The SunSmart Skin Cancer Campaign: An Intervention That Fails To Recognize Social And Behavioral Components – Deep Patadia

Over the last two decades, the rates of skin cancer have been increasing. As a result, over 90% of skin cancers are caused by sun exposure (1). One in five Americans and one in three Caucasians will develop skin cancer during the course of their lifetime (2). Moreover, research from the American Cancer Society suggests that more than twenty people die each from skin cancer (3).
There exist three types of skin cancers: squamous cell carcinoma, basal cell carcinoma, and melanoma. Non-melanoma (or squamous cell and basal cell carcinomas) is the most common; however melanoma skin cancer is the most lethal. In 2004, the total direct cost associated with the treatment of melanoma amounted $291 million, which included office visits, hospital inpatient and outpatient treatment, prescription drugs, and emergency room treatment. On the flip side, the cost of non-melanoma skin cancer during that year was much higher, totaling $1.5 billion (4).
In an attempt to raise awareness and practice safe habits with regards to excess exposure to the sun, The Cancer Council Victoria launched the SunSMART campaign in 1988. Their goals involve reducing the prevalence of skin cancer, decreasing the mortality rate, and assessing baseline levels of UV radiation awareness to the public with regards to all types of skin cancer. Multiple countries such as the United States, Great Britain, and Australia have taken part in this program. The program proposes a five-letter acronym: S.M.A.R.T.:
Spending time in the shade between 11am and 3pm
Making sure you never burn
Aiming to cover up with a t-shirt, hat, and sunglasses
Remembering to take extra care with children
Then using factor 15+ sunscreen (5)

This is not an effective acronym because it is not well thought out nor does it consider social and behavioral standards carried out in society. The SunSMART campaign lacks credibility as a practical public health intervention because it is too age-specific, violates the social expectations theory, and disregards occupational and nutritional consequences.
Age-Specificity
SunSMART proposes to take special care of children. The reason for this is that one sunburn in childhood more than doubles the chances of a person developing skin cancer later in their life (6). While it is important to target these issues towards younger individuals, it is also equally as necessary to include adults.
This program fails to direct any attention towards the adolescent and adult population, skewing their overall message. Skin cancer is a progressive disease and will develop later in life, where more than 90% of skin cancers cases are attributed to those over 40 years of age (7). Less than 0.1% of children acquire skin cancer, predominantly because skin cancer is a progressive disease (8). However, this program’s intention in preventing skin cancer in the long run is contradicted by the research that claims men and women born in 1970, now in their mid-30s, are being diagnosed with melanoma at the same rate as people who were born in 1930 and didn't develop melanoma until their 50s (9). Thus, the age of incidence of skin cancer is occurring much earlier than it has been in the past and protecting children is not sufficient enough.
Though the incidence of obtaining skin cancer decreases if one is protected from the sun as a child, it is not adequate considering that the skin cancer latency period is narrowing and that there should be more of an effort to target the older generation. If SunSMART were more comprehensive in their program’s protocol by expanding their age-window, it would raise awareness to individuals off all ages, fulfilling their ultimate aim to reduce the prevalence and mortalities associated with skin cancers.
History, Beaches, and Social Norms
Culturally, a skin tan is viewed as attractive, which dated back to the time of the end of World War II. During this time, the middle class citizen got more time and money to spend on leisurely activities due to the economic boom. As a result, vacationing became a standard practice, especially going to tropic areas. Thus a socioeconomic shift occurred, where dark and tanned skin (usually of a lower-economic status) labor worker transformed into a sign of a well-cultured and wealthy individual that enjoyed life at beaches, pools, barbeques, and exotic vacations, and dinner parties. It also became an indication of health and strength as the bodybuilding and fitness industries vastly promoted tanning to highlight muscle tone and definition (10).
Sun tanning is acquired through skin exposure to UV rays from the sun. The greatest exposure to UV rays for a majority of the population occurs on shores and beaches, where over 50% of people in these locations do not wear hats, large sunglasses, or sufficient clothing necessary to protect against sunlight (7). SunSMART urges individuals to make sure to stay covered up, which violates the Social Expectations Theory and Social Learning Theory. The Social Expectations Theory suggests that social norms affect an individual’s expectations while the Social Learning Theory states that individuals model what they see (11,12).
It is socially acceptable and expected for individual to go to a beach in order to relax and be minimally clothed to engage in sun bathing. However, it would be socially unfavorable for an individual to be in an environment, such as a beach, in which he or she is fully clothed. According to Miles’ study, 50.7% people feel a suntan makes them look more attractive and 66.3% feel a suntan makes them look healthier (7). According to the Social Expectations Theory and Social Learning Theory, if an individual is in an environment where the population wears minimal clothing, they will be inclined to behavior almost synonymously.
Violation of the Social Expectations Theory and Social Learning Theory could lead to various effects for the individual. One may feel ostracized, embarrassed, neglected, or simply out of place. This could lead to lead various psychological affects, such as neglect, loss of self-esteem, or in the extreme case, depression (9).
Thus, SunSMART does not take into account the violation of the Social Expectation Theory or Social Learning Theory with regards to beaches and other outdoor recreational areas, places where UV rays are most prevalent. Failure to address these social and cultural issues makes this intervention’s goals even more difficult to obtain, an angle at which SunSMART neglected to address.

Occupation, Race, and Vitamin D
It is well understood that sunlight is the most efficient way to absorb vitamin D. This vitamin D is an essential vitamin protects against osteoporosis, heart disease, cancers, diabetes, osteomalacia, and rickets (13). SunSMART stresses to avoid the sun as much as possible between the hours of 11am and 3pm. However, according to Michael Holick’s study, the greatest amount of vitamin D is absorbed between noon and 4pm (13). To avoid these particular times could be detrimental to an individual’s health in the long run because these are periods at which the greatest amount of vitamin D can be absorbed. The economic burden for the nation of chronic disease due to inadequate vitamin D is estimated at $25–36 billion- a significant amount of money spent on a deficiency that can be easily addressed (14).
In response to SunSMART’s lack of consideration for vitamin D, this campaign just recently suggested that people can supplement themselves with vitamin D by eating eggs, fatty fish, and liver oils (15). However, this diet is not pertinent to vegetarians, a large portion of the population. Various individuals and communities do not eat meat or eggs due to religious or ethical reasons. In a sense, SunSMART is asking to these people to go against their principles and morals to absorb vitamin D into their diets. As a result, most individuals would not eat eggs, fish, or liver oils to obtain adequate amount of vitamin D. Thus, rather than making the program more comprehensive, SunSMART can now only be attributed to non-vegetarians, failing to address eating habits of various communities.
The 11am to 3pm time restriction also affects the portion of individuals that work outdoors. Over 40% of the working class in the United States works outdoors, in which over 85% of these people work between 11am and 3pm, the time where SunSMART advises individuals to avoid (16). This restriction fails to address the issue to the majority of the outdoor working class. If put in this predicament, an individual will choose to work outdoors rather than be “at risk” for acquiring skin cancer. If one does not to work out doors, it could potentially mean a reduction in wages or getting fired by their employer. Most individuals will do what it takes to be financially stable, whether it means involves buying food to eat, supporting the family, or having heat under a roof. Most American’s would choose their job over not working long hours outdoors to prevent skin cancer because of the economic advantage. Thus, SunSMART does not take account for the occupational risks their program has on the outdoor working force.
In addition to the outdoor working class in America, 64% of workers are African-American (17). Those with darker skin are less likely to get skin cancer because they absorb less UV light than light-skinned people (13). Thus, darker-skinned individuals need to stay in the sun for a longer period of time to absorb more vitamin D. Limiting African Americans to less sun exposure outdoors will put them at risk for possibly losing their job and a lower concentration of vitamin D absorption, resulting in various health complications, such as osteoporosis, heart disease, cancers, diabetes, osteomalacia, and rickets. Thus, SunSMART should standardize their interventions based on different ethnicities and races with regards to their time restriction in the sun because it impacts the occupational, nutritional, and racial levels separately and together.
In summation, the SunSMART program should adopt new guidelines to allow it to be more age-specific, in addition to socially, behaviorally, nutritionally, racially, and occupationally acceptable standards. The SunSMART acronym is intended to be catchy and memorable; however the acronym is too weak to publicize a growing epidemic around the world. Its phrases are too long to memorize and intervention regulations do not attack the issue from all angles.
Since this campaign was launched, the rate of skin melanoma has increased by 107%, proving that their model is insufficient to prevent against skin cancer (18). This program should be framed to publicize the issue from a power-coercive and normative-re-educative standpoint rather than a rational-empirical. This way, there may be more persuasive techniques that could encourage individuals to change social norms and make it more acceptable. For example, a bill could be passed asking employers to have their employees wear more appropriate clothing to protect against the effects of skin cancer. Implementing this change could bring forth much more positive results from a occupational standpoint so they can get the same wage, a nutritional standpoint so they can absorb the appropriate amount of vitamin D, a physiological standpoint so that they would be at a lower risk for obtaining skin cancer, and an economic standpoint so they would keep the national costs low. In addition, opening up the age-window to all group and not specifically younger individuals could also bring about some more comprehensive solutions to the problem since the latency period is decreasing.
SunSMART’s intentions in preventing the rising epidemic of skin cancer were appropriate. However, the measures they took to carry out those objectives were not fully thought out from a cultural and social standpoint. Maybe with some changes to the program, we would see more positive results with regards to skin cancer prevalence and mortalities.

References
1- Fayid, Lisa. About Cancer- “Top 8 Shocking Facts About Cancer.
June21, 2007.
2 - Pfahlberg A, Kolmel KF, Gefeller O. Adult vs childhood susceptibility to melanoma. Is there a difference? Arch Dermatol, Sept 2002; 138: 1234-1235.
3 - American Cancer Society's 2007 Facts & Figures. American Cancer Society, Inc.
4 - SunSMART- Cost to Employeers. National Business Group on Health. Jul. 6, 2008. http://www.businessgrouphealth.org/healthtopics/sunsmartarticle.cfm>
5 - SunSMART. Cancer Council Victoria. 1988.
6 – Mayo Clinic Skin Cancer Facts 2006
7- A. Miles. SunSmart? Skin cancer knowledge and preventive behaviour in a British population representative sample. Health Education Research. 2005: 20(5), 579-585.
8- Hoey, S.E.H. Skin cancer trends in Northern Ireland and consequences for provision of dermatology services. British Journal of Dermatology. 2007: 156, 301-307
9- Medical News Today. Deadly Skin Cancer Set to Treble.

10 – Sikes, Ruth G. The History of Suntanning. A Love/Hate Affair. Journal of Aesthetic Science, 1998: I, 2: 6 -7
11 - Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, Massachusetts: Jones and Bartlett Publishers:2007.
12 - Bandura, A. Social Learning Theory. New York: General Learning Press: 1977.
13- Holick, Michael F. Vitamin D: importance in the prevention of cancers, type 1 diabetes, heart disease and osteoporosis. American Journal of Clinical Nutrition. 2004: 79, 362-371.
14 - Grant WB, Garland CF, Holick MF. Comparisons of estimated economic burdens due to insufficient solar ultraviolet irradiance and vitamin D and excess solar UV irradiance for the United States. Photochem Photobiol. 2005 Nov-Dec;81(6):1276-86.
15- SunSMART. Vitamin D.

16- Green, Adele, et. al. Skin cancer in a subtropical Australian population: Incidence and Lack of Association with Occupation; American Journal of Epidemiology. 1996: 144(11), 1034-1041.
17 – US Bureau of Labor Statistics. United States Department of Labor. Employment status of the civilian population by race, sex, and age. Table A-2.Apr. 4, 2008.
18- Center for Disease Control and Prevention. Comparing Melanoma of the Skin by Race and Ethnicity. 2007.

National School Lunch Program Doesn’t Make the Grade: Why America’s Children are Obese- Jayme Lerner

Over the past decade, childhood obesity has increased significantly. Degree of obesity is commonly assessed through body mass index (BMI), a ratio of weight to height (1). A BMI of 25-29.9 is classified as overweight, 30 as obese with greater then 40 indicative of morbid obesity (1). According to the National Health and Nutrition Examination Survey (NHANES), in the 2003-2004 year, 17.1% of United States children and adolescents were overweight and 32.3% of adults were obese (2). Between 1999-2000 and 2003-2004, an increase in overweight children and adolescents rose from 13.8% to 16.0% in females and 14.0% to 18.2% in males (2). The more prevalent overweight and obesity occurs is in childhood and adolescent years, the higher risk of being overweight and obese is in adulthood.
In the past, health related complications of obesity were common only in adults, but now has been found in staggering numbers in children. Obesity is a multisystem disease, affecting psychological, neurological, pulmonary, cardiovascular, gastrointestinal, renal, musculoskeletal and endocrine systems (3, 4). The most prevalent complications include depression, sleep apnea, asthma, exercise intolerance, hypertension, atherosclerosis, dislipidemia, chronic inflammation, and type 2 diabetes mellitus (4). Each condition may have been avoided through weight loss, exercise and healthy eating (1).
The National School Lunch Program (NSLP) began in 1946 as part of the National School Lunch Act to ensure the health of children in the United States (5, 6). NSLP is a federally assisted meal program with the aim of providing nutritionally balanced, low-cost or free lunches to children in public, non-profit private schools and residential child care institutions. Individual school boards must apply to their state education agency to establish the program. Each district receives a cash subsidy and donated commodities from the United States Department of Agriculture for each meal served (5). In 1998, NSLP was expanded to include reimbursement for snacks served during after school educational programs (6). The number of participating children has grown from 7.1 million in 1946 to upwards of 30.1 million (5).
To combat the widespread epidemic of childhood obesity, Healthy People 2010 aims to decrease the proportion of youth who are overweight and obese (3). A specific objective is to increase the proportion of children and adolescents aged 6-19, whose intake of meals and snacks at school contributes proportionally to good overall dietary quality (7). The National School Lunch Program’s approach to resolving childhood malnutrition and obesity ignores pertinent aspects involved in combating this widespread epidemic. These faults are centered around includes low participation rates, competition, poor regulations, and deficient nutrition and physical education.
Low Participation Rates
The National School Lunch Program (NSLP) is available in all 50 states as well as the District of Columbia, Guam, Mariana Islands, Puerto Rico and Samoa (8).Even though the NSLP is available to all students, not all school districts partake in this program. Only 14,000 of 99,500 districts participated in 2006 (9, 10). Delaware, with a total of 34 school districts has only 19 participating. Nevada is one of the only states that have all 17 districts participating (9, 10). Participation is the highest in elementary schools at 67%, and lowest in high schools, 39% (12). Due to these low participation rates, the number of children and families taking advantage of the National School Lunch Program is extremely limited.
While a total of 30.1 million children participate in the National School Lunch Program, according to 2005-2006 school year data, there are strict eligibility requirements. Eligibility is contingent upon on household income levels and federal poverty lines (6). If a family currently receives Food Stamps, Temporary Assistance for Needy Families (TANF), participates in the Food Distribution Program on Indian Reservations (FDPIR) or if a child is homeless, runaway or migrant, they are automatically entitled to free meals (6). In these instances, the school works directly with the State to ensure families are aware that their children can receive free meals (6). A child whose family income falls below 130% of federal poverty level, $26,845 for a family of four, is eligible for free meals. In these situations, the school does not work in conjunction with the State to offer the program (11). Incomes higher then 185%, $38,203 for a family of four, must pay full price for meals (5, 6). Incomes falling between 130 and 185 % receive reduced fare lunches (5, 6). For those receiving free meals, participation reaches 80% while reduced priced meals and full price meals have lower rates of 69 and 48% respectively (12). Even though there are a high number of students receiving free lunches, there are low participation rates for the other meals. Coupled with the lack of participation throughout the United States, many students are no receiving the entitled meals, thus not improving the overall health status of children. In addition, some families feel that income and financial status is something that should be kept confidential, and because of this do not ask for help even though it is needed. The majority of families are left alone to determine their eligibility for NSLP. Since many may not be aware that such programs exist, or know how to start their children in the program, participation for reduced and full price meals is low.
There are potential additional reasons why children and adolescents who are eligible to receive meals are not participating in the program. According to public health theories, social norms and social networking theory have significant implications for people. Social norms are expected codes of behaviors set forth by and experienced by a group or culture (17). These codes are guidelines for how to behave, including the unspoken standards about what are “normal” and acceptable behaviors (17). Similarly, social networking theory assumes that depending on the social network someone belongs to, behaviors are influenced to conform to the group (17). If eating school provided meals is not something that is socially acceptable, NSLP participation rates will be low. Those who must pay the full price or reduced fares have the lowest participation rates compared to those receiving free meals. Students who can afford other foods may find it more socially acceptable to purchase foods from other sources. This may be the reason for why on a typical day only 17.7 million students are taking advantage even though 30.1 million are eligible (6).
Competitive Forces & the Lack of Regulation
The National School Lunch Program has narrow regulations on what foods can and cannot be served as lunches. The United States Department of Agriculture (USDA) sets the standards for nutrition guidelines found in school lunches. The target goal is for lunches to meet the recommendations of the Dietary Guidelines for Americas, with no more then 30% of calories from fat, and less than 10% from saturated fat. It is also suggested that lunches provide one third of the Recommended Dietary Allowances (RDA) for protein, vitamin A, vitamin C, iron, calcium, and total calories (5). In the 2004-2005 school years, around 15% of schools served lunches that did not meet the RDA standards, and 2/3 of schools served lunches that did not meet the standards for total fat and saturated fat (14). On average, lunches contained 34% of calories from fat and 11% of calories from saturated fat, missing the target goals (14). When evaluating elementary students’ nutrient intake composition, there was no difference between those who participate and those who do not, proving the ineffectiveness of the program (14). Even though each school must meet these requirements, they are at liberty to select the foods and preparation methods for each (5).
Although schools can select preparation methods, the USDA has some guidelines. It is required that schools follow one of two procedures. They must either offer five food items selected from four food types: fluid milk, meat or meat alternatives, at least one serving of grain, and two or more servings of fruit, vegetables or both, or determine foods based on weekly nutrient composition of meals (12). Requirements for fruits and vegetables are not specified. Similarly, there is no restriction for high calorie energy dense items such as cookies and cakes that are served with lunches (12). With these lax regulations, there is a wide variety of food types that can be served.
The National School Lunch Program has narrow restrictions on competitive foods found in and around schools. Competitive foods include a la carte foods and beverages, foods sold as fundraising efforts, vending machines, snacks in classrooms and those made available during after-school activities (12). Foods of low nutrient density that are high in calories are sold in competition to school meals through vending machines, school stores and off campus locations when students are allowed to leave school property (12). Fundraisers focused on food and beverage sales in 37% of elementary schools and 50 to 60% of middle and high schools included foods of minimal nutritional value (14). Although vending machines are sometimes located away from cafeterias, they are still are available in 17% of elementary schools, 82% of middle schools and 97% of high schools (14). In a study of 20 Minnesota schools, on average there were 11 vending machines in each school (12). Since there are no strict guidelines for hours of operation of competitive foods they are readily available.
With the high prevalence of competition, some states have enacted their own set of guidelines in addition to those set forth by the USDA. In Florida, competitive foods are not allowed in elementary schools, and are not available until one hour following the last lunch period in secondary schools. The sale of carbonated beverages is allowed at all times in high schools permitting there are 100% fruit juices available at each location (8). In Virginia, coffee and tea can not be sold to students regardless of the time of day (8). Even with these additional recommendations, foods of low quality are allowed for consumption and compete with school served lunches.
Additionally, the National School Lunch Program has no guidelines regarding portion sizes that are served to students. When there are no standards for portion control, even if a food is deemed to be “healthy”, in large quantities it may not be. Over the past 20 years, portion sizes for the majority of foods have increased significantly (15). This growing trend is one of the main reasons for the rise in obesity, since energy intake is exceeding energy expenditure (15). It would be virtually impossible to monitor each child’s eating behavior, but not having standard portions exacerbates the problem of obesity in children and adolescents.
Lack of Nutrition and Physical Education
While the National School Lunch Program aims to increase the proportion of healthy foods served at lunch to increase child and adolescent health, there is no simultaneous discussion of nutrition education. Food choices are influenced by the total environment, not just the availability of foods. Nutrition education is not something that is mandatory for each state. 69% of states require health education curricula to include nutrition and dietary behaviors (13). In a 2000 survey, 75% of health courses included lessons on nutritional and dietary behavior (12). On average, a total of 5 hours per academic year is spent on topics of nutrition and diet (12). In comparison to time spent on traditional subjects, these 5 hours are not enough to educate students on making the necessary changes. Additionally, many school districts do not require all grades to have health education classes. Some schools offer health education every other year. With the extreme lack of nutrition education, children are not learning about the c0responding health benefits of making these choices. The availability of healthy foods such as fruits and vegetables is not enough to prompt children to choose them especially when competition is available (12). For dietary changes to take place, it is essential to educate children and adolescents about the benefits of making dietary changes, and how to do so properly.
It is also vital that children participate in physical activity. Physical education (PE) is required by law, but there are no requirements on the nature and duration of classes (12). Physical education is mandated in 36 states for elementary school students, 33 states and 42 states for middle school and high school respectively (13). A 2000 School Health Policy and Programs Study (SHPPS) found that typical PE classes, lasted on average 45 minutes. Students spent an average of 15.3 minutes participating in games, sports or dance and 9.6 minutes on skill drills (13). In a typical 30 minute elementary school PE class, the average child was vigorously active for only two to three minutes of class time (13). In 2006, SHPPS found that 69% of elementary schools, 84% of middle schools, and 95% of high school required physical education. Students were exempt from gym if they participate in community service activities, community sport activities, band or chorus (16). At the same time, only 62% of states require physical activity and fitness education in health curriculums (13). In 2000, 69% of health courses addressed physical activity and fitness, averaging a total of 4 hours per year (12). With the lack of physical education students are not getting the activity necessary for optimal health.
The National School Lunch Program (NSLP) focuses only on what children consume for lunch in schools as a means of promoting good health. Since this program only focuses on school lunches, there is a large divide between what children and adolescents consume at school versus elsewhere. Parents and caregivers are often unaware their children are obese or at risk for obesity (13). When families are not aware of the risks of being overweight, the benefits of consuming nutritionally balanced meals and performing physical activity there are barriers to combating the obesity epidemic. If parents become aware of the consequences of poor health on their children, some may make the effort to increase healthful behaviors at home.
Associated with the lack of family education, NSLP lacks family involvement and encouragement which are vital components of children being healthy. Parents are the ones doing the food shopping, preparation or purchasing of meals, for the majority of children. It has been found that teens who eat meals with their families more frequently, or who assist in preparation of meals report higher intakes of fruits, vegetables, grains and essential nutrients (13). There are also lower intakes of sweetened soft drinks and dietary fat and are at lower risk for developing eating disorders (13). Even though 30% of meals are consumed outside the home, what children see and experience on a daily basis influences choices, as evident in these findings (1). Social learning theory explains the idea that people acquire behaviors through observation or vicarious learning (17). While people are not necessarily cognizant of this, the behaviors modeled are subconsciously acquired and put into practice. Parents and peers are two of the most prominent people modeled after. Children are picking up behaviors of their parents and caregivers. If a child is not exposed to healthy behaviors at a young age, when the majority of their time is spent with parents and caregivers, it is less likely that they will practice healthy behaviors on their own. This process occurs throughout life for both positive and negative behaviors, but it is up to parents to start the positive behaviors early, and to reinforce those acquired throughout their children’s lives.
Implications & Conclusion
A multifaceted program that involves healthy eating, physical activity and support systems is the optimal method to ensure overall health for children and adolescents 13). Due to the lack of these attributes, the National School Lunch Program fails in its mission to increase the overall health and nutritional status of students. Not all schools participate and those that do have relatively low participation. With low participation rates many of the eligible students are not receiving their entitled lunches. Additionally, the lack of regulatory action against competitive foods and portion sizes further complicates the issue of obesity. Targets for nutritional composition are not being reached. There is lack of support and encouragement from family members and potentially other students as seen through public health theories that are being overlooked. In order for this program to fulfill its mission of bettering the health status of students it is necessary to alter the approaches taken. Increasing participation rates, creating strict regulations, increasing health and physical education, and generating family education programs to increase involvement are necessary to make the National School Lunch Program efficient in promoting good overall health for students and decreasing the high rates of childhood obesity.
References
1. Mahan, L.K, Escott-Stump, S. Krause’s Food, Nutrition, & Diet Therapy. Philadelphia, PA: Elsevier, 2004
2. Ogden, C. et al, Prevalence of Overweight and Obesity in the United States, 1999-2004. Journal of American Medical Association, 2006; 295; 1549-1555.
3. Kreipe, R. Adolescent Health and Youth Development: Turning Social Policy into Public Health Practice. Journal of Public Health Management and Practice 2006; S4-S8
4. Ebbeling, C. Pawlak, D. Ludwig, D. Childhood Obesity: Public Health Crisis, Common Sense Cure. The Lancet 2002; 360: 473-482
5. Food and Nutrition Services. National School Lunch Program. United States Department of Agriculture
6. Food Research and Action Center. National School Lunch Program. Food and Research Action Center, 2008
7. United States Department of Agriculture. National School Lunch Program/School Breakfast Program: Foods of Minimal Nutritional Value. 2001. http://www.fns.usda.gov/cnd/lunch/CompetitiveFoods/fmnv.pdf
8. American Dietetic Association. Competitive Food Policies by State- A Report to Congress. Washington, D.C: American Dietetic Association. http://www.fns.usda.gov/cnd/lunch/
9. LaFaive, M.D. A School Privatization Primer. Michigan: Mackinac Center, 2006
10. Great Schools. List of School Districts. San Francisco, California: Great Schools http://www.greatschools.net
11. American Dietetic Association. Income Eligibility Requirements. Washington, D.C; American Dietetic Association. http://www.fns.usda.gov/cnd/governance/notices/iegs/iegs.htm
12. Koplan, J. Liverman, C. Kraak, V. Preventing Childhood Obesity: Health in the Balance. 2005.
13. Progress in Preventing Childhood Obesity: How Do We Measure Up?
Authors- Committee on Progress in Preventing Childhood Obesity
14. Food and Nutrition Service. School Nutrition Dietary Assessment Study- III, Summary of Findings. Washington, D.C; United States Department of Agriculture http://www.fns.usda.gov/oane/menu/Published/CNP/FILES/SNDAIII-SummaryofFindings.pdf
15. Smicikilas-Wright, H et al. Foods Commonly Eaten in the United States. 1989-1991 and 1994-1996: Are Portion Sizes Changing? Journal of the American Dietetic Association. 2003, 103:41-47
16. Centers for Disease Control. School Health Policies and Program Studies. Washington, DC Centers for Disease Control: http://www.cdc.gov/HealthyYouth/shpps/2006/factsheets/pdf/FS_PhysicalEducation_SHPPS2006.pdf
17. Edberg, M. Essentials of Health Behavior Social and Behavioral Theory in Public Health. Sudbury, Massachusetts: Jones and Bartlett Publishers, 2007

The Shortcomings of Public Health in Promoting Nutrition to Fight Cancer - Jean Kim

Cancer is one of the leading causes of death in the United States. Its widespread nature has led to the development of numerous public health campaigns all aimed at its defeat. However, current campaigns place a great emphasis on clinical intervention, failing to shed light on primary prevention of cancer. Dietary habits are increasingly being recognized through research as an important contributing factor to the disease. Not having an optimal diet may contribute to as much as 35% of all cancer cases (1). Even as this knowledge emerges, though, it is often overshadowed by messages to the public advocating only clinical therapies. Due to the focus on cancer from a clinical perspective, there is limited awareness of the link between nutrition and cancer due to a lack of effective promotional activities.
The Relationship between Nutrition and Cancer
Despite successful efforts in bringing cancer to the forefront of public health, there are gaps in approaches to cancer that must be addressed. Nutrition is crucial in aspects of cancer prevention, treatment, and cures. An individual’s diet can help establish his or her risk of developing the disease. Thus, it is imperative that the public is aware of dietary guidelines, as well as the importance of detecting suboptimal nutritional statuses. Subsequent intervention for any nutritional problems can be a significant factor in the prevention of cancer, as well as other diseases. Issues such as malnutrition, weight loss, and muscle wasting prior to diagnosis will only be worsened with treatment if they are not addressed first (2).
Nutritional status is directly correlated with a cancer patient’s response to treatment. Malnutrition can play a major role in the deaths of as much as 20% of patients. Additionally, malnutrition is shown to significantly decrease quality of life and the effect of treatment (3). A patient will become more susceptible to infections and less responsive to chemotherapy (1). However, performing nutritional assessments and addressing symptoms from both a clinical and nutritional perspective can restore weight in 50% to 88% of undernourished cancer patients (2). Some experts recommend that nutritional support be started when the patient loses at least 5% of his or her body weight, but even less weight loss can be detrimental. Nutritional guidelines should be given early in the diagnosis so that patients can make the appropriate dietary changes. These guidelines are crucial because they lay the foundation for preventing harmful fat and muscle loss associated with the disease (1).
The nutritional needs of those fighting cancer can be different from the general public. Many patients are told to “eat whatever they want,” but nutritional professionals now realize that advocating foods that support the immune system and overall good health is more beneficial. The key point is allowing the body to have the greatest advantage in fighting cancer. A lot of patients respond to ill advice or total lack of guidance by adopting diets or taking supplements that might have negative effects unbeknownst to them. This indicates the need for increased awareness of nutritional support and the application of reliable guidelines that people can assuredly rely on (1).
Food components that have been shown to help fight carcinogens include selenium, folate, carotenoids, and dietary fiber. Folate affects the cell cycle, which can influence the growth and survival of cancer cells. Additionally, certain food components have been shown to be beneficial in fighting more specific cancers. For example, greater ability to fight the disease is associated with lycopene and prostate, lung and stomach cancers (3).
In addition to those looking to prevent cancer and patients who are undergoing treatment, nutrition is important for those who are in remission. The key concept is that adopting a healthy diet will improve overall health, protect the body against other diseases, and help prevent future malignancies (2). Epidemiologic results show that reducing intake of red meat, animal fat, excess calories and alcohol, while increasing intake of fruit, vegetables, and fiber can help prevent cancer (1). Not only will the risk of cancer be reduced, but the dietary changes could increase overall health to decrease risk of other diseases.
The American Institute for Cancer Research supports research related to preventing cancer with nutritional support. It has provided guidelines and reports announcing the link between fat and cancer, and a list of foods and their relationship with cancer, among numerous other findings. People can access their resources and learn more about nutritional guidelines (5). However, this type of research remains in the dark for many individuals. They are unaware not only of the findings, but also of the research’s very existence. This unawareness can be attributed to the failure of public health in placing nutrition and cancer on the agenda.
Public Health and Medical Professionals Fail to Emphasize Nutrition
In order to make proper nutritional interventions possible, the cooperation of doctors, nurses, registered dietitians, and other healthcare professionals is necessary (2). However, currently more focus is placed on clinical oncology, which approaches cancer with surgery, radiotherapy, and chemotherapy. A cancerous tumor itself can cause problems with absorption of nutrients and digestion of food. Additionally, the clinical therapies can cause fatigue, nausea, vomiting, pain, diarrhea, constipation, and changes in appetite, all which can affect adequate oral intake of foods. Thus the patient is unable to tolerate usual foods, which leads to weight and muscle loss. Although adverse reactions to the treatments can cause suboptimal nutritional statuses in patients, oftentimes the medical team lacks competence in nutrition and cancer (1).
Oncologists are generally unqualified or untrained in identifying patients at risk for malnutrition, and lack knowledge in appropriate nutritional interventions (4). Hospital surveys reveal that nutritional screenings and assessments are not carried out on a routine basis (6). However, the debilitative nature of cancer should make nutritional assessment of patients a priority. Nutritional status can help indicate the strength of a patient in responding to treatment, and his or her ability to recover. Health professionals may recognize the importance of nutrition, but mere recognition is not enough. There is no requirement in medical training for professionals to have a background in nutrition. Insufficient training prohibits them from advocating preventive nutritional counseling to patients, and assessing for malnutrition (4). These findings highlight the fact that nutritional education must be distinguished as a priority for professionals across a range of health fields.
The same concept should apply to public health promotion strategies. The primary motto of major cancer campaigns is that early screening saves lives. Supporting this motto is focus placed on funding research to develop drugs for decreasing the incidence of breast cancer (8). The campaigns are placing the major cause of cancer incidence on lack of screening, or lack of medical prevention of the disease. No social factors are incorporated into the campaigns. Little focus is placed on primary prevention techniques, especially the self-efficacy of individuals with respect to modifying their diets. Individuals are fully capable of changing their lifestyle and behaviors to improve their health and possible outcomes with cancer. Most cancer patients would be willing to change their diets if that would mean a more positive result. If they had known of dietary guidelines in preventing cancer prior to their diagnosis, most would respond by saying they would have adopted the modifications. However, without proper promotion of nutrition, the public cannot put their self-efficacy to use. Instead, the current campaigns force them to look at cancer through only the aspect of medical screenings and treatment.
People are urged to receive mammograms starting as early as age 25, but there is much less encouragement of maintaining lifelong health through dietary changes. One such campaign that narrowly supports mainly clinical action is the Pink Ribbon Campaign for breast cancer (8). While it has been effective in increasing awareness and setting the agenda, it is being framed in a way that prevents full progress in fighting cancer.
Example of Flaws in Framing the Issue
The Pink Ribbon Campaign is framed largely around the concept that “early detection is the best protection.” Its successes are complicated by the fact that it does not acknowledge the need for reframing the breast cancer issue. The campaign calls upon different models from the social and behavioral sciences, including the agenda setting theory and advertising theory. It directly targets people’s core values of hope, survivorship, and courage. The pink ribbon itself acts as a symbol of the breast cancer movement, having been first handed out to cancer survivors by the Susan G. Komen Breast Cancer Foundation in 1990. Contributing to the movement’s success was the involvement of corporations including cosmetics companies such as Estee Lauder. The ribbons were distributed in stores across the U.S. Profits from the pink ribbon are to be donated to charities such as the Breast Cancer Research Fund (7).
Now, more products promoting the pink ribbon are being sold, including caps, t-shirts, etc. Thousands of women participate in functions such as Race for the Cure and other walks. There is no doubt that the pink ribbon has put breast cancer on the map, dispelling many of the social stigmas surrounding it and thus allowing affected women to open up about the issue. However, a major problem exists in that the federal funding for breast cancer research, which in recent years has increased to over $55o million, is not directed towards preventive strategies. Instead, research for more clinical therapies and clinical preventive techniques is being done (7).
Advocating early detection leaves the public with the impression that the major contributing factor to cancer is failure to receive a mammogram. The pink ribbon is still representative of setting the agenda for breast cancer, but further action against the disease has been long overdue. Most of the public is well aware of the need for screening, self-administered exams, and the progression of good treatment options. What they are much less aware of is how they can prevent malignancies through changes including dietary modifications. The role of physicians here is critical, as they can provide more personal recommendations, but public health campaigns themselves must also shift gears. The public and even patients, if their medical team is also unaware, often do not know where to go for reliable information on “cancer nutrition.”
The pink ribbon campaign does not address this issue. Leading breast cancer organizations, such as the Komen Foundation, are still making preventive research a low priority. In addition, the research that is carried out on prevention is related to pills for breast cancer, which may pose safety issues. Even while many medical advances have been made, the treatment options available to patients 35 years ago still remain to be surgery, radiation therapy, and chemotherapy (9). On the contrary, research on nutrition has been rapidly expanding. New findings such as the relation of soy and breast cancer, the positive effects of milk, and trends in total fat intake and breast cancer have emerged. A diet low in fat was found to help decrease breast cancer risk (10). Studies have also indicated that the consumption of alcohol may increase risk (11). Many other findings exist, but the public is largely unaware of them because most campaigns do not consider them high priority. In order to effectively incorporate preventive strategies, campaigns such as the pink ribbon must be reframed to focus on them.
Current Approach to Cancer Lacks Integration
Although the pink ribbon is one of the more widely publicized campaigns, most anti-cancer campaigns are less widely known. This is considerably due to the absence of effective marketing techniques, including the advertising theory. Health promotion agencies such as the National Cancer Institute spend much less on advertising than large corporations such as McDonald’s (12).
With less advertising promoting cancer prevention, it is even more difficult to reach a wider audience. In this case, public health needs to increase awareness among children, adults, healthcare professionals, and just the general public. However, a major missing link in the campaigns is an appropriate way to reach children. The most effective would be to counsel parents on nutrition, which would in turn affect their children (13). It is essential to broaden awareness among all people and begin prevention at an early age, which will decrease cancer incidence. Current approaches are mainly targeted towards an older audience, leaving adolescents in the dark about changes they can make to improve their health and future (14).
Existing public health interventions target cancer with either a rational-empirical or normative-reeducative approach, but fail to integrate a power-coercive approach. A combination of the three is necessary. Education and persuasion can help increase awareness through patient counseling and informing health care professionals. However, because behavior is largely influenced by social norms and other cultural factors, it can be difficult to apply actual changes with just promotion campaigns. With consideration of current nutrition research, government policies could be enforced in future years. This is an area that has not been touched on by anti-cancer campaigns. Legislation could help shift the nation’s diet towards more healthful options, thus promoting more optimal nutritional status (15).
Conclusion
As medical advances are continuously made, nutrition knowledge is also expanding. There is already adequate research to provide the basis for preventive strategies against cancer. However, the current state of public health campaigns addressing this issue does not evolve around prevention. Rather, campaigns are focused on early detection and other clinical therapies. This failure to reframe the cancer topic and incorporate a multidisciplinary approach acts as a barrier in preventing cancer. The key is to involve teams of healthcare professionals and combine different social theories and approaches to increase awareness among a wider audience.
REFERENCES

1. Mason J. Cancer Nutrition: Prevention and Treatment. Switzerland: Nestec, Ltd., 2000.
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4. Spiro A, Baldwin C et al. The views and practice of oncologists towards nutritional support in patients receiving chemotherapy. British Journal of Cancer 2006; 95: 431-434.
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10. Liaw Y, Chen H et al. An international epidemiologic study of breast cancer mortality and total fat intake in postmenopausal women. Nutrition Research 2005; 25:823-834.
11. Harvard School of Public Health Nutrition Source. Alcohol. President and Fellow of Harvard College. http://www.hsph.harvard.edu /nutritionsource/alcohol.html.
12. Nestle M, Jacobson M. Halting the obesity epidemic: a public health policy approach. Public Health Rep 2000; 115: 12–24.
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15. World Health Organization Regional Office for Europe. The Adelaide
Recommendations: Healthy Public Policy. Geneva: WHO, 1988.

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.
Conclusion
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.
REFERENCES
1. Department of Health and Human Services: Centers for Disease Control and Prevention. U.S. Obesity Trends 1985-2006. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/
2. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. Journal of the American Medical Association 2006;295:1549-1555.
3. Ogden CL, Flegal KM Carroll MD, Johnson CL. Prevalence and trends of overweight among US children and adolescents, 1999-2000. Journal of the American Medical Association 2002;288:1728-32.
4. Department of Health and Human Services: Centers for Disease Control and Prevention. Overweight and Obesity: Childhood Overweight. Atlanta, GA: Centers for Disease Control and Prevention.
http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/index.htm
5. Daniels SR, Arnett DK, Eckel RH, Gidding SS, Hayman LL, Kumanyika S, Robinson TN, Scott BJ, Jeor SS, Williams CL. Overweight in Children and Adolescents: Pathophysiology, Consequences, Prevention and Treatment. Circulation 2005;111:1999-2012.
6. Aetna. Children’s Health: Health Consequences of Childhood Obesity. Hartford, Connecticut: Aetna. http://womenshealth.aetna.com/WH/ihtWH/r.WSIHW000/st.48408/t.48814.html
7. Mahan LK, Escott-Stump S. Krause’s Food, Nutrition and Diet Therapy 11th Edition. Elsevier:2004. 259-318.
8. Deckelbaum RJ, Williams CL. Childhood Obesity: The Health Issue. Obesity Research 2001; 9: 239-243.
9. Dietz WH. Health Consequences of Obesity in Youth: Childhood Predictors of Adult Disease. Pediatrics 1998;101:518-525.
10. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. New England Journal of Medicine 1997;37:869-873.
11. Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Preventive Medicine 1993;22:167-177.
12. Freedman DS, Dietz WH, Srinivasan SR, Berenson GS. The relation of overweight to cardiovascular risk factors among children and adolescents: The Bogalusa Heart Study. Pediatrics 1999;103:1175-1182.
13. Department of Health and Human Services: National Institute of Health. Ways to Enhance Children’s Activity and Nutrition.
http://www.nhlni.nih.gov/health/public/heart/obesity/wecan/
14. Santrock, JW. CHILDREN 9th Edition. New York, New York: McGraw-Hill Companies, 2007.
15. Birch LL. Development of Food Preferences. Annual Review of Nutrition 1999;19:41-62.
16. Brown JE. Nutrition Through the Life Cycle 2nd Edition. California: Thomson Wadsworth:2005.
17. Patrick H. A Review of Family and Social Determinants of Children’s Eating Patterns and Diet Quality. Journal of the American College of Nutrition 2005;24:83-92.
18. National Dairy Council. Factors Influencing Eating Behaviors. Rosemont, Illinois: National Daity Council. http://www.nationaldairycouncil.org/NationalDairyCouncil/Health/Digest/dcd74-3Page4.htm
19. Johannsen DL, Johannsen NM, Specker BL. Influence of Parents’ Eating Behavior and Child Feeding Practices on Children’s Weight Status. Obesity 2006;14:431-439.
20. Cullen KW, Baranowski T, Rittenberry L, Cosart C, Hebert D, Moor C. Child-reported family and peer influences on fruit, juice and vegetable consumption: reliability and validity of measures. Health Education Research 2001;16:187-200.
21. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, Massachusetts: Jones and Bartlett Publishers:2007.
22. Salvy SJ, Bowker JW, Roemmich JN, Romero N, Kieffer E, Paluch R, Epstein L. Peer Influence on Children’s Physical Activity: An Experience Sampling Study. Journal of Pediatric Psychology 2008;33:39-49.
23. Bandura, A. Social Learning Theory. New York: General Learning Press:1977.
24. Tibbs T, Haire-Joshu D, Schechtman KB. The Relationship Between Parental Modeling, Eating Patterns, and Dietary Intake Among African-American Parents. Journal of the American Dietetics Association 2001;101:535-541.
25. Home Educator’s Family Times. Parental Modeling. Brunswick, Maine: Home Educator’s Family Times. http://www.homeeducator.com/FamilyTimes/articles/8-5article11.htm
26. Wrotniak BH, Epstein LH, Paluch RA, Roemmich JN. The Relationship Between Parent and Child Self-Reported Adherence and Weight Loss. Obesity Research 2005;13:1089-1096.
27. American Association of Colleges for Teacher Education. Defining Obesity in Children and Adolescents. Washington, DC: American Association of Colleges for Teacher Education. http://www.kidsource.com/kidsource/content2/obesity.html
28. Dietz, W. H. Childhood obesity: Susceptibility, cause, and management. Journal of Pediatrics 1983; 103(5), 676-686.
29. Wardle J, Guthrie C, Sanderson S, Birch L, Plomin R. Food and Activity Preferences in Children of Lean and Obese Parents. International Journal of Obesity 2001;25:971-977.
30. Yale-New Haven Children’s Hospital. Adolescent Rebellion: A Survival Guide for Living with a Teenager. New Haven, Connecticut: Yale-New Haven Children’s Hospital. http://www.ynhh.org/pediatrics/behavior/adolescent_rebellion.html
31. Bloomberg News. Limiting TV, Screen Time Curbs Childhood Obesity, Study Finds. Tuscan, Arizona: Bloomberg News. http://www.azstarnet.com/sn/health/227997
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33. Lanningham-Foster L, Jensen TB, Foster RC, Redmond AB, Walker BA, Heinz D, Levine JA. Energy Expenditure of Sedentary Screen Time Compared With Active Screen Time for Children. Pediatrics 2006;118:1831-1835.
34. Allina Hospitals and Clinics. Downloading Obesity: Balancing Screen Time and Healthy Weight. Minneapolis, Minnesota: Allina Hospitals and Clinics. http://www.allina.com/ahs/aboutall.nsf/page/balancing_screen_time
35. Nemours Foundation Kids Health. How TV Affects Your Child. Nemours Foundation Kids Health. http://www.kidshealth.org/parent/positive/family/tv_affects_child.html
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37. Finkelstein EA, Fiebelkorn IC, Wang G. National Medical Expenditures Attributable to Overweight and Obesity: How Much and Who’s Paying? Health Affairs (Web Exclusive);2003:W3-219-W3-226.

The Failure of Abstinence-Only Sexual Education in Schools in Reducing the Rates of STD’s and Pregnancy in the Adolescent Population – Katelyn Spada

Abstinence-only sexual education has failed in reducing the rates of STD’s and pregnancy in teens because those implementing the program neglected to frame the issue to teens in a relatable manner. The main focus of this paper is to address the need for abstinence-only sexual education programs to incorporate the social and behavioral sciences, such as psychology and sociology, in order to reframe abstinence-only sexual education so that it appeals to teens. Current abstinence-only sexual education programs fail to incorporate concepts that play important roles in teenagers’ lives. These programs neglect to address the importance of the messages about sex that are displayed by the mass media and accepted by society. Also, many abstinence-only educators fail to realize that teens are in the process of establishing their own sense of autonomy and may not abstain in order to prove that they can make their own decisions about sex (1). Although many teens intend to abstain from sex until marriage, there are few who are able to maintain this commitment (2). Abstinence-only sexual education fails to inform teens about contraceptives and birth control that could protect them should they choose to have sex. By incorporating the social and behavioral sciences, these programs would be able to address these issues and be more effective in lowering the rates of pregnancy and STD’s in the adolescent population.
About Abstinence-Only Sexual Education
Abstinence-only sexual education exclusively promotes the importance of abstaining from sexual intercourse until marriage and typically includes no discussion of contraceptives, birth control, or abortion. The abstinence-only curriculum emphasizes that abstinence is the expected social standard for school-aged children and teaches children that pre-marital sex leads to STD’s, teen pregnancy, and social stigma (3).
The federal government largely funds abstinence-only sexual education in public schools through Title V of the 1996 Welfare Reform Act and through Community-Based Abstinence Education. Title V of the Welfare Reform Act allows the government to allocate grants to states whose public schools teach abstinence-only sexual education (3). The government outlines strict curriculum criteria that must be met in order for the state to receive federal funding. The programs funded by this act are able to discuss contraceptives, but are allowed only to give examples of their failures. These programs do not educate teens on the benefits of contraceptive use (4). A large amount of money has been allocated to fund abstinence-only education programs. From 1996-2006, the federal government has given over 1 billion dollars to state-run abstinence-only programs through Title V of the Welfare Reform Act. Abstinence-only sexual education programs also receive funding through Community-Based Abstinence Education (CBAE), which began in 2000. CBAE is the largest federal abstinence-only funding source, giving 115 million dollars in grants in 2006. These grants bypass state governments and are awarded directly to state and local organizations that teach abstinence-only sexual education. Many grantees are faith-based or small non-profit organizations that service local private and public schools and other organizations in their area (3).
The Importance of Recognizing Teen Autonomy
Current abstinence-only sexual education programs fail to engage teens and educate them about the dangers of promiscuity because the curriculum does not take into account the fact that teens are in the process of establishing their own sense of autonomy. Proponents of abstinence-only programs argue that teens must be taught abstinence in order to guide them away from promiscuity, but they fail to recognize that many teens are mature enough to know the difference between acceptable and unacceptable behavior. According to psychological theory, teens aim to be independent, self-governing individuals who make their own decisions and live by their own rules of morality (3). Programs aimed at educating teens about sexual behavior should incorporate this theory in order to help teens create their own set of morals without the values of others being forced upon them.
Studies have shown that sexuality is especially associated to freedom and control during adolescence. While parents and teachers should be involved in the surveillance and control of teen behaviors to ensure their safety, teens should be in charge of creating their own morals and making their own decisions. Battles over right and wrong behavior are often fought between adult and child, but the more important struggles are within the teens themselves (5). Sexual education programs should not emphasize the beliefs of those in charge of presenting the material, but should present information on all of the ways to practice safe sex.
The Impact of the Mass Media and Societal Norms
Society as a whole regards sex as normal and acceptable. This conflicts with the message that “sex is immoral and wrong” that is being presented by abstinence-only educators. Oftentimes, teens feel pressured to do what everyone else is doing in order to fit in with their peers (6). By not taking into account the role of social norms and the messages presented by the media, abstinence-only educators are setting their programs up for failure. Teens are exposed to the “sex sells” message sent out by the media on a daily basis. Media outlets, such as television, radio, and magazines, are constantly presenting teens with sexual images and lyrics that are contradictory to the message taught by abstinence-only programs (7).
Media sources are important life-lesson educators for teens and teens often use media sources to gain information about sexuality (7). Bandura’s Observational Learning Theory is based on the idea that learning results from observing the behavior of some other person or model (7). This theory can be applied to suggest that teens can learn the mechanics, motives, and consequences of sexuality from the media and store such knowledge for use in their own personal circumstances. Teens often use this information like a script that outlines what behaviors are expected of them in sexual situations (7). For example, many articles in teen magazines say that girls should not kiss their dates until they have had a second date with them to avoid giving off the wrong impression, and studies have shown that many girls take this advice (8). In this way, the media plays a crucial role in educating teens on the “right” way to act according to societal norms.
While parents and the community may have some influence on the decisions teens make, studies have shown that the mass media and peer influence have the most impact on teen decision-making processes (9). These studies have also shown that families have little to no influence on adolescents’ self-evaluation of sexuality when compared to the influence of the media and peers (9, 10). The information that teens gather about sexuality from the media and from their peers plays an important role in the development of their own sexual behavior (10).
Intent Does Not Always Lead to Behavior
Abstinence-only sexual education programs have failed in reducing the rate of pregnancy and the incidence of STD’s in the adolescent population because these programs have relied too heavily on the idea that if teens intend to abstain from sexual intercourse until marriage, they will uphold that commitment (2). In reality, intentions to abstain from sexual intercourse until marriage may not determine whether or not teens actually do abstain (2). Many external factors may interrupt the intention-behavior continuum.
A recent study presented at the 2003 annual meeting of the American Psychological Society found that over 60% of college students who had pledged virginity during their middle or high school years had broken their vow to remain abstinent until marriage (2). While many of these students may have intended to uphold their vows to abstain from sexual intercourse until marriage, their behavior did not follow their intentions.
There are many situations in which adolescents choose to have sexual intercourse even if they had previously intended to abstain. Teenage romance often evokes strong emotions. Studies have shown that when involved in a serious relationship, teenagers who may have intended to abstain from sexual intercourse before marriage choose to have sex for a number of reasons (11). Most commonly, teens who once intended to remain abstinent have had sex in order to make their relationship feel more adult and to feel more intimate with their partner (11).
Teens also choose to engage in sexual intercourse when under the influence of alcohol or drugs. An estimated 50% of American teenagers have experimented with alcohol and/or drugs at least once (12). Alcohol and drug use has been proven to cause individuals to engage in behaviors that they would not have engaged in otherwise (12). For this reason, intentions to abstain from sexual intercourse until marriage do not accurately predict one’s actual behavior.
Correcting Abstinence-Only Sexual Education Programs’ Failures
Today’s abstinence-only sexual education programs neglect many issues that affect how teens view sexuality. Those developing these programs must realize that social norms and peer pressure, in conjunction with a teen’s developing sense of autonomy, have a strong influence on sexual behaviors. It is also important for these programs to provide teens who choose not to abstain from sex with information on ways to protect themselves. In order to be more effective in reducing the rates of pregnancy and STD’s in America’s adolescent population, these ideas must be incorporated into abstinence-only education programs.
Social norms must be modified in order to make abstinence a more acceptable option in today’s society (13). Abstinence-only sexual education proponents must work with the media in order to incorporate more examples of behaviors that are in accordance with abstinence-only program values. By making abstinence a social norm, these programs will be more relatable, and therefore more successful, in increasing the number of teens who choose to abstain (13).
Abstinence-only sexual education programs need to be restructured in order to be effective in reducing the rates of pregnancy and STD’s in teens (14). While abstinence should remain the focus of these programs, information regarding contraceptives and birth control should also be included. Many proponents of abstinence-only education may be unwilling to accept the need for information about contraception and birth control in abstinence-only programs, but this information is important for those who choose to have sex to know in order to protect themselves from STD’s and to prevent unplanned pregnancies. Studies have shown that programs that focus on abstinence but include information regarding contraceptives have been the most successful in reducing pregnancy and STD’s in adolescents (14). Since abstinence-only sexual education is taught in many public schools and students do not have a choice to enroll in other sexual education programs, including information regarding safe sex is important for all students – especially those who do not agree with the abstinence-only sexual education programs’ goals.
Involving teens in the development and the presentation of the abstinence-only sexual education curriculum would also have a positive impact on abstinence-only programs. Peer influence plays a major role in decision-making processes during adolescence (6). By involving teens in the development and the delivery of the abstinence-only sexual education curriculum, these programs would be able to increase the social acceptance of abstinence among the adolescent population (13).
Conclusion
Current abstinence-only sexual education programs have failed to reduce the rate of pregnancy and incidence of STD’s in the adolescent population. This failure is a result of the fact that those implementing the programs have not framed the issue in a way that is relatable to teens. Abstinence-only sexual education program creators neglect to consider the fact that teens are in the process of establishing their own sense of autonomy and may rebel against the messages being taught to them by their instructors (1). They also fail to acknowledge that the messages about sex received by teens through the mass media and social norms conflict with the values being promoted by abstinence-only programs (7). Lastly, abstinence-only sexual education programs are based on the idea that intent directly governs behavior. This is not always true; there are many external factors that influence whether or not an individual’s behavior reflects their intentions (2).
Addressing the failure of current abstinence-only sexual education programs is an important public health matter because of the high rates of pregnancy and STD’s in the American adolescent population. In order for these programs to have an impact on teen sexuality, social norms must be altered to make abstinence more commonplace and information about contraceptives needs to be included in these programs.

REFERENCES
1. Huebner, Angela. Adolescent Growth and Development. Virginia Cooperative Extension: Virginia Polytechnic Institute and State University; 2000. Publication 350-850.
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3. Howell, M. "The History of Federal Abstinence-Only Funding." July 2007. Advocates for Youth. http://www.advocatesforyouth.org/publications/factsheet/fshistoryabonly.htm
4. United States House of Representatives Committee on Government Reform –Minority Staff Special Investigations Division. The Content of Federally Funded Abstinence-Only Education Programs. Washington D.C.: U.S. House of Representatives, 2004.
5. Griffin, C. Troubled teens: Managing Disorders of Transition and Consumption. Feminist Review 1997; 55:4-21.
6. Brown, B. The Extent and Effects of Peer Pressure Among High School Students: A Retrospective Analysis. The Journal of Youth and Adolescence 1982; 11:121-133.
7. Donnerstein, E., Huston, A., Wartella, E. Measuring the Effects of Sexual Content in the Media: A Report to the Kaiser Family Foundation. Menlo Park, CA: Kaiser Family Foundation; 1998.
8. Adams, S., Garner, A., Sterk, H.M. Narrative Analysis of Sexual Etiquette in Teenage Magazines. Journal of Communication 1998; 48:59–78.
9. Baran, S.J., Courtright, J.A. The Acquisition of Sexual Information by Young People. Journalism Quarterly 1980; 57:107-114.
10. Brown, J., Guo, G., Jackson, C., Kenneavy, K., L’Engle, K., Pardun, C. Sexy Media Matter: Exposure to Sexual Content in Music, Movies, Television, and Magazines Predicts Black and White Adolescents’ Sexual Behavior. Pediatrics 2006; 117:1018-1027.
11. Ott, M. Media May Prompt Teen Sex. Perspectives on Sexual and Reproductive Health 2006; 38:84-89.
12. Califano Jr., J., Foster, S., Foster, W., Vaughan, R. Alcohol Consumption and Expenditures for Underage Drinking and Adult Excessive Drinking. JAMA 2003; 289:989-995.
13. Bersamin, M., et al. Promising to Wait: Virginity Pledges and Adolescent Sexual Behavior. Journal of Adolescent Health 2005; 36:428-436.
14. DeJoy, S., Perrin, K. Abstinence-Only Education: How We Got Here and Where We're Going. Journal of Public Health Policy 2003; 24:445-459

Kids in the Kitchen: There is morKids in the Kitchen: There is more to Obesity than Eating Righte to Obesity than Eating Right- Andrea Walkonen

The Problem: One out of every three children in the United States is considered obese by today’s standards. The occurrence of childhood obesity has more than doubled since the early 1970’s. There have been many initiatives to put a stop to childhood obesity, but few have succeeded. Kids in the Kitchen, an initiative of the Association of Junior Leagues International, was launched in 2006 to address the growing problem of childhood obesity. The program was launched in over 225 communities worldwide, including Canada, Mexico, the United Kingdom and the United States. It grew to 255 communities in less than a year. The objective of Kid’s in the Kitchen is to educate the public on solutions to the children’s obesity epidemic.
According to the Junior League, the key impact of the Kid’s in the Kitchen program is educating families through their website. The website includes fitness and nutrition tips from supporting organizations and partnering campaigns such as the United States Department of Agriculture, the American Dietetic Association, Women’s National Basketball Association, Cartoon Network and many others. It also includes a virtual recipe collection consisting of recipes from celebrity chefs, local restaurateurs, celebrity moms and nutrition experts. These nutrition and fitness tips and recipes are designed to teach children and parents about healthy eating habits starting at a young age. Kid’s in the Kitchen has approached this initiative with live events and demonstrations that involve the kids and their parents in hands-on activities. The activities are designed to teach families about healthy habits. Events range from local chefs giving cooking demonstrations in schools and community centers to grocery-store tours that educate kids and their parents on selecting nutritious and affordable recipe ingredients.
Different leagues use different events based on location and resources. For example, at the Junior League of Brooklyn, a petition was addressed to the Board of Education which resulted in the school providing free lunches in city schools. It also created a model for school lunches everywhere. The Junior League claims that education is the first and most important step to prevent further problems with obesity in children. While the Junior League’s program has made an impact, it has yet to improve the nation’s childhood obesity epidemic. Kid’s in the Kitchen carries reminiscences of the modeling theory. It assumes that the best way to prevent childhood obesity is to get the children to model their parents eating behaviors.
Kids in the Kitchen fails to decrease the incidence of childhood obesity because it fails to consider socioeconomic factors influencing food choice and activity level, it places little emphasis on the importance of physical activity as well as proper nutrition in preventing childhood obesity, and it fails to address the importance of the role of parents in encouraging healthy behaviors. The program places too much emphasis on individual factors affecting behavioral decisions and fails to address the equally important social contexts in which individuals base their behavioral decisions.
Social Learning Theory: Kids in the Kitchen exemplifies the modeling theory of behavior also known as the social learning theory (13) The program resonates aspects of the social learning by teaching children to model the behaviors of their parents when it comes to meal preparation and activity choices to adopt healthier behaviors. While the program has the right idea in educating families on the importance of preparing meals together, it fails to identify the lifestyles and different environments in which the children are raised.
The social learning theory is a very simple theory. The basic design of the theory is that an individual observes a behavior, that individual then imitates the behavior and the result of the behavior is a consequence (13). In this model individuals learn by vicarious learning. The Kids in the Kitchen program reflects characteristics of the social learning theory by attempting to have children observe their parents dietary behaviors through active participation in family meal preparation. The goal is to have children adopt their parents’ dietary behaviors by observation and interaction. The problem with Kids in the Kitchen is that it fails to consider the influences on parents’ behavior that result in poor behavior in children. The dietary behaviors of parents are affected by their socioeconomic status as well as their knowledge of what healthy behaviors they should be practicing. The social learning theory might be beneficial if the correct behaviors were being modeled. Not only is Kids in the Kitchen failing to recognize environmental and social influences on dietary behaviors, they are also not fully emphasizing the importance of physical activity. The social learning theory might also be beneficial in this circumstance if parents were to model healthy physical activities, which are also influenced by environmental and social factors. The limitations of the social learning theory are that it does not consider the idea of choices; it assumes that what an individual sees is what an individual does. It also is a very time consuming model that greatly depends on the ability to change prior generation’s behaviors in order to influence future generations. If Kids in the Kitchen wants to continue to use this model, there are several factors that must be considered in order to have an impact on the increasing rates of childhood obesity.
Socioeconomic Status influences Obesity: The socioeconomic status of the family is a key factor influencing food choices. Parents are forced to spend longer hours working to support the family and therefore have litte, if any, time to prepare healthy meals and spend time with their families. Studies have shown that individuals of low-income areas have higher rates of obesity as a result of availability and quality of food (2). Due to the lack of resources in poorer communities there are less supermarkets available and smaller independent grocery stores that provide low cost high-energy foods. Those healthier options that are available are unaffordable and often very poor quality (2). As a result parents choose to buy cheap convenient meals and snacks that require little to no preparation and offer little nutritional value.
Fast food has also become an affordable option for both low-income and wealthier families. The fast food trend is continually increasing as parents and children are spending less time at home and more time with friends, at work, at school, etc. Our society has placed an emphasis on the unlimited supply of convenient, relatively inexpensive, energy dense foods (4). In the 1970’s, only 17% of children consumed their meals away from home of which 2% of energy intake was from fast foods. Today children and families consume more than 30% of the meals away from home of which 10% of energy intake is from fast foods (3). The increase in fast food consumption is a result in the change of family oriented lifestyles.
Parents either choose or are forced to work long hours resulting in no time to prepared nutritious home cooked meals. Family meals have been replaced by take-out and fast food meals. Instead of focusing on how to get kids to want to help prepare family meals, Kids in the Kitchen must first focus on how to get families back into the habit of eating meals together. Their program is unsuccessful because it fails to recognize that some families lack both the time and resources to prepare home cooked meals together. Kids in the Kitchen advertises the importance of getting kids involved in their own health but needs to fails to recognize that the availability of healthy ingredients and food options varies within socioeconomic areas. If the parents do not have the resources to provide healthy food options they cannot teach their children how to make healthier choices when they themselves do not have the means to purchase healthier food options. The program is unsuccessful because it does not implement educational tools to help lower income families find healthier affordable options.
Few families recognize that there are programs available that will help provide healthy food options. One of the largest programs involved with low-income families is WIC. WIC provides food, nutritional counseling, and access to health services for women, infants and children of low-income families (6). Another large food initiative for low-income families is the Food Stamp Program. In this program, the families receive a card, similar to a credit card, with which they can purchase healthier foods for better health (7). Kids in the Kitchen would benefit from partnering with associations such as WIC and Food Stamps to help increase awareness of programs such as these offered to low-income families. Many families don’t know about these programs or are ashamed to participate. Kids in the Kitchen has failed to recognize the opportunities available for underserved individuals. Higher levels of obesity have been reported in low-income families (2). By failing to address the issue of socioeconomic status, Kids in the Kitchen has overlooked an important part of the obese population. The WIC program and the Food Stamp program are both available for lower income individuals. The decision of who receives help from either program is based on several factors that are established during a pre-screening process. Those who receive food stamps or help from the WIC program are allotted a certain amount of money to purchase food items necessary for proper nutrition. The Food Stamp program allows for the purchase of breads, cereals, fruits, vegetables, meats, fish, poultry, and dairy products (15). Similarly, the WIC program allows the purchase of iron-fortified cereals, juice, eggs, dairy products, nuts and seeds, fish, iron fortified infant formula, fruits and vegetables (14). Both programs have strict guidelines about which foods are acceptable for purchase. Their guidelines are Federally regulated by the Food and Drug Administration (14). Kids in the Kitchen does not have partnership with programs such as WIC and Food Stamp and is therefore weak in the fight against childhood obesity. Food Stamp served over 25 million individuals in 2005 giving over $28.6 billion for the year (15). This shows how beneficial these types of programs can be in providing nutritious foods for families of lower socioeconomic status.
The financial issues of proper nutrition have also spread to school districts. School districts that do not have efficient funding establish pouring rights contracts with soft drink companies, which allow the schools to place vending machines on school property and sell beverages at school (3). This has helped schools to make money while also helping to promote sugary, high calorie beverage consumption further complicating the obesity issue. In an effort to save money, schools have subcontracted lunch programs to corporate food services, which encourage the sale of low quality foods including fast foods (3). The same budgetary constraints have led to a decrease in physical education programs and classes (3). Physical activity is one of the most controllable factors influencing obesity that needs to be addressed along with socioeconomic status.
Physical Activity: Physical activity is one of the most controllable factors in preventing obesity. Changes in physical activity are a result of changes in environment including safe areas for children to play and walk, vehicle use, and decreasing school physical education programs. Children who are from ethnic minorities, children living in neighborhoods where physical activity is limited, children with disabilities, and children living in apartments or public housing are at higher risk of obesity (5). These children do not have access to safe play areas and are often times forced to play inside where television and video games have replaced physical activity (5). A nationally representative survey in 2002 found that 53 percent of parents drove their children to school while 38 percent had their children take the bus, 17 percent of their children walked, and only 5 percent rode their bikes (8). Parents whose children did not walk or bike were asked why their children were not allowed to walk or bike. The most common responses were that the school was too far away, there was too much traffic with no safe walking route, parents fear their children being abducted, its not convenient for the child to walk to school, there is high crime in the neighborhood, and their children simply do not want to walk to school (8). Not only are children missing out on opportunities for physical activity in getting to school, they are being deprived of physical activity in the schools as well. The lack of funding in schools had led to a cut in the physical education programs in schools in and effort to save money and increase emphasis on academic achievements.
The National Association of Early Childhood Specialists in State Departments of Education recently reported that 40 percent of elementary schools have reduced, deleted or are beginning to consider deleting recess since 1989 (8). There has been a 25 percent drop in play and a 50 percent drop in structured physical activities said to be a result of an increase in homework from the early 1980s to the late 1990s (8). Kids in the Kitchen recognizes the need for an increase in physical activity. They have partnered with Cartoon Network’s Get Animated program to increase kids motivation to be physically active (1). However, they place more emphasis on the nutritional aspect of childhood obesity and fail to equally emphasize the importance physical activity in fighting the obesity epidemic. Using a television programs seems contradictory to promoting physical activity. It requires that children watch television in order to learn about the benefits of physical activity. Children today spend more time in front of the television than ever. They are viewing the message about the importance of being physically active yet they are not becoming more physically active. According to the American Academy of Pediatrics, kids are watching more then four hours of television a day, over twice the amount recommended (10). The guidelines state that children older than two should watch no more than one to two hours of quality television each day while children under two should not be watching television at all (10). Studies show that ‘screen time’ may result in obesity as a result of replacing times for physical activity (3). A study on the reasons as to why children participate in physical activities found that there are three main reasons for participation in physical activity including the development of physical competence, gaining social acceptance and support from peers, family, coaches, etc., and simply for the fun derived from participating in such activities (9). In order to enhance children’s perceptions of their physical competence there needs to be an environment that will focus on helping children to learn these skills through support of educators and families (9). Kids in the Kitchen provides hand on cooking demonstrations that have been effective in the past. They could therefore benefit from providing hands on fitness demonstrations where fitness instructors and educators are available to interact with children and families to show them that physical activity can be fun and rewarding. Current physical activity promotion campaigns focus highly on the health benefits of physical activity however children and even adults are not interested in how the activity affects their health if it is not an activity that they enjoy doing. This is why personal interaction with the families would be more useful. It would show families that physical activities don’t have to be difficult and can be adjusted to fit their level of perceived ability. It is important to target the entire family as the parents are role models for their children and greatly influence their children’s behaviors. Kids in the Kitchen also overlooks the importance of the parents role in changing children’s behaviors.
Parental Influence: Parents play a critical role in the development of children. They are responsible for the dietary patterns, the exercise and physical activities, and overall behavioral patterns of their children. Therefore the parents’ awareness of promoting healthy behaviors to prevent childhood and adult obesity is equally, if not more important than the children’s awareness (5). The parents raise their children according to their own beliefs and experiences. If their beliefs and experiences result in unhealthy behaviors then the children are going to grow up believing what their parents have taught them is acceptable. If more emphasis is placed on parents to make lifestyle changes then the children will adopt similar behaviors. There are two main factors affecting children’s obesity that can be controlled by parents. The factors include physical activity levels and dietary behaviors. Based on several studies, both of these factors are highly influenced by the media, which can also be controlled by the parents. A seven-year study on the affects of parent-only based interventions compared to child-only based interventions found that a family-based, health-centered approach targeting parents only induced greater weight loss in obese children upon termination of the study (11). The parents of the study were taught how to influence their children through their own behaviors by modeling self-regulation skills as opposed to making decisions for them. The study also revealed that there was a lower rate of resistance in the parent-focused group’s children. This was believed to be a result of the children in the child focused group being actively responsible for their own behaviors and feeling forced to change. Upon termination of the study 60 percent of the children from the parent focused group changed from obese to normal weight status while only 31 percent of the child-focused group changed weight status (11). These studies reveal the importance of parental influence on changing children’s behaviors. Kids in the Kitchen focuses on directly changing children’s behaviors while failing to consider how influencial parents can be on their children.
Improvements in Public Health: Kids in the Kitchen has the right idea in using the social learning theory as a model for behavior modification, however they are focusing on the wrong models. The parents are one of the most influential models to children and should therefore be targeted for obesity prevention. One of the biggest issues that parents need to become aware of is the effect of the media on their children’s behaviors.
As previously discussed, children are watching twice as much television today compared to previous years (10). Several changes need to happen to reduce the media’s influence on children. One of the most important is the amount of time spent in front of the television. The time children spend watching television displaces time they could spend doing physical activities (12). Parents need to limit the amount of time their children watch television and replace that time with family activities that incorporate physical activity. Another problem with television is the effect of advertisements. One study found that in the early 70’s children were exposed to approximately 20,000 TV commercials a year which increased to 30,000 commercials a year in the late 80’s (12). The most recent estimates of commercial exposure are 40,000 per year (12). The majority of commercial advertisements targeting children are for food. Candy compromises 32 percent of all commercial ads with cereal compromising 31 percent and fast food compromising 9 percent (12). Studies show that television was a significant predictor of how often and what type of food products the children requested at the grocery store and at home with three out of four requests being products seen in television ads (12). There have also been experiments proving that the type of advertisement seen affects the children’s food choices. One experiment involved the manipulation of the type of advertisement shown to 5 through 8 year olds at a summer camp. One group of children was exposed to ads for candy and other sugary snacks while a second group was exposed to ads for fruits and juices. Results of the study revealed that the children who saw the fruits and juices ads requested these types of products, as did the other group with the unhealthy food ads (12).
Kids in the Kitchen would be more successful if they focused more of their attention on educating parents about healthy behaviors including diet and physical activity with an emphasis on reducing the amount of time spend watching television. The program should make an effort to change the type of advertisements shown on TV by replacing sugary snack and junk food commercials with commercials that make healthy food options more attractive to children. The unhealthy food commercials make the products very desirable to kids by convincing them that its ‘cool’ to eat those types of food and that life is easier with those types of foods. Programs like Kids in the Kitchen should create advertisements that make healthy food options seem ‘cool’ and desirable to both kids and parents. Parents have the final decision in what types of foods are available and what types of activities their kids are involved in and should therefore be the main target for preventing obesity.
With childhood obesity on the rise, people need to step back and really examine what is making our children obese and where changes can be made to prevent the obesity epidemic from spreading. Programs such as Kids in the Kitchen are on the right path to obesity prevention, however, they are not focusing their attention on the correct areas of intervention.
Kids in the Kitchen focuses on individual behaviors that influence obesity but the real problem with obesity stems from social and environmental factors influencing our children’s dietary and physical activity behaviors. The socioeconomic status is highly overlooked as a key area of obesity prevention. With lower socioeconomic groups having less access to quality foods, one area of change for intervention should be how to make healthy food options available for an affordable price. Kids in the Kitchen should encourage programs like WIC and Food Stamps as an acceptable option for low-income families. Not only should dietary interventions be improved, but physical activity programs must be strengthened.
In order to change physical activity levels in children, they need to have resources available to support safe and fun physical activity. Physical education programs must be reintroduced back into schools. Parents must learn to make better decisions regarding their own health in order to influence their children to make similar decisions. While parents should be heavily targeted to influence behavior change, so too should the media. More advertisements should be advertised encouraging healthier food options as opposed to junk food options. Children will base their decisions on how appealing a product appears on television therefore targeting the media to change the types of advertisements would change children’s opinions of how healthy foods are more appealing than unhealthy foods. The major change that characterizes all of the previously mentioned changes is the alteration of focus from individual factors that influence behavior to social and environmental factors that influence behavior. Should Kids in the Kitchen shift their focus and address the social and environmental factors, they would be more successful in reducing childhood obesity.

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