Challenging Dogma - Spring 2008

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

Sunday, April 20, 2008

SHAPEDOWN- How A Successful Program Can Fail By Not Considering Socioeconomic Barriers And The Transtheortetical Model - Michele Osbourne

The increased incidence of overweight or obese children has become a major concern of pediatricians, parents, and policy makers in the United States (1). In the years 2003-2004, The National Health and Nutrition Examination Survey by the Centers for Disease Control reported an estimated 17 percent of children and adolescents ages 2-19 years were overweight. The percentage of children overweight increased from 7.2 to 13.9% among 2-5 year olds and from 11 to 19% among 6-11 year olds between 1988-94 and 2003-2004. For adolescents aged 12-19, overweight increased from 11 to 17% during the same years (2).

Overweight is classified by using body mass index (BMI) which is a measurement of weight compared to height. Children with a BMI between the 85th and 94th percentile by age and sex are considered at risk of being overweight. Children with a BMI greater than or equal to the 95th percentile are considered to be overweight. The terms overweight and obesity are often used interchangeably; however, obesity is a measurement of excess fat compared to lean muscle mass. Although there is not a perfect relationship between body fat and body heaviness, there is a good correlation (3).

Overweight and obese children are at higher risk for health problems such as Type II diabetes, coronary heart disease, pediatric hypertension, high cholesterol, sleep apnea, and bone and joint problems. They are also at greater risk for social and psychological problems such as stigmatization and poor self esteem (4).

SHAPEDOWN is a clinically based program designed for overweight and obese children and adolescents along with their families to promote lifestyle changes that lead to healthy weight loss. The program includes contributions from nutrition, exercise physiology, endocrinology, psychology, family therapy, adolescent medicine, family medicine and behavioral and developmental pediatrics. SHAPEDOWN is a family oriented program. It supports families in creating an active lifestyle and a healthy but not depriving diet, focusing on educating and changing the behaviors of the family instead of singling out one member. Research has repeatedly shown that without a family approach, all treatments - diet, exercise, behavioral approaches - are ineffective. “It is only by building on the strength of the family that child obesity programs have their long lasting, beneficial effect on weight” (5).

The SHAPEDOWN program was implemented at two local community hospitals in the towns of Medford, MA. and Everett, MA. The program was not successful, because the promoting facility failed to recognize the socioeconomic barriers and their effects on people’s ability to make lifestyle behavior changes. The hospital did not consider the work schedules or financial status of the population being targeted. This paper will discuss how the disregard of these factors prevented families from participating in this public health program and how low participation led to the eventual termination of the program.

Transtheoretical Model
In order to successfully change people’s health behaviors, the implementers of a public health program such as SHAPEDOWN need to understand how people modify a negative behavior or acquire a positive one. Prochaska and DiClemente developed the Transtheoretical Model (TTM), which describes how individuals move through a series of stages—pre-contemplation, contemplation, preparation, action, maintenance, and termination when adopting healthy behaviors or modifying or doing away with unhealthy behaviors (6). There are a number of change processes that can contribute to the individuals moving from one stage to another. Examples of these include consciousness-raising: increasing awareness through information, education, and personal feedback about the healthy behavior; self-reevaluation: realizing that the healthy behavior is an important part of who they are and want to be; and reinforcement management: increasing the rewards that come from positive behavior and reducing those that come from negative behavior. These change processes along with increasing self efficacy, confidence that they can make and maintain change, should be used as guides for interventions intended to progress people through each of the stages of change until the behavior change is fully adopted and has become a part of their lifestyle (7)(8)(9). Just as there are processes that can contribute to moving through the stages, there are also barriers that may prevent movement from one stage to the next. These barriers need to be recognized and addressed for the program to be successful.

Argument 1
The promoting facility’s failure to provide a variety of class days and times to working parents was a major barrier in moving families from the Contemplation Stage to the Preparation Stage. The Contemplation Stage of the TTM model involves a decisional balance of weighing the pros and cons of changing the health behavior (7). Families who were interested in finding out more about SHAPEDOWN attended an informational session to learn about the program and consider whether or not they wanted to make some lifestyle changes. One of the requirements of the SHAPEDOWN program was that both parents (if both were involved in raising the child) attend all classes. The target population was made up of families with working parents. Many parents could not commit to the limited classes, and therefore, their families were unable to participate. A low number of participants contributed to the program’s termination.

Argument 2
The facility implementing SHAPEDOWN did not recognize the financial commitment required by the program as a barrier to moving families from the Preparation Stage to the Action Stage. In the Preparation Stage, there is intention or preparation to act soon. There is a plan of action (7). Some families decided that they were able and willing to make the commitment to the SHAPEDOWN program; they were getting ready to act. However, most families were not covered by insurance and could not afford to pay for the program. The intervention was not successful because many children and adolescents were not able to participate. The financial barrier made the program inaccessible for many families and thereby contributed to its failure.

Argument 3
Another contributing barrier to the failure of SHAPEDOWN was the restrictions placed by the promoting facility which resulted in the cancellation of many classes. The class cancellations prevented families from moving through the Action Stage and to the Maintenance Stage. In the Action Stage, there has been recent action towards the behavior change (8). Some families were willing and able to make the commitment and pay for the SHAPEDOWN program. They acted by signing up, paying, and in some cases attending the first class. Sessions that did not have at least eight families participating were cancelled. Many motivated families who were “ready to act” on changing their behaviors, were left discouraged, disappointed, and angry. The inability of the facility to invest in SHAPEDOWN by allowing the program to run with smaller groups, develop a success rate, and eventually generate more participation contributed to the program failing and ultimately resulted in its termination.

The failure of the program lies in the facility’s failure to recognize socioeconomic barriers and their effects on people’s ability to move through the different stages of the Transtheoretical Model to make behavioral changes. The SHAPEDOWN program did have some families who made it through the three stages discussed above. Most all of them had short term success with their relative weight loss. However, the program never developed a Maintenance Stage. In the Maintenance Stage, significant change has been made in behavior and the focus is on sustaining the behavior change (7). Long term results were not tracked due to the discontinuation of the program. By providing a variety of class days and times and using alternative funding options such as a grant or community sponsors to cover some of the cost, more families would have been able to participate. Had the factors preventing behavior change been addressed, the program would likely have been more successful.

Paxson, C., Donahue, E., Orleans, C., Grisso, J. Introducing the Issue. Future of Children, Vol. 16/No. 1/Spring 2006; 3. Available at
National Center for Health Statistics...Monitoring the Nation’s Health. Prevalence of Overweight Among Children and Adolescents: United States 2003-2004. Hyattsville, MD. US Department of Health and Human Services, Centers for Disease Control and Prevention, January 30, 2007. Available at
Crawford, P., Mitchell, R., Ikeda, J., Childhood Overweight, A Fact Sheet for Professionals. University of California Berkley, Cooperative Extension, Department of Nutrition Services January 2000; 1. Available at
The National Institute of Health. Word on Health, Childhood Obesity on the Rise. Bethesda, Maryland: The National Institute of Health. Accessed March 31, 2008.
Shapedown. Shapedown. San Anselmo, CA. Available at Accessed on March 31, 2008.
Cancer Prevention Research Center. Detailed Overview of the Transtheoretical Model. University of Rhode Island; Cancer Prevention Research Center. Available at Accessed on March 31, 2008.
Center for Health Communications Research. Health Behavior Theories. University of Michigan. Center for Health Communications Research. Available at: Accessed on March 31, 2008.
Edberg M. Essentials of Health Behavior, Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
Oregon Science and Health University. Pro-Change Behavior Systems. Oregon: Oregon Science and Health University. Available at Updated and accessed March 2008.

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