Challenging Dogma - Spring 2008

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

Monday, April 21, 2008

How the “We Can!” Childhood Obesity Prevention Program Fails To Overcome and Address Environmental and Access Issues- Stefanie Pilla

We Can! is a national program that is designed to help children eight to thirteen years old achieve and maintain a healthy weight. We Can! stands for “Ways to Enhance Children’s Activity & Nutrition” and has three main goals: improve food choice, increase physical activity, and reduce screen time. The program tries to achieve those goals through educational materials directed at parents, educators and caregivers, in addition to organizing community events for parents and children through local We Can! sites.

In November of 2007, First Lady Laura Bush and the Acting U.S. Surgeon General Rear Admiral Steven K. Galson announced their plan to expand the We Can! program to address the epidemic of childhood obesity (5). Currently, 16% of U.S. children six to nineteen years of age are overweight and an additional 15% of children in the same age group are at risk for becoming overweight(6). These numbers have not declined in the past few years, but have increased, stressing the importance of creating an effective prevention and intervention program designed for children and adolescents.

Though the We Can! program appears promising, there are several aspects of the program that are problematic. First, the education based program places an emphasis on knowledge and information, assuming that access to knowledge about obesity will result in obesity reduction. I will show why this is faulty logic. We Can! outlines ways for parents to increase physical activity in children and make healthier food choices, but these tips appear to only be applicable to parents who can be home around dinner time, have the time to be active in the community, and have a yard or live in a safe neighborhood. Many parents with overweight children may not fit those criteria, making these tips useless to them. Finally, We Can! assumes that parents have access to healthy foods and can afford these foods, ignoring the reality that this is not always the case. In order to be more effective, the program should address, or at least acknowledge these social and economic barriers that cannot be overcome with knowledge alone.

Emphasis on Individual Rational Choice
We Can! appears to incorporate ideas from the Health Belief Model, a model that approaches behavior on a rational and individual level. The Health Belief Model is based on the idea that when individuals receive information regarding the severity of an unfavorable behavior, benefits of changing that behavior, and their susceptibly to the harmful effects of the behavior, individual intention and behavior will change. While the program does not explicitly state that it is based on the Health Belief Model, the program does rely heavily on education and incorporates the general principles of the Health Belief Model. In the parent handbook, many diseases associated with obesity are listed, including heart disease, type 2 diabetes, high blood pressure, and high cholesterol, among others. Statistics about rising childhood obesity rates are presented, showing why parents should care. The benefits of weight loss are also mentioned, including increased self esteem and general well-being.

Another example of the emphasis on individual action can be found in the “We Can! Families Finding the Balance Parent Handbook,” where parents are told repeatedly that they are the key to helping their children manage their weight. In one of the first pages, the handbook declares, “That’s what this We Can! handbook is all about—giving you lots of ideas that can help you and your family take action for a healthy weight.” Later on, a list of tips use bold-faced font for the word “can” in tips such as “You can give your family more vegetables for dinner,” highlighting the power of individual choice and action (1).

These words appear to be encouraging, but ignore the many factors that influence individual behavior. Knowledge is an important part of behavior change, but knowledge alone is not sufficient in attacking this multifaceted public health problem. Several studies have concluded that knowledge of nutrition or food composition does not necessarily lead to a healthier diet (3, 8). By focusing solely on individual choice, the program may end up discouraging parents and children that cannot make healthier food choices or exercise more frequently due to external factors such as access and economic restraints.

We Can! assumes that knowledge about healthy food options will lead to healthy food consumption, however, the failure of recent fruit and vegetable campaigns illustrate s how a narrow focus on knowledge may be ineffective in changing health behavior. Despite campaigns for increasing produce consumption and the awareness of the health benefits of eating fruits and vegetables, between 1994 and 2005, there was little change in the average number of servings eaten by Americans (9). One statistic shows that only 45% of Americans over the age of two eat 3 vegetables a day, and only 28% eat two servings of fruit (10). An education based anti-childhood obesity program might be a good place to start, but it is not enough on its own to combat the complexities of the relationship people have with food and exercise within the context of their lives.

Very Limited Target Audience
The program provides parents and caregivers with such tips as: take a walk with your children after dinner, play outside with the dog after work and go for a hike with your teenager (1). These tips seem to be targeted towards a middle class and upper middle class parent—an image of a house in the suburbs with a picket fence and a dog. This is not the reality for many people, and these tips may not be effective for families living in the inner-city. We Can! also offers parent workshops that are four sessions long and 90 minutes per session. Because the workshops are coordinated through the local We Can! sites, there is no information available on the main website. To participate, parents have to contact the local sites for more information, which can be inconvenient. In addition, the workshops are in-person and are only offered a few times a year. The type of parent who can attend these meetings may be different than the parents that should be targeted by anti-childhood obesity programs. It is difficult for any parent to take time to partake in these workshops, but for working parents, single parents, or parents struggling financially, these workshops are even more difficult to attend. Parents may have to travel long distances to the workshop, leave work early, or find a babysitter just to participate. The reality of these inconveniences can be seen in the fact that a total of only 36 parents attended the three workshops offered by the local Boston We Can! site in 2006.

The We Can! website and literature suggests the following ways to increase physical activity: take walks after dinner, go to the zoo, get off the bus one stop early and walk the rest of the way, take your child rollerblading, bike to the library, play singles tennis rather than doubles tennis. Other tips include take the long way to the water cooler, wash your car outside, or walk to your colleague’s office instead of writing an email. While these tips sound helpful, to a working parent with little time for personal leisure, playing singles tennis rather than doubles will probably not be useful. To a single mother working the night shift at a diner, walking to your colleague’s office is not applicable. Most of the tips, if not all of them, are geared towards parents of higher social economic status (SES), rather than a working class parent of lower SES. While it cannot be expected that one public health program can address everyone in their target audience, in this case, the parents of lower SES are the parents that should be receiving the most help.

The highest rate of obesity occurs among populations with the highest poverty rates and the least education (3). Poverty affects every ethnicity and race, but a disproportionate number of minorities live in poverty. Non-Hispanic Whites have a poverty rate of 8.2%, and Hispanics and Blacks have a poverty rate of 20.6% and 24.3%, respectively (11). This same discrepancy can be seen in obesity rates—non-Hispanic Black children have an obesity rate of 23.5%, and Hispanic children and non-Hispanic White children have an obesity rate of 18.8% and 12%, respectively (7). We Can! relies on parents to initiate and maintain healthy eating and exercise behaviors for their children, yet the discrepancy within the adult rates of obesity is even greater. Non-Hispanic White women have an obesity rate of 31%, which is very high in itself, but non-Hispanic Black women have an obesity rate of 49% (6). These numbers show that designing an anti-childhood obesity outreach program with an obvious focus on middle-class to upper-middle class parents and children may be doing a huge disservice to the thousands of parents who do not fit within that category, especially when the problem is most severe for them.

The We Can! website encourages parents and communities to get involved by providing seminars and workshops for parents, and tools to start We Can! community sites in their area. This involvement would definitely be beneficial to the community, but the very parents and communities that are in need of this intervention, may not have the resources to launch these programs. This can be illustrated by the sentiment expressed in focus groups conducted with urban African American overweight children and their parents. The parents reported feeling stressed by competing priorities, constrained by time and by a limit of financial resources (12). A more effective way to involve the community might be to have public health workers, or educators attend these seminars and then create community sites in impoverished areas. If the We Can! community sites provide useful tips that are applicable to members of the community, or organize community events such as having the gym of the local elementary school open two nights a week for recreational purposes, the program could be more effective for lower SES parents and children.

Neglectful of Larger Social Forces and Barriers
In addition to focusing on a narrow audience, We Can! does not acknowledge or consider that there are access barriers for many Americans and their children. Due to economic restraints, many low income families face challenges accessing healthy food options and opportunities for physically active recreation (15). These barriers contribute to the rising obesity epidemic. When it is more economical and convenient for a parent to buy dinner from McDonalds than it is to purchase lean meats and produce and cook at home, the solution to childhood obesity may not be as simple as saying “make the right food choices.”

As mentioned earlier, the tips provided by the We Can! materials suggest that parents and children exercise outside, whether it is playing with the dog, going for a walk after dinner, or playing ball. For many families, this is feasible, but for families living in unsafe neighborhoods or in cities, playing outside is not an option. In a study focused on physical activity levels, parents were asked about barriers that prevented their families from being physically active. Although all parents perceived the same barriers—transportation, opportunity in the area, and expense, barriers were reported significantly more frequently by Hispanic and non-Hispanic Black parents. Overall, parents with lower incomes and education levels reported more barriers (13).

In addition to tips on increasing physical activity, We Can! also calls for making better food choices. These tips include: putting a bowl of fruit on the counter, keeping high calorie snacks such as chips out of the house, eating strawberries for dessert instead of cakes and ice cream. The fact that many families do not have access to fresh produce, whether geographically or economically, is not addressed. We Can! calls for increasing consumption of fruits, vegetables, whole grains, lean meat, poultry, fish, and nuts—and decreasing consumption of high fat and high sugar food (1). Listing the components of a healthy diet does not necessarily mean that people will be able to change their diet to include those healthier foods. According to an article published in the American Journal of Clinical Nutrition, diets composed of whole grains, fish, and fresh vegetables and fruit are far more expensive than refined grains, added sugars and added fats (3). This makes processed, sugary and high fat foods an economical choice for parents on a budget (3). Dry foods with stable shelf life are generally less costly than fresh produce and meat with high water content, which may be one reason why poverty is associated with low fruit and vegetable consumption and lower quality diets (3).

We Can! offers a print-out sheet called “Parent Tips: Healthier Eating While Saving Money.” While this sounds promising, the tips do little to actually give parents on budgets the tools to access healthier foods. Tips include: don’t shop hungry, sign up for your grocer’s bonus card, buy in-season fruits and vegetables—use local farmers markets when possible, cook once, eat twice (4). The tips do not acknowledge that in some neighborhoods, there is limited access to good fresh produce. Greater vegetable availability within 100 meters of residence has been shown to be a positive predictor of vegetable intake, illustrating that there is a relationship between ease of access and consumption (16). Impoverished cities and towns may not only have less access to healthy produce, but also may have increased access to fast food. After comparing the mean numbers of McDonald’s in different areas, a study found a positive association between neighborhood deprivation and the number of McDonald’s outlets per 1,000 people (17). I looked at the five wealthiest and the five poorest cities and towns in Massachusetts and found that the five wealthiest places had an average of 2.4 McDonald’s within 5 miles of their zip code, and the five poorest places had an average of 3.2 McDonald’s within 5 miles (18). These examples provide support for the idea that to effectively combat obesity, the environment has to be taken into account, as well as individual factors.

Obesity is an increasingly urgent health crisis facing our nation. Obesity causes many chronic and preventable diseases, and costs the country millions of dollars a year in treatment. Targeting youth is a smart way to approach the issue, since adolescents with a body mass index (BMI) at above the 95th percentile have a 50% chance of becoming obese adults, and 70% will be obese or overweight adults (19). The We Can! program attempts to reduce childhood obesity by giving parents information on making better food choices and becoming physically active. While that is an excellent starting point, it is not enough. The program ignores the access issues that many parents and their children face, making many of the tips and suggestions that the program outlines irrelevant to their lives. It may be impossible to create a national childhood obesity prevention program that eradicates poverty, provides fresh produce stores and safe parks in every neighborhood, but I do not think that it is implausible for a campaign to at least address the access issues.

1. U.S. Department of Health and Human Services- National Institutes of Health. We Can! Families Finding the Balance: A Parent Handbook.
2. The Annie E. Casey Foundation. Data Snapshot: State Differences in Rates of Overweight or Obese Youth, based on the 2003 National Survey of Children’s Health.
3. Drewnowski A. & Specter SE. Poverty and Obesity: The Role of Energy Density and Energy Costs. American Journal of Clinical Nutrition January 2004; Vol. 79, No. 1, 6-16.
4. We Can! Parent Tips: Healthier Eating While Saving Money.
5. National Heath Lung and Blood Institute and We Can! Acting U.S. Surgeon General and NIH Director Announce Expanded We Can! Efforts.
6. CDC, National Center for Health Statistics. Obesity Still a Major Problem, New Data Show.
7. National Survey of Children’s Health. Weight Status of Children/Youth based on Body Mass Index for Age.
8. Patterson R., Kristal A., White E. Do Beliefs, Knowledge, and Perceived Norms about Diet and Cancer Predict Dietary Change? American Journal of Public Health 1996; Vol. 86, No. 10, 1394-1400.
9. Blanck H.M., Gillespie C., Kimmons J.E., Seymour J.D., Serdula M.K. Trends in Fruit and Vegetable Consumption Among U.S. Men and Women, 1994-2005. Preventing Chronic Disease 2008; April: A35.
10. Flaherty J. Who Made America Fat? Tufts Nutrition Magazine 2004, Volume 6, No.1, 19-23.
11. U.S. Census Bureau. Poverty: 2006 Highlights.
12. Neumark-Sztainer D., Story M., Perry C., Casey M.A. Factors Influencing Food Choices of Adolescents: Findings from Focus-Group Discussions. Journal of the American Dietetic Association 1999; Vol. 99, Issue 8, 929-937.
13. Babey SH, Hastert TA, Yu H, Brown ER. Physical Activity Among Adolescents. American Journal of Preventive Medicine 2008; 34 (4) 341-344.
14. Martin S., Carlson S. Barriers to Children Walking to or from School- United States 2004. MMWR, September 30, 2005, 54(38), 949-952.
15. Kumanyika SK, Whitt-Glover MC, Gary TL, Prewitt TE, Odoms-Young AM, Banks-Wallace J, et al. Expanding the obesity research paradigm to reach African American communities. Preventing Chronic Disease 2007; Vol. 4, No. 4.
16. Bodor JN, Rose D, Farley TA, Swalm C, Scott SK. Neighborhood Fruit and Vegetable Availability and Consumption: the Role of Small Food Stores in an Urban Environment. Public Health Nutrition 2007; 11 (4), 413-420.
17. Cummins SC, McKay L, MacIntyre S. McDonald’s Restaurants and Neighborhood Deprivation in Scotland and England. American Journal of Preventive Medicine 2005; 29(4), 308-310.
18. Mass Benchmarks. Median Household and Family Income, Census 1990 & 2000.
19. Thompson J, Shaw J, Card-Higginson P, Kahn R. Overweight Among Students in Grade K-12, 2003-04 and 2004-05 School Years. MMWR January 13, 206, 55 (01), 5-8.

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