Challenging Dogma - Fall 2007

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

Tuesday, December 11, 2007

The Crusade of Children Obesity and Fitness by Texan State Government Falls Short: A Critique of Senate Bill 530 Fitnessgram – Chieh Chu

Recent generations of the United States population have experienced high rates of obesity. An increased prevalence of child obesity is associated with a rise in health problems such as diabetes and coronary heart diseases (1). In an effort to address this issue the Texan state government has initiated the “fitnessgram” project (Senate Bill 530), which aims to reduce obesity rates among children. The fitnessgram project mandates a standard fitness test for every student from grades three to twelve, accompanied by a report card which allows parents and teachers to record the child’s progress (4-6). The legislation will take effect in the 2007-2008 school year (4-6). The fitness scores of the students will be collected by the Texas Education Agency (TEA) and used to assess associations between fitness level and student grades, attendance, obesity, disciplinary problems and school meal programs (4-6). The fitnessgram includes tests of aerobic capacity, body composition, muscular strength, muscular endurance and flexibility (4-6).

SB530 mandates a minimum of 30 minutes moderate-to-vigorous daily exercise per child (4-6). However, the curriculum does not provide comprehensive support for a healthy lifestyle, and does not consider students’ motivations for physical exercise. For example, students may be drawn to exercise by conceptualizing it as entertainment or competition, or personal achievement and social participation, rather than maintaining high fitness scores. Another issue is the fact that there is no definite outcome linked to engaging in physical exercise in this project.

The fitnessgram program adopts the traditional, but flawed Health Belief Model (HBM), rather than the more recently proposed Social Behavioral Approach. The HBM frames obesity as an individual’s problem, failing to address the broader context of social factors (7). It requires students to engage in vigorous exercise without addressing the concepts of healthy eating and adequate energy consumption. These factors are largely shaped by social influences and if not appropriately addressed students can become malnourished or initiate inadequate eating behavior. Social factors such as access to exercise facilities, availability of healthy foods, and student attitudes need to be considered for successful behavior change (8). Framing obesity and fitness as an individual responsibility creates stress by imposing high expectancies on students. The program’s ignorance of social factors may lead to low perceived self-efficacy with respect to weight loss, and eventually low self-esteem among students (9). Thus a power coercive approach such as SB530 is inappropriate for solving the current child obesity epidemic (10, 12).

Another issue with SB530 is the TEA’s emphasis on the association between physical fitness and variables such as school grades and disciplinary problems, as this focus implies a causal link (5). The use of fitness report cards may lead to unfit students being labeled lazy or stupid by both parents and teachers, which in turn discourages these students from pursuing desirable behaviors and outcomes (11, 21).

Senate Bill 530 is a Power Coercive Approach which Fails to Promote Self-Efficacy

Senate Bill 530 mandates that grade three to grade twelve students undertake moderate-to-vigorous physical exercise for 30 minutes daily and regularly take a fitnessgram test (4-6). The Texan state government has hence adopted a power coercive approach in an effort to change physical exercise-related behaviors. The power coercive approach refers to the use of laws to mandate certain behavior (12). The goals in this case are to improve health and overall fitness of children and teenagers, and subsequently improve academic performance and discipline (4-6). The power coercive strategy has been successful in several public health campaigns, such as banning smoking in bars and restaurants (18). However, this approach also has limitations, particularly when the desirable change is not achieved and further public health problems are incurred (12-13). For instance, in The Rest of the Story: Tobacco News Analysis and Commentary, Siegel examined the government effort to ban smoking at home (13). He found that use of the coercive approach did not stop children from being exposed to second hand smoke, and indeed prevented children accessing medical treatment for second-hand smoke-induced diseases because parents were afraid of being subject to penalties for their behavior (13).

The power coercive approach to addressing child obesity, exemplified by SB530, is also likely to fail. This approach does not recognize factors such as performance accomplishment, vicarious experience, and verbal persuasion that are major sources of information in shaping perceived self-efficacy (9). Self-efficacy is an individual level theory for predicting behavior. This model suggests that without an expectation of mastery of a task, one is unlikely to persist in executing the action even when the outcome expected is rewarding (9). In the fitnessgram program there is very little incentive provided for performance accomplishment. The project mandates that students engage in vigorous exercise on a daily basis but it does not specify plans of activity or guarantee resources to assist students in meeting this requirement. For example, there is no support provided for the establishment of school sports leagues or competition games. Rather, the program only provides students with a report card of their fitness is kept confidential. In other words, it would be difficult for students to articulate their fitness score in terms of personal achievement.

It is also important to recognize that not all students deem weight or health as a concern. The need to gain a high fitness score may be hard to translate to non-obese students or “cool kids” (14). As a result, students may feel that the mandatory daily exercise is valueless. The vicarious experience thus becomes dimmed or non-existent as students are indifferent of their score and cannot compare their scores (9). Finally, note that self-efficacy is influenced by verbal persuasion, which implies the possible use of a normative re-educative strategy (9). This strategy uses tools to persuade people to change existing social norms to those which support healthy behaviors (9). The fitnessgram has completely disregarded the social norms that shape student motivation and incentive to engage in physical exercise (7,9). Enforcing mandatory physical education classes will only ensure students perceive a higher rate of schoolwork. An alterative approach that should be more effective is the normative-re-educative strategy, such as the “Truth Campaign” for youth tobacco reduction, that seeks to change behavioral norms (15). An advertising strategy could also be used to emphasize the positive outcomes of physical exercise and shape students’ perception of physical education.

It is important to remember that while some students can meet the requirements of the fitnessgram easily, others will have more difficulty improving their fitness level and losing weight. Such students will have to work harder to attain the same scores as their peers. Expectancies of these students are relatively high, which may lead to low perceived self-efficacy and result in low self-esteem (9). Such students are more likely to give up physical education after the introduction of the fitnessgram. In attempt to achieve a desirable body weight, such individuals are also at higher risk of using unhealthy diet strategies, such as inadequate energy intake, purging, or anorexia (19). Teenagers, who are very sensitive to their appearance, are more susceptible to engaging in such behaviors.

In summary, SB530 is likely to fail because it adopts a power coercive approach, forcing students to engage in physical exercise. This strategy fails to address students’ perceived self-efficacy, a critical factor determining whether students will undergo behavior change with respect to physical exercise (9). The use of report cards imposes high expectancy on overweight students and is likely to trigger low self-esteem (9). As a consequence, these students are more likely to engage in unhealthy eating behaviors (19).

Greater Fitness Equals Good Academic Performance? False Causation Engenders Negative Labeling

The original intention of the fitnessgram is to improve health and fitness among children, however the government of Texas has also implied that “improved fitness equals improved academic performance” (4-6). This belief had arisen from a trend study conducted in Texas in 2005 by the Texas Comptroller. The study revealed that obese individuals are more likely to drop out of high school compared to non-obese individuals (drop out rate 67.8% vs. 59.9%) (3). To establish whether this is a causal relationship, the SB530 empowers the TEA to undertake correlative analyses between students’ fitness scores, their academic grades, attendance rates, disciplinary problems, obesity level, and school meal programs (4-6). The findings will be released annually on September 1st without displaying students’ names (4-6). Teachers and parents can then review individual student’s fitness scores by examining their test report cards (4-6).

Though the trend study does demonstrate a correlation between weight/fitness and education level, this data is still far from sufficient to establish a causal relationship. The trend study assessed students’ weight and education levels at the same point at time. Thus it was not a longitudinal analysis and thus the emergence of an outcome (i.e., education) cannot be situated before or after the proposed exposure factor (i.e., obesity, 8). Indeed, reverse causality could be taking place, such that low education level leads to obesity, given that individuals with low levels of education are more likely to have low “social economic status” (SES) and lack of knowledge of healthy eating patterns. Alternatively, there could be a third factor simultaneously affecting the variables of obesity and education. For instance, students that come from lower SES families may tend to eat more junk foods, and their parents may be too busy or unable to supervise their schoolwork. Therefore, these students would be more likely to become obese and perform less well in school. Thus the results of the trend study do not necessarily suggest that obesity causes low academic performance or vice versa.

The underlying mechanism of how fitness might affect student grades is not well understood. The TEA has essentially taken a theoretical leap from a link between obesity and academic performance to the proposal that improving fitness will improve academic performance. It is highly irresponsible to put forward this message without providing a clear mechanism for such a relationship. The key impact on students from this proposal is the negative labeling effect. Teachers and parents who absorb this message may label students based on their fitness scores and make presumptions with regard to their behaviors and academic performance (21). Emphasis of this relationship could also mean that other factors could be ignored when student issues arise, if parents and teachers assume problems are based on the fitness-academic performance link (21). According to Bigler and Liben, personal characteristics that are perceptually discriminable are more likely to become the basis of stereotyping than other characteristics (11). Nonetheless, appearance alone does not cause stereotyping or stigma, rather it is the labeling of distinguishable groups by adults which forms social stereotypes (11).

Through the fitnessgram project overweight and unfit students may learn that poor academic grades are linked to their fitness level. According to labeling theory, when individuals are named as part of a group they tend to assume the characteristics of that group (20). Therefore, children who are overweight may learn to give up before they even initiate learning at school. That is, they may feel that there is no expectancy of good grades/discipline in their stereotyped group, and that to attain good performance they have to lose weight to escape the stereotyped group. However, losing weight is unlikely to occur in a short period of time. The combined expectancy of high weight loss and good academic performance may stress obese students and further lower their perceived self-efficacy (7,9).

In summary, SB530 is likely to generate a negative labeling effect on overweight and unfit students by stressing an as yet unsubstantiated causation between good academic performance and physical fitness. Such labeling changes both adults’ and peers’ perceptions of the labeled group and self-expectancy of the labeled individuals.

The Fitnessgram and Flaws in the Traditional Health Belief Model

SB530 mandates that students undertake moderate-to-vigorous physical exercise for 30 minutes daily. It assumes that students dislike physical exercise. Students make rational decisions as to whether they engage in exercise (9,16). The implementation of the fitnessgram program is intended to adjust this personal behavior (9,16). The program is a typical instantiation of the Health Belief Model (HBM). According to the HBM, an individual’s readiness to take action is determined by weighing the perceived benefits of the action against perceived costs (9,16). It assumes human behavior is based on objective logical thought processes (9). In the case of physical exercise, students’ perceived benefits (perceived susceptibility and severity) are weight loss or obesity prevention. Perceived costs may be time and energy spent. Students then individually make rational decisions with respect to exercising. SB530 (reflective of the HBM) frames obesity as an individual problem (7), and fails to contextualize social factors such as lack of exercising facilities and social groups that would prompt individuals to engage in exercise (8). In contrast, Social Network Theory suggests an individual’s decision is dependent the social support available to them (17). Access and affordability are seen as crucial for physical exercise and a healthy diet. The HBM disregards these factors, and thus students are missing important information regarding the factors affecting their fitness levels and weight. They will gradually feel loss of control as more individual responsibilities are stressed by SB530.

In summary, SB530 cannot successfully improve students’ fitness because it adopts the flaws of the HBM. By assuming that being overweight is solely an individual responsibility this approach disregards the broader social context that engenders child obesity. Such social barriers will impede students from performing regular exercise to an extent they cannot control.

Conclusion:

Fitnessgram SB530 aims to improve students’ well-being. It mandates that students engage in daily physical exercise and use the fitnessgram for outcome evaluation (4-6). However, the use of a power coercive approach does not support positive perceived self-efficacy (9). Lack of incentives can lead to an indifferent attitude toward physical exercise. For overweight children expectancies are higher than other children, which can lead to low perceived self-efficacy and self-esteem (9). The emphasis on the relationship between fitness and school performance has not yet been scientifically demonstrated. The proposed link may lead to negatively labeling students who perform badly at school as unfit and overweight, and vice versa. Stereotyping may cause these students to be treated differently by adults and peers (11).

The design of the fitnessgram program is based on the HBM, which fails to contextualize the social factors that affect students’ behavior (8). Overall, the program inflicts more personal responsibility on students than can be repaired by the health benefits. To ensure the success of the program, the Texan government should adopt a normative re-education approach to increase students’ awareness of physical exercise (12). The relationship between grades and obesity needs to be carefully examined, and the program should cease labeling unfit and overweight students as having bad grades and behavior problems. Finally, social factors need to be addressed within the program in order to empower students with knowledge of the underlying causes of obesity, which will allow a more efficient strategy to be designed to encourage healthy behaviors (8).

REFERENCES:

1. Tanner L. Doctor Report on Heart Attacks in Kids. New York, NY: Associated Press. http://www.physorg.com/news110442448.html.

2. Carlton J. Texas Unveil Fitness Test for Students. New York, NY: Associated Press. http://www.boston.com/news/education/k_12/articles/2007/09/27/texas_unveils_fitness_test_for_students/.

3. Combs S. Weighing the Costs: Obesity Affects the Work Force. Austin, Tx: Texas Comptroller of Public Accounts. http://www.window.state.tx.us/comptrol/fnotes/fn0705/.

4. Nelson J. et al. Lagislative Update: Latest on SB 530. Austin, Tx: Texas Association for Health, Physical Education, Recreation, and Dance. http://www.tahperd.org/LINKS/SUB_LINKS/ISSUES_LEGISLATIVE/legislative_action.html.

5. Partnership for a Healthy Texas. Physical Education in Texas. Austin, Tx: Texas Health Institute. http://www.tahperd.org/LINKS/SUB_LINKS/ISSUES_LEGISLATIVE/issues_pdfs/PE_Talking_Points.pdf.

6. Nelson J. et al. Student Fitness Legislation (SB 530). Austin, Tx: The Senate of Texas. http://www.tahperd.org/LINKS/SUB_LINKS/ISSUES_LEGISLATIVE/issues_pdfs/SB530_Nelson_Information_Handout.pdf.

7. Edberg M. Individual Health Behavior Theories (pp. 35-49). In: Edberg M, ed. Essentials of Health Behavior. Sudbury, MA: Jones and Barlett Publishers, Inc., 2007.

8. Link B. G. & Phelan J. Social Conditions as Fundamental Causes of Disease 1996; (Extra Issue):80-94.

9. Salazar M. K. Comparison of Four Behavioral Theories: A Literature Review 1991; Vol. 39, NO. 3: 92-99.

10. Benne K. & Chin R. General Strategies For Effecting Changes in Human Systems (pp. 22-45). In: Bennis W, ed. The Planning of Change. New York, NY: Holt, Rinehart And Winston, 1965.

11. Bigler R. S. & Liben L. S. A Developmental Intergroup Theory of Social Stereotypes and Prejudice. Advances in Child Development and Behavior 2006; 34:39-89.

12. Siegel M. Education and Perssuasion Versus Coercion as Public Health Approaches. Boston, MA: The Rest of the Story: Tobacco News Analysis and Commentary. http://tobaccoanalysis.blogspot.com/.

13. Siegel M. Making it Unlawful to Smoke Around Children Could have Detrimental Effect on Children’s Health, Especially among Disavantaged Populations. Boston, MA: The Rest of the Story: Tobacco News Analysis and Commentary. http://tobaccoanalysis.blogspot.com/.

14. Gladwell M. The Tipping Point. New York, NY: Little, Brown and Company, 2002.

15. Hicks J. The Strategy Behind Florida’s “Truth” Campaign. Tobacco Control 2001; 10:3-5.

16. Rosenberg I. Historical Origins of the Health Belief Model. Health Education Monographs; Vol. 2, NO 4:328-335

17. Edberg M. Social, Cultural, and Environmental Theories (Part I) (pp. 51-64). In: Edberg M, ed. Essentials of Health Behavior. Sudbury, MA: Jones and Barlett Publishers, Inc., 2007.

18. Beiner L. & Siegel M. Banning Smoking Could Boost Business for Restaurants and Bars. Boston, MA: American Medical Association’s Science News Department. http://www.wish-wi.org/siegel.html

19. Gilbert P. & Miles J. Eating disorders, shame and pride (pp. 219-255). In: Gilbert P. & Miles J, ed. Body Shame: Conceptualization, Research, and Treatment. New York, NY: Psychology Press, 2002

20. Wikipedia. Labeling Theory. Wikimedia Foundation Inc. http://en.wikipedia.org/wiki/Labeling_theory.

21. Campos P. Why American’s obsession with weight is hazardous to your health (pp.247-251). In: Campos P, ed. The Obesity Myth. New York, NY: Gotham Books, 2004.

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