Challenging Dogma - Spring 2008

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

Friday, April 18, 2008

Fat Chance Campaign Fighting Childhood Obesity: Let’s Bully with a Bulletin Board – Lina Rekstyte-Sims

The obesity epidemic in youths is spreading at an alarming rate. By 2010, it is predicted that the number of overweight children will increase significantly worldwide, with almost 50% of children in North America and 38% of children in the European Union becoming overweight (1, 2).
Yes, obesity among children is increasing in America at an alarming rate and there are many health risks associated with the condition. Even though numerous interventions are already in place to combat childhood obesity, the rates are still increasing (3), which raises a number of questions. How good are these interventions? Are they designed to reach people at different levels of socio economic status (SES)? Are their messages appropriate for this particular issue? Are they considering all contributing factors of obesity? We all hope that prevention programs investigate these questions, but it’s not always true. It takes a single intervention program with a ridiculous bulletin board to disrupt the good intentions and worsen the situation they are combating.
The intervention examined in this paper is the “Fat Chance Campaign”, which was launched in the MetroWest area, outside Boston. The goal of the campaign is to educate children and families in MetroWest about the health risks associated with obesity, encourage them to consult with professional health care providers and promote healthy food choices and physical activity. The campaign will include local billboards, print advertising in area newspapers, television spots and public relations, with other special components focused on groups such as area pediatricians (4). The goal of ads in the media is to encourage parents and children to visit the campaign’s website, where they will find useful information about improving their health. The proposed measure of success of the intervention will be measured by the number of website visitors. The campaign’s bulletin boards and ads display pictures of overweight kids with a black background accompanied by judgmental messages and gloomy, almost death like surroundings. One ad in the newspaper depicts a finger pointing at the spectator along with the message – “This is not a blame game”. Other visual materials are of the similar nature (4).
The “Fat Chance Campaign” is a fundamentally flawed intervention, because first, it is based on an assumption that parental education and awareness of an issue will lead directly to behavioral changes, which in turn will change their kids’ behavior. Next, the intervention is based only on a few simplistic external risk factors, such as food, exercise and medical health checkups, but totally ignores their relationship with SES. Lastly, it doesn’t take into consideration the impact of internal factors, such as the social and psychological environment of overweight children.
Intent alone does not predict behavior.
The “Fat Chance Campaign” is based on an assumption that parental awareness of the obesity issue will lead to their health behavior changes, which in turn will lead to behavioral changes in their children. The campaign assumes that visiting the website and acquiring knowledge of adverse health outcomes due to obesity will stimulate changes in behavior. This assumption is one-dimensional and contradicts research findings – human behavior is not automatic and doesn’t necessarily have a logical thought process. There are many other variables that influence our behavior, such as self-efficacy, attitudes and beliefs. One study found that self-efficacy plays an important role in determining human behavior. Self-efficacy refers to individual’s beliefs about their ability to perform the behavior of interest (5). Another study revealed that in order for an intervention program to be successful, people must feel competent to make necessary changes in behavior (6).
Not only self-efficacy, but personal beliefs and attitudes as well influence the way people behave (6). In order for children to start losing weight their parents have to feel competent in addressing the issue. They have to believe that they can be a positive example to their children. However, instead of supporting parents and boosting their confidence, the “Fat Chance Campaign” puts blame on them, which is unlikely to lead to positive feelings about oneself.
It’s not that simple.
Another major flaw of this campaign is that it is based on only a few simplistic external risk factors, such as food, exercise and medical health checkups, which are strongly dependant on the SES of a family. “Fat Chance” program fails to address this link.
The campaign states that the reason they chose childhood obesity for their intervention is because it is an urgent public health issue, which is equally spread among all SES levels! It doesn’t, this is an erroneous assumption of the campaign. Though it is important to know the prevalence of obesity among different levels of SES, it is more important to understand that families with different SES do not have equal resources or opportunities to address health, nutrition and poor housing issues. These factors were shown to be related to obesity and general health (7-9). The campaign proposes 3 actions that should help parents to help themselves and their kids - exercise, diet and regular medical check ups. And how many times have we heard that before? Why does the issue still persist? The advice seems logical, but it does not address some important realities.
SES can have an effect on weight in many indirect and sometimes unexpected ways. One study found that people are more likely to become overweight if they live in poorer neighborhoods, have limited access to local shops, financial services and health –related stores (7). Furthermore, it was shown that people living in more disadvantaged neighborhoods had a higher rate of premature death (8). Thus, people of lower SES, who usually live in disadvantaged neighborhoods, are more susceptible to these negative factors and in turn have a higher chance of becoming overweight, compared to those with higher SES. In other words, the environment of your residency affects your health status, including obesity.
Furthermore, it was also found that fear is inversely related to physical activity levels. Parental rating of safety was associated with childhood obesity (9). These findings imply that families living in poorer neighborhoods, which tend to have more crime and street violence, are fearful of being hurt on the street, consequently having less physical activity opportunities as compared to families living in safer and wealthier neighborhoods.
Above are only a few examples of the findings from studies which confirm that SES is associated with health behavior and especially resources for the behavior change. The “Fat Chance Campaign” dismisses this link altogether and therefore neglects a key component of the childhood obesity problem.
Medical health doesn’t mean mental health.
The “Fat Chance Campaign” doesn’t take into consideration important internal factors that have an effect on childhood obesity, such as weight stigmatization, bullying, eating disorders and depression. In order to combat childhood obesity it is critical to address these issues. The consequences of social and psychological distress may have immediate and potentially lasting effects on the well-being of overweight children and may even aggravate adverse medical outcomes that they already face (10).
Weight stigma is closely associated with obesity. It is also known as weight bias or weight-based discrimination and refers to discriminatory attitudes towards overweight/obese individuals that influence interpersonal interactions. Weight stigma reflects internalized attitudes towards overweight and obese people and effects how these people – the targets of bias – are treated. (11)
Weight stigma is a direct cause of bullying, which in turn leads to other negative outcomes, such as eating disorders, rejection and depression. A recent study assessing 8210 children documented that 36% of overweight boys and 34% of overweight girls reported being victims of weight-based teasing and various forms of bullying (12). It was found that the level of obesity predicted weight-based teasing, which in turn predicted body dissatisfaction and led to unhealthy eating behaviors over a 3-year period (13). It was reported that obese children are liked less and rejected more often by peers than are average-weight students (18). They are also more likely than nonoverweight children to engage in binge eating and chronic dieting (19). Therefore, it’s equally critical to include weight stigma in a fight against childhood obesity. Researchers have found that body-related concerns have been reported as specific and frequent barriers to participation in physical activity by overweight students, suggesting that interventions need to promote body esteem among overweight children in order for them to feel comfortable doing physical activities (14). The “Fat Chance” program does the opposite by using negative images and messages as their motivational tool.
Another important negative outcome and often cause of obesity is depression. One study found that childhood depression predicted development of obesity at 1-year follow-up (15) and another reported that adolescent depression predicted obesity in adulthood (16).
Taking into consideration all the above influences, researchers have cautioned that childhood obesity prevention programs have the potential to further stigmatize overweight and obese youths. Negatively focused health messages (e.g., that emphasize the undesirability of being overweight) may lead students to feel worse about themselves. They further suggest that to avoid many potential psychological and physical health consequences which can result from bias, researchers must take careful consideration of how messages are framed in programs that address childhood obesity (17). The “Fat Chance Campaign” is not helping children when they portray obesity as a shameful, dark issue. To the contrary, it encourages and strengthens social stereotyping, negative self-image and intensifies depression in overweight kids.
Conclusion
The failure to recognize, multiple determinants of human behavior, the link between SES, health status and behavior, and lastly, ignoring social and psychological factors and their negative effect on overweight children, makes the “Fat Chance Campaign” a “Big Looser”. Nevertheless, the fight against childhood obesity is an ongoing battle and there is always room for improvement. The campaign would be more appropriate for this issue if it employed positive messages and images rather then negative ones. Also, it would be more effective if it offered realistic solutions to the problem based on multiple determinants of the problem rather than simple individual factors. Finally, getting rid of the derogatory name such as “Fat Chance” would be a perfect small step in easing the lives of overweight children.
REFERENCES
Eaton, D.K., Kann, L., Kinchen, S., Ross, et al. (2006) Youth risk behavior surveilance – United States, 2005. Morbidity and Mortality Weekly Report, 55(SS-5), 1-108.
Wang, Y., & Lobstein, T. (2006). World wide trends in childhood overweight and obesity. International Journal of Pediatric Obesity, 1, 11-25.
Ogden, C.L., Carroll, M.D., et al. (2006) Prevalence of overweight and obesity in the United States, 1999-2004. Journal of the American Medical Association, 295, 1549-1555.
MetroWest Community Health Care Foundation. Childhood Obesity-Understanding and Addressing an Epidemic. Metrowest, MA: A Report from the MetroWest Community Health Care Foundation, Winter 2007. http://www.metrowestkids.org/MISC/Obesity%20Report.pdf
Salazar MK. (1991) Comparison of four behavioral theories. AAOHN Journal; 39:128-135.
Rosenstock, I.M. (1990) The health belief model: Explaining health behaviors through expectancies. Health Behavior and Health Education Theory Research and Practice. San Francisco, CA: Jossey-Bass Publishers
Stafford, M., et al. (2007) Pathways to obesity: Identifying local, modifiable determinants of physical activity and diet. Social Science and Medicine , 65, 1882-1897.
Sloggett A, Joshi H. Higher mortality in deprived areas: community or personal disadvantage? BMJ 1994; 309:1470-1474.
Lumeng, J.C., Appugliese, D., Cabral, H.J., Bradley, R.H., & Zuckerman, B. (2006). Neighborhood safety and overweight status in children. Archives of Pediatric & Adolescent Medicine, 160(1), 25-31.
Puhl, M. R., & Latner, J.D. (2007) Stigma, obesity, and the health of nation’s children. Psychological Bulletin, Vol. 133, No. 4, 557-558.
Wikipedia The Free Encyclopedia. Wikimedia Foundation, Inc. http://en.wikipedia.org/wiki/Self-efficacy.
Griffiths, L.J., et al. (2006) Obesity and bullying: Different effects for boys and girls. Archives of Disease in Childhood, 91, 121-125.
Cattarin. J.A., & Thompson, J.K. (1994) A three-year longitudinal study of body image, eating disturbance, and general psychological functioning in adolescent females. Eating Disorders: Journal of Treatment & Prevention, 2, 114-125.
Zabinski, M.F., et al. (2003). Overweight children barriers to and support for physical activity. Obesity Research, 11, 238-246.
Goodman, E., & Whitaker, R.C. (2002). A prospective study of the role of depression in the development and persistence of adolescent obesity. Pediatrics, 110, 497-504.
Richardson, L. P., et al. (2003) A longitudinal evaluation of adolescent depression and adult obesity. Archives of Pediatric & Adolescent Medicine, 157, 739-745.
O’Dea, J. A. (2005) Prevention of child obesity: ‘First, do no harm’. Health Education Research. 20, 259-265.
Strauss, C. C., et. at. (1985) Personal and interpersonal characteristics associated with childhood obesity. Journal of Pediatric Psychology. 10, 337-343.
Neumark-Sztainer, D., et. at. (1997) Psychosocial concerns and health-compromising behaviors among overweight and nonoverweight adolescents. Obesity Research. 5, 237-249.

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1 Comments:

  • At April 24, 2008 at 9:24 AM , Anonymous kerin said...

    I think one of the most egregious errors of this campaign is the slogan itself. "Fat chance" implies a slim probability. Therefore the slogan is effectively telling overweight kids that becoming leaner is a losing battle and that the public health officials who came up with this campaign have little faith that the kids can slim down.

     

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