Challenging Dogma - Spring 2008

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

Thursday, April 17, 2008

Powerful Bones. Powerful Girls. – National Bone Health Campaign in serious Need of Age Adjustment and Attention to Causation - Jesse Macomber

The basis of the Powerful Bones. Powerful Girls. Campaign is a combination of several of the most prominent group behavior theories, particularly, Framing Theory, Social Marketing Theory, and Advertising Theory. Although this campaign makes broad use of these public health theories, the creators fail to realize that although appealing to the very young youth with its cartoon caricatures and fun links on its primary base, the web, it carries the same tragic flaw as the Health Belief Model. It fails to take into account major factors that would prevent these young girls from growing and building strong and healthy bones. In order for this campaign to be successful, the creators need to address ways for girls to cope with the forces that would prevent them from engaging in health-promoting activities, make the site more appealing to a broader age range of girls, and tap into resources to promote and better advertise this campaign and mission. By enlisting the help of calcium/bone health product companies, such as Viactiv, the campaign could have the ability to reach millions of people. If all these improvements were made, this campaign would have the potential to be a great success in public health.

The Campaign
The Powerful Bones. Powerful Girls. Campaign was launched as part of the National Bone Health Campaign, a partnership of the Office on Women’s Health within the Department of Health and Human Services, the Centers for Disease Control and Prevention, and the National Osteoporosis Foundation in September 2001 (1). Targeting optimal bone health in girls ages nine to twelve, the goal of the website is to promote bone health in girls through spreading the word on the importance of healthy, lifelong habits, such as calcium consumption and physical activity (2). Dr. Saralyn Mark, senior medical advisor for the Office on Women’s Health explains of the website:

We created this site to educate and encourage girls to establish lifelong healthy habits that help build and maintain strong bones, especially increased calcium consumption and weight-bearing physical activity. This site strives to achieve that goal in a fun way that empowers girls to be strong, both inside and out (1).

The site opens with an introduction from the site’s main animated character, Carla, and displays links to several interactive tools, which provide the viewer with information, as well as links to pages of interest. The five categories to choose from are Healthy Bones, Staying Strong, Carla’s Space (which includes a journal and videos,) Fun and Downloads, and Home. Through these five areas of the site, the user can find useful information to help the user strengthen her bones. With the nation’s nutrition and physical activity at all-time lows, the Powerful Bones. Powerful Girls. Campaign began none too soon.  

Weak Bones, a Widespread Epidemic
It is no secret that today’s youth are falling victim to unhealthy behaviors and, consequently, developing life-altering diseases such as obesity, heart disease, and diabetes at a young age. With such emphasis in the media placed on the latter three conditions, other health risks have been overlooked and ignored. One of the most prevalent amidst female youth is weak bones. This condition often leads to osteoporosis later in life due to decreased calcium intake and lack of physical activity, particularly weight-bearing activity (2). However, as several studies from the last decade have proven, the gospel that many of our health care providers continue to preach is incorrect and lacking important factors. A 2000 study conducted by the American Society for Bone and Mineral Research explains that the vast majority of nutritionists hold to the idea that “daily consumption by children and adolescents of the appropriate numbers of servings of foods in the major food groups, according to the food pyramid, should yield healthy bones” (3). However, as this study found, as well as another conducted by BL Speckler in 1996, diet alone does not contribute to healthy, strong bones. Another key factor that needs to be considered is the importance of regular physical activity during the adolescence years and continuing into adulthood (3).

A Newsday article entitled, A Bone to Pick with the Nation’s Kids, outlines the graveness of the epidemic, going as far as to compare the growing condition to that of the 19th century epidemic of rickets (4). From the time of the Powerful Bones. Powerful Girls. Campaign’s conception, up until the present, science has seen a dramatic increase in bone studies. Scientists are beginning to track kids’ bone quality in order to learn just how big this problem is. Dr. Heidi Kalkwarf of the Cincinnati Children’s Hospital led a study that gave bone scans to 1,500 healthy children between the ages of 6 and 17. The goal of the study was to see just how bone mass was accumulated and the results led to the first bone-growth guide. This chart helps pediatricians to track bone growth in those children who are most at risk for bone problems. This same group of children was then tested seven years later, as adults, to see how their bones had developed over the years. The study’s results concluded that half of peak bone mass develops during adolescence. This fact, coupled with the knowledge that by age 30, bones break down faster than they rebuild themselves, turns the matter into a race against the clock. Children must build strong bones during their adolescent years, or suffer the consequences in a short period of time (4).  

Causation of Behavior Needs Consideration
The basis of the Powerful Bones. Powerful Girls. Campaign is a solid attempt at using age-appropriate tactics to connect with youth, and thus effectively alter their lifestyles for the better. However, as is the problem with numerous public health interventions today, the campaign is missing a key link. The campaign needs to address reasons why girls are not consuming enough calcium and partaking in other bone-healthy activities, not only concentrate on how to build healthy bones. Chances are, those interested in these suggestions for improving their bone health have been raised with health awareness and already have healthy bones. Thus, it is crucial to look at the two most significant variables contributing to the condition, diet and exercise. By understanding why this population of adolescent girls eats healthful, calcium-rich diets, or why they do not, and partake in physical activity, especially weight-bearing activity, or do not, will lead to answers that will ultimately increase of effectiveness of the campaign.

Part 1: Exercise
In a recent campaign from the Irish Society of Chartered Physiotherapists, the importance of weight-bearing exercise in childhood bone growth was shown, which is any exercise where weight is carried through the limbs. Examples of this type of exercise are running, dancing, or brisk walking and examples of low weight-bearing exercises are swimming or riding a bicycle. Weight-bearing exercises utilize the bones, which in turn makes them more dense and ultimately, stronger. Children should engage in approximately 60 minutes of moderate exercise each day, with half of it weight-bearing. However, as Elaine Barker, chartered physiotherapist and chairwoman of the campaign stresses that today’s society prides itself in driving kids everywhere, thus spawning a much less active population (5). This is certainly one of the main culprits in today’s children’s lack of physical activity. And as Nicole Kerr, a health communications specialist at the Centers for Disease Control and Prevention in Atlanta, attests, “We’ve engineered our way out of activity with all these labour-saving devices” (6). This, coupled with more and more physical activity programs being cut to allow more funding for academic classes, is contributing greatly to the overall unhealthy state of our youth. This emphasis on physical activity during and after school has spawned numerous studies. Both emphasize the importance of participating in sports at school, especially during high school, as these participants have a greater chance of staying active into their 30’s than those who do not.

Not all studies are gravely looking at the statistics and simply condemning today’s youth with weak bones and unhealthy lifestyles. A 2007 article published in the Journal of Adolescent Health outlines a study conducted by several research departments at the Waterford Institute of Technology in Waterford, Ireland. The purpose of the study was to investigate the effectiveness of a six-month teacher-led osteogenic physical activity program versus a self-led activity program. With a goal of determining the difference, if any, in effectiveness of the two approaches, this study enlisted 90 sedentary girls age 16 chosen from 300 subjects who were assessed for physical activity across five different schools in southeast Ireland. The participants were then matched randomly to either a teacher-led physical activity program or a self-led physical activity program. Each group engaged in an average of 4 hours of physical activity per week over the intervention period. After one month of participation in the programs, the students were tested for aerobic fitness, bone strength (through bone scans,) and overall physical fitness (7). This study is a very formal example of the basic and widespread understanding of the importance of fitness; however the conclusions drawn from the study were very informative: Previously inactive teenage girls can adhere to an osteogenic activity program whether supervised or directing their own activity. However, the self-led exercise group continued to exercise after the intervention had ended and the teacher-led group did not. This further stresses how crucial it is for youth to develop a self-directed approach to exercise, based on the comparison of success rates from the two different types of exercise. However, the start of this desire for physical fitness is often brought about through important group-led physical activity, such as gym class at school. Thus, funds enabling these programs to continue in our schools are essential to the development of fit behaviors (7).

Another recent study which attests to the importance of fitness classes at schools was that done by the Rady Children’s Hospital in San Diego, CA, and published in a 2008 edition of the Journal of Sports Science and Medicine. This study investigated whether moderate, organized physical activity during the high school years has a positive effect on bone mineral density later in life. In this study, seventy-three 30-35 year old female former high school varsity athletes and sixty-seven self-reported low-activity controls of the same age range completed a women’s health survey and participated in a clinical health evaluation, including a bone scan (8). Aside from the bone scan, the subjects were also evaluated on percentage of body fat, history of amenorrhea, age of menarche, family history of osteoporosis, alcohol consumption while in college, current nutritional intake, frequency of weekly weight training sessions, caloric expenditure, and seasons involved in high school varsity sports. The conclusions drawn from this study emphasize the immense significance of school sports on life-long health. By using the study previously mentioned as a backdrop to the findings in this study, we are able to see the process of developing a fit lifestyle, from involvement in gym class in middle school, through high school sports. It was not only determined that participation in high school sports is associated with greater Bone Mineral Density, but that varsity athletes continue exercise regimes into their thirties at a much more often than those subjects who did not participate in high school sports (8).

Part 2: Nutrition
Aside from the importance of physical activity in healthy bone growth, nutrition must also be considered. In a recent Newsday article entitled, “Milking diet fads makes no bones for young girls,” the author explores the correlation between the previously-established low intake of calcium in adolescent girls and a much broader crisis: the unrealistic desire to obtain a size zero figure. The obsession of thinness in the American culture today has spawned an epidemic of various eating disorders which not only cause calcium deficiencies, but often cause Amenhorrea, which has been proven to decrease bone density. The hazardous goal of extreme thinness is strived towards by the adoption of extreme dieting behaviors. However, new research has found that strict dietary restrictions, such as those used to conform to this stereotype, could significantly increase this population’s risk of osteoporosis. A common trend found in the habits of extreme dieters is the elimination of dairy. This, in turn, deprives the adolescent’s body of calcium, which is essential in the growth of strong bones. Dr. Judith Bryans, the director of The Dairy Council explains: “Adolescence is a critical period for laying the foundation for future bone health as at least 90% of peak bone mass is achieved by 18 years of age” (9). Another issue addressed by Dr. Bryans is the widespread perceived milk-intolerance among young girls. It has become “fashionable” to be lactose intolerant (9), much like the trend of vegetarianism in recent years, as a result of the growing popularity of extreme fad diets. Eliminating one less food group is a mannerism people with eating disorders use in order to eliminate entire groups of food from the food they are “allowed” to eat overall. Interestingly, however, another widespread approach among researchers is to look to practices at school, as has been done with physical activity, to determine changes that can be made to increase calcium consumption. One such study targets school soda machines as the culprit.

In an article published in 2002 in The Toronto Sun, Atlanta’s Nicole Kerr, a communications specialist at the Centers for Disease Control and Prevention, presents her findings from a research project funded by the Dairy Farmers of Ontario. In line with other current research, she too found that girls are not consuming as much calcium as they should, falling short, on average, 500 milligrams of the suggested daily amount, with only 10% of all girls aged 9 to 13 consuming the recommended amount. However, Kerr dove past the mere statistics and postulates in this article that pop is replacing milk as a drink of choice in young people, and thus is partly responsible for calcium deficiency (6). Many schools in both Canada and the United States have contracts with soda companies and, due to the widespread placement of these machines around schools, it is not surprising that two-thirds of all teenage girls drink an average of two cans of soda per day. If we cut back on school soda machines and better advertised the positive effects of low-fat dairy products, it would be a good first step towards the construction of solid nutritional habits amongst our youth (6).

Campaign’s Presentation Needs Age Adjustment
All of the previously mentioned studies attesting to physical activity, dietary habits, and overall health behaviors, have focused on our nation’s youth. However, one of the most inarguable characteristics of being young is wanting to be older. In order to effectively change the behavior of young girls, the campaign needs to alter its presentation from Saturday morning cartoon, to something a little more “grown-up” and desirable to the adolescent through young adult. Chances are, most girls who come across this website while surfing online are way past the age of cartoons anyway! Thus, it is important to look to other studies of the same nature and target audience and analyze their techniques and effectiveness. Unlike the cartoon icons who represent the Powerful Bones. Powerful Girls. Campaign, a bone health campaign funded by the Irish Society of Chartered Physiotherapists, which studied the significance of weight-bearing exercises in the growth of strong bones, enlisted four international rugby players to support their campaign. This 2007 campaign, entitled, The Healthy Bones – A Hop, Skip, and Jump Away, targeted the same age group as the Powerful Bones. Powerful Girls. Campaign, but represented their intervention in a drastically different way. They presented their campaign in a way that utilized the population’s sports icons to relay a message, and who better to preach about the importance of physical fitness and activity than pro athletes? After all, youth look for approval from those they admire, not from their younger sibling’s cartoons (5).

Another way in which public health officials can effectively communicate a message to the youth is by looking at the most prominent and well-supported group behavior theories. By doing this, we may be able to implement the efforts by the proven behavioral patterns represented therein. One of the most effective ways to get people to behave in a particular manner is frame it in an appealing way, based upon the different characteristics of the population at hand. Image is everything in the Framing Theory, but the way in which this image is delivered is what distinctly separates it from the popular Health Belief Model. This theory plays entirely off of emotion, which explains entirely why it is so effective for younger people. Adolescents are bursting with conflicting feelings, emotions, and thoughts (10). Public health aside, if an advertisement, music video, or presidential speech makes a person feel something intensely, it is a success. This theory plays off exactly what the field of public health is lacking, too little emotion and too many statistics. Emotion is an entity that is common in all human beings. Thus, it is no surprise that a theory whose success is based upon resonation within a large group of people finds success by targeting such an innate aspect of humanity. The same concept is at the core of many of the social, cultural, and environmental theories in public health, particularly the Social Network Theory. This idea is based upon the notion that the most important determinant in the behavior of certain populations is not the specific or individual characteristics of a person, but rather the relationships he or she holds with others in the same group (10). Concerning health, these networks play a key role in determining whether an individual partakes in risky behavior or not (By paying close attention to the way in which the website frames the weak-bones epidemic, as well as further considering the important relationships amidst its target population, the Powerful Bones. Powerful Girls. Campaign has the potential to easily become much more appealing to young girls and consequently have a greater impact (10).

Advertisement and Promotion of Campaign
Every genuine public health intervention or campaign hopes to succeed by effectively spreading a belief, lesson, or message. There is no doubt that the National Bone Health Campaign created the Powerful Bones. Powerful Girls. Campaign with hopes for success. However, it is undeniable that more needs to be done in the way of advertising and promotion of the campaign. Sure, some people are apt to come across the website while casually playing online, but it would be extreme luck if these users were indeed female adolescents wondering how to make their bones stronger. The campaign needs to take a different approach to their advertising campaign. Here, it would be useful for creators to consider the Social Marketing Theory, which stresses the importance of applying a marketing perspective to the public health perspective. As in the corporate world, we need to figure out a successful way to sell a product to the consumer, in this case strong bones. Through the consideration of innumerable studies about you people’s attitudes towards diet and exercise, we have already answered the most difficult question, what does this group of people want? It is now time to frame the idea of strong, healthy bones by understanding the relationships between young females, as expressed in the Social Network Theory, and spread the word of the campaign in a more active way. It may be useful for the creators of the Powerful Bones. Powerful Girls. Campaign to enlist the help of pre-established health and pharmaceutical companies. McNeil Nutritionals, LLC, for instance, is the maker of an immensely popular chocolate calcium supplement named Viactiv. Attaching this well-established brand to the website provides Viactiv free advertising and offers the campaign validity (11). This affiliation would also help to promote the similar lifestyle guidelines that the company preaches on its website. If this relationship came to fruition, the two campaigns would have built a powerful connection and strong outlet for the exchange of information, ideas, and even clientele.

The Powerful Bones. Powerful Girls. Campaign has the potential to be very effective in resonating with young girls and helping them to realize how important proper nutrition and an active lifestyle are to their overall health. However, this broad goal cannot be accomplished through the campaign’s current format and approach. It must be implemented to further incorporate social and behavioral theories. By examining what leads adolescent girls to live the way they do, considering physical activity and nutrition equally, effective changes can be made to improve all aspects of the effort. With women four times more likely than men to develop osteoporosis, and nearly 8 million women plagued with the disease, there is no denying the gravity of the epidemic. The hope lies in the recent widespread body of research that has been conducted worldwide in an effort to better understand just why the problem has developed with such velocity (12).

1. Szadkowski, Joe. (2001, December 9). Girl Power Starts with Strong Bones. The Washington Times, p. D5
2. Department of Health and Human Services’ Office on Women’s Health. (2001). Powerful Bones. Powerful Girls. The National Bone Health Campaign. February 1, 2008, from:
3. Anderson, John J.B. Exercise, dietary calcium, and bone gain in girls and young adult women. Journal of Bone and Mineral Research. 2000; 15:8.
4. Associated Press. (2007, November 28.) A bone to pick with the nation’s kids. Newsday, p. A11
5. Hofman, Helene. (2007, March 6). Weight-bearing exercises crucial for children. The Irish Times, p. 1.
6. Linton, Marilyn. (2002, June 2). Girls Just Wanna…Have Junk Food; Pre-Teeners Need to be Aware of Calcium Intake to Prevent Osteoporosis. The Toronto Sun, p. 38.
7. Murphy, Naimh, Ph.D. Physical activity for bone health in inactive teenage girls: is a supervised, teacher-led program or self-led program best? Journal of Adolescent Health. 2006; 4:508-514.
8. Rady’s Children’s Hospital. Female high-school varsity athletics: an opportunity to improve bone mineral density. Journal of Sports Science and Medicine. 2008 Mar 18.
9. Brindley, Madeleine. (2007, October 1). Milking diet fads makes no bones for young girls. The Western Mail, p. 24
10. Edberg, Mark. (2007). Social, Cultural, and Environmental Theories (Part I) in Essentials of Health Behavior, Social and Behavioral Theory in Public Health (35-38, 56-58). Sudbury: Jones and Bartlett Publishers.
11. McNeil Nutritionals, LLC. (2002). Viactiv, The Nutrition Women Want! March 2, 2008, from:
12. Centers for Disease Control & Prevention. (2004, June 25). Osteoporosis: website helps parents raise strong daughters. Drug Week, p. 444.

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