Challenging Dogma - Spring 2008

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

Monday, April 21, 2008

Why Interventions for Adolescent Overweight and Obesity Are Not Effective - Junta Yamamichi

In the United States, 17% of children and adolescents are currently overweight (1). Three times as many children and adolescents are overweight, compared to 1980 (1). Childhood obesity is commonly measured by body mass index (BMI), or weight to squared height ratio, of greater than the gender- and age-specific 95th percentile based on the revised Growth Charts for the United States by Centers for Disease Control and Prevention (1). Overweight accounts for approximately 365,000 deaths in the United States every year (2, 3). Overweight in childhood and adolescents is strongly associated with obesity in adulthood (4). The estimates of causes of death shows that overweight is the second leading and preventable cause of death (2). Therefore, in the national initiative, Healthy People 2010 report, the goal for reducing overweight and obesity in children and adolescents is set at 5% prevalence in 2010, compared with 11% as the baseline prevalence during 1988-1984 (5).

A recent review revealed the ineffectiveness of various school-based interventions focused on adolescent obesity (6). Most of the interventions focused on individual level behavioral changes, targeting both eating behaviors and physical activity. But some interventions focused on only one factor such as reducing TV watching, limiting the drinking of carbonated drinks, or increasing physical education in school (6). These interventions achieved only minimal changes in behaviors and changes in BMI were inconsistent (6).

This critique paper will analyze the possible limitations of many interventions from the socio-environmental point of view. Most of current interventions have focused chiefly on individual level behavioral change approaches and few have tried to address broader social and environmental level changes.

Lack of supports from neighbors

Adolescents have inadequate social autonomy or social competence because they can only accept the social constructs as they are around them (7). Consequently, adolescents’ behaviors are strongly influenced by their social environment such as adult neighbors. Therefore, adolescents might need appropriate supports from adult neighbors to reduce unhealthy behaviors associated with overweight or obesity.

One example of supports from adult neighbors is collective efficacy, positive and active supports from community members to take care of each other. The collective efficacy contributes to establish favorable environment especially for younger generations (8). A recent study showed an association of collective efficacy with following outcomes related obesity: BMI, risk for overweight and overweight status. (8). Adolescents living in neighborhood with high collective efficacy may feel more social supports, which will foster their healthy behaviors (8). Current interventions do not focus on collective efficacy and they ignore the role that social support plays in healthy behaviors.

As well as the whole neighborhood social supports, many interventions have lacked of involvement of family members. A study of physical activity in children and adolescents revealed strong and positive influences towards activity by family members, such as parents and siblings (9). In this intervention authors achieved success in increasing obese adolescents’ activity during study. However, the activity levels were not maintained because of the lack of engagement by family members after study. Another study also identified social supports from parents, teachers, and friends as one of the two strongest factors in physical activity (10). Modeling and social support in the adolescents’ home environment are important determinants for long-term maintenance of physical activity to reduce overweight (9). Thus, interventions that ignore continuous supports from family members or adult neighbors are not likely to have successful results to reduce overweight and obesity.

Emphasis on blaming individual behaviors

Television programs are frequently used to decrease overweight and obesity among adolescents (11). Individual behaviors such as poor nutrition and physical inactivity are represented in television programs. Mass media, including television programs, establish social norms, which dictate that the causes of overweight and obesity are individual level factors not social environmental factors. For example, Australian researchers analyzed contents of television news about overweight and obesity aired by five New South Wales television channels (12). Most television programs framed obesity as a problem to be solved by individual nutritional habit, physical exercise and medical treatments, not by social and environmental efforts.

The problem with focusing on individual factors in mass media is that adolescents will feel guilty because they are blamed for their individual behaviors. Eventually, such blaming leads to an adverse effect on them such as depression or stress through stigmatizing them (13). Several studies revealed that emotion and stress related diet habits lead to overeating (14). People change their eating habits to relieve stress or depression (14). This emotional relationship between depression and poor eating habits can make overweight status worse. Especially for early life adolescents, this bad cycle can turn their overweight into life long chronic diseases (14). As shown above, interventions only focusing on individual behavior changes may induce adolescents’ depression or stress, which eventually leads to further overweight and obesity.

Influence of school community

Current interventions for adolescent overweight and obesity ignore the influence of school settings on social factors. Interactions among school friends emotionally affect adolescents’ eating habits. For adolescents, school settings are very important determinants for overweight because they are developing both physically and psychologically.

As an illustration, the effect of school popularity on girls’ weight was recently studied prospectively (15). A student’s subjective perceptions of her social status within her school played a role in controlling her weight for a long term. This study suggested that relationship between low Subjective Social Status in school community and increase of BMI is significant.

In addition to the self perceptions of the social status, a public high school study in New England found that lower peer-perceived objective popularity significantly associated with heavier body shapes among adolescents (16). Moreover, adolescents have especially increased concerns and dissatisfaction of their body images in their life. Therefore, peers’ perceptions are important and inevitable points of intervention (16).

Conventional interventions do not consider the effect of school community on adolescents’ behavior, particularly adolescents’ social status within their school. Consequently, they do not include the importance of this social construct in controlling overweight and obesity in adolescents.


As mentioned in this critique paper, there are many evidences which support that social and environmental constructs are more effective points of view in adolescents’ obesity research and intervention than individual level behaviors. First, adult neighbors can support adolescent healthy behaviors. Second, sociocultural factors induce emotional changes that lead to overweight. Third, adolescents’ low social status perception in their school is a driving force toward overweight and obesity. Nevertheless, most intervenient studies have relied mainly on individual risk factors because these factors are viewed as proximal causes of overweight and obesity.

To understand more profoundly the causes of overweight or obesity, broader social and environmental perspectives may be necessary for public health practitioners. If public health practitioners continue to emphasize individual level behaviors, they will not approach to effective interventions to reduce overweight and obesity in adolescence.

As a whole, these arguments suggest that public health interventions in obesity should not focus only on individual diet and physical activity but also on broader context of socio-environmental factors, such as social support, emotion, and social status.


1. National Center for Health Statistics, Centers for Disease Control and Prevention. Prevalence of Overweight Among Children and Adolescents: United States, 2003-2004. Hyattsville, MD: Centers for Disease Control and Prevention.

2. Mokdad AH et al. Actual Causes of Death in the United States, 2000. JAMA 2004; 291: 1238-1245.

3. Mokdad AH et al. Correction: Actual Causes of Death in the United States, 2000. JAMA 2005; 293: 293.

4. Whitaker RC et al. Predicting Obesity in Young Adulthood from Childhood and Parental Obesity. N. Engl. J. Med. 1997; 337: 869–873.

5. Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services. Healthy People 2010. Rockville, MD: Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services.

6. Sharma M. School-based interventions for childhood and adolescent obesity. Obes. Rev. 2006; 7: 261-269.

7. Welsh JA et al. Social Competence. In: Encyclopedia of Childhood and Adolescence. San Francisco, CA: CNET Networks, Inc..

8. Cohen DA et al. Collective efficacy and obesity: The potential influence of social factors on health. Soc. Sci. Med. 2006; 62: 769-778.

9. Deforche B et al. Changes in physical activity and psychosocial determinants of physical activity in children and adolescents treated for obesity. Patient Educ. Couns. 2004; 55: 407-415.

10. Neumark-Sztainer D et al. Factors Associated With Changes in Physical Activity. Arch. Pediatr. Adolesc. Med. 2003; 157: 803-810.

11. Federal Communications Commission. Task Force on Media & Childhood Obesity. Washington, DC: Federal Communications Commission.

12. Bonfiglioli CMF et al. Choice and voice: obesity debates in television news. Med. J. Aust. 2007; 187: 442-445.

13. Schwartz MB et al. Childhood obesity: a societal problem to solve. Obes. Rev. 2003; 4: 57–71.

14. Ozier AD et al. Overweight and Obesity Are Associated with Emotion- and Stress-Related Eating as Measured by the Eating and Appraisal Due to Emotions and Stress Questionnaire. J. Am. Diet. Assoc. 2008; 108: 49-56.

15. Lemeshow AR et al. Subjective Social Status in the School and Change in Adiposity in Female Adolescents. Arch. Pediatr. Adolesc. Med. 2008; 162: 23-28.

16. Wang SS et al. Adolescent Girls’ and Boys’ Weight-Related Health Behaviors and Cognitions: Associations With Reputation- and Preference-Based Peer Status. Health Psychol. 2006; 25: 658-663.

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