Challenging Dogma - Spring 2008

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

Wednesday, April 23, 2008

The “WE CAN!” Campaign Has Missed The Target – Gayle Salomon

The increasing prevalence of obesity in children is a significant and alarming public health problem. During the last 20 years there has been a dramatic increase of overweight and obesity in the United States. In 2006, according to the Centers for Disease Control and Prevention, only four states had a prevalence of obesity less than 20%, twenty-two states had a prevalence equal or greater than 25%; two of these states had a prevalence of obesity equal to or greater than 30% (1). In 1971, the National Health and Nutrition Examination Survey (NHANES) was started to document the growing prevalence of overweight and obesity across different age groups. Analysis of the 2003-2004 NHANES shows that an estimated 17.1% of children aged 2-19 years old in the United States were overweight (2). In comparison with the original NHANES data from 1971-1974 the 2003-2004 data showed a significant increase of prevalence across all age groups: 8.9% for ages 2-5 years, 14.8% for ages 6-11 years and 11.3% for ages 12-19 years (1,2). The consequences of childhood obesity are both short-term and long-term, differing in severity from mild to potentially life-threatening (3). In the short-term, health problems such as asthma, Type 2 Diabetes Mellitus, and sleep apnea (3-7) are directly associated with obesity. Additionally, there are social and psychological problems associated with childhood obesity. For example, teasing and isolation from the other children, low self-esteem, depression, loneliness, sadness, nervousness, and poor body image (4, 7, 8). In the long-term, children who were obese have a greater chance of becoming obese adults (5, 9, 10) and an increased risk of cardiovascular disease through increased risk of hypertension, high cholesterol, elevated triglycerides, and elevated fasting insulin levels. In addition, obese adults who were obese children have a lower self-efficacy to lose the weight that they have had all their lives (10-12). Long-term costs associated with obesity are also of concern for the individual and society in general (1). There is a need for public health interventions targeting children at a young age to help with both the short-term and the long-term problems associated with childhood obesity (7).
Prevention of childhood obesity is beginning to be addressed as an important public health policy in the United States. Intervention programs are being created to try and decrease the amount of children suffering from this epidemic. The Ways to Enhance Children’s Activity and Nutrition (We Can!) Campaign is an example of such a program. We Can! is a collaboration of the National Heart, Lung, and Blood Institute, the National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Child Health and Human Development, and the National Cancer Institute (13). It is a national education program designed for parents and caregivers to help children ages 8-13 stay at a healthy weight (13). The campaign targets parents and families as a primary group for influencing the youth audience (13). The program focuses on three important behaviors: improved food choices, increased physical activity, and reduced screen time (13). The We Can! Campaign is a website that provides families and communities with helpful resources including practical tips and handouts. It also offers community groups and health professionals resources to implement programs and fun activities for parents and youth in communities around the country (13). The We Can! Campaign has significantly missed the target by attempting to influence the wrong population, neglecting to target all sources of influence on children, and by not properly creating awareness of their program.
We Can! Targets the Wrong Population to Achieve Their Goals
The We Can! program targets children aged 8-13. We Can! needs to expand their age range to include younger children. Feeding skills are closely linked to Piaget’s Theory of Child Psychology and Development (7). Jean Piaget’s theory states that children actively construct their understanding of the world and go through four stages of cognitive development: sensorimotor stage (birth – 2 years), preoperational stage (2-7 years), concrete operational stage (7-11 years), and formal operational stage (11 years and beyond) (7, 14). During the preoperational stage food is described by color, shape, and quantity, but the child has only a limited ability to classify food into groups (7). Foods tend to be categorized into “like” and “don’t like” as well as “good for you,” but the reasons they are “good for you” are unknown or mistaken (7). During the concrete operations stage, mealtimes take on a social significance to children and can influence their eating patterns (7). Unrealistic expectations for a child’s mealtime manners, arguments, and other emotional stress can have a negative effect (7). Moreover, meals that are rushed create a hectic atmosphere and reinforce the tendency to eat too fast (7). In the formal operations stage, the expanding environment around the child increases the opportunities for and the influences on food selection. Additionally, the conflicts in making food choices may be realized; that is, knowledge of the nutritious value of foods may conflict with preferences and non-nutritive influences (7). Therefore interventions aimed at children of all ages, including those younger than age 8, can try and influence children’s perception of healthy foods as something they like (7, 15). Aside from Piaget’s Theory of Child Psychology and Development, differences shown through data from NHANES support the idea that children are becoming obese at a younger age (16). Data compiled from NHANES 1971-1974 and 2004-2005 shows a larger increase in obesity among children aged 2-11 (23.7%) than children aged 12-19 (11.3%) (16). The overlap of the 8-13 age range within these categories should be expanded and started at a younger age.
Along with targeting the wrong population of children, We Can! sites are located and concentrated in the wrong places. Based on the U.S. Obesity trends from 1985-2006, in 2006 the most concentrated areas of obesity are in Mississippi and West Virginia followed by states such as Texas, Oklahoma, Louisiana and Arkansas (1). Mississippi and West Virginia had a prevalence of obesity equal to or greater than 30% (1). In general, the south has the highest concentrations of obesity in the country, however, We Can! sites are more concentrated in the northeast (1,13). West Virginia and Mississippi, the states that have the most concentrated obesity rates have the least amount of We Can! sites (13). West Virginia has two sites throughout the entire state and Mississippi has four (13). We Can! needs to refocus their efforts on the areas of the country that have the highest prevalence of obesity in order to make a larger impact.
The Primary Influence on Children Aged 8-13 is Not Their Parents, But Their Peers
As previously mentioned, the We Can! program targets children through their parents and communities (13). Although parents are a significant influence on children aged 8-13, they are not the primary influence (17). By not aiming their campaign at the children themselves, the We Can! program is missing out on many opportunities to influence the targeted population. For toddlers and preschool children the primary influence is the family (17-20). Children aged 8-13 spend more time in school, at after-school activities and with friends than they spend with their parents (7). The influence of peers and significant adults such as teachers, coaches, or sports idols increases throughout adolescents (7). Parents begin to have less of an impact on the food choices when the children begin to purchase and make their own decisions about food (7). These children are busier than those generations before them and have less time to eat. Therefore, they often choose fast foods, foods from vending machines, and skip breakfast (7, 16, 20). They also have less money for these purchases, which causes them to choose cheaper, usually less healthy, options (7). School aged children and adolescents strive to be accepted by their peers and do what their friends are doing as well as their parents, which is explained by Social Network Theory (7, 19-21). Social Network Theory states that inter- and intra-individual relationships, as well as the nature of those relationships, are important influences of beliefs and behavior (21). These networks can play an important role in whether someone acts in a way that is either risky or good for their health, what information someone is exposed to about health, and what kinds of social support a person has available to them (21). In a recent study, children were more likely to report more intense physical activity when in the company of peers or close friends than family (22). Overweight children reported greater physical activity when in the presence of peers, compared to family, than did lean children (22). Both these findings confirm the idea that peers are a great influence on overweight children and should be taken into consideration when formulating a public health campaign such as We Can!
The We Can! campaign does not directly aim their intervention at the children themselves. This is extremely shortsighted on their part because the children need motivation to make the changes to their lifestyle (7). The program assumes that Social Learning Theory, which states that children will do what they have seen modeled by their parents is the correct model to follow for their intervention, however they are wrong (21-23). The key principle to this theory is that children learn by observing and vicarious learning in their immediate environment, for example, their parents and family (23). As previously mentioned, the children are being influenced by their peers, teachers and coaches as well as their family (8). This can cause conflicting ideas of what is good and bad for their health if each influential person is stressing different behaviors. The Social Learning Theory assumption may hold true for parents who model good behavior, however many times parents are not perfect and they model behaviors that children should not be learning (24-26). The risk of becoming obese is greatest among children who have obese parents due possibly to parental modeling of both eating and exercise behaviors (27-30). Therefore, if the parents do not care about making a lifestyle change for themselves and send contradictory messages to their children than they are doing themselves, the modeling is null and void.
We Can! Uses the Wrong Approach to Creating Awareness and Change
We Can! runs their campaign through a website in which parents, community groups and professionals can go online and get handouts, tips, and resources for their children (13). It allows people to start their own We Can! sites throughout the country to try and combat obesity (13). However, this approach is ineffective because there is no way for people to find out about the program through media or advertising. Part of their plan is to decrease television screen time because studies have directly linked the amount of television screen with obesity risk (7, 13, 31-35). By not using television as a way of reaching out to children, they are missing a large portion of their target population. Television and magazines have a greater influence on children’s eating habits than any other form of mass media (7). Preschool and school-aged children watch between 23-27 hours of television per week (7, 35). According to the American Academy of Pediatrics (AAP), children in the United States see 40,000 commercials a year and half of them advertise food (7, 35). Although We Can! does not want to promote television screen time, these children are watching television and the best way to influence them is by commercials (7). By doing this, way can combat the commercials encouraging children to eat unhealthy empty-calorie foods (35).
Since We Can! does not market their program in any way, parents do not hear about the program. Unless someone in a community has already started a We Can! site, there is no way to learn about the program and get involved. There are great resources and tips on the website but there is no marketing campaign to let people know that they are there. Other public health campaigns use relevant messages disseminated through existing community networks such as, such as beauty parlors, health centers and public schools (36). The more ways that We Can! creates awareness of their program, the more successful it will become (36). Thus, without a marketing strategy, We Can! is not effective.
The rates of obesity in the United States are increasing exponentially and have no indication of slowing down anytime soon (1-3). The only way to try and stop this epidemic is to start targeting children at a younger age to instill in them the values and knowledge to be healthy (2, 3, 7, 13, 16). Obesity and overweight have many consequences for the individual and society in general (3). For the individual consequences can include health problems, psychological and social problems lasting from childhood throughout life (3-6). Society has a price to pay for obese individuals as well. Financially, more than $90 billion dollars are spent per year on obesity related medical costs and costs to employers for absenteeism, life insurance, retraining, and disability costs (1, 37).
The We Can! program has constructed a good base to start their intervention however, many changes need to be made in order for it to be a successful program. The population that We Can! targets is very narrow in scope and needs to be expanded, to target children younger than 8 years old. They need to recruit children that are good role models, perhaps a child celebrity, to help model the behaviors set forth by the program. More We Can! sites need to be opened in areas where there is a higher prevalence of obesity to help combat it. In addition, the marketing plan of We Can! needs to be rethought to include ways of actively creating traffic to their website. For example, they should use mass media such as television and magazines to spread awareness.
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