Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Monday, April 21, 2008

The Failure of Arkansas School Act 1220 to Decrease Childhood Obesity: Applying Social Settings to Improve Public Health Intervention – Omar Hamdani

Arguably one of the largest topics in public health today is childhood obesity. This topic hits nowhere closer than home for Americans. When compared with the rest of the world the U.S. is in the 95 percentile for BMI throughout the world. Our rate of obesity has increased rapidly over the past 25 five years (1). This should be considered a deadly epidemic because of the many risk factors that have been associated with being obese as a child. In past studies obesity has been linked to several outcomes including hypertension, dyslipidaemia, chronic inflammation, increased blood clotting tendency, endothelial dysfunction, and hyperinsulinaemia (1-2). The recent rise in type 2 diabetes is almost completely attributed to growing numbers of childhood obesity cases in the U.S. (1). If some type of intervention could be made to reduce childhood obesity, incidence of cardiovascular complications in adulthood could be reduced (2). The U.S. government has been trying to implement such an intervention. In the year 2000 $117 billion was spent on programs to reduce childhood obesity, yet something is still not working (3). One of the major acts recently put in place to combat the growing obesity epidemic was the Arkansas Act 1220.

Act 1220 was put in place in 2003 in the state of Arkansas. The main purpose of the act was to reduce childhood obesity in the state of Arkansas, as well as raise awareness of the growing problems that childhood obesity presents (2-5). Several measures were taken to reduce childhood obesity through the school system. Some of the major undertakings were creating a Child Health Advisory Committee, eliminating vending machines from public elementary schools, assessing body mass index (BMI) annually for all public school students, and creating local community committees to raise awareness of the risk factors of obesity (5). The report cards aimed to track their children’s weight in order to raise awareness of the risks of obesity, as well as ways in which BMI can be kept at healthy levels (5). However, when percentages of overweight children are actually examined over the past 3 years since the act was put in place we find little to no decrease in obesity in Arkansas, 17.2% in 2003-4 and 17.1% in 2005-2006 (6). The main fault in this act is the fact that it only makes an attempt to determine how bad the obesity problem is in Arkansas, but it makes no attempt to determine how or why obesity is such a problem in Arkansas and the rest of the U.S. The Arkansas School Act did not reduce childhood obesity in Arkansas because it failed to appeal to the social settings in which unhealthy activities were taking place.

Act 1220 fails to compete with socially appealing advertising campaigns of corporations promoting unhealthy behaviors by following the Health Belief Model

One of the main faults of Act 1220 is that of many of today’s public health interventions, which is that it relies on the classic Health Belief Model. Health Belief Model states that if the perceived benefits of quitting a behavior outweigh the costs then that person will have the intention to quit the behavior, and therefore quit the behavior (7-9). By showing parents their children’s BMI and making them aware of the risks of being overweight and obese, it is thought that the parents will weigh these costs with the benefits of being at a healthy weight. The parent will then make the decision to intervene in the child’s behavior. However, this model does not account for the fact that intention does not always predict behavior (8). Similar mistakes were made in the past with campaigns such as the “5 a Day” campaign which sought to increase fruit and vegetable consumption. Almost no increase in consumption was observed and millions of dollars were spent. One of the reasons that corporations market so well is that they stray away from these types of models which seek to predict intention rather than behavior.

Another downfall of following the traditional Health Belief Model is the fact that this model relies on rational thought. The approach can be described as Empirical-Rational. In this strategy it is assumed that men/women are rational and will follow their rational self-interest when information is presented to them (10). Act 1220 relies on the fact that parents will be able to come to the rational decision of intervening in the behaviors of their children as a result of being made aware of the risk factors of being obese (5). However, in many cases we find that human logic is not rational. In fact much of human logic is irrational. Even though the parents of the children may be completely aware of the risks that come with obesity, they may still not intervene in that child’s behavior. Corporations know that human logic is irrational, and they use strategies that account for this. When a commercial shows people smiling and having fun, and then flashes to a McDonald’s logo they are not letting a person make a rational decision. McDonald’s is saying, “Buy this hamburger it will make you happy.” This is hardly rational, but apparently effective.

In order to be successful in changing behavior and raising awareness different strategies must be used. One effective form of intervention that could be used as a model was the use of branding in the “Verb” campaign. Branding is giving something that a person is able to define their identity with, and it is very important in the way the mind of a youth works (11). The verb campaign consisted of paid advertisements that showed kids and adolescents engaging in numerous outdoor activities. The catch phrase for the campaign was “Verb. It’s what you do.” After only one year a survey of children showed that 74% of children knew of the verb brand, and higher physical activity was identified in several subgroups of children (12). This campaign systematically gathered information on its target audience, and made a campaign that appealed socially to its target audience of children. It employed a model that accounted for irrational thought, and did not count on intention to predict behavior. This is the exact approach that fast food corporations take when preparing their campaigns, and that is why they work. The “Verb” campaign is just one successful use of an alternative model that could be employed in future interventions.

Act 1220 fails to set healthy social norms

Act 1220 seeks to reestablish social norms in children by removing unhealthy foods from the schools, i.e. removing vending machines from the schools and requiring certain compliances in what food may be served (5). By removing this unhealthy food from the public schools, the act is trying to set a social norm of the school as a healthy environment. This is a similar strategy to the smoking ban recently put in place in Massachusetts. However, the act fails to recognize that it may be motivating the behavior as well. One of the core values of youth is to rebel (11). By banning unhealthy foods in public schools, Act 1220 may even be fueling the consumption of junk food as an act of rebellion. This in turn plays back into the corporations hands because it is basically free advertising. It makes it an act of rebellion to eat these banned items, and in many cases children may find this cool or fun to do.

Requiring BMI report card submissions also runs the risk of negatively branding children as overweight and obese. The target age of Act 1220 is a very sensitive state for the mind of a child. By creating these BMI report cards and classifying children into different categories we create other reasons for children to be self-conscious of their current health state. This could actually create negative awareness, rather than casting the intervention in a positive light that would have greater effectiveness on children. Bullying and teasing is one of the unfortunate social norms affecting children in school, and by labeling children as obese and overweight with these report cards we could just end up making it worse.

Act 1220 also seeks to create social norms by using agenda setting. The act puts childhood obesity on a pedestal in an attempt to make it a big issue. The act is somewhat successful as it has spurred a good amount of interest in the topic of monitoring childhood obesity, but it is also a double edged sword. While the act does raise awareness and make monitoring a child’s weight a prime concern, this is a social norm that tends to lead nowhere. The percentages for overweight and obese children have not changed to any real degree in the past 5 years since the act was put in place (6). Parents’ awareness of childhood obesity has changed since the act has been put in place, but their attitudes towards risk factors associated with obesity remain unchanged (5). In order for a public health intervention to work properly it needs to go beyond just addressing the problem and making the public aware. Act 1220 does not make an attempt to stop the problem at its source. In the case of obesity we must think beyond the fact that our children our already overweight. The act needs to address why the children of Arkansas are overweight.

Act 1220 focuses too much on the immediate causes of obesity

Modern public health tends to focus on the immediate causes of an outcome in order to intervene (13-14). Act 1220 is no different than most public health interventions in this manner. When the act was made they thought of the most proximate cause to obesity which is unhealthy eating, and got rid of it in public schools. However, there is much more that goes into why and how a child ended up being obese in the first place. It would be much more effective seek to address the underlying processes that are causing these behaviors in the first place. For example, there could be low enrollment in after school sports thus decreasing the activity level of children. Instead the act uses an extremely proximate form of assessing obesity (BMI) that gives relatively no information other than to say whether the child is obese or not. It is evident that the act only serves to stop the behaviors and not understand them. Until an understanding of why kids choose these behaviors is drawn long lasting and healthy social norms will never be built appropriately.

By focusing on these immediate causes, Act 1220 fails to contextualize the risk factors in which childhood obesity is occurring. Contextualization of risk factors is defined as “using an interpretive frame work to understand why people come to be exposed to risk or protective factors, and to determine the social conditions under which individual risk factors are related to disease” (14). This lack of contextualization is one of the main failures of Act 1220. The intervention makes no attempt to identify the social constructs in which these behaviors are occurring. The act only seeks to address the proximal/immediate causes, rather than acting to change the conditions in which these unhealthy behaviors are occurring. By failing to contextualize these risk factors in society we can no effectively create long lasting healthy social norms. Once interventions are able to understand the types of environments that these risk factors are occurring in, they will be able to properly intervene and stop them at their source.

Another reason that the act fails in addressing the immediate causes is that its main feature, the BMI Report Card, is actually given to the parent. The act completely relies on the parent to intervene in the home environment to improve the health of the child. It is making no direct attempt to improve awareness among children, and thus making no attempt to change the social norms that the children’s are already used to. The act recognizes the parents as the most immediate influence on the child, and believes targeting the parents will be enough to change that child’s behavior. However, many children will choose not to listen to their parents. An intervention needs to be able to collaborate more effectively between groups, and raise awareness throughout a community to work effectively. If the children aren’t mainly targeted in an act that is supposed to be solely for their benefit, it will not work.


Act 1220 did make some strides in fighting the obesity epidemic in Arkansas. Obesity rates were soaring prior to Act 1220 being put in place, and over the years since the act was enacted the rising rate of obesity has been arrested. Awareness has also been increased in Arkansas as a result of the BMI report cards and various committees to improve awareness of the risks that come with being overweight and obese. However, it isn’t enough only to stop the obesity rates from rising. This can not be considered a success. Obesity rates are already dangerously high in the U.S., so just stopping the increase in rate of obesity is not enough. New strategies need to be used to compete with the media savvy corporations. Interventions that seek to only increase awareness and restrict unhealthy behaviors do nothing to set social norms because they do not appeal to the natural lifestyles of children. An attempt to target their core values in order to change behaviors must be made. In a sense we need to make it “cool” to be healthy rather than making it a rule. Also the problem of addressing only immediate causes is imminent. If we are unable to contextualize the root of risk factors for obesity, we will never understand why it happens. Thus we will not be able to stop it.

It is not to say that steps aren’t being taken in Public Health to do this. The use of social settings is being employed in several current campaigns. We need to learn from the few campaigns that are successful so far, and improve on what they have been able to do. Until we can target the underlying social settings in which these unhealthy behaviors that cause obesity occur, the epidemic will continue to grow, and interventions like Act 1220 will only arrest the fall.


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