Challenging Dogma - Fall 2009

Thursday, December 17, 2009

The President’s Challenge-A Good Fit for Childhood Overweight and Obesity?-Marlaina Lee

Childhood overweight and obesity is undoubtedly one of the most important health issues facing the United States. Overweight and obesity is quantified by the use of the Body Mass Index. According to the Centers for Disease Control and Prevention, CDC, an overweight child has a Body Mass Index of greater or equal to the 85th percentile. An obese child is classified as having a Body Mass Index of greater or equal to the 95th percentile (1). Youth overweight and obesity has been on the rise in the United States for the past four decades (2). Data from the most recent National Health and Nutrition Examination Survey, NHANES (2003-2006), finds that 33.3 percent of children ages 6 –11 and 34.1 percent of children ages 12–19 qualify as overweight (2). Three classes of contributing factors for childhood overweight and obesity have been identified by the CDC: genetic, behavioral and environmental (3). In response to the proclaimed “Obesity Epidemic” in the United States, research efforts have focused on the causal factors linked to obesity and effective interventions for behavioral and environmental influences (4). Additionally, the United States’ federal government recognizes the problem of increased overweight and obesity at all ages and committed to a goal of reducing the rates of childhood overweight and obesity to 5 percent in Healthy People 2010 (5). This goal will be retained for Healthy People 2020 (5).
The President’s Challenge
One of the most recognized government programs intended to promote physical fitness and activity is the President’s Challenge sponsored by the President’s Council on Physical Fitness and Sports, PCPFS, an office within the Department of Health and Human Services (6). The President’s Challenge began in 1966 with the development of the Presidential Physical Fitness Award; the program continues today as an age-specific recognition and awards program comprised of a physical fitness test, health fitness test, active lifestyle program and Presidential Champions program (7). The most prominent aspect of the President’s Challenge is the physical fitness test that includes curl-ups, push-ups, pull-ups, a shuttle run and a v-sit flexibility test. Awards are distributed in three categories: Participant (those not meeting the 50th percentile), National (above the 50th Percentile), and Presidential (above the 85th percentile) (7). Besides having nation-wide participation, the Challenge has demonstrated proven benefits for its participants. An independent study conducted at Louisiana State University found that students who receive recognition (Presidential Fitness Awards) for their physical fitness efforts “reported higher levels of task orientation, perceived competence, enjoyment, effort, and stronger intentions to participate in fitness testing in the future than those who did not receive awards” (8). While the program has many positive aspects and outcomes, this intervention could achieve greater potential if three critical areas, program design, acknowledgement of limited physical education, and marketing/advertisement were addressed and improved.
Flawed Design
The President’s Challenge is designed based on standards developed from the 1985 School Population Fitness Survey (9). This data is used to set the award levels for physical fitness achieved amongst participants (9). This is a critical flaw in the design of this public health intervention. Current participants are being compared to the performance of a previous generation. The comparison of the 1976-1980 and 2003-2006 NHANES surveys shows that overweight rates have more than tripled for children ages 12-19, increasing from 5 percent to 17.6 percent (10). The landscape of the US population, rates of overweight and obesity, and physical activity guidelines have changed drastically over this same time period. The use of 25 year-old data as a standard significantly hinders the potential effectiveness of the President’s Challenge. One could argue that this previous generation was healthier and holding today’s students to those physical standards is beneficial, however, this demonstrates a lack of understanding of the population the initiative attempts to serve. A student taking the physical fitness test today may not meet the 50th percentile of the 1985 standards and be discouraged by his results. His results might be very different if compared to updated youth standards. This child could possibly qualify for the next level of recognition if compared to accurate peer data, but the use of the 1985 numbers prevents this. Furthermore, the discouragement generated by the 1985 comparison could prevent the student from having self-efficacy in regards to physical activity and fitness. The theory of self-efficacy argues that the “expectation of personal mastery and success determines whether or not an individual will engage in a particular behavior” (11). If a student does not meet the 50th percentile, and earns only a “Participant” achievement level, he will not cultivate the sense of mastery described in the theory of self-efficacy. This could have lifelong behavioral repercussions if the student elects not to partake in future physical activity for fear of below average performance. Self-efficacy is a component of many health behavior change models and is a primary element in sport psychology (12). Holding today’s children to the standards of a prior generation is counter-productive to the President’s Challenge because it ignores the potential source of negative reinforcement and neglects to foster self-efficacy. The use of the 1985 School Population Fitness Survey does not account for the societal or lifestyle changes that have occurred in this time-period and does not necessarily provide participants with a realistic view of their individual physical fitness levels.
Environmental Constraints
Educators are the individuals who implement the President’s Challenge in schools. Materials are available to assist educators in operating the program; there is an online tracking system to enter students’ progress, online order forms for the rewards, etc (13). However, these enhancements to the well-established program do not address the critical issue of the national trend towards the reduction or elimination of allocated physical education in schools (14). Physical Education is omitted from the core subjects included in the No Child Left Behind Act, which has greatly influenced the shape of US K-12 curriculum since its passage it 2002 (15). No Child Left Behind focuses on reading and mathematics and has pushed curriculum developers to reduce health and physical education in an effort to allocate more time for core subjects (14). The Shape of the Nation 2006, a report published jointly by the American Heart Association and the National Association for Sport and Physical Education, NASPE, states the number of students participating in daily physical education has declined from 42 percent in 1991 to 28 percent in 2003 (16). Another survey conducted by the CDC, the 2006 School Health Policies and Programs Survey, found that 21.7% of schools participating in the survey did not have any physical education requirement (17). With instructional physical education time being extremely limited or non-existent, participation in the President’s Challenge can be difficult for teachers to implement. Classes that are actually held present educators with large student enrollment and time constraints. This restrictive environment to not conducive to participation in the Challenge or for conducting bi-annual fitness testing as recommended by the PCPFS (18).
For a public health initiative to be successful, it is necessary for the individuals designing the initiative to have an understanding of the environment in which the intervention will be executed. The President’s Challenge is designed with the assumption that teachers will have sufficient time to enact the program and be able to track performance. When the PCPFS first introduced the concept of fitness awards, the program was being released to a public whose school children had regular, if not daily, physical education (14). There is a reduced opportunity for reinforcement of positive physical activity behaviors if time spent in the intervention environment is limited. Social Learning Theory, developed in mid-1980’s, maintains that:
People are influenced by observing others, and their health behavior is affected by knowledge of steps necessary to avoid risk, motivation to avoid risk, the perceived benefits of the protective action and the belief that one can effectively carry out the protective action…four major conditions are needed for behavior change: (a) information (b) the development of self-protective skills and controlling self-efficacy; (c) skill enhancement and building resilient self-efficacy; (d) and social supports for desired personal changes. (19)
The Challenge is presented as a school-wide group activity, with the physical education classroom as its setting. Without instructional classroom time, the program has no means to provide the Social Learning Theory’s conditions for behavior change. Limited instructional time prevents students from observing each other’s participation in the program, developing their own physical activity skills and self-efficacy and receiving social support for their Challenge participation. According to the Social Learning Theory, these are all vital components and reinforcements of health behavior change; the physical education classroom is the only structured outlet provided for these activities contributing to the success of the Challenge. Though the Department of Health and Human Services has listed as a new initiative in Healthy People 2020 to “increase the proportion of States and school districts that require regularly scheduled elementary school recess” (20), recess is not instructional physical education, and this increase will not influence curriculum changes or assist teachers in implementing the Challenge. Overall, the Challenge’s failure to address time constraints and limited exposure to physical education demonstrates a lack of environmental consideration in the program’s design and leaves it susceptible to failure.
Promotion Pitfalls
The President’s Challenge has existed for many decades and over 70 million individuals are estimated to have received Presidential Fitness recognitions since the program’s commencement. Despite its history, the free program is not consistently utilized throughout the country. State participation rates vary greatly from state to state and some states do not even meet the minimum three submissions for certain state-wide awards programs (21). Though the Challenge makes print media materials and a user-friendly website available for schools and individual participants, there are no Public Service Announcements or widely circulated mainstream advertisements promoting the program. The program recently branched out through a more popular social network by launching a Facebook group, but it has a mere 1,650 members, most of who appear to be adults (22). It order to expand participation on both the school and individual levels, the President’s Challenge needs to effectively utilize mainstream media outlets and networking resources. Facebook is a start, but low membership reflects a limited interest in the program. Furthermore, the page does not even offer a full description of the many aspects of the President’s Challenge. Effective utilization of popular communication methods could generate greater awareness, interest and participation in the program.
Multiple studies have been conducted evaluating the influence of social networks on health behaviors and outcomes. A social network consists of the people one regularly communicates and comes into contact with. A student’s teachers and classmates are part of their social network, as are their Facebook friends. Researchers at Harvard University have established that “network phenomena appear to be relevant to the biologic and behavioral trait of obesity, and obesity appears to spread through social ties. These findings have implications for clinical and public health interventions” (23). Since networks contribute to and can influence rates of obesity, they should be employed as agents of health behavior change. The Challenge has put a limited effort into taking advantage of both media and social networks to promote itself. The most fantastic website will not achieve wide circulation if the only advertisement for it is a printed poster hanging in the corner of a school gymnasium. The program does itself a disservice by putting forth a mediocre media and social networking campaign. Without exciting promotion, student interest in the program can falter and participation rates will remain stagnant.
The President’s Challenge has many positive features and should not be hastily cast aside. The faulty aspects of the President’s Challenge could be altered to better serve the youth population. Its foundation as a national program to promote fitness, its accessibility and relatively simple methods of fitness testing are redeeming qualities that if combined with recent data, thorough environmental assessment and strategic marketing/networking could produce a strong childhood overweight and obesity initiative.
A New Challenge
An improved and remarketed program could be designed based on the President’s Challenge. A “National School Fitness Challenge” would incorporate the positive aspects of the President’s Challenge, but utilize more current standards, accommodate limited physical education and advertise itself as a nationwide, school-spirit, physical activity competition. The program would run annually for the duration of the school year and include fitness testing and physical activity participation both inside and outside of the school facility. This proposed program would develop partnerships with athletes, sports teams and celebrities to provide incentives, such as school appearances and apparel to motivate students and prompt participation. Currently, the highest performing “Champion Schools” in the President’s Challenge receive a school award certificate and emblems to place on student award certificates (21). The new program would strive to secure more desirable incentives to spark student excitement for the program.
Current Data
The School Population Fitness Survey has not been conducted since 1985, but other more current physical fitness data has been collected and is readily available to the public. In 2004, NASPE published physical education standards for every grade level (24). These would be appropriate standards to develop a program curriculum around, since NASPE represents physical educators through the country and is a part of the American Alliance for Health, Physical Education, Recreation and Dance. These standards were developed with an understanding of the current physical education environment and because of that are more conducive to promoting self-efficacy in students. The standards include concepts such as achieving and maintaining a health-enhancing level of physical fitness, and valuing physical activity for health, enjoyment, challenge, self-expression, and/or social interaction (24). The standards include both performance and participation-based assessment which creates a positive fitness attitude. Using these standards would allow students to develop a sense of self-efficacy, a critical component of behavior change.
Environmental Embraces
Understanding the constraints on instructional physical education time, the National School Fitness Challenge would include supplementary activities that could be completed outside of the gymnasium and at home. Students would be encouraged to participate in physical activity at both recess and home and complete their own fitness logs on the program’s website. If students do not have access to the internet at home, there would be a paper-based method to submit physical activity logs. The use of at-home activities would supplement and enhance physical education. The at-home activities would also serve as reinforcement for physical activity and aid in the information and skill development elements outlined in the Social Learning Theory (11). Classroom time would be optimized by participation in the nationwide program because it would be a year-long reinforcement of fitness concepts with a rewarding conclusion at the end of the school-year.
Popular Communication
In order for the National School Fitness Challenge to have any impact, it must be creatively marketed as an exciting competition that ignites school spirit. General Mills sponsors “Box Tops for Education” which encourages students to collect General Mills product box tops and bring them to school. Based on the number of collected box tops, General Mills makes a donation to the school. In 2008, because of such high participation rates, General Mills donated $50.6 million dollars to participating schools (25). Though the National School Fitness Challenge would not offer monetary incentives for school participation, it would utilize the benefits of marketing and advertising theories utilized by General Mills for the promotion of the program. Since box tops are located on General Mills’ products, the company promotes its school program through the advertisement of its products. David Ogilvy, founder of the global Ogilvy advertising agency writes that in advertising “your most important job is to decide what you are going to say about your product, what benefit you are going to promise” (26). Most Americans could quote General Mills’ Cheerios as being “heart healthy” (27) and Cheerios have delivered on this promise for decades. To successfully advertise the National School Fitness Challenge, the promise of a fun, beneficial, school physical activity program would have to be amplified through television, print and internet advertisements where it would reach the targeted population of children and educators.
This promise would be further spread through appropriate social networks, both physical and virtual, by using online communities such as Facebook to promote the program to the targeted audience. Obesity researchers suggest:
The spread of obesity in social networks appears to be a factor in the obesity epidemic. Yet the relevance of social influence also suggests that it may be possible to harness this same force to slow the spread of obesity. Network phenomena might be exploited to spread positive health behaviors, in part because people’s perceptions of their own risk of illness may depend on the people around them. (19)
If network phenomena are truly influential in health behavior, their utilization is key to promoting this childhood intervention. If individuals see their peers and counterparts involved in the National School Fitness Challenge, they might be more inclined to participate. If a student sees his classmate completing fitness logs, this may result in a form of positive peer pressure motivating the student to do the same. Cross-country friends could notice a Facebook friend’s school participating in the Challenge and urge their teachers to enter their school into the competition. The combination of advertising and social networking would launch the program into the schools and homes of every potential participant. Awareness of the program will prompt higher participation, making the program more exciting for participating students and translate into a greater impact.
The identification of school physical education programs as a vehicle to combat childhood obesity is not new. Conversely, many of the obstacles and tools presented to public health program designers are new and are still in the process of being demystified. Pre-existing programs like the President’s Challenge have value in the health-conscious principles they aim to promote. However, updated and modified programs like the proposed National School Fitness Challenge are better equipped to advance the nation’s aspirations of reducing childhood overweight and obesity.
1. Centers for Disease Control and Prevention. Obesity and Overweight for Professionals: Childhood. Atlanta, GA: Centers for Disease Control and Prevention.
2. Centers for Disease Control and Prevention. Obesity and Overweight for Professionals: Childhood: Trends: NHANES. Atlanta, GA: Centers for Disease Control and Prevention.
3. Centers for Disease Control and Prevention. Obesity and Overweight for Professionals: Childhood: Contributing Factors. Atlanta, GA: Centers for Disease Control and Prevention.
4. The Campaign to End Obesity. The Campaign to End Obesity: About the Campaign. Washington, DC: The Campaign to End Obesity.
5. Healthy People 2010. 19-3-Reduce the proportion of children and adolescents who are overweight or obese. Washington, DC: US Department of Health and Human Services.
6. President’s Council on Physical Fitness and Sports. The President’s Council on Physical Fitness and Sports: About the Council. Washington, DC: President’s Council on Physical Fitness and Sports.
7. The President’s Challenge. Educators. Washington DC: President’s Council on Physical Fitness and Sports-Department of Health and Human Services.
8. Domangue, E., Solmon, A. Relationships Between Motivation and Award Status on Norm-Referenced Fitness Tests. 2009 AAPHERD Exposition. Tampa, Fl:
9. The President’s Challenge. Educators-Physical Fitness Test. Washington DC: President’s Council on Physical Fitness and Sports-Department of Health and Human Services.
10. Centers for Disease Control and Prevention. Obesity and Overweight for Professionals: Childhood: Trends in Childhood Obesity. Atlanta, GA: Centers for Disease Control and Prevention.
11. Salazar, M. Comparison of Four Behavioral Theories. American Association of Occupational Health Nurses Journal March 1991; 39:3:128-135.
12. Cox, R. Sport Psychology: Concepts and Applications. New York, NY: McGraw-Hill, 2002.
13. The President’s Challenge. Educators. Washington DC: President’s Council on Physical Fitness and Sports-Department of Health and Human Services.
14. Azzarito, L. “Shape Up America!”: Understanding Fatness as a Curriculum Project. Journal of the American Association for the Advancement of Curriculum Studies. February 2007.
15. US Department of Education. Elementary and Secondary Education Act. Washington, DC: US Department of Education.
16. National Association for Sport and Physical Education. The Shape of The Nation. Reston, VA: National Association for Sport and Physical Education.
17. Lee, S., Burgeson, C., Fulton, J., Spain, C. Physical Education and Physical Activity: Results From the School Health Policies and Programs Study 2006. Journal of School Health, October 2007. 77:8:435-463.
18. The President’s Challenge. Educators-Testing Guidelines and Events. Washington DC: President’s Council on Physical Fitness and Sports-Department of Health and Human Services.
19. Choi, K., Yep, G., Kumekawa, E. HIV Prevention Among Asian and Pacific Islander American Men Who Have Sex with Men: A Critical Review of Theoretical Models and Directions for Future Research. AIDS Education and Prevention, 10, 1998:19-30.
20. Healthy People 2020. Physical Activity and Fitness-PAFHP2020-12. Washington, DC: US Department of Health and Human Services.
21. The President’s Challenge. Educators-Recognition. Washington DC: President’s Council on Physical Fitness and Sports-Department of Health and Human Services.
22. The President’s Challenge Facebook Group.
23. Christakis, N., Fowler, J. The Spread of Obesity in a Large Social Network over 32 Years. New England Journal of Medicine 2007;357:370-379.
24. National Association for Sport and Physical Education. National Standards. Reston, Va: National Association for Sport and Physical Education.
25. General Mills. Box Tops for Education-Success Stories. Young America, MN: General Mills.
26. Oglivy, D. Confessions of an Advertising Man. New York, NY: Atheneum, 1964. 93.
27. General Mills. Cheerios. Young America, MN: General Mills.

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