Challenging Dogma - Fall 2007

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

Monday, December 10, 2007

El Paso CATCH Falls Short: The Failure of a School-Based Health Education Program to Reduce Obesity on the U.S.-Mexico Border – Jessica Fargnoli

Since the 1980’s the prevalence of childhood overweight and obesity has been steadily on the rise. Now, with an estimated 17.1% of children and adolescents overweight, this trend has become an alarming public health problem with serious ramifications for the health of American children (1). Risk factors for cardiovascular disease such as hypertension, high cholesterol, and impaired glucose tolerance are manifesting themselves in overweight children at increasingly early ages (2). More shockingly, Type 2 diabetes, a disease traditionally occurring in middle-aged adults, is now being diagnosed in children (2). As in adults, the burden of this epidemic of childhood overweight and obesity is not shared equally among all Americans. The prevalence of obesity in Mexican-American children aged 6-11 is 22.5% compared with 17.7% in non-Hispanic white children (1).

Clearly, childhood obesity, particularly among Mexican-American children, is a pressing public health concern. Numerous interventions have been developed to address this problem, many of them focused on reducing the prevalence of childhood obesity by altering the school environment. One of the most popular and widely institutionalized interventions, the Coordinated Approach to Child Health, or CATCH, (formerly the Child and Adolescent Trial for Cardiovascular Health) focuses on reducing childhood overweight and obesity with the major goals of: 1) Reducing the amount of total and saturated fat in school lunch; 2) Increasing the intensity of physical activity in school physical education programs; and 3) Improving students self-reported eating and physical activity behaviors (3). CATCH seeks to accomplish these goals through a classroom health curriculum focused on nutrition and exercise with accompanying family materials, a physical education curriculum, and a school foodservice component focused on reducing fat and sodium content in school lunches (4). CATCH’s approach of modifying the school environment and distributing nutrition and exercise information to families was deemed a success when tested in 96 elementary schools across the country (3). After 3 years of implementation, students at CATCH schools had lower self-reported energy from fat intake and higher daily physical activity; however, there were no differences in BMI, blood pressure, or cholesterol levels between CATCH students and control students (3).

After the success of CATCH in its target elementary schools, researchers began implementing the program in schools in Texas, where there is a particularly high risk for childhood obesity. Since the prevalence of overweight and obesity are higher in Mexican-American children, the first site chosen to test the program was El Paso, Texas, which lies on the US-Mexico border and has a population that is 78% Hispanic (5). Each site selected was also designated a Title I school, meaning that most of the children in attendance came from low-income families. Though the researchers involved sought specifically to reduce childhood obesity in low-income, predominantly Hispanic schools, no alterations were made to the program to account for the economic and social challenges to obesity reduction this population. CATCH has not been sufficient to reduce childhood obesity in El Paso because it does not take into account the effect of economics, social networks, and immigrant perceptions of US social norms surrounding food and obesity in this region of the US.

Failure to take economics into consideration

El Paso CATCH does not account for the prevalence of poverty in its target population, and the consequent lack of access to nutritious foods and opportunities for physical activity. Changing the school environment alone will not significantly improve the health of El Paso’s children if the positive changes cannot be continued once they leave school.

The El Paso CATCH curriculum includes recommendations for families on nutrition at home. Advice includes buying more whole grains, fruits, and vegetables and avoiding fast food and “food of minimum nutritional value” (6). While this is clearly good advice, CATCH does not address the way economics in the United States promote obesity in low-income families. Energy-dense foods tend to be lower in cost, and poverty is associated with lower available expenditure for food (7). As a result, low-income families often spend less money on food but have a higher caloric intake, mostly from fats and sweets. Research has shown that healthy diets like the one CATCH promotes, which are associated with the USDA nutritional recommendations, also cost more money (about $1.75 more per person per day on average) (8). Thus, educating low-income families about nutrition, as El Paso CATCH does, is not sufficient to improve their diets if they still cannot afford to purchase the recommended foods.

El Paso CATCH also makes recommendations to increase physical activity during and after school (6). However, low-income areas offer fewer opportunities for physical activity. The availability of exercise facilities, both in and out of school, is lower in communities with higher levels of deprivation, such as El Paso (9). In addition, children from low-income families may have trouble affording the physical examinations required to join sports teams (10). Moreover, Title I schools, which are often scrambling to meet state and national standards in academic subjects, often devote much less time to physical education than schools in higher income communities (11). Since it is not possible for some students in to obtain a healthy amount of physical activity during school hours, it is extremely important to have programs in place to encourage and facilitate exercise after school. CATCH neither provides after school access to exercise facilities nor coordinates sports and other games in which children can be physically active outside of school. CATCH educates children and their families about healthy food choices and exercise, but this is unlikely have an effect on the prevalence of childhood obesity in El Paso if the students do not have access to nutritious foods or exercise facilities.

Social Network Theory is not utilized

By focusing solely on school health education, improving school lunches, and increasing physical activity in school, El Paso CATCH fails to include Social Network Theory in its intervention, and does not take into account the relationships children with obesity have with their peers. Social Network Theory, first formulated by sociologists, explains individual behavior in the context of the relationships between individuals (12). Relationships are defined in terms of social networks, and one individual may interact with many different types of networks, such as family, work, and school. Social Network Theory proposes that these networks play a large role in whether or not an individual engages in a certain health behavior. Thus, conducting a successful intervention involves researching the pertinent social networks and intervening appropriately on aspects of these relationships that will promote a certain health behavior.

Clearly, one of the most important social networks in the life of a child is made up of peers at school. This social network could be used to encourage children with obesity to participate in healthy activities during school. As it stands, children who are overweight and obese are often stigmatized by their peers at school, which could prevent them from participating in physical education. Overweight and obese school children are more likely to be both the victims and perpetrators of bullying than normal weight children (13). In addition, children with overweight or obesity are more socially isolated, tending to have fewer friends and be less likely to participate in school activities than their normal weight peers (14). Weight stigma can also lead to body dissatisfaction and low self-esteem, among other psychosocial consequences (15).

A child with low self-esteem who is stigmatized by his or her peers may feel uncomfortable with participating in physical education in school. Since such a child is also less likely to participate in school activities such as sports and games, he or she will probably not benefit from the school programs that CATCH offers. CATCH does not take into account the social isolation or low self-esteem that overweight children experience by developing programs to improve the acceptance of these children within their school social network. Even if the health and physical education activities that are offered by CATCH are well designed, they will not have an effect if their target audience is prevented from participating by isolation from their school social network. Social Network Theory could help intervention programs like CATCH target the crucial peer relationships that govern a great deal of children’s health behaviors. In order to more effectively reduce childhood obesity, El Paso CATCH should utilize the school social network to encourage and support the target behavior of increased physical activity.

Social norms are not addressed

When implementing the CATCH program on the US/Mexico border, Mexican-American body weight norms and the changes in food norms associated with acculturation were not taken into account. Mexican-American norms associated with healthy body weight may differ from the medically accepted ideal healthy body weight. A study conducted on the US-Mexico border found that mothers’ perceptions of whether their children were overweight were not dependent on BMI, but rather on whether the child was active and could lead a normal life (16). In another study of mothers’ perceptions of body image, every mother viewed her daughter’s body size as ideal, even though 34% of the daughters enrolled in the study were overweight (17). This research suggests that it may be necessary to address social norms surrounding overweight and obesity at the family level before CATCH’s education programs can reduce childhood obesity in El Paso.

The large immigrant population in El Paso may also lead to other barriers for the CATCH. Immigrants’ perceptions of what is acceptable for an American to eat may lead to less healthful food choices. Acculturation is associated with changing ideas about what constitutes a “normal” diet and less healthy food choices in Mexican-Americans. CATCH makes no attempts are made to address these issues. As Mexican-Americans become more acculturated to the US, their diets are associated with higher fat intake and lower fruit and vegetable intake than their less acculturated counterparts (18). Risk of obesity also varies by levels of acculturation in Mexican-Americans. Those born in Mexico are less likely to be overweight than US-born Mexican-Americans, and there is an increased risk of obesity with increasing years of residence in the United States (19). These trends are likely due to an attempt to adapt to American culture by adopting what is perceived to be a “normal” diet in the United States. CATCH misses an opportunity to encourage Mexican-Americans to embrace traditional dietary practices, which include higher consumption of fresh fruits and lower consumption of fats than in the US. CATCH does not research or take into account the social norms of its target population and address them in its intervention. Differing ideas about what constitutes a healthy body weight and “normal” American diet could undermine the advice offered by the CATCH program. By ignoring the social norms of its target population, El Paso CATCH may be misunderstood and thus, be ineffective in reducing childhood obesity.


As overweight and obesity continue to increase in the United States at alarming rates, interventions must be developed to successfully reduce the prevalence of childhood overweight and obesity, particularly in Mexican-Americans. The Coordinated Approach to Child Health attempts to meet these needs on the border of US and Mexico through a school-based education program, but fails to address the social issues necessary to reverse the rate of childhood obesity in Mexican-American children. While this program tries to educate children and their families on the importance of a healthy diet and increased physical activity, it does not into account the economic barriers to nutrition and exercise in low-income communities, the effect of school-based social networks on overweight and obese children’s willingness and ability to participate in physical activity programs, or the social norms surrounding obesity and food in Mexican-American communities. CATCH could be more successful in El Paso if it helped increase the availability of nutritious foods and opportunities for exercise in the area or helped families learn about affordable and healthy food and exercise options. CATCH could also introduce programs to increase students’ self-esteem and encourage healthy peer relationships, and operate within social norms by addressing misconceptions about healthy body weight and “normal” US food patterns with families and the community. The ignorance of the social influences on childhood obesity means that these and other important opportunities for intervention have been lost, impeding the ability of CATCH to be effective in El Paso, TX.


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