will not be exposed to important ideas about how important exercise is and how important changes in sedentary behavior – including watching large quantities of television – are to not becoming obese.
Without all of these inputs, children are missing many of the components of the Theory of Planned Behavior, which is an important theory that helps to effect changes in many behaviors when used properly in different public health interventions. The Theory of Planned Behavior contains both the components of perceived behavioral control and also perceived control beliefs (8) and children are not being given these options by only being shielded from these “junk food” advertisements. Many children highly value situations where they are given a choice in what they do.
First of all, children are not the ones who control what they eat, for the most part. They are not the ones with the ability to purchase the food they consume so they are often under the constraint of what their parents buy or what is served for lunch at school. They do not have the self-efficacy to change what they eat in this sense. Parents are unlikely to take advice from their children about which foods they should purchase when shopping for food. This means that children are held back by what food items their parents purchase and serve to them and what items are served during school lunches.
Another problem with solely limiting commercials advertising unhealthy foods is that children and adolescents are not being taught about portion control. All foods, even those foods that are healthy and would fall under Tier 1, should be consumed in moderation and simply shielding children from commercials about unhealthy food does not teach them the valuable lesson of portion control. Children tend to eat greater quantities of food when larger portions are provided to them (9) so they need to be taught not only about the appropriate foods to eat, but also about the appropriate amounts of these foods.
Also, while children may not be exposed to advertisements portraying a large amount of “junk food,” they are still being exposed to these foods in the television shows they may be watching. In television shows, actors and actresses are often consuming unhealthy foods. Since actors and actresses are often very thin, children may be subject to optimistic bias (10), or the belief that if actors and actresses can consume those foods and still remain at a below average weight, then so can anyone else who consumes those foods.
Finally, if children and adolescents do not know what options they have in terms of being healthier, then it is very difficult for them to make a choice about their behaviors and make a change in those behaviors, such as choosing healthier foods, exercising more, or spending less time being sedentary, unless they are taught otherwise. Children and adolescents need to be given the tools of self-efficacy and knowledge of control over behaviors to make positive choices in their lives that will help them to lead healthier lives. Solely limiting the number of “junk food” commercials they will be exposed to does not give them these tools.
B. The Healthy Kids Act Does Not Take Outside Environmental and Social Factors Into Account
Another important factor of the Theory of Planned Behavior is the idea of subjective norms, or what an individual believes others, such as parents or peers, think of the behavior and the pressure they feel to also perform that behavior (8). This is also an important component of the Social Learning Theory, in which children adopt behaviors through observational learning, especially of peers and parents because they are models similar and well-known to the child (11). Children and adolescents are especially sensitive to these ideas of subjective norms, since they are highly influenced by peers and have a need for acceptance (12). This need for acceptance drives children and adolescents to make many of the behavioral choices they make. Children and adolescents are also highly influenced by parental and sibling behaviors as these are the environment in which they typically see behavior modeled.
The Healthy Kids Act fails to account for the fact that even though children and adolescents may not be exposed to as many advertisements about “junk foods” with the institution of the Healthy Kids Act, they will still be exposed to whatever their peers, siblings and parents consume. If this happens to be unhealthy foods, children and adolescents will continue to see their role models eating these foods and will continue to desire them. One study found that even though primates were initially opposed to eating chili-pepper flavored crackers, they developed a liking for them when they repeatedly watched their zookeepers eating them (13). This study also found that toddlers were much more likely to put food in their mouths after watching a parent eat the food, rather than if they are just given the food with no modeling (13).
Parents have a very strong influence on what children will and will not eat and parents’ eating, dietary restraint, and disinhibition associated with eating habits were also strongly correlated with the way a child eats (13). Ritchey found that children’s eating habits were also highly influenced by parents, especially that the frequency of consumption of sweet food in children was highly correlated with parents’ consumption of sweet foods and parents’ attitudes toward giving their children sweet foods in positive contexts (14). Children’s intake of fruits and vegetables has been found to be positively correlated with the fruit and vegetable intake of their parents and healthy dietary intake by parents has been shown to result in lower fat diet and lower calorie intake in their children (9).
Although parents tend to be the strongest influence in the eating habits of younger children, children do also model their eating behavior very much after what they see their peers eating. Birch found that children who initially listed off a vegetable as highly non-preferred were likely to choose to eat that vegetable if they saw peers preferring and eating the same food (9,15). Not only was the influence strong enough to make children choose a non-preferred food, it was also strong enough to make child change their preferences on their originally preferred foods (15). This was true more so for younger children than older children, showing that it is easier to influence younger children’s eating habits solely by peer influence (15). Adolescents tend to associate “junk food” more with their peers so they are more likely to eat similar unhealthy foods if their friends are also consuming them (16).
Children and adolescents are only exposed to approximately two hours of television per day on average (4). These two hours contain only scattered commercials about unhealthy foods, but children and adolescents are exposed to parents and peers for a much larger portion of the day. This means that they are receiving much more outside influence on their dietary habits than just through their television watching habits. Solely limiting the number of commercials about unhealthy foods that children and adolescents are exposed to will not be enough to change their eating habits to include a much more healthful diet. We must also act on changing the eating habits of all those in the environment of children and adolescents, especially a child’s parents, in order to fully be able to begin the process of changing the eating habits of young children and adolescents.
C. The Healthy Kids Act Assumes that Children and Adolescents Will Act Rationally Based on Healthy Foods on Television Commercials
The Healthy Kids Act assumes that if a child or adolescent sees healthy food in commercials on television, he or she will automatically rationally pick these foods as their preferred foods. The problem with this assumption is that people, especially children and adolescents, do not act rationally. Children and adolescents do not see foods on television and desire to eat them because they are healthy and they know that the foods will be good for them. There are many other factors influencing a child’s dietary habits.
The assumption of rational behavior and the idea that people make use of the information available to them in decision making is a key component of the Theory of Planned Behavior (17), which is unfortunately, one of its downfalls as human beings are not always rational in their decision making and do not always have clear inputs to each decision they make. However, the Theory of Planned Behavior does contain the idea of subjective norms, which helps to control for some of the irrational behavior that drives the decisions of human beings.
Children and adolescents do not watch television and assess their decisions about their diets through seeing healthy or unhealthy food items on commercials. Children and adolescents are also subject to seeing food items in stores, seeing what their parents and peers eat, and seeing food available in schools (13-16). All of these inputs are highly correlated with what a child ultimately ends up eating and it is difficult to determine exactly how a child will decide which foods they prefer with all of these different inputs. This is true unless we could assume that a child or adolescent would act rationally and that, to the child or adolescent, the benefit of health would outweigh the benefit of food preference. We already know that children and adolescents do not weigh out health benefits of eating healthy foods and do not look at the perceived costs of becoming overweight or obese (15) as the Health Belief Model suggests that humans do to make their decisions (18).
We assume that children will not look at all the inputs into their decision making about eating habits, and that they will not weigh out all of the costs and benefits of a healthy or unhealthy diet, so their decision about what to eat will not be entirely rational. Thus, we have to give children and adolescents all of their options and try to influence the factors that we think will help change their decisions the most.
III. Redesigning the Healthy Kids Act
This section will focus on redesigning the Healthy Kids Act in order to better reach children and adolescents and effect change in their eating behaviors and exercise behaviors to reduce the rate of childhood overweight and obesity in the United States. We will provide both the proposed changes to the act and the ways these changes will address the flaws discussed in Section II.
A. Proposed Intervention
We propose that the Healthy Kids Act can be updated so that it reaches children and helps them to choose healthy eating and other healthy behaviors using the Social Norms Theory. The Social Norms Theory is based on the idea that “people tend to adopt group attitudes and act in accordance with group expectations and behaviors based on affiliation needs and social comparison processes” (19). Another idea behind the Social Norms Theory is that we tend to have incorrect perceptions about the way other members of our social groups think and act (20). We may have the incorrect assumption that other members of our social group are not as healthy as they actually are or do not exercise as much as they actually do. In order to change children’s habits, we need to impress upon them the idea that those in their social groups are engaging in healthful behaviors. Even overestimations of healthful behavior will result in increased healthful behaviors by children and adolescents (20), which is ultimately what we would like to see in this population.
In order to employ the Social Norms Theory, we would like to add advertisements that children and adolescents will see, rather than just limiting the number of commercials with unhealthy foods shown during children’s programming, to promote healthful behaviors and instill the idea in this age group that their peers are engaging in healthful behaviors, including eating healthy and exercising regularly. Since the Healthy Kids Act only involves limiting the number of “junk food” advertisements, it is not promoting the health and wellbeing of this age group. It has a solid foundation and a good message behind it, but there must be more in order to effect behavioral changes in children and adolescents.
There is likely to be some opposition to the Healthy Kids Act and to the idea of limiting the number of advertisements about unhealthy foods during children’s programs, especially stating that it is a violation of First Amendment rights. If there is too much opposition, implementing advertisements that promote healthful behaviors is still a viable option, rather than limiting advertisements about unhealthy food products at all.
We would like to implement more advertisements, not just during children’s television programs, but during all television shows at all times, promoting healthy eating, including portion control and dietary content, and regular exercise. The reason we would like to extend these advertisements to all age groups is to change the behaviors of all who will have effects on obesity-related behaviors of children and adolescents. The content of these commercial advertisements would be showing that peer groups are engaging in healthful behaviors, with the commercials designed to address the group that is most likely to watching television during that time period. For children and adolescents, the content would be directed at their own age groups, showing that people their age are engaging in healthy eating behaviors and regular exercise. For adults, these advertisements would be directed at their own age and gender groups with these age and gender groups based on the population that is most likely to watch the show. There would also be an element directed at attempts to teach their children to engage in healthful behaviors and warning them about the impacts of their behaviors on their children’s behaviors, since parents have such a large influence on the behaviors of their children. All advertisements will push the idea of acceptance within peer groups if behaviors are changed to match the behaviors presented in the commercials.
B. How the Proposed Changes Will Address Problems Associated with the Healthy Kids Act
1. The Proposed Changes Give Children and Adolescents the Tools to Change Their Health Behaviors to Prevent Overweight/Obesity
Since the proposed changes to the Healthy Kids Act include addressing more behaviors than just eating, including exercise, children, adolescents, and adults will be given the knowledge they need about other weight-related behaviors as well. They will be given the tools and ideas regarding issues related to obesity that give them to opportunity to make the choices they need about their own health behaviors and their children’s, as in the case of adults.
All members of the population will be shown commercials that will show them the importance of exercise and not leading a sedentary life in order to combat overweight and obesity. They will also be shown commercials that not only endorse healthy foods, but also discuss important issues such as portion size and food consumption based on age, weight and exercise regularity. Thus, they will have the information they need to be able to make healthy dietary decisions and engage in an adequate amount of exercise.
Giving people knowledge and empowerment over their own choices is important and these commercials will do just that. People will be given the option that they can change and improve their lives to help combat the problem of overweight and obesity. The commercials will also contain the message that these healthful behaviors are the normal and accepted behaviors of peer groups in order to drive both children and adults alike to want to participate in healthier activities.
2. The Proposed Changes Address How Social and Environmental Factors Affect People
Since the proposed changes are based on the Social Norms Theory and the idea that social norms significantly affect the way people act (20), the changes do, in fact, directly take into account that people, especially children, will make their decisions on eating habits and healthy living with some effect from those around them. The proposed changes are based on the idea that if people believe that their peers and those in their immediate environment are engaging in healthful behaviors, then they will see this as a motivation to also engage in these behaviors.
The proposed changes will consist of commercials that show people that their peers are involved in activities like exercise and eating proper amounts of healthful foods and will present these ideas in a way that shows that these are the social norms. For advertisements during children’s television shows, these advertisements will show images of other children both engaging in and enjoying healthful behaviors. For adult television programs, the commercials will present the same sort of images, but use adults to do. Overall, the idea is to appeal to the idea that peers’ decisions highly affect the decisions people make.
Since children and adolescents live with their parents and often are restrained by the limitation that they can only eat the foods that their parents buy, instilling the idea of healthfulness in parents is important as this is the environment that children, especially young children, live in. In order to truly begin to change the dietary and exercise behaviors of children and adolescents, we have to reach them through all aspects of their lives, including both their peers and their families, so they will be given positive messages from every source they encounter. Children’s behaviors are much easier to mold so if we begin by trying to change their social and environmental inputs at a young age, they will be likely to be healthier as adolescents and adults.
3. The Proposed Changes Take Into Account the Fact That People Do Not Act Rationally
The proposed changes to the Healthy Kids Act do not assume that people, especially children, weigh out all of the pros and cons of healthy eating and exercising and rationally make a decision from all of these inputs. These changes also take into account the fact that there are a large number of inputs into the decision-making process and that many decisions do not happen based on a conscious, rational though, but rather, impulsively, based on a large number of factors.
The proposed changes especially take into account the fact that people are highly affected by what those around them are doing and often make unconscious decisions to act based on what those around them are doing. The commercials will try to focus on the factors that are most likely to influence the unconscious decisions of people to eat healthier, in the right proportions, to exercise, and to engage in other healthful behaviors that will fight obesity. These decisions are often unconscious and, especially in children, are influenced by their peers.
Children also cannot rationally choose their own eating behaviors if they are only being fed the food purchased by their parents so parents must be reached as well in order to change these behaviors. Since parents also often do not make their choices in food and exercising by weighing out all pros and cons, they will also be reached through the Social Norms Theory in order to influence their subconscious decisions about dietary and exercise habits.
IV. Conclusion
The proposed Healthy Kids Act, as it is, is unlikely to result in large changes in the eating habits of children and adolescents and lowering the overweight and obese population in this age group. The problems with the current proposal are that it does not give children and adolescents the means to be able to change their behaviors, both dietary and exercise, it does not address the fact that children have many other inputs that affect their dietary habits, including environmental and social factors, and it assumes that children and adolescents rationally decide about what they are going to eat.
With the changes suggested in Section III, there is likely to be much more behavioral change in the dietary and exercise habits of children and adolescents. These changes include addressing the fact that this population is heavily influenced both by peers and by family members so healthy behaviors must be shown as widely accepted by those around children and adolescents. This can be done by adding additional commercials with positive messages from peers about healthful behaviors.
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