Why Transtheoretical Model is Making Small Step Campaign Have a Small Impact: A Critique Based on . . .

. . . Social Marketing and Integrated Theory of Health Behavior Change – Annie Peer

For a limited time only the price to get you 640 calories and 39 grams of fat will get you double - nearly 1300 calories and 80 grams of fat! Soon you too will be on your way to craving this many calories at every meal until you are in the “select” group of 72 million Americans in the obesity club. (1). If Burger King advertised their new buy one Original Chicken Sandwich and get one free offer in this way, obesity would not be such an issue as it is in America today. Instead Burger King focuses on people getting people what they want, how they want it, and with bigger portions than they imagined. The sandwich is described as being “unchanged since 1979, which no other burger can say” and “not a handful but a handsful”. Even the website allows the consumer to decide how much food, fun, and king images they want on the main menu as seen below:
Figure 1 www.bk.com
This is what public health intervention against obesity is up against. “Obesity is the second leading cause of preventable premature death in this country, with some researchers predicting it may soon outpace smoking as the leading cause of preventable death. A solution will likely be multi-faceted, with emphases on prevention, improvements in treatments, policy change, and environmental changes, among others” (1). One attempt to make exercise and healthy living more “do-able” is the Small Step campaign that was started by the government. This makes exercise look easy by just getting into the habit of small changes everyday that will make you healthier such as taking the stairs instead of the elevator.
Using the six-stage behavior change theory (transtheoretical model) to plan their approach, researchers determined that the public is aware of the dangers of obesity but remains complacent about it (has yet to take action, see rewards from doing so, and commit to ongoing change). Why? Because people want a quick-fix in modern life and none of the promised "quick-fix" diet plans actually work, so consumers have concluded that it's impossible to get healthy.
The transtheoretical model shows the six stages that a person must pass through to achieve behavioral change:
Consciousness/Awareness
Emotional Arousal/Interest
Self-evaluation/Preparation
Commitment/Action
Reward/Positive Reinforcement
Self Liberation/On-going Commitment to Change
(2)
Critique 1 – Transtheoretical Model Does Not Account for Everyone
The primary use of the transtheoretical model is the first mistake this campaign makes. This model “integrates two interrelated dimensions of change, stages of change and processes of change, along with the constructs of self-efficacy and decisional balance. Stages of change represent when an individual is ready to change. Self-efficacy refers to the conviction that one can successfully execute the behavior required to produce the desired outcomes, and decisional balance encompasses the pros and cons or perceived benefits and barriers of making the change” (3). The stages of change reflect a person’s intention to change or the degree to which a person gives serious consideration to change. Individuals may progress through stages at varying rates, may regress, and may reenter the continuum of change at carrying points.
Cons to the physical exercise model showed that “precontemplators” see physical activity as having nearly as much cost as it has benefits and score highest on the cons of engaging in physical activity. (3). A study by Marcus, et al. (4) found that, similar to self-efficacy, pros and cons of physical activity were related to physical activity behavior only indirectly. The pros and cons constructs were related to stage of physical activity readiness (intention), and stage of physical activity readiness served as the mediator influencing actual physical activity patterns. Compared to individuals who were not regularly physically active, individuals who engaged in regular physical activity used physical activity to cope with unpleasant emotions such as stress and fatigue, rewarded themselves for engaging in physical activity, made a commitment to be physically active, and employed reminders to be physically active. Furthermore, these regularly active individuals had more confidence in their ability to be physically active and placed greater emphasis on the benefits of being physically active. It appears that those who were not physically active had less confidence in their ability to be physically active and perceived the barriers to engaging in physical activity as outweighing the benefits. (3).
Transtheoretical Model posits that decisional balance, self-efficacy and processes of change are the most important stage transition determinants. (5). The evidence for the importance of these constructs is mostly based on cross-sectional data and more convincing evidence based on longitudinal data or experimental research is mostly lacking.
Critique 2- Food Ads Dominate in Exposure Time over Small Campaign
The fact that unhealthy food advertisements are dominant and result in fatter people is the second critique. Small Steps’ handful of ads and website isn’t nearly enough to counteract the pervasiveness of advertisements for unhealthy food -- particularly for teens. A study (6) found that fast-food restaurant advertisements were found to make up 23.1% of all food ads seen by adolescents (21.5% and 23.6% for African-American and white teens respectively), and McDonald’s and Burger King advertisements made up approximately 44% of fast-food ads seen by teens. Sweets and beverages ads counted for 22% and 17% of all food ads, respectively, while cereal ads made up 11%.

Figure 2 shows the distribution of the advertisements seen by a group of adolescents in a study done by Powell et al. (6).
Food advertising that promoted snacking, fun, happiness and excitement (i.e., the majority of children’s food advertisements) directly contributed to increased food intake. In addition, these effects occurred regardless of participants’ initial hunger. (7). Furthermore, the amount of calories consumed by the participants after viewing snack advertisements was completely dissociated with the adults’ reported hunger. This was particularly true for men and those attempting to diet. (7). In addition, the effects persisted after the viewing session.
It is not even as simple as restricting television advertising of calorie-dense, nutrient-poor foods… one study (8) proposed a food marketing defense model that posits four necessary conditions to effectively counter harmful food marketing practices: awareness, understanding, ability and motivation to resist. While it is extremely complicated and involved to control the effect of advertising, is it suggested here under the understanding category, to propose a way to effectively market foods and healthy behaviors is a way to defend against food marketing. The way to successfully achieve this will be discussed later in the improved intervention. Psychological theories predict that food marketing, in all its forms, has a profound negative impact on public health among young people and adults. Similarly they predict that proposals by the food industry, such as increased marketing of “better for you” foods or the inclusion of physical activity in food advertising, would not even begin to counteract these effects, and could make them worse. (8).
Critique 3- Health Belief Model Does Not Account For Social And Environmental Factors
The last critique is that the website is based on the health belief model and that people just need education to adopt a healthier lifestyle. This idea of the public simply needing information about nutrition is very wrong. A study (9) showed that providing calorie information at the point-of-purchase on a fast food restaurant menu had little effect on food selection and consumption among a sample of adolescents and adults who eat regularly at fast food restaurants.
Even when people are familiar with a specific risk, social norms and support play a huge role in a campaign’s success. When looking at diabetes prevention in Latino and other racial/ethnic populations (10) they found that integrating cultural factors into prevention interventions involves a proactive analysis of the needs of a specific cultural sub-group, and of how specific cultural factors (perceptions, attitudes, skills in self-regulation, family obligations, low social supports for a healthy lifestyle, etc.) may operate as personal or cultural barriers (or a facilitators) of sustained behavior change.
Broad contextual factors found that cultural influence included aspects of the built environment, as well as local norms and national policies that influence lifestyle choices. Consideration of these factors may augment cultural sensitivity, ideally facilitating program participation and thus enhancing the efficacy of interventions designed to change dietary and exercise behaviors. The Small Step program’s website focuses on educating the public about nutrition, while social norms and individual environments are not addressed.
The consumeR Campaign
The “consumeR” campaign will show how consumerism in America has made Americans fat. The blame for being fat will be placed on the companies’ campaigns to manipulate people into eating more thereby making them more money. This campaign will have people rebelling against fast-food by creating their own independent thoughts. The person that is a member of this “I am not a consumeR” web group will live up to this rebellious title according to the labeling theory. The R in consumeR will always be capitalized to emphasize that resisting consumption at these types of establishments relates to the second part of the campaign called “Reality check”. The “Reality” will take people behind big business to have people question the messages behind the ads and why they are getting bigger sizes or second hamburgers for free.
Since public health campaigns do not typically have large budgets, the considerable amount of the influential food advertisements would be combated by this rebellion against big food companies. Additionally, a website will be made where people can sign up for text messages to motivate them to exercise and stay away from fast-food. A section of the website will be a forum where members can post a ridiculous ad put out by companies designed to get them to eat more. When told that these companies are trying to get the consumers to not think and just be followers, they will rebel.
Solution 1- Segmentation to Appeal to Each Segment of the Population
Since the Small Step campaign does not appeal to “precontemplators”, the new campaign will take into account that all people need to be healthy and will use a variety of mediums to appeal to a diverse population. Developing interventions that are indeed stage-matched requires knowledge about important and modifiable stage transition determinants…making specific action plans may help people to turn their intentions into health promoting action. (5). The Transtheoretical model used in Small Step does not account for all people. It assumes that everyone watching is at point of being willing to make the changes necessary to live a healthier lifestyle.
There are nearly 66% of Americans who are overweight and they do not form a homogeneous group - attitudes, demographic characteristics and lifestyle choices vary greatly within this subset of the US population. (11). Segmentation theory tells us that a “one size fits all” approach to marketing social change may not meet the needs of all people. Further, marketing research has revealed the importance and effectiveness of tailoring messages and incentives to meet the needs of different population segments. Social marketing is defined as “a social change campaign organized by a group which intends to persuade others to accept, modify or abandon certain ideas, attitudes, practices or behavior” (11). Just as the “truth” campaign was able to appeal to the teens’ need for a feeling of independence and rebellion using the social marketing theory against smoking (11), this new campaign for obesity prevention will target different segments too. While overweight adults will primarily be the television ad viewers, teens and kids will be more into the website design. Looking at the following screen shots of the facts pages on the “truth” and “Small Step” campaign, it is easy to see which one is more appealing to teens.

Figure 3 www.thetruth.com

Versus:


Figure 4 www.smallstep.gov
Another way to appeal to more people is through the use of more technology. A study (12) found that text messages were shown to be highly effective and used in several ways: to promote interaction with the intervention, send motivational messages (e.g., reminders of the benefits of exercise), challenge dysfunctional beliefs, or provide a cue to action. Use of communicative functions, especially access to an advisor to request advice, also tended to be effective. It may be that, although the Internet provides a suitable medium for delivering interventions, personal contact via email, online, or text message helps to support behavior change.
Solution 2- Marketing Healthy Behaviors
Social marketing of health behavior change posit that educational interventions may help to improve motivation to change, but that better opportunities for healthy behavior are needed to move people to action. (13). Findings suggest that in contexts like physical activity, condom use and recycling, negative messages about non-enactment will be inherently less efficient than positive messages about enactments. In contrast, in substance abuse-related contexts, the use of positive messages will be inherently less efficient than negative messages due to the negated linguistic form of the target, anchoring concepts denoting non-enactment. (13). While the consumeR campaign with not directly focus on physical activity and labeling people with being active, it will focus on encouraging people to not fall prey to big food chain advertisements by thinking for themselves.
One possible solution to the inefficiency problem is to utilize affirmative brand names to anchor associations with non-enactment concepts. A predominate example of this strategy is “truth” campaign, which was intended to establish “truth” as an aspirational nonsmoking brand. (14). Teens’ social images of smoking (e.g., promoting the appeal of nonsmoking as a way of achieving a desired personal image of independence or rebelliousness) appears to be a useful framework within which to understand intended campaign effects. Evaluation of the campaign’s effectiveness suggests that “truth” has affected social imagery about nonsmoking, achieved high brand equity among its target audience, and contributed to reduced rates of smoking initiation. (15). In other words, blame company instead of yourself.
The campaign should have people revolting against the ridiculousness of unhealthy food commercials since they have been shown to increase food consumption. Therefore, the campaign that sells exercise, as way for people to maintain their freedom and youth will be successful because it focused not on the product but on the desires of the audience. Key core ideals that people do not want taken away include youthfulness and freedom.
Solution 3 – Social Support and Environment Addressed
To assist people working to live healthier lifestyles, the Integrated Theory of Health Behavior change has been found (16) to be helpful. The ITBC is an integration of past successes and makes substantive contributions to understanding health behavior by combining knowledge and beliefs, self-regulation processes, and social facilitation. According to this theory, persons will be more likely to engage in the recommended health behaviors if they have information about and embrace health beliefs consistent with behavior, if they develop self-regulation ability to change their behavior, and if they experience social facilitation that positively influences and supports their engagement in preventative health behaviors.
Knowledge and belief systems impact behavior-specific self-efficacy, outcome expectancy, and goal congruence. Self-regulation is the process used to change health behavior and includes activities such as goal setting, self-monitoring and reflective thinking, decision making, planning for and engaging in specific behaviors, and self-evaluation and self-managing physical, emotional, and cognitive responses associated with health behavior change. Social facilitation includes the concepts of social influence, social support, and negotiated collaboration between individuals and families and healthcare professionals.
Figure 5: Integrated Theory of Health Behavior Change (16).
Another study found that one of the strongest correlations with a child’s BMI was a parent’s BMI. (17). Since the environment in America is so commercialized with a heavy emphasis on food, the social norms and environment must be accounted for in obesity intervention. Although altering American social regarding fast-food will not be an easy task, a website that challenges these norms will be a good start. Members will be a part of a rebellious group going up against food companies that prey on their vulnerabilities.
Competing against huge corporations that have succeeded in controlling the emotions of a majority of Americans is a difficult task. However, the “consumeR” campaign will draw attention to unnoticed unhealthy behaviors by highlighting the absurdity of food advertisements. Social support is given through a fun and resourceful website with forums and text/email motivation. The “consumeR” campaign will draw attention to the lack of thought that Americans put into food and exercise choices. The campaign’s revelation that people are merely blind consumers getting tricked into making harmful personal choices by the advertisements of multibillion-dollar food companies will motivate rebellion. Furthermore, allowing people who never considered themselves as unhealthy - merely because they are not obese- to think differently, will be a huge benefit in setting them on healthier paths and preventing a worsening obesity epidemic in America.
REFERENCES

1. Bean, M. K., Stewart, K., & Olbrisch, M. E. Obesity in america: Implications for clinical and health psychologists. Journal of Clinical Psychology in Medical Settings 2008; 15(3): 214-224.
2. Woods, C., Mutrie, N., & Scott, M. Physical activity intervention: A transtheoretical model-based intervention designed to help sedentary young adults become active. Health Education Research 2002; 17(4): 451-460.
3. Barrett, B. S. An application of the transtheoretical model to physical activity. Ph.D. dissertation, University of Minnesota, United States -- Minnesota. 2007. Retrieved December 3, 2010, from Dissertations & Theses: Full Text.(Publication No. AAT 9815016).
4. Marcus, B. H., Eaton, C. A., Rossi, J.S., & Harlow, L. L. Self-efficacy, decision-making, and stages of change: An intergrative model of physical exercise. Journal of Applied Social Psychology 1994; 24:489-508.
5. Gollwitzer, P.M. Implementation intentions: strong effects of simple plans. American Psychologist 1999; 54: 493-503.
6. Powell, L. M., Szczypka, G., & Chaloupka, F. J. Adolescent exposure to food advertising on television. American Journal of Preventive Medicine 2007; 33(4, Supplement 1): S251-S256.
7. Harris, J. L., Bargh, J. A., & Brownell, K. D. Priming effects of television food advertising on eating behavior. Health Psychology 2009; 28(4): 404-413.
8. Harris, J. L., Brownell, K. D., & Bargh, J. A. The food marketing defense model: Integrating psychological research to protect youth and inform public policy. Social Issues Policy Review 2009; 3(1): 211-271.
9. Harnack, L. J., French, S. A., Oakes, M., Story, M. T., Jeffery, R. W., & Rydell, S. A. Effects of calorie labeling and value size pricing on fast food meal choices: Results from an experimental trail. International Journal of Behavioral Nutrition and Physical Activity 2008; 5(63).
10. Castro, F. G., Shaibi, G. Q., & Boehm-Smith, E. Ecodevelopmental contexts for prevention type 2 diabetes in Latino and other racial/ethnic minority populations. Journal of Behavioral Medicine 2009; 32(1): 89-105.
11. Kolodinsky, J. & Reynolds, T. Segmentation of overweight Americans and opportunities for social marketing. International Journal of Behavioral Nutrition and Physical Activity 2009; 6(13).
12. Webb, T. L., Joseph, J., Yardley, L., & Michie, S. Using the Internet to promotes health behavior change: A systematic review and meta-analysis of the impact of theoretical basis, use of behavior change technique, and mode of delivery on efficacy. Journal of Medical Internet Research 2010; 12(1): e4.
13. Brug, J., Conner, M., Harré, N., Kremers, S., McKellar, S., & Whitelaw, S. The transtheoretical model and stages of change: A critique. observations by five commentators on the paper by adams, J. and white, M. (2004) why don't stage-based activity promotion interventions work? Health Education Research 2005; 20(2): 244-258.
14. Freeman, D., Shapiro, S., Brucks, M. Memory issues pertaining to social marketing messages about behavior enactment versus non-enactment. Journal of Consumer Psychology 2009; 19(4): 629-642.
15. Evans, W. D., Wasserman, J., Bertolotti, E., Martino, S. Branding behavior: The strategy behind the Truth campaign. Social Marketing Quarterly 2002; 8: 17-29.
16. Ryan, Polly. Integrated theory of health behavior change: Background and intervention development. Clinical Nurse Specialist 2009; 23(3): 161-172.
17. Elder, J. P. et al. Individual, family, and community environmental correlates of obesity on Latino elementary school children. Journal of School Health 2010; 18(1): 20-31.

Critique of the Delaware Based Public Health Campaign to Reduce Childhood Obesity: Potential Weaknesses in the Application of . . .

. . . Ecological Perspective Theory – Beth Morse

INTRODUCTION
The Delaware based Nemours Health and Prevention Services (NHPS) 5-2-1-Almost None intervention describes itself as a social marketing campaign that fights childhood obesity (1) yet it fails to adequately influence the public to develop healthy behaviors. The intervention appears to be based on an Ecological Perspective approach described by McLeroy et al. (1988) as an overarching public health approach that includes interpersonal, intrapersonal and community levels of intervention (2). The NHPS campaign fails at each level of intervention to make an impact on the lifestyle choices of families and children.

BACKGROUND: Nemours Health and Prevention Services 5-2-1-Almost None Campaign and Ecological Perspective Theory
The NHPS campaign to fight childhood obesity is a multiyear statewide campaign to improve the health of children in Delaware through policy change and social marketing for lifestyle improvement (1). The campaign promotes itself using the slogan “5-2-1-Almost None.” The numbers stand for 5 servings of fruit and vegetables a day, no more than 2 hours of screen time per day, 1 hour of physical activity, and almost no sugary beverages,” (1). The program reaches out to caregivers and policy makers with the message that children cannot develop healthy habits on their own and that they need adults to help. The campaign is split into two main parts; the first part focuses on policy and practice changes while the second part provides resources and tips to help caregivers teach their children to live a “5-2-1-Almost None” lifestyle. The teaching materials are not spread by NHPS itself but are made available online for groups or organizations who can use the resources to educate the public on a healthy lifestyle (1). The program advertises itself through billboards and radio adds that send the message ‘Children cannot do it alone, they need our help to live a healthy lifestyle,’ (1). The website does not appear very user friendly to the public but does offer a link for kids to play video games or watch episodes of The Mighty Timoneers, a group of cartoon pirates who battle a candy filled Sea and learn to eat healthier diets (1). Along with the cartoon program, the NHPHS website offers other useful materials for educating children and families on healthy lifestyle behaviors.
The major flaw in the NHPS campaign is that it fails to market itself in an effective manner. The campaign attempts to advertise itself through billboards and radio ads so that other groups will pick up the message and send out the educational materials thus creating a social network for the public health intervention. The problem here is that NHPS fails to adequately reach these social groups. Beyond the basic marketing failure of this campaign, the intervention is based on a combination of faulty social science theories. There are holes in the multiple social science theories upon which the Ecological Perspective theory bases its approach.
The NHPS intervention is based on an ecological perspective theory that encompasses multiple levels of intervention including intrapersonal, interpersonal and community (2,3). The goal is to change the physical and social environment that surrounds diet and physical activity in Delaware by influencing personal, social and community attitudes towards adopting healthy behaviors. An analysis of the NHPS campaign finds that intrapersonal attitudes are targeted with the health belief model, interpersonal attitudes are targeted with social learning theory, family relationships, and modeling, and finally community attitudes are targeted with organizational policy changes. There are failures within the basic social theory upon which each of these three levels are based. This paper will examine these failures.

INTRODUCTION TO THE CRITIQUE
The NHPS intervention is based upon an Ecological Perspective Theory (2). The basic assumption of the theory is that changes in the social environment will lead to changes in the individual and that individuals should be supported within the population in order to implement the environmental change (2). This applies to the NHPS intervention because the goal of the intervention is to change the social environment to bring about an individual’s focus on healthy lifestyle behaviors, and then to have those individuals support an increase in health behaviors and activities within the community.
There are three levels of analysis in the ecological theory that can be applied to the NHPS intervention: intrapersonal, interpersonal and community. The theory operates under the assumption that each level of analysis is based on existing effective psychological theory of health promotion. The basic failure of the NHPS intervention is that it fails to use adequate and effective social theory on each level of behavior change. The NHPS program fails to change the social environment because the basic theories upon which it is based are inappropriate for the intervention.

CRITIQUE #1: Failure to Reach Individuals at the Intrapersonal Level of the Ecological Perspective Theory though the Health Belief Model
As described by McLeroy et al., (1988) the Ecological Perspective Theory suggests that public health interventions should aim to change individuals at the intrapersonal level before there can be changes at the interpersonal and community levels. The NHPS intervention uses the Health Belief Model (4-8) to target caregivers and children at the intrapersonal level regarding their knowledge and beliefs toward a health behavior. This marks the first failure of the NHPS intervention. The Health Belief Model is ineffective in targeting caregivers and children because it cannot adequately address all of the contextual issues surrounding the audience and is unable to reach or influence the irrational element of human behavior (4-8).
The basic postulates of the health belief model as it is applied to the NHPS intervention are described below (2,4). It is important to note that the intervention takes the Model one step further by convincing caregivers that the health of their child is at risk, and using the caregivers to change the child’s behavior. The model applies to the NHPS campaign as follows:
o The individual must perceive that his/her child is susceptible to the poor health outcomes that may be caused by poor lifestyle behaviors and resulting obesity (2,4-8).
o The individual must perceive that poor diet and inadequate physical activity can lead to childhood obesity and that obesity can be a serious health threat (2,4-8).
o The individual must perceive that there is a low barrier cost in helping their children develop healthy lifestyle behaviors (2,4-8).

As seen in other interventions, the Health Belief Model contains certain limitations that contribute to failure of the model (8-10). A basic assumption, and weakness, of the Health Belief Model is that all people carry a central set of core values and will react rationally to information that targets these values (8-10). The NHPS campaign relies on the Health Belief Model in its assumption that the provision of information should be enough to convince caregivers that their child is at risk for poor health outcome (5). However, researchers have found that presentation of information does not always lead to intention. According to Thomas (1995) the Health Belief Model operates under the faulty assumption that all people will be similarly affected by the use of traditional scientific fact. It is not surprising that the NHPS campaign fails to create an ‘it could happen to my child’ attitude in the caregivers because the Model assumes that all people share the same value system for health and will respond uniformly to a traditional scientific approach (8). A better intervention would take the value systems of sub-units of the population into account before attempting to reach people at a statewide level.
Thomas (1995) cited that one of the assumptions underlying the Health Belief Model is that it only considers knowledge to have been gained if the behavior has been changed. This infers all adults will be changed once they learn that a behavior can affect their health. The faultiness of this approach is evident in the NHPS campaign where scare-statistics were cited to convince caregivers that their child needs a health intervention (1). The campaign provides this information to the caregivers with the intent that it will then relate the health issue, childhood obesity, to be something that is relevant to their own children’s health (3). The campaign fails to address the potential effect of environment context where individual subgroups may operate with unique core values (3).
Assuming that some people may respond straightforward effort of the NHPS campaign, the Health Belief Model remains ineffective because it does not provide sufficient motivation for caregivers to perceive their children as highly capable of improving their lifestyle choices. The Health Belief Model postulates that individuals will change their behavior when they hold the belief that following a certain health recommendation will reduce the risk of a perceived threat and that there is a low cost to implementing the new behavior (3). The NHPS intervention teaches caregivers that their children are at risk for poor health outcomes and that following the 5-2-1-Almost None model will reduce their risk of disease. The intervention operates on the basic assumption of the Health Belief Model that if the caregivers believe that there is a low barrier cost to changing behavior that they will work with their children to improve lifestyle choices. This aspect of the Health Belief Model is inappropriate for the NHPS intervention because it fails to address social or political barriers that may prevent some subsets of the population from seeking healthcare and other health behaviors (9,10). For example, some subsets of the population may be less likely to seek policy change within their schools or for available spaces for physical activity (3). The campaign must address these issues instead of assuming that all children have access to nutritious food and spaces for recreation.

CRITIQUE #2: Failure to Reach Individuals at the Interpersonal Level of the Ecological Perspective Theory
According to McLeroy et al. (1988), the Ecological Theory assumes that interventions at the interpersonal level will occur when social relationships have an influence on attitude and behavior change. The NHPS intervention focuses its interpersonal intervention on two elements. The first targets caregivers through relationships with caregivers who desire a healthy lifestyle for their child. The second is an interpersonal intervention using Modeling theory through the Mighty Timoneers interactive video games. The intervention fails to produce the appropriate interpersonal influence to create a sustained behavior change in children.
The interpersonal sector of the Ecological Perspective theory can only be effective if individuals are affected at the intrapersonal level before moving on to influence others at the interpersonal level (3, 5). The hypothesis that parental influence will lead the child to develop healthy behavior is based on the assumption that the caregivers were adequately influenced by the information provide by NHPS to make a change in their child’s lifestyle (5). As discussed in critique #1, this may not necessarily be the case. The failure to change behavior on one level may reduce the effectiveness of the intervention as a whole (3). For purpose of critiquing of the interpersonal approach, we will assume that the intrapersonal level of the intervention was effective.
The campaign attempts to target children at the intrapersonal level by using Social Learning Theory in networked video games where the child observes a social norm among cartoon children whose health behavior they can model (1,5). Social Learning Theory is used in the Mighty Timoneers video to accomplish behavior change through the child’s expectancies and incentives (5). The theory is intended to influence an individual’s expectancies about how a behavior may affect a certain health outcome and to convince the individual that they are capable of achieving that behavior change (5). The theory takes into account the factor of self-efficacy, reinforcement from past behaviors, and modeling those who have performed the behavior (5). The Mighty Timoneers video teaches children to model cartoon characters who are capable of fighting off the evils of unhealthy foods by being physically active and eating fruit and vegetables (1). Although the interactive video program may enforce some aspects of social learning theory, such as modeling the character’s behaviors and incentives for children to gain experience through food trials (5), it fails to address what may happen when the children are confronted with others who have not been exposed to the intervention. As described in Marks (1996) critique of the Social Learning Theory, the theory focuses too heavily on the individual and fails to take the effect of social and environmental context into account.
The NHPS video creates an influential social context within the parameters of population who plays the video game but fails to take outer social networks into account. McLeroy et al (1988) point out that a common flaw in public health interventions is that they often use interpersonal theory to change behavior through social influences while interventions may do better if they focus on changing the norms or social groups to which individuals belong. The NHPS campaign attempts to change the social norm by offering the Mighty Timoneers video to a wide social network that could potentially have an influence over the broad social environment of children in Delaware. However, because the intervention was not adequately marketed, it fails to compensate for what may happen when the child returns to siblings, classmates, or family who may continue to serve as an influence toward unhealthy behaviors.

CRITIQUE #3: Failure of Ecological Perspective Intervention to Address Social Influences at the Community Level
The NHPS campaign attempts to influence policy in Delaware for improving nutrition in school lunches and expanding locations for physical activity. The campaign uses little advertising and appears to rely on theories such as the Diffusion of Innovation Theory to spread its message across the state. The intervention fails because it does not support the maintenance of existing networks of communication and fails to create awareness within social networks and norms (3).
The environmental phase of the ecological perspective includes an intervention that aims to change organizations in order to support individual behavior changes (3). As previously discussed, the ecological perspective model is built so that the efficiency of one level of the model is dependent on those that come beforehand. McLeroy et al. (1988) suggest that the effects of interpersonal relationships are the first step to changing behavior through environment because interpersonal relationships exist outside the individual and can lead to implementation of changes in the community.
The basic failure of NHPS at the community level intervention is that its message was not properly diffused. For example, members of the community may not be aware of supplemental opportunities for physical activity even if they do exist. A study by Cevita & Dasgupta (2007) examined the use of the Diffusion of Innovation Model for development of a diabetes management program. The authors found that this model can only be effective if there is a maintenance of the network from which the information was first diffused (12). In other words, if the early adopters of health behaviors fail to communicate their achievements, the intervention will go nowhere. In the NHPS example, a neighborhood association who creates a recreational space but does not communicate their achievement to other communities is not helping propel the behavior change across the state. If there is no tipping point (12), then those who have not yet adopted the change may fail to do so.


ALTERNATE APPROACH: Improving the NHPS Intervention
The NHPS intervention can be considered a strong campaign because it is based on Ecological Perspective Theory, which combines multidisciplinary efforts at the individual, social and community level (5, 11). There are weaknesses, however, in using this Ecological Perspective. The overarching issue is that the approach is dependant upon the campaign having had an effect on the individual level before it can affect the interpersonal and then community level. The campaign will not work if it targets only the community but fails to have a strong foundation in its effect on the individual or interpersonal level. There are areas within each of these three phases that need improvement before the campaign can be effective. The following proposal will describe alternate approaches to reach children and caregivers at the intrapersonal, interpersonal and community levels. These approaches include: introducing Optimistic Bias, creating new social relationships, and introducing the ‘social’ in a Socioecological Theory.

DEFENSE OF NEW INTERVENTION #1: Use Elements of Optimistic Bias as well as the Health Belief Model to Support Behavior Change
The intrapersonal element of the NHPS ecological approach should be expanded to include Optimistic bias (13) to the Health Belief intervention in order to effectively influence caregivers to initiate behavior change. The health belief model assumes that if caregivers believe their child is at risk for poor health, they may make a change. If Optimistic Bias is introduced to the intervention, then the caregivers will become overly optimistic that they are capable of using the available resources to help improve their child’s chance for a healthy life. This optimism can serve as the spark to ignite a behavior change among families and children.
Weinstein (1980) cites that individuals tend to be unrealistically optimistic about future life events if they perceive the event as highly desirable, probable, and controllable. The author also cites that an individual may have optimism about an event based on prior experiences (13). This theory can be used to influence caregivers and children to become optimistic about their ability to improve their health through lifestyle behavior change. For example, the intervention can remind a caregiver who has had successful weight loss in the past that their child may be able to easily follow in their footsteps. The intervention should send the message that caregivers can easily control their child’s health behaviors and that this will increase the probability for a healthy and happy life. If caregivers and children believe that they can easily achieve a healthy lifestyle then they may be motivated to begin to make the necessary behavior changes. Some health behavior studies have shown that people are often intimidated by the amount of effort that they perceive is required to improve health (14,15). If the intervention can implement optimistic theory to supplement the health belief model, then this will lower the perceived barriers to entry (8) and may motivate caregivers and children to initiate a change in behavior that could ultimately lead to a healthier life.

DEFENSE OF NEW INTERVENTION #2: Create a New Social Role for Children
According to McLeroy et al. (1988), Ecological Theory should aim to change the nature of existing interpersonal relationships so that the relationship can become one that nurtures healthy behavior. The current NHPS intervention aims to create a nurturing relationship between caregivers and children, but has failed to make a difference. This lack of change can be traced back to the fact that caregivers are not properly influenced at the intrapersonal level to actively try to help their children improve healthy behaviors. A solution for this could be to target both the children and caregivers to change their interpersonal relationship, and not just the caregivers. It might be mutually beneficial if both the caregivers and children are pushing each other toward a healthy lifestyle.
McLeroy et al. (1988) suggest that social relationships can provide access to new social roles and that social interactions can have an influence on attitude and behavior change. This can be observed in the NHPS intervention where caregivers are urged to develop a social role where they help their child develop healthy lifestyle behaviors. Children are given the opportunity to create a role for themselves where they can choose to perform health behaviors by modeling the cartoon characters from The Mighty Timoneers (1). Yet the intervention fails to produce adequate social influence to maintain behavior change. A new intervention should capitalize on the effect of social relationships and role-playing by allowing the children to create a new social role for themselves where they influence their caregiver and/or peers. This new social role will create a reciprocal relationship where the child is influencing others while at the same time creating a space for social support within the group.
The interactive Mighty Timoneers video can be a useful aide for implementing social behavioral theories to improve health behaviors of children if it reaches children in the correct manner. According to Leiberman (1992), properly implemented video games have been found to improve mediating factors for health behavior change among children. One of the factors that Leiberman (1992) mentions is that the game should improve the communication that a child has with their peers and caregivers who can provide social support for making the behavior change. A good way ensure that a peer or caregiver can provide the necessary social support is to create a mutually supportive relationship where the child can motivate the caregiver or peer with the new information while gaining personal health motivation from that relationship. Research has found that direct experience, such as role-playing, can strengthen the relationship between a newly developed attitude towards health and the health behavior (17). Perhaps children can improve upon their lifestyle choices by role-playing as the teacher to influence others around them as well as reinforcing their personal attitude toward health behaviors.

DEFENSE OF NEW INTERVENTION #3: Introduce Social Elements to Ecological Perspective Theory via Socioecological Theory
The ecological perspective is useful in that it encompasses a wide range of behavior change theories at various personal and community levels of the population (18). The NHPS program should continue to use the Ecological Perspective Model, but supplement it by combining a sociological model. Stokols (1996) describes a Socioecological Theory as it applies to community health promotion. The Socioecological Perspective Theory operates under the assumption that health is a product of the relationship between individuals and the environment (17). As previously discussed, an individual benefits when there is a mutual relationship where he or she is able to influence others toward taking up a health behavior while reinforcing the behavior on a personal level. This can be expanded to the community level where the individual can develop a neighborhood exercise program as a way to participate in making a difference. This is mutually beneficial for the individuals and the community and, if communicated properly, can expand on itself through the Diffusions of Innovation Model described in the above critique. The goal is to give the individual a personal attachment to the changes in their community so that they will want to spread those achievements on a public level (17).
According to McLeroy et al., (1988), interventions can effectively promote health by creating opportunities for large groups of people to gain access to the health behavior in the space where they spend most of their time. It might be useful if the campaign to introduces voluntary organizations within neighborhoods and communities to create opportunities for physical activity such as kickball teams and more.

CONCLUSION
A new intervention should maintain the strengths of the Ecological Perspective Model by continuing to target the campaign at the intrapersonal, interpersonal, and community levels (3). Critiques of the Ecological Perspective Model cite that it assumes interventions are effective at each level of the ecological framework. (3,17). As described in the defense of the new intervention, social influence can broadly affect the community at both large and small interpersonal and group levels. It may be useful to introduce more of a social focus to the ecological perspective theory.
A Socioecological Perspective Theory may be more effective than a basic Ecological Perspective Theory. In the future, public health professionals who use this approach should keep in mind that if done correctly, the Socioecological Perspective can be very influential but that it is important to ensure that each level of the intervention is effective.

REFERENCES:
1. Nemours Health and Prevention Services. 5-2-1-Almost None. Newark, Delaware. Nemours Children’s Health System.
2. McLeroy KR, Bibeau D, Steckler A, & Glanz, K. An Ecological Perspective on Health Promotion Programs. Health Education Quarterly, 1988; 15, 351-377
3. Stokols, D. Translating social ecological theory into guidelines for community health promotion. American Journal of Health Promotion, 1996; 10, 282-298.
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11. Marks DF. Healthy psychology in context. Journal of Health Psychology 1996; 1:7-21
12. Cevita MD, Dasgupta K. Using diffusion of innovations theory to guide diabetes management program development: an illustrative example. Journal of Public Health. 2007; 29(3): 263-268.
13. Weinstein ND. Unrealistic optimisim about future life events. Journal of Personality and Social Psychology 1980; 39:806-820
14. Kreitler, S. Cognitive orientation and health-protective behaviors. International Journal of Rehabilitation and Health; 1997 3(1).
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16. Lieberman, D.A. Interactive video games for health promotion: Effects on knowledge, self- efficacy, social support, and health. Mahwah, NJ: Lawrence Erlbaum Associates
17. Jackson, C. Behavioral Science Theory and Principles for Practice in Health Education. Health Education Research. 1997; 12(1).
18. Edelman & Mandle. Health Promotion Throughout the Lifespan. St. Louis, Missouri: Elsevier, 2006

The New San Francisco Happy Meal Ban Fails to Address Underlying Issues and May Backfire—Priyanka Bearelly

The issue of childhood obesity is certainly not a new topic in the scene of public health; however, the severity of the issue is rapidly increasing as the rate of obesity in youth has more than tripled in the past 30 years (1). The prevalence of obesity among children of ages 6 to 11 years has increased from 6.5% in 1980 to 19.6% in 2008 (1).
Numerous organizations under the Department of Health and Human Services conduct various surveys and surveillance systems in order to gather information. Additionally, several interventions, such as the Body Mass Index Measurement in Schools, have been presented as means to combat this affliction (2). However, on November 9, 2010, a more dramatic change within the realm of fast food industries was passed and set to be implemented by December 2011 (3). In the city of San Francisco in Northern California, the Board of Supervisors banned the inclusion of toys in Happy Meals that do not meet certain requirements regarding nutritional value (3). These nutritional standards include reduced calories, salt, fat, and sugar as well as the addition of fruits and vegetables. With an 8 to 3 voting majority, the decision was practically unanimous (3). In fact, this ban goes beyond McDonalds and affects about a dozen fast food chains and some family-owned restaurants, which can all face fines up to $1000 per violation (3).
The idea behind this public health intervention is that children are not attracted to the food in the Happy Meal, but the toys. The subsequent conclusion is that in order to get those toys, the children will now only have the option of consuming foods with higher nutritional value. The original issue stems from the clever use of Marketing Theory by the fast food industry. “Packaging has become a form of advertisement, as companies innovate by putting food into “cool” new containers or adding licensed characters, games, and ads for other branded foods” (4). Therefore, children’s desires to follow the trend of collecting toys manifest as their desire for Happy Meals. Thus, this intervention tries to attack what the marketers do, by ensuring that the trendy thing to do is to eat healthy. However, there are several aspects of this approach that leave some room for potential failure.
The Happy Meal ban may inspire the opposite reaction.
The first problem can be explained by Reactance Theory. This idea, formulated by theorist Jack W. Brehm, addresses people’s reactions to threatened or eliminated freedoms and explains that people are likely to respond by reasserting their freedom (5). The theory suggests that they will do this by overreacting in the negative direction, usually doing the opposite of what they are told, also known as the Boomerang Effect (6). In the case of this intervention, consumers are losing this option of toys with their Happy Meals and may perceive this as a threat to their freedom. The actual consumers, in this case the children, may in fact still be too young to strongly react to this infringement on their freedom to choose, although psychological reactance does indeed begins at an early age. However, many parents undoubtedly will feel that they are being explicitly told how to be a good parent while further prohibiting them from purchasing the traditional Happy Meal. Essentially, they will lose their freedom to choose what to feed their children. Moreover, this ban will likely only draw more interest from children by presenting the traditional Happy Meals as forbidden. Therefore, these children will only be more attracted to the Happy Meal once it becomes unavailable.
The new law has been passed for only one month, and the backlash has already begun. In a letter to the board of supervisors who made the legislative vote, a frustrated parent wrote, “Do you really think the government needs to make these decisions for the citizens you represent? Are we not capable of deciding what we will eat and where we will take our children? Back off.” (7). This is a clear example of a person who does not appreciate being instructed by someone else how to live their own life and consequently feels a serious threat to their freedom. According to the Boomerang Effect, consumers will merely end up doing the opposite of what the government has aimed to achieve (6). According to a 1990 study examining nursing practices, one aspect of health education was the communication of information to certain people who were perceived to live “in ignorance” of their health (15). Patients did not appreciate being classified as such and were less receptive to any advice (15). It was concluded that this type of approach would be more likely to cause the individual to actively oppose the health intervention by even increasing their involvement in the unhealthy behavior (15).
Parents, as well as McDonald’s, can now respond to this threat in a variety of ways. For instance, the fast food restaurant can simply sell the toys separately, allowing for parents to regain their freedom to purchase the toy and meal of choice. This would certainly work against the efforts of the intervention. Thus, although parents may agree with the idea of combating obesity, they may in fact end up standing against the government as their own personal means of rebellion. Clearly, placing a prohibitory ban is not the most effective way to glean support among the population of interest.
The Happy Meal ban does not address the overall choice of diet.
The Health Belief Model (HBM) explains that people will essentially weigh the perceived benefits against the perceived barriers to engaging in a particular behavior (9). This decision is dictated by a person’s perceived susceptibility to the disease as well as the perceived severity of the disease, if contracted (9). In this case, the disease is obesity. According to the 2009 National Youth Risk Behavior Survey Overview, only 13.8% of high school students ate vegetables three or more times per day and only 22.3% had eaten fruits and vegetables five or more times per day (8). Moreover, 29.2% of students had drunk a can of soda, bottle, or glass of soda at least one time per day (8). Although the Happy Meals affect a much younger age group than is evaluated in this survey, their dietary behavior when young will still carry on to their choice of meals when older. Unfortunately, this current intervention addresses no aspect of the HBM. Just as before, the only factor affecting the consumer’s decision to purchase the Happy Meal is the toy. There is no certainty that the child will even eat the nutritionally improved food. There is no evaluation of the food being eaten—no recognition that the food is even healthier. Thus, neither the child nor the parent is taking an active role in making healthier decisions.
Moreover, the overall message of this new meal is telling people to eat fewer calories, as well as less sodium, fat and sugar. However, this is not a steadfast rule. For a growing child, it is important to get enough calories and fat, but the right kinds (23). In reality, kids older than 2 years-old should receive 30% of their calories from fat so that the brain and nervous system can develop correctly (23). This fat, or certain oils, can come from various products including peanut butter, fish, milk, etc. (23). This educational side of the obesity affliction is not merely a contributing aspect. It is crucial for the consumer to make the connection between the food he or she is eating and the subsequent health effects. People should be able to accurately recognize their susceptibility to obesity by being conscious of the quality and quantity of food that they are eating. However, this Happy Meal ban almost completely looks past the rudimentary, yet nonetheless important, values presented by the HBM. The intervention essentially forces consumers to select the healthier option and does not teach them to choose the healthy meal.
Although a rather simple model, the HBM has indeed proved effective in other diet-related settings. For instance, in the year 1982, the Food and Drug Administration along with the National Heart, Lung, and Blood Institute sponsored a sodium initiative in order to educate the public and increase awareness of the association of sodium consumption and the risk of hypertension (11). This was accomplished via display of sodium content on food labels (11). In fact, awareness in the American population across all societies of differing education levels increased by 38% in the following year and by 50% by year 1988 (11). As efforts to improve, or even merely maintain, such a level of dietary education began to diminish, people’s awareness slowly began to drop again (11). Similar studies regarding the associations between fiber consumption and the risk of cancer, between consumption of dietary fats and risk of heart disease, and between cholesterol and risk of heart disease all showed similar trends (11). Thus, while the values of the HBM may not be strong enough to serve as a sole solution, it is necessary and can be successful to use as a means of educating the population.
The Happy Meal ban is saying that it’s okay to eat the new Happy Meal?
Not only is the new law prohibiting the marketing of nutritionally-poor food to children, but they are also setting nutritional standards for the new Happy Meal. Such close governmental regulations may make it appear as though the new meals are now no longer a threat to people’s overall health. This may translate into the idea that it is still okay to eat at fast-food restaurants now with these healthier menus, when in reality the truth is that it is only okay to eat at these places in moderation. In fact, when children of the age 7-17 eat out at restaurants, they consume on average 55% more calories than when they eat at home (12).
This traces back to the very basic approach of using the principle of liking to sell a behavior. This stems as a subcategory of the Communication Theory, specifically as a topic termed Compliance Gaining Strategies by theorist Robert B. Cialdini (13). This refers to specific efforts that must be put in place in order to gain the compliance of the target population (13). One of these efforts is the principle of liking that “is based on warm ingratiatory behaviors and attractiveness” (13).
For instance, in 2005, Carl’s Jr. featured Paris Hilton in a commercial to promote their newest product. The target population, young males aged 18-34, tend to positively respond to the sexual appeal of attractive famous figures, such as Paris Hilton (10, 14). Therefore, their liking of Paris Hilton translates into their liking the new Carl’s Jr. product. According to the 2005 CKE Restaurants Sales Report, the sales for this particular burger rose 15.1 % over two years (22). The only difference in the case of this Happy Meal ban is that the government may not have intended to create this association. The primary restriction is that this phenomenon will predominantly only apply to the portion of the U.S. population that respects the government and tends to heed the advice given by political officials. Thus, it is possible that, according to this concept of liking, certain people will create this link between the government and the new and improved Happy Meal. With the belief that the government is a positive influence, they will view the new meal as a positive change and may eat it more frequently. Subsequently, they may end up eating at McDonald’s more often, which instead only exacerbates the issue of increased fast-food consumption. In the late 1970’s, children were eating 17% of their meals outside of the home, and fast food accounted for 2% of those meals (4). By the late 1990’s, children were eating 30% of meals outside, 10% of which being fast food (4). Clearly, it is important, at the very least, to not increase people’s attraction to fast food and hopefully sometime in the near future even reduce this appeal. Thus, for some people, this ban may only increase exposure to fast food restaurants as a result of people constructing this association between the government and the Happy Meal.
Proposal for improved intervention.
This more appropriate intervention will no longer entail the existence of a ban. Instead there will merely be a healthier addition to the McDonald’s menu. This new meal will still adhere to the new nutritional requirements, but will also contain the same toy as the regular Happy Meal option. Moreover, a small informative booklet will be included in the packaging that serves to educate the parent and the child about the effects of their dietary decisions. Finally, with the implementation of the intervention, the government will release an information sheet regarding their position on obesity and fast food as well as “The Healthy List,” that aims to promote nutritional foods and to encourage eating at home.
New intervention provides solution to psychological reactance.
The key idea behind any such resolution is to preserve the consumer’s ability to choose. Once this option vanishes, so does the increased efficacy of the intervention program. Therefore, the goal of this intervention is to present alternate choices to the consumer without them feeling as though the government is suggesting people’s freedom to choose should be limited.
Whereas the current ban in San Francisco may in fact even increase demand for the traditional Happy Meal, at least this altered approach will ensure that people will not be more attracted to the original product. A classic example demonstrating the potential opposing results of these two different situations is seen in one of Brehm’s earlier studies. There were 3 design groups differing based on the availability of certain phonograph records, and one group under the impression that all records would be present, at the last minute was informed that one of the records was missing (6). This group showed an increased desire for this particular lost record in comparison to the control group that was free to choose from all records (6). Equating the missing record to the traditional Happy Meal, people will only show an increased desire for it. Therefore, by maintaining options, consumers will not feel this enhanced attraction to the original meal, much like Brehm’s control group.
One possible approach would be to add this new Happy Meal to the menu in addition to the more traditional one, both containing the same toys. This way, no one is directly telling the parents how to feed their children, but this option of a healthier choice will still cause the parents to acknowledge that this problem exists and that there are solutions. Instead of running in the opposite direction due to the oppression by rules and regulations, parents will feel that they are now finally presented with a more complete list of options. Similarly, the reactance would decrease on McDonald’s behalf. Although making additions to the menu will still require some force on the government’s part, board members can present this approach to McDonald’s administrators as a part of an effort to work together. This way, the fast food chain’s administrators would not feel as though the government is telling them how to run their restaurant, and would therefore be less likely to search for ways to work against the government.
New intervention provides solution to lack of health education.
Even if people find themselves forced to choose a healthier option, they will fail to make more permanent lifestyle changes if they do not properly understand the consequences of their dietary decisions. Moreover, obesity rates are much higher in certain minority populations that include Hispanics as well as non-Hispanic blacks (16). According to measurements from 2006 to 2008, the overall prevalence of obesity in Hispanics across the United States was 28.7% and was 35.7% for non-Hispanic blacks (16). One of the explanations for this trend is that these minority populations have less access to healthy, affordable supermarkets. Furthermore, in low-income communities, their educational levels are much lower, and they do not necessarily understand how to evaluate the nutritional quality of their food (16). Therefore, it is clear that lack of proper education regarding nutrition is still an issue in some populations.
Alternately, it is certainly true that older age groups, not necessarily the target population of the Happy Meals, tend to have a better understanding of the overall importance of a healthy diet. A 1978 study concluded that 67% of the adult population acknowledged that they would be healthier if they ate better (17). However, in this case today with childhood obesity, parents are making dietary decisions for their young children who may be too young to make such evaluations on their own. Some parents may in fact be knowledgeable when it comes to their own dietary choices, but may not be as well-informed about the stark nutritional needs and limits of their children. In a 2001 study done in an Australian primary school to evaluate parental awareness of nutritional health, 42% of parents with obese children, 81% with overweight children, and 70% with underweight children did not report any concern (18). Certainly, this does not reflect a group of parents that can recognize the nutritional inadequacies from which their children suffer.
Therefore, in an effort to resolve this issue, small nutritional booklets may be included in both Happy Meals. These booklets, due to such a young target audience, will have to make more of an impact on the parents rather than the children. These booklets may include information regarding the nutritional quality of the food in the Happy Meal as well as the standard nutritional needs of growing children. According to the U.S. Department of Agriculture’s new Food Pyramid, these needs include five servings of fruit and vegetable per day, whole grain breads and cereals, fairly conservative amounts of lean meat or nuts and eggs as sources of protein, and the list continues (23). To ensure that the booklet is not simply thrown away along with the container, a coloring page or crossword can be included and advertised on the box. Moreover, specifically due to their young age, these children almost certainly do not know enough about their nutritional needs. In a 2010 study evaluating the effects of a health education program implemented in two Jewish schools in Chicago with grades 1 through 8, the results were significant (19). The students in grades 2-4, compared to their baseline knowledge from 2 years prior, were more capable of identifying the healthier foods after steps to improve health education were put in place (19). For instance, in the baseline survey, only 75% recognized that wheat bread is healthier than white bread, compared to 93% two years later (19). Thus, the younger age groups can also successfully respond to measures that promote health education. Therefore, this intervention can have a positive effect on both the parents and the children.
New intervention offers solution to government’s indirect perceived advocacy of the Happy Meal.
Firstly, eliminating the prohibitory portion of this intervention, based on the aforementioned explanation concerning psychological reactance, will minimize the overall attention given to the legislation. Secondly, it will be difficult for the government to pass legislation while trying to remain neutral or trying to avoid creating any possible associations that the public might conceive. To avoid this ambiguity, the government should actively take a position about where they stand with the Happy Meal situation and be clear about it. Currently, most media and news regarding this ban fail to clearly explain the San Francisco board’s principal goals, leaving much room for interpretation. For instance, the most direct explanation given in an article by The Huffington Post is that the legislation “would limit toy giveaways in children's meals that have excessive calories, sodium and fat. It also requires servings of fruits or vegetables with each meal” (20). This is certainly the truth, but with incomplete information like this, the public will not fully understand the motivation behind this proposal.
Thus, the federal group that proposes this new intervention should also release an information sheet, explicitly stating their ultimate goals and the messages they hope to send. It should be clear that the new Happy Meal is not a new regulation, but rather a compromise between McDonald’s and the government, since federal officials cannot, nor do they wish, to control the fast-food restaurant business. In this sheet, they can also list foods and grocery stores that they believe actually do their best to cater to the health of consumers in a financially reasonable manner. Making such a list for restaurants would only encourage people to continue to eat out, thus only specific meals that can be made at home and particular grocery stores that provide healthy products should be the primary focus. For instance, the George Mateljan Foundation, a non-profit organization that has been in existence since the year 2000, has focused on what it calls “The World’s Healthiest Foods” (21). Offering new recipes, foods or ingredients of the week, tips on how to select fresh produce, and much more, the organization presents a healthier lifestyle as positive and enjoyable (21). Mateljan’s dietary advice over the years has achieved much popularity by gaining the support of the New York Times, ABC News, Yale University School of Medicine, and many other well-known associations (21).
The goal is that this new government-released list of healthy foods and stores will hopefully inspire similar support and attention as did Mateljan’s foundation. Examples of healthy, affordable foods include bell peppers, carrots, and garbanzo beans (21). As for the stores, most large local supermarkets, such as Stop n’ Shop in Boston, MA, have a wide selection of relatively inexpensive fresh produce, as well as other groceries. With this clear information provided to the public, it would be rather difficult for a person to believe that the government is in any way advocating McDonald’s or is coercively intervening in the fast food business.
Conclusion
As mentioned before, the original issue of the Happy Meal is the extensive marketing of the product to the children. Therefore, it seems reasonable that this intervention would try to acutely attack this underlying problem by forcing the McDonald’s representatives to use their deceitful tactics, currently aimed toward children, to instead market healthier food. However, history has shown that force and implied obligations fail to play a positive role in improving communities. Moreover, an effective intervention should strive to change the intrinsic decision-making process involved in people’s dietary choices.
The newly-designed intervention attempts to address all of these flaws present in the original proposal. It is certainly difficult for one single intervention to address all the issues of childhood obesity and attempt to resolve them. It is much more likely that a campaign that involves several interventions would be capable of encompassing all aspects of this problem. However, it is still crucial to strive for completeness with even just one intervention, as does this new intervention. Eliminating the greater possibility of immediate opposition, improving the nutritional knowledge of consumers, and avoiding any misconceptions concerning the opinions of any major players of this intervention, this proposal offers a more comprehensive solution.

REFERENCES
1. Centers for Disease Control and Prevention. Childhood Overweight and Obesity. Atlanta, GA: Department of Health and Human Services, 2009.
2. Centers for Disease Control and Prevention. Body Mass Index Measurement in Schools. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion, 2007.
3. McKinley, J. You Want a Toy With That? New York, NY: New York Times. http://www.nytimes.com/2010/11/04/us/04happy.html.
4. Schor, J.B., & Ford, M. From Tastes Great to Cool: Children’s Food Marketing and the Rise of the Symbolic. The Journal of Law, Medicine, & Ethics 2007; 35(1):10-21.
5. Brehm, J.A. A Theory of Psychological Reactance. New York, NY: Academic Press, 1966.
6. Clee, M.A., & Wicklund, R.A. Consumer Behavior and Psychological Reactance. The Journal of Consumer Research 1980; 6(4):389-405.
7. McConahay, P. Santa Clara’s Happy Meal Toy Ban Carefully Watched. Santa Clara, CA: California Healthcare Foundation. http://www.californiahealthline.org/features/2010/santa-claras-happy-meal-toy-ban-carefully-watched.aspx.
8. Centers for Disease Control and Prevention. Dietary Behaviors and Obesity. Atlanta, GA: National Youth Risk Behavior Survey Overview, 2009.
9. Glanz, K.. Rimer, B.K., & Lewis, F.M. Health Behavior and Health Education (3rd ed.). San Francisco, CA: Jossey-Bass, 2002.
10. Noe, E. How Well Does Pair Sell Burgers? New York, N: ABC News. http://abcnews.go.com/Business/story?id=893867&page=1.
11. Shapiro, R. Nutrition Labeling Handbook (Food Science and Technology). New York, NY: CRC Press, 1995.
12. Lynne, E., Bulmer, S., & De Bruin, A. Exploring the Link Between Obesity and Advertising in New Zealand. The Journal of Marketing Communications 2004; 10:49-67
13. Littlejohn, S.W., & Foss, K.A. Compliance Gaining Strategies (pp. 155-157). In: Littlejohn, S.W., & Foss, K.A., ed. Encyclopedia of Communication Theory, Volume 1. Thousand Oaks, CA: Sage Publications, Inc., 2009.
14. Sarracino, C., & Scott, K.M. Introduction (pp. ix-xx). In Sarracino, C., & Scott, K.M., ed. The Porning of America: The Rise of Porn Culture, What It Means, and Where We Go from Here. Boston, MA: Beacon Press, 2008.
15. Gott, M., O’Brien, M. Policy framework for health promotion. Nursing Standard 1990; 5(1): 90–92.
16. Centers for Disease Control and Prevention. Differences in Prevalence of Obesity Among Black, White, and Hispanic Adults—United States, 2006-2008. Atlanta, GA: Department of Health and Human Services, 2009.
17. Louis Harris and Associates, Inc., Health Maintenance. New York, NY: Louis Harris and Associates, Inc., 1978.
18. Wake, M., Salmon, L., Waters, E., Wright, M., & Hesketh, K. Parent-reported Health Status of Overweight and Obese Australian Primary School Children: A Cross-Sectional Population Survey. International Journal of Obesity 2002; 26: 717-724.
19. Benjamins M.R., Whitman S. A culturally appropriate school wellness initiative: results of a 2-year pilot intervention in 2 Jewish schools. J School Health 2010; 80: 378-386.
20. Sterling, C. San Francisco Bans the Happy Meal. New York, NY: The Huffington Post. http://www.huffingtonpost.com/2010/11/02/san-francisco-happy-meal-ban-mcdonalds_n_777939.html
21. Mateljan, G. The World’s Healthiest Foods, Essential Guide for the Healthiest Way of Eating. Seattle, WA: George Mateljan Foundation, 2006.
22. Broussard, I. CKE Restaurants, Inc. Reports 26th Consecutive Period of Same-Store Sales Increases at Carl’s Jr. Carpinteria, CA: CKE Restaurants, Inc. http://phx.corporateir.net/phoenix.zhtml?c=117249&p=irolnewsArticle&ID=705243&highlight=
23. National Institutes of Health. Child Nutrition. Bethesda, MD: U.S. National Library of Medicine, 2010.

BMI Report Cards: Pass or Fail? – Jenna D. Lovaas

I. Introduction
Obesity is a major public health concern and is quickly becoming an epidemic, as evidenced by rapidly increasing prevalence rates (1, 2). Rates of obesity are increasing across all age groups, but the rise in childhood and adolescent obesity is of particular concern. Obesity in youth is defined as greater than the 95th body mass index (BMI) percentile for age- and sex-specific growth charts (3). Between the 1960s and the 1988-1994, the prevalence of obesity among children and adolescents more than doubled, going from 4 percent to 11.3 percent in 6- through 11-year-olds and from 5 percent to 10.5 percent among 12- through 19-year-olds (4). Estimates calculated with measurements obtained through the 1999-2000 NHANES show that the prevalence of obesity is 10.4 percent among 2- through 5-year-olds (up from 7.3 percent in 1988-1994), 15.3 percent among 6- through 11-year-olds, and 15.5 percent among 12- through 19-year-olds (4). More recent estimates show that in 2003-2004, 17.1 percent of U.S. children and adolescents were overweight (5). There is recent research suggesting that the overweight and obesity trends among children and adolescents are leveling off, but the proportion of these populations classified as obese are still high (3, 6). Furthermore, the prevalence of severe obesity in youth, defined as greater than the 97th BMI percentile, continues to rise (7).
This continued trend of obesity and overweight places children and adolescents at risk for developing a number of adverse health conditions that are likely to continue into adulthood, including cardiovascular, gastrointestinal, pulmonary and orthopedic complications (3). Hyperlipidaemia, hypertension and abnormal glucose tolerance are occurring with increasing frequency among obese youth (8). In addition, children are now presenting with type 2 diabetes mellitus, which has previously rarely been seen in children (4, 8). Childhood obesity is also known to be an independent risk factor for adult obesity, and there is evidence of an association between adolescent obesity and increased health risks as adults, independent of adult weight (8). In addition to physiological disorders, overweight and obese youth are at increased risk of developing psychological complications, such as depression, behavioral problems and low self-esteem (9). These psychological disorders can potentially affect a child’s adherence or self-motivation to adopt healthier behaviors (3).
Considering the severe health consequences, both physiological and psychological, effective public health interventions are necessary to address the problem. Schools can have an important role in youth obesity prevention because the majority of young people are enrolled in school; therefore, the CDC has identified a number of strategies that schools can use for obesity prevention (10). Although it is not one of the strategies recommended by the CDC, a number of school districts have begun implementing BMI-screening programs in schools (11). Screening results are often sent to parents and include the child’s BMI-for-age percentile and an explanation of the results. Additional information in the report may be healthy eating and physical activity tips, and any recommended follow-up actions (10). The school health policies and programs study performed by the CDC in 2006 found that 22 percent of states required schools or school districts to measure and assess height and weight or body mass; 73 percent of those states required parent notification of the results (10). As an example, Arkansas, California, Illinois, New York, Pennsylvania, Tennessee and West Virginia use BMI report cards for parent notification (12), while districts in other states have also piloted similar programs.
This paper focuses on school-based BMI measurement and BMI report cards. Section II presents three critiques of this approach to overweight and obesity in youth. Section III then proposes and provides support for an alternative multi-level intervention to address childhood overweight and obesity, taking into consideration the flaws of the BMI report card intervention.
II. A Critique of School-based BMI Measurement and BMI Report Cards
BMI report cards are likely to raise awareness of the importance of childhood overweight and obesity prevention, but the intervention has the potential to do more harm than good. This section presents three arguments for why school-based BMI measurement and report card programs are flawed. First, BMI report cards lack tools to promote self-efficacy; second, this intervention fails to consider the importance of self-esteem in behavior change; and third, BMI report cards neglect to consider the potential for negative labeling.
A. BMI Report Cards Do Not Promote Self-Efficacy
Self-efficacy is one component of Albert Bandura’s Social Cognitive Theory (SCT), which describes dynamic interactions between personal and environmental factors and human behavior. According to Bandura, self-efficacy, goals and outcome expectancies are the three main factors that influence behavior change (13, 14). Self-efficacy, or the belief that one can successfully implement the behavior required to achieve the outcome, can determine whether or not the individual engages in that behavior (13, 15). If individuals have a feeling of self-efficacy, they are capable of behavior change regardless of potential obstacles. On the other hand, if they do not feel like they have any control over their lives or health, individuals are not motivated to work past the challenges (13).
Some BMI report cards simply report the child’s status as underweight, normal weight, at risk for overweight or overweight (16). If parents are expected to help their children deal with the problem of obesity, they need more information and advice than their child’s weight status. A pilot study in Cambridge, MA included suggestions for daily lifestyle changes in their BMI report cards; these suggestions consisted of watching less than two hours of TV, getting one hour of physical activity, and eating five fruits and vegetables (11). While providing this information is certainly a step in the right direction, it is not enough by itself to promote self-efficacy. Both parents and children need to feel that they can be successful at making healthy lifestyle changes.
In the Cambridge study, approximately half of the families who received report cards stating their child was overweight were somewhat or very concerned about their child’s weight status (11). While concerned parents were more likely to plan weight-control strategies, they were not more likely to engage in the suggested preventive measures than less concerned parents. In addition, almost twenty percent of families reported planning diet-related activities to control their child’s weight, regardless of the amount of anti-diet information included in the materials sent home. These results would support the fact that more is needed than reporting a child’s weight status along with suggestions for lifestyle changes. This strategy does not bridge the gap between knowing what to do and actually doing it, a gap that can only be filled by the belief in the ability to perform the behavior (15).
Additional barriers to achieving self-efficacy and behavior change are the schools themselves; the school environment must support the desired behavior in order for the intervention to be successful. Despite state mandates, a recent audit of New York public schools found that few provide the required physical education hours and many violate their own policies by providing vending machines that sell junk food and sugar-sweetened drinks (17). In addition, in a survey of middle school children in two public schools in the Northeast, a study found that competitiveness hampered physical activity, as children who were overweight or not as skilled were less likely to participate during physical education classes and open gym periods. Lack of nutritious food and time to eat prevented healthy nutrition choices (18). School environments with unhealthy food choices and low physical activity do not promote self-efficacy, because overweight children are not able to model the successful, healthy behaviors of their peers, nor are they likely to receive encouragement from teachers and peers to pursue such choices themselves.
B. BMI Report Cards and the Importance of Self-Esteem
BMI report cards fail to take into consideration the importance of self-esteem in motivation and behavior change. Abraham Maslow’s Hierarchy of Needs describes different levels of human needs and how those needs affect motivation and behavior (19). According to Maslow, all needs and drives do not exist in isolation and every drive is related to level of satisfaction or dissatisfaction of other drives. Maslow describes what he calls “deficiency needs”, which include physiological, safety, social and esteem needs, that must be satisfied before a person can beginning achieving the higher-level need of self-actualization (19). Humans have a desire to be accepted and valued by others. Fulfillment of the esteem need leads to feelings of self-confidence, capability, worth, strength and purpose. However, if this need is not met, it produces feelings of helplessness, weakness and inferiority, which can lead to discouragement or compensatory unhealthy behaviors (19).
As evidenced by this theory, children whose self-esteem need is not met are unable to undertake the healthy lifestyle changes necessary to prevent overweight and obesity. Research has shown that young girls who consider themselves overweight are especially vulnerable to low self-esteem (16). Although one study found that many adolescents report using healthy weight control practices, such as decreasing fat intake, they also found a high prevalence of binge eating and unhealthy or extreme weight control behaviors in overweight youth, especially girls; body dissatisfaction, which is closely tied to self-esteem, is a strong predictor of unhealthy weight control practices (20). Regardless of actual BMI, children or adolescents with high levels of body dissatisfaction have lower feelings of self-worth, poorer self-esteem, and more dissatisfaction with other areas of their lives (16, 21). In addition, obese children with low self-esteem are more likely to experience sadness, loneliness and nervousness, as well as more likely to experiment with high-risk behaviors (22).
BMI report cards may actually decrease self-esteem by making children feel they are being judged by their weight. Additionally, the concept of a report card for a health factor such as weight implies that a child can fail (23), which is not the best motivational message. BMI report cards could also increase weight-based teasing in school, further lowering the self-esteem of overweight children and further decreasing their ability to make healthy behavior changes. As Maslow discussed, without self-esteem, people often feel helpless and discouraged. Therefore, to successfully combat childhood obesity, interventions must address the issue of self-esteem.
C. Negative Labeling as a Consequence of BMI Report Cards
Negative labeling is closely tied to self-esteem, as being labeled often leads to teasing and lower self-esteem. The goal of BMI report cards is surveillance and prevention of obesity in children. However, by basing the program in schools and focusing on the individual, this type of intervention not only brings attention to the issue of weight, it also increases the risk that a child will be labeled as fat. Labeling theory was developed in the 1960’s to explain deviance, with Howard Becker’s Outsiders (1963) being the most frequently cited source. According to Becker, one of the most important steps in the development of a deviant career is being labeled as a deviant. Once a person is labeled, he/she is cut off from participation in more conventional groups, leaving the individual no choice but to pursue his/her expected deviant activities (24, 25). This theory has often been applied to mental illness as well. One study of patients discharged from mental hospitals found that stigma was a persistent problem in their lives, and experiences of social rejection were a constant source of stress. The patients’ efforts to cope with the labels resulted in further social isolation and reinforcement of negative self-concepts, and diminished motivation and recurrent psychological problems (26).
These concepts can easily be applied to youth and being labeled as ‘fat’. Overweight girls report experience direct and intentional stigmatization from peers, family members, employers and strangers; the most common place of occurrence for these experiences was school (16). Being labeled increases the risk that youth will be exposed to hurtful experiences, such as teasing or bullying, that have a negative impact on self-esteem. Overweight children have more trouble making friends and are often teased about their appearance (27, 28). Even children as young as five-years-old express a preference for thin figures (29). As Becker discussed, the label of ‘fat’ can result in children conforming to the label in a self-fulfilling prophecy. BMI report cards could, therefore, perpetuate obesity as children who feel they have been labeled as fat resign themselves to the role of the ‘fat kid’ and participate in activities, such as overeating and not exercising, that they feel are expected.
Being labeled can also result in pressure from peers, family and society to engage in harmful weight loss practices that could potentially lead to eating disorders (30). Studies done on the BMI report card program in Arkansas show that dieting and dietary restriction has been increasingly encouraged by parents and practiced by students; this is troubling because research has shown that dieting predicts weight gain in adolescents (31). The 2005 Youth Risk Behavior Survey (YRBS) found that approximately 1 in 6 high school students engaged in unsafe weight loss practices, such as fasting, inducing vomiting, or using diet pills or laxatives (30). However, overweight children are not the only ones at risk for these unhealthy behaviors. The focus on weight created by BMI report cards and the negative attitudes towards overweight children may increase fears that healthy-weight children have about being labeled as fat; this could then push them into adopting unhealthy dieting practices to avoid the socially unacceptable ‘fat’ label.
III. An Alternative Multi-Level Intervention to Address Childhood Obesity
While schools provide an excellent setting to address healthy lifestyle changes since 95 percent of youth are enrolled in school (31), in order for an intervention to be successful, the program also needs to target the community and family levels. Parents are particularly important in any youth obesity intervention because they control much of a child’s food consumption, influence physical activity opportunities (32), and control access to television, computer, and video games. Additionally, there is much evidence suggesting that the eating behaviors of children are shaped by parental feeding behaviors and parental eating behaviors, as well as by parental weight status (33). The nutritional knowledge of mothers and their concern about disease prevention is positively associated with children’s fruit and vegetable consumption and negatively with children’s total fat and energy intake (33). It is therefore important to provide extensive parental education on the importance of providing healthy food choices in the home, especially beginning at an early age since food preferences are learned through repeated exposure to foods. It is also important to educate parents about the importance of eating at home as a family; this has been shown to improve children’s dietary quality, even in adolescence when children tend to make more independent food choices (33).
In terms of physical activity, children with parents who are more physically active are more likely to be physically active themselves (33). Parental encouragement is also related to increased or continued physical activity in youth. However, family resources can also influence physical activity levels; children whose parents transport them to after school activities, or pay fees for lessons or community sports organizations have higher levels of physical activity (33). To remove the disparity in access, schools or community organizations could provide similar activities for free or at reduced costs for families with limited resources.
For the family-based part of the intervention, it is important to emphasize reasonable goals for parents and children to work towards together, as well as to incorporate positive reinforcement. Research has also shown that nutrition education combined with behavior modification results in greater relative weight loss, and increasing problem solving capabilities is also important to successful changes in lifestyle habits (33). A successful intervention would, therefore, include not only nutrition education, but also educate parents about self-monitoring, social reinforcement, modifying their family’s environment for a healthier lifestyle, and problem-solving strategies for themselves and their children.
The school-based part of this intervention would have different levels for the different age groups. Teaching children early about good nutrition choices and the importance of physical activity is key to a healthier lifestyle as they get older. Children at the elementary school level would need fun, entertaining and interactive activities to keep their attention engaged and absorb the information. A pilot program in Missouri is trying such an approach, and something similar would be appropriate for this intervention. The Missouri program works to incorporate brief periods of exercise into the students’ day in addition to regularly scheduled physical education classes and recess (34). The nutrition part of their program teaches students how to read food labels, identify and choose healthy foods and identify deceptive marketing practices. Physical education classes could also incorporate fun games, rather than traditional sporting activities, to engage children who may not be as athletically talented.
At the middle and high school level, nutrition education should continue, along with problem-solving strategies to increase self-efficacy. Children are particularly vulnerable to teasing and bullying at the middle school level, so strategies for dealing with this type of harassment could also be useful; positive reinforcement from teachers, and ideally peers, would also help promote healthy lifestyle habits. Many states have a required number of hours of physical education, but as mentioned previously, not all states fulfill that obligation. It is critical that physical education continue through middle and high school, and it is equally important that these classes incorporate many different types of physical activity to encourage life-long habits. Rather than only incorporating traditional sporting activities, schools should consider adding units on yoga, kickboxing, Pilates, Tai Chi, swimming (if a pool is available), dance, and even walking to name a few. This would allow students to explore more options and potentially find something that suits their needs better.
At all levels of school, there need to be healthy eating options. Lunches provided in cafeterias need to have decreased levels of fat and increased levels of fiber, especially fruits and vegetables. The unhealthy snacks and sugary beverages available in vending machines should be replaced with healthier options. In this way, the school environment will support what the students are learning in class and at home.
The community level of this intervention would be focused more on promoting awareness of the issue of childhood overweight and obesity, as well as awareness of the school and family-based parts of the intervention (35). With community support for the campaign, there is likely to be increased community involvement in schools, increased promotion of healthy behaviors, and development of health and fitness partnerships for schools and families.
A. Tools to Promote Self-Efficacy
The alternative multi-level intervention has numerous ways to promote self-efficacy. One way in which it does this is by approaching behavior change in small steps to ensure the success of those changes (13). Rather than suggesting immediate drastic changes in lifestyle habits, this intervention would promote gradual change through steady modifications in nutrition at home, slow increases in daily physical activity, and promotion of less time spent watching television or playing video games.
In addition, the alternative intervention addresses the four sources of information that provide the basis for expectations of personal self-efficacy (15). The first source is performance accomplishment, or the successful mastery of skills. By teaching skills in problem-solving, self-monitoring, and alternative physical activities, this intervention increases confidence in one’s abilities, thereby increasing self-efficacy. The next source of information is vicarious experiences, which refers to learning from observing others performing difficult activities. Watching parents and other students make healthy food choices and watching their peers successfully involved in daily (fun) physical activity will enhance one’s expectations of mastering those skills.
Verbal persuasion, the third source, will come from both educators and parents as they teach the children about healthy lifestyle choices and encourage their efforts. Finally, emotional/physiological arousal also influences expectations of self-efficacy. People are more likely to expect success when they are not adversely aroused. This alternative intervention would ideally keep emotional stress to a minimum by not focusing solely on weight, as BMI report cards do, and decreasing the amount of potential teasing overweight children may experience. Since the children are then less likely to feel discouraged, they are more likely to expect, and experience, success when they attempt the desired behavior changes.
B. The Importance of Self-Esteem
It is difficult to promote healthy self-esteem in a society that bombards children with images of thin, beautiful people. However, this intervention has the potential to at least give self-esteem a boost for many youth, not just those that are overweight. The education component can not only provide information about healthy nutrition, but can also focus on images and discussions of ‘real’ people and emphasize the importance of healthy rather than thin in an effort to decrease body dissatisfaction. Also, by removing the report card format, the intervention would eliminate those feelings children may have that they are being judged by their size. As mentioned above, the focus on healthy living rather than weight has the potential to decrease teasing and bullying of overweight children, thereby significantly decreasing the feelings of helplessness and discouragement that can interfere with successful behavior change. The self-esteem of individual children is also likely to increase as their feelings of self-efficacy increase, as they successfully work towards the goals that have been established by the program.
C. Removal of Negative Labeling
Negative labeling and self-esteem are, as previously mentioned, closely related. Again, removing the report card-type intervention eliminates the label children may feel they are assigned when their parents receive the report. Removing this label reduces the risk that children will fall into the self-fulfilling prophecy of being ‘fat’, and will instead feel they are capable of eating right and being physically active. Also, the alternative intervention focuses on group activities that engage all children rather than only those with athletic talent, so children will not be excluded and feel isolated. There is much less risk of labeling with this intervention because the issue of weight is rarely, if ever, the focus; instead the focus is on living a healthy lifestyle. Removal of negative labeling also decreases the risk of healthy weight, and overweight, children engaging in harmful weight loss practices by decreasing the level of stigma attached to weight.
IV. Conclusion
While BMI report cards may be successful at bringing attention to the issue of childhood overweight and obesity, they are a number of potential unintended negative consequences. In addition to those outlined in this paper, BMI report cards also fail to identify a large population of children with normal BMIs but unhealthy lifestyle habits (23). The alternative multi-level intervention outlined not only address the negative consequences of BMI report cards, it also promotes healthy lifestyle behavior changes for all children in effort to ensure the children grow up into healthy adults.
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