Challenging Dogma - Fall 2009

Thursday, December 17, 2009

Interventions Addressing Childhood and Adolescent Obesity in an Educational Setting Fall Short-LT

Childhood and adolescent obesity is a major public health issue that needs to be addressed by interventions with renewed strength. Childhood obesity rates have continued to rise. In 2005 to 2006 15.5% of children and adolescence were considered obese and 30.1% were considered overweight based on their BMI, which were greater than or equal to 95the percentile and the 85th percentile of the CDC Growth Chart respectively. (1,2) Childhood and adolescent obesity is a good predictor of adult obesity. (3,4,5) Children that were obese after age 6 had a 50% probability of being obese as adults compared with only 10% probability for children who were not obese at that age. (5) Other studies find that up to 70% of obese adolescent become obese adults.(6) It is well known that obesity is a predictor of adverse health outcomes among obese adults and is also a predictor of short term and long term health of children. The adverse health outcomes for obesity range from the psychosocial issues, early maturation in childhood, physical strain on the joints and bones of adolescence, type II diabetes and coronary artery disease of adulthood. (7, 8) More recently with the continued increase in obesity among children, we are seeing these diseases commonly associated with adult obesity in children. Type II diabetes now accounts for 45% of the newly diagnose cases of diabetes in children. Also there has been an increase in asthma and high blood pressure during childhood and adolescence associated with obesity.(8)
Obesity has also been shown to be a multigenerational problem. Children of obese parent are more likely to become obese children and adults. Studies found that obese children with at least one obese parent were significantly more likely to be obese adults. (9, 10) Even children of normal weight have higher risk of becoming obese adults if one or more of their parents are obese.(5) Maternal obesity was the strongest predictor of childhood obesity. (9) The connection between parental obesity and childhood obesity may be associated with the environmental factor within the home. Indicators like race, parental relationship status, parental employment, socioeconomic status, etc. have been found to be associated with the development of childhood obesity. (9)
It is important to address childhood obesity early even before a child is overweight, because it is increasingly difficult to change behaviors and circumstance that contribute to obesity later in life.(10) This makes schools a desirable location for childhood obesity interventions. This way we can possibly influence a greater number of children without relying solely on parents to provide healthy food and physical activity, singling out at risk or obese children by labeling them, and focusing entirely on a child’s weight by sending “health report cards” home to parents.
Choice of Theories: Individual Level Theories that Rely on Behavior Being Rational, Static, and Planned

Social Cognitive Theory (SCT) (11,12,13) is the most used theory for school based interventions. Although it can be effective in triggering initiation of behaviors and takes into account the social aspects of behaviors leading to obesity, it still relies on the participants (parents and children) behavior being rational, planned, and commitment to following through with healthy behaviors. Once the behavior looses its luster, the intervention has little influence on maintenance of healthy behavior.(14) This is why it is important not just to change an individual’s behavior, but the social norms that influence the behavior of the group or the community.
Social Cognitive Theory and other individual level theories also rely to heavily on self-control and assume behavior is rational. This is the thought process behind the Health Report Cards that have been used in different school systems. They assume that once parents are made aware of their child’s weight status they will take action. They rely on parents increasing their child’s physical activity level without providing the necessary information and opportunity to facilitate these changes.(15, 16) We often overestimate our self-control when were feel motivated to make a change. When there is chocolate cake with ice cream available or our favorite television show is on it becomes more difficult to follow through with those actions. Even for parents, when they want to bring their child outside or to a park so that they can be involved in physical activity they can be conflicted by other responsibilities and work obligations. People have difficulty committing to getting healthy because it is not easy or quick. If it were there would be fewer people who make their yearly New Years resolutions to get in shape, join the gym and then after the first month or two never go back. It is important to provide opportunities for a healthy lifestyle such as: physical and health educations classes and healthy food options in the school setting that do not rely solely on the individual or families commitment.
These interventions based on individual level models do not take into account whether the participants have the ability to carryout the changes. In the Planet Health intervention, based on SCT, the participants were encouraged to add additional activities into their lives, reduce their television watching, and increasing their intake of fruits and vegetables, however they did not ensure that the participants would have to ability to follow through.(17) Other interventions rely on the parents finding their own way to change the behavior, such as the Health Report cards used in Cambridge, Massachusetts. In this intervention they made suggestions about activities, but did not insure that there was any way to conduct the activities. They also made encourage parents to seek advice from physicians before implementing any change in diet. This may have been particularly difficult for families with both parents working or low SES. They may not have had the time or money to go to the doctors or a nutritionist. Also, in the Cambridge intervention they have very low participation rates among families that receive subsidized school lunches. For
children who rely on school lunch programs as their main source of food, no one can expect a parent to be able to change their eating habits. Therefore the low participation rates may have been due to the fact that low income parents felt they did not have the ability to make these changes. The lack of self-efficacy or belief that one has the ability to complete a task extinguishes the parent’s vigor and only perpetuates their frustration. (18) In addition, self-efficacy does not determine behavioral changes. If the parents do not perceive their child’ weight as a health issue or do not understand the connection between childhood obesity, adult obesity, and long-term health consequences they will have no incentive to make the changes. (18) It is vital that parent be provided with the appropriate information and children have access to these necessary healthy foods and the opportunity to participant in physical activities during the school day.
Labeling Puts Children at Risk
Parents, educators, and students have had concerns about how labeling these children will effect them. Although care has been taken to ensure privacy when providing the parents with their child’s BMI and weight status, there is still major room for concern, since children are greatly effected by the labels placed on them. Once we categorize children the stereotyping and discriminations will start according to developmental intergroup theory.(19) It is not just the peers and society that we should be concerned about. Educators and even parents (families) have been found to treat their children in a negatively because of their being labeled as obese or overweight.(20) One study found that 16.1% of boys and 14.6% of girls reported being teased by their own family members about their weight.(21) Another critic of the use of health report cards said that one girl they had spoken with stopped going to school after a teacher made a wounding comment about her weight.(22) School needs to be a safe place where children are protected from overt discrimination by an authority figure. Once we start focusing on the weight status we start creating a stigma about obesity, which can lead to children who are overweight being isolated from their peers and even their families. Once we identify and label children as overweight or obese this can lead to their being stereotyped as unclean, slow, pigs, overeaters, and any number of negative terms. The children who are unfairly isolated from their peers feel a deep hurt and sometimes lash out at either themselves or others.(23)
Similar to internalized racism, the stigmatization that is associated with obesity can be internalized. Children labeling themselves may perpetuate their self-esteem and body image issues causing them to fall deeper into the trap of that label. This is also noted in young adults.(24) In the Cambridge Health Report Card intervention fifty-two parents said that they had spoken with their children about the results of the study. Sixty percent of the overweight children reported being uncomfortable hearing the information and surprisingly 41% of the normal weight children where uncomfortable hearing the information.(15) Children are extremely sensitive and need to be protected.
Although obese individuals face discriminations throughout their lives teasing and bullying during childhood is particularly cruel. One study found that overweight and obese children are more likely to experience both rational and overt victimization. Rational victimization is characterized by the individual withdrawing from friendship and spreading lives about others. Overt victimization are usually actions done towards the individual such as; name-calling, teasing, and physical assault. This study also found that there is a strong association between a girl’s BMI and her change of being physically assaulted. As the child’s BMI increased their likelihood of being physically assaulted also increased.(25) Since these children are already at a disadvantage in their social interactions we need to spend more time focusing on living a healthy life and creating a supportive school environment.
Labeling a child based on their weight status can even have the opposite effect than what was intended, instead of reducing obesity it may increase eating disorders and negative body-images. Children are constantly exposed to media that create unrealistic and unhealthy images that they feel them must achieve. Discussing information about unhealthy weight or the possibility of gaining weight may add to their fear of develop a weight issue or worse the fear they already do.(6,19) As mentioned before 41% of normal weight children were concerned when their parents discussed the health report cards with them when they had no need to be concerned.(15) Another issue with using BMI as the criteria for determining a child’s weight status is the BMI measurement is not as accurate for children. It does not take into account their normal growth patterns. In addition it cannot differential between fat and non-fatty muscular tissue.(6) This can lead to normal weight and overweight children being misclassified. This could lead to parents and even children to making poor health decisions that could put the child at unnecessary risk for negative health outcomes.
Framing Obesity as a Weight Issue and not as an Opportunity to Live a Healthy and Happy Life

When intervention for childhood and adolescence obesity focus just on the weight of the child and weight loss, it limits the possibility of success and as mention before may cause more harm than good. The causes of obesity are traditionally framed in several ways in public health; obesity as a risky behavior, a disease and an epidemic. The way you frame obesity will effect how children perceive their weight and their self-efficacy.
Obesity framed as a risky behavior (compared to smoking), this implies that children have direct control over their weight and that their behavior is the direct cause of their obesity. This frame cannot account for the genetic, social, and even cultural factors that influence a child’s weight. Framing obesity as a risky behavior also perpetuates the stigmatization of obesity and can destroy the self-efficacy of children and their parents.(26) It also assumes that people who are thin eat well and exercise regularly, they are to “blame” for their healthy physique. This may not be the case; thin individuals can live very unhealthy lifestyles full of bad food choices and inactivity. There are actually people who are considered metabolically obese with normal body weight, these individuals would be missed in these interventions leaving them at higher risk for future health complications.(27)
Obesity is also framed as a disease. If obesity is framed as a disease it removes the blame that comes with being obese. However it now compels obese persons to seek medical treatment to cure their obesity or to believe there is nothing they can do about it because it is a disease. Although medical advice is advised for starting diets or an exercise routine, it may also increase the likelihood of radical medical interventions that can be risky.(15, 26) Risky interventions can be use of prescriptions diet pills or bariatric surgery. In the same sense obesity commonly framed as an epidemic.(26) Almost every article about childhood, adolescent and adult obesity starts by mentioning that it is an epidemic, even though it does not meet the true definition of an epidemic, which usually refers to a widespread outbreak of an infectious disease.(4,6,10,28) Researchers and public health worker label obesity as an epidemic with the intention of triggers the emotional reaction. They think it will jolt people into action. But this framing can also have a negative effect; by framing it as an epidemic it labels the overweight and obese as a contagious disease.(26) Obesity is not a contagious disease such as HIV, influenza, or Ebola. Although we should be alarmed about the increasing rates of obesity, we should take care not perpetuate the negative labeling of overweight individual.
How should we frame obesity and overweight for children. Which method of framing will do the least damage to their fragile self-esteem and self-image. We need to stop using these traditional frames when we look at obesity in both children and adults. Instead we should follow the “Guidelines for Childhood Obesity Prevention Programs: Promoting Healthy Weight in Children” which recommends framing childhood obesity interventions in the light of fat acceptance. Fat acceptance is a movement that does not focus on an individual’s weight or body shape, it fosters acceptance for all.(29) This is a way of addressing childhood obesity without causing harm to their self-image.(26) In the healthy lifestyle based interventions children and parents have many opportunities to have small successes that will help increase their self-efficacy. Successes such as eating a piece of fruit instead of cookies, taking a walk after dinner instead of watching television, or participating in a physical education class instead of sitting on the sidelines. It is important for children to not only be accepted by their peers, but also their families and society. When children can feel that they are accepted as they are and not as a number on the scale, they can increase their self-esteem and gain a more positive body image. This may lead to a higher level self-efficacy, which will increase their perceived ability to make healthy choices.
Proposed Intervention
In order to address a complex issue such as obesity there needs to be a multidimensional intervention that not only addresses the needs of an individuals physiological, biological, and intellectual self, but also the needs of the family, community, society, and culture.
Ecological systems theory can be used as a starting point for the framework of an effective intervention.(30) Since within the education setting there is unprecedented access to the minds of children, this can be an effective venue for the start of a national or even internationals intervention.
It is important that any intervention used to address childhood and adolescent obesity take care to protect the delicate nature of a child’s self-esteem and self-image. As mentioned before the “Guidelines for Childhood Obesity Prevention Programs: Promoting Healthy Weight in Children” recommended framing any interventions goal as increasing ones healthy lifestyle and not a weight loss intervention.(29) It is important to realize that children’s weight fluctuates as they grow and mature. Therefore it is not as important to focus on a child’s weight on a given day, but to focus on their life style. Ensuring that they gain healthy eating habit, participate in adequate physical activity, and develop a healthy body image is much more important.(31) This will be a three-part intervention to address all the factors that influence not only a child’s lifestyle, but also the families and the community. The main focus of the interventions will be children from kindergarten through high school how attend public school in the state of Massachusetts. Private schools will be encouraged to participate, however as a criteria for state and federal funding public schools will be required to participate.
Physical Activity: Increasing Activity in Physical Educations Classes
Since children spend a large portion of their waking hours in school, therefore it is important to ensure they have ample opportunity to participate in physical activities at school or during after school programs. Healthy People 2010 recommend that children get at least 60 minutes of vigorous physical activity each day.(32) Physical education (PE) class is a perfect setting for student to participant in physical activities. In this intervention care will be taken to ensure that PE class is a safe and encouraging learning environment. This is an appropriate application for Social Learning Theory, since a PE class can be directed more towards an individual learning a changed in behavior in a social setting.(33) The PE teacher is a vital component of this part of the intervention. It is important that the PE teacher be enthusiastic and accessible to the students. Teaching by example will show the students how to perform the activity and will encourage them in doing these activities. As they improve their abilities the behavior can act as a re-enforcer for their participating in more physical activities. In order to encourage participation for children during PE class it is important that they activities be carefully chosen. Activities will be age and skill appropriate to increase the student self-efficacy. (18) Not every child is athletic, but every child should be encouraged to participate in physical activities that they are capable of. No sports that may single out the weaker or less coordinated children will be required. Also, a variety of activities will be available so children do not become bored with the physical activities and so they have the opportunity to participate in actives they enjoy. Level of participation has been shown to decrease with age especially in highs school aged girls. However some studies have found that they are more willing to participate in non-sports related physical activities such as dancing and yoga which will be available to encourage their participation.(8) Activities in PE class may act as Bandura’s “reciprocal determinism”, as the students perform the activities their behavior towards the activities will change and their social interaction within the class will change.(34) As children become more physically active during school hopefully those activities they enjoy will go home with them. Each day children will take home information on the “games” they had enjoyed that day during PE class to encourage their being more active at home and in their communities.
Eating Healthy Foods: Changing Food Options and Encouraging Healthy Eating in the School Setting

Changing the food that is sold and served to the children in the school system is vital to improving the lives of the students. In 2007 around 30.5 million children ate school lunches that were served through the National School Lunch Program.(35) Taking steps to increase the nutritional value of school lunches and providing healthier options students like will provide them with better food. By providing better food in the controlled school environment, we will not rely solely on the parents and student making healthy choices at home. Removing sodas from the schools is another important step in improving not only the health of the students, but also improving their academic performance. Since sodas, high sugar fruit drinks, and junk food sale is often a revenue source for schools, it is important to take a strong stand against sales of these products.(8) The positive message of improving academic performance will increase the likelihood of parents of obese, overweight, and healthy weight student’s participation; because every parent knows that the most important goal for these students is their academic performance.(36) One issue with eliminating soda and junk foods from the school is that restricting food can sometimes make those foods more desirable and increase the student’s consumption of these foods.(37) In order to combat this we will not entirely eliminate sweets and juice drinks from the schools, however will pick healthier options and also increase the availability of good snack choices. For example offering apples and caramel sauce, low fat ice creams, and snack size candies instead of full size candies and full fat ice cream will allow the students to still enjoy a treat that is somewhat healthier for them. Kids need to learn a healthy respect for sweats and realize that they are good in moderations. Putting any food or food group off limits to both children and adults can trigger an unhealthy desire or obsession for the food. In order to engage students in eating healthier food at lunch time and at their homes we will label each day of the week with an intriguing lunch name. for example on intervention used “Meatless Mondays” to show students that they can have healthy meatless alternatives.(8) We will move beyond this using one for each day of the school week. For example we can have “Try something new Tuesday,” “Whole wheat Wednesday,” “Three veggies Thursday,” and “Fat Free Friday.” This way the students will associate the food they ate that day with a healthy message. We will encourage students to bring these messages of healthy food choices home to their families and maybe some will have a fat free dinner on Friday or at least incorporate some fat free options into their meals.
Healthy Lifestyle: Using Health Class as an Opportunity to Reinforce Healthy Living
Health education class is another opportunity to teach students about how their bodies work and what their bodies need to be healthy. It is not sufficient just to teach students about the effects of obesity, they need to understand their bodies. Most high school students know that overeating causes weight gain, however they do not understand their caloric intake. They did not know how fat, carbohydrates, and protein differ in amount of calories they hold.(38) Understanding how are body burns calories and what it needs is important to making health food choices. The challenge behind teaching healthy eating and behavior is it requires that students think rationally about their lifestyles. This is why it is important that schools offer both healthy food choice and physical activity. One method that will be used to teach students about living a healthy lifestyle is by integrating the message into other classes like the Planet Health intervention.(13) By integrating these lessons into the core curriculum; we can ensure that children will be getting the right message about their health. These lessons will be framed in a way that they are not about a student’s weight or weight loss, but about the joy of living a healthy life.
Family and Community: Using Family and the Community as a Support for Children’s Healthy Lifestyles

In order to get both families and the community involved in improving the health of their children, at the start of the intervention and one Saturday a month we will host a family activity day at each of the public schools. For the kickoff we will ask the mayors of each town or local athletes to join us, by doing this we will hopefully get more people involved. During these activity days we will host games for children to participate in which will be age and weather appropriate. At the events there will also be opportunities for parents to get information about both physical activity and nutrition. We will also have nutritionist and health educations participant so parent can talk about their specific concerns for their children health. There has been some success in interventions that include parents and children.(39) These activity days will increase the connection between community members and will influence them to work together towards becoming a healthy community.
One important factor that we will need to look into is if parents and the community have access to healthy food and places to participate in physical activity. It is vital to self-efficacy of the parents to ensure that they can provide the healthy environment to their children that the intervention is encouraging them to. For communities that have inadequate access to healthy foods we will work on providing a farmers market or other fruit and vegetables stands. Also, if there are families who still will not be able to access healthy foods we will set up a community based partnership for arranging rides to grocery stores or farmers markets. At each activity day we will ask for mother with vehicles to volunteer to provide rides to mothers who do not have vehicles. Then in areas that do not have safe locations for outdoor physical activity, we will work with the community leaders to establish a safe zone. This will be areas where children and parents can come and be physically active.

Changing the World: Moving Beyond the Individual, Family, and Community to Effect the World

Massachusetts is often used as an example for different political and health policy changes; universal health insurance and same-sex marriage. If Massachusetts is able to successfully change the way we deal with childhood obesity on the individual, family, community, and state level hopefully it will be an influence for this nation and the world to change how we all deal with childhood obesity. Obesity is a sensitive issue that cannot be fixed with on an individual or even family level if we want to make a lasting change. We need to look beyond and individuals food intake and physical activity levels into the deeper reasons behind their weight status. It is a lifestyle, not a diet or a trip to the gym that is going to save these children from a lifetime of psychological and physiological pain.


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