“Fat Chance:” The MetroWest Community Health Care Foundation’s Flawed Childhood Obesity Public Education Initiative – Leslie Judge

The prevalence of overweight and obesity in the United States is rising. In 2005, nearly 21 percent of Massachusetts adults were obese (defined as a body mass index [BMI] >30), while nationally, the rates of obesity are even higher (1). Paralleling the rate of concern over adult weight issues, child and adolescent obesity (defined as >95^th percentile according to CDC weight-for-height charts) has become a pressing public health concern. Since 1980, rates of overweight have doubled for children and tripled for adolescents (2). Nationally, 17.1 percent of children aged 6-19 were overweight in 2006 (approximately 9 million children) (2). The problem of childhood obesity is especially concerning because it threatens the physical health of our nation’s youngest citizens. Being overweight increases a child’s risk of developing Type 2 diabetes and the symptoms of cardiovascular disease at a younger age (2). In addition, the likelihood that other conditions, like asthma, sleep-apnea and depression may develop is increased if a child is overweight (2).

In an effort to combat the rising rates of childhood obesity, many public health initiatives have arisen, employing various methods to address the problem. One such initiative was started by the MetroWest Community Health Care Foundation (MCHCF) of Framingham, Massachusetts, in January of 2007. The campaign consisted primarily of billboards and television advertisements, targeted at parents to address the issue of childhood obesity. One billboard, which featured the image of a child’s chubby legs and feet on a scale stated, “Fat chance: Obese children are a good bet for Type 2 diabetes, heart disease, stroke, cancer, sleep-apnea and depression” (3). Another billboard depicted an overweight child from the back and included text asking, “If that’s your kid, what are you waiting for?”(3) The television commercial featured an overweight child snacking and playing video games, while parents danced around the child, in an effort to symbolize parents, ‘dancing around the issue’(3). The media campaign was designed to catch the eye of parents. As Dr. Jerry Wortzman, chairmen of pediatrics at the MetroWest Medical Center stated, “…the campaign is directed at parents, not children…issues surrounding food are mainly controlled by parents. They buy the groceries” (4).

The MCHCF failed to consider several factors when designing their public health initiative. Although the campaign was directed at parents, the derogatory images displayed in the media campaign were easily visible to children, increasing the likelihood that overweight children would self-identify with the negative images portrayed. In addition, the campaign used fear and blame as methods to motivate parents, and therefore decreased their self-efficacy. Finally, by using deprecating images of children, the initiative to raise awareness of childhood obesity only served to further stigmatize the population it was seemingly designed to help. The childhood obesity public education initiative, launched by the MetroWest Community Health Care Foundation (MCHCF), was flawed because it failed to take into account basic social and behavioral science principles.

Labeling Theory: The obese label decreases self-efficacy

The MCHCF’s public education initiative to raise awareness of childhood obesity was flawed because it supported the Labeling Theory. Although the campaign was directed at parents of overweight children, the billboards were displayed on highways where they were easily viewed by children and potentially missed by driving adults. These billboards labeled overweight children as the object of ridicule and deemed them socially unacceptable. Depicting overweight children in this negative manner only served to increase the likelihood that overweight children would identify with the socially unacceptable label of ‘obese,’ which decreased self-efficacy among this population (5, 6).

The Social Cognitive Theory (SCT) was developed by Albert Bandura in the 1960s and was based on the earlier Social Learning Theory to explain behavior (6). The Social Learning Theory is based on the concept that individuals learn by modeling the behaviors of others. Bandura took this theory one step further and added the concept of self-efficacy to create the Social Cognitive Theory (6). The concept of self-efficacy is defined as a person’s belief that they have the ability to perform a behavior (6). In essence, the SCT presumes that individuals learn by observing and modeling the behavior of others, but ultimately an individual’s behavior is influenced by whether or not they believe they can do that behavior.

An individual’s self-efficacy is challenged by the concepts developed in Labeling Theory. Labeling Theory explains the behavior of an individual as the result of their identification or ‘label’ as a member of a particular group. An individual’s identification as a member of a particular group allows that person to adopt the characteristics as defined by membership in the group, and therefore influences the person’s behavior (5). Labels come with their own connotations; some positive and some negative. Often times, labels are used in society to stereotype people and deem them “socially unacceptable.” Applying negative labels to members of a group decreases their self-efficacy and encourages society to further stigmatize that group (5). As Link and Phelan state in their article entitled Stigma and its Pubic Health Implications, “…when people are labeled, set apart, and linked to undesirable characteristics, a rationale is constructed for devaluing, rejecting, and excluding them” (5). If an individual is identified with a particular label, for instance “obese” or “fat”, and believes the negative characteristics that society uses to define that label like, “lazy”, “ignorant”, “ugly” and “undesirable”, than a person may identify themselves with these characteristics and adopt these shameful attributes (5).

In an article examining the stigma of overweight in U.S. culture, Crocker and colleagues identify stigmatizing conditions as labels that, “…lead to the rejection of individuals because those individuals have an attribute that compromises their humanity in the eyes of others” (7). Crocker et al goes on to talk about the fact that although there are numerous conditions for which a person may be stigmatized in society, including racial or ethnic group membership, religious affiliation, physical handicaps and sexual orientation, the stigma of being overweight may be the most debilitating (7). Unlike some conditions that are deemed socially unacceptable but can be concealed from others, like sexual preference, overweight is immediately visible to society. Further blurring the lines between stigmatized groups is the fact that overweight and obesity is more prevalent in certain ethnic and racial populations, particularly among African Americans and Mexican Americans (7). In addition, unlike other stigmatizing conditions like physical handicaps or being seen as ‘poor’ or ‘disadvantaged’ which might elicit sympathy or understanding, Crocker states that, “people who are overweight elicit almost uniformly negative responses from others”(7). In this way, being overweight in society packs a double punch. Being overweight is viewed as, “…both an abomination of the body that elicits immediate negative responses from others on the basis of aesthetically displeasing qualities, and a character stigma that carries with it shame and guilt of self-blame for a moral failure (8).

Applying labels to groups does not encourage the individuals within that group to change in order to avoid the label. In fact, the result of labeling is quite the opposite. According to Allon, overweight people tend to interpret their social experiences in terms of their weight and are more likely than members of other stigmatized groups to see their weight as the cause of their social outcomes, particularly negative outcomes (8). Overweight individuals are much more likely to blame themselves for the negative reactions their weight provokes from society rather than blaming the prejudice that society condones against the overweight (8). As Allon states, “…consequently, overweight persons may be vulnerable to depressed affect and low self-esteem” (8).

If we apply the label of “obese” to children the effects are just as harmful as in their adult counterparts. In a study that evaluated the contributions of weight, skin tone, peer teasing, and parental appraisals of a child’s size to self-esteem in African American children ages 5-10, Young-Hyman et al found that being overweight was associated with low self-esteem and increased body size dissatisfaction (9). In addition, parental perception of child’s size as “heavier than average”, and the child’s own skin tone dissatisfaction were also associated with low self-esteem in the children studied (9). Young-Hyman found that heavier children were also more apt to act out in school or be reported as having behavioral and psychosocial problems (9). Overweight children in this study also reported that weight-related peer teasing was especially hurtful, and direct correlations were observed between the amount of teasing a child experienced and their decreased self-esteem (9). Several other studies in children from various ethnic and racial groups have reported similar findings in the relationship between obesity and decreased self-efficacy regarding weight in children and adolescents (10-12). The result of declining self-efficacy in children is especially problematic because their experiences in childhood largely shape their perceptions of their abilities as they move towards adulthood (10-12).

Billboards touting the MCHCF’s anti-childhood obesity message were displayed prominently on highways and busy streets in suburban Massachusetts. Although the MCHCF’s campaign was directed at parents of overweight children, the billboards were displayed in locations where they were easily viewed by children and potentially missed by driving adults. As one resident of Natick, Ma noted, “I don’t know where they got the idea that kids can’t see these billboards…fat kids are already teased mercilessly” (3). In addition, television commercials were shown during regular nightly programming and on weekend afternoons, which are both times that children are likely viewers. These billboards and TV ads contributed to the social labels of overweight children by portraying them as socially unacceptable and undesirable. Depicting overweight children in this negative manner, and in locations clearly viewed by the children themselves only served to increase the likelihood that overweight children would identify with the socially unacceptable label of “obese,” which decreased self-efficacy among this population.

The Blame Game: Decreased self-efficacy in parents of overweight children

As previously discussed, the concept of self-efficacy states that a person’s ability to perform a behavior is directly impacted by their belief that they can do the behavior (5). The MCHCF’s public education initiative was flawed because it did not take into account the concept of self-efficacy as defined by the Social Cognitive Theory. Placing blame for the rising childhood obesity epidemic on the shoulders of parents only served to decrease self-efficacy among parents of obese children. Billboards that asked, “If that’s your kid, what are you waiting for?” and a television commercial that featured an overweight child snacking and playing video games, while parents danced around the child, in an effort to symbolize parents, ‘dancing around the issue’ unfairly targeted parents. Parents were ridiculed as the cause of the problem, making parents feel shunned and outcast by a society that favors thinness.

Blaming parents for their child’s overweight decreases the self-efficacy of the parents in addressing the problem. Attributing blame, in an effort to inspire feelings of shame, fear and guilt to motivate parents was the strategy that the MCHCF hoped to employ. However, utilizing fear of their child’s overweight and its potential health implications to motivate parents was not an effective strategy. As noted by Vedantum in a Washington Post review of current research on effective motivation strategies to influence health behaviors, “scaring people about the health risks of smoking and obesity…is an ineffective way to change their behavior…giving people the confidence that they can make such changes is far more effective, according to an analysis of hundreds of research studies involving 47 different kinds of behaviors” (13). The article noted that in contrast to motivational strategies that used positive messages to increase self-efficacy, “…public interest methods that seek to induce fear, guilt, or regret were ineffective” (13).

In addition to being a poor strategy for motivation, creating feelings of fear, guilt and shame in the minds of parents of overweight children might actually contribute to the decreased health of the children. The vilification of parents potentially decreases the likelihood that overweight children will receive appropriate medical care. Research supporting this concept has not been documented in parents of overweight children to date but the phenomenon has been considered in parents who smoke around their children and it can be argued that the situations have many similarities. As parents of overweight children are often deemed “abusive” or “neglectful” for allowing their children to eat too much or remain sedentary, parents who smoke around their children are also considered to be “bad parents” for exposing their children to potentially harmful cigarette smoke (14-15).

With the recent attention on the effects of secondhand smoke on children, parents who smoke around their kids have been blamed for increased rates of childhood asthma and ear infections and threatened with policies that would make their conduct unlawful (14). Similarly, the mother of an eight year-old British boy was recently threatened with removal of the child from her care because his obesity was deemed to be her fault for “allowing” him to gain so much weight (16). Laws and policies put in place to seemingly “protect” children might not achieve their desired outcomes. As Siegel argues in his blog from 2006, “…imposing criminal or even civil penalties, referring parents who smoke around their children to authorities, or treating smoking around children as a form of child abuse, we would actually be imposing a huge barrier to children’s access to appropriate medical treatment for conditions that are associated with secondhand smoke exposure” (14). Siegel goes on to compare this problem to that of the children of illegal immigrants. It is well-documented that many immigrant families are reluctant to seek proper medical care because they fear the discovery of their “illegal” status and the potential for deportation (14, 17). In the same way, it can be argued that blaming parents for their child’s overweight might decrease the likelihood that parents would take their overweight child to the physician. In this way, overweight children are placed at greater medical risk if parents believe that they will be judged or criticized at the pediatrician’s office if their child presents with a weight-related problem like Type 2 diabetes or high blood pressure.

Flawed Purpose: Perpetuating prejudice against overweight individuals

In addition to being an ineffective motivational strategy to parents and a method of decreasing self-efficacy in both parents and their overweight children, the MCHCF’s public education initiative was flawed because it contributed directly to the ongoing prejudice against overweight individuals. The use of negative images to portray overweight children on billboards and on television only contributed to the idea that it is acceptable in present culture to ridicule people based on their weight. In this way the public education initiative to raise awareness of childhood obesity only served to further stigmatize the population it was seemingly designed to help.

In an article examining childhood obesity in a societal context, Schwartz and Puhl state, “the societal message about being fat in the 21^st Century is clear: it is bad to be fat. But why is it bad? Clearly, there are serious medical consequences of obesity…However, obese people are not discriminated against because they are medically compromised. They are stigmatized because their obesity is viewed as a reflection of poor character” (18). Schwartz and Puhl go on to discuss the manner in which overweight children are increasingly becoming the objects of ridicule. They cite prejudiced attitudes from other children that lead to bullying and on a daily basis, in addition to the more covert stigmatization that overweight children face from teachers, doctors and parents (18).

The stigmatization that overweight people face from parents, health professionals, and in the academic setting is particularly astounding. A study of obese college-aged females reported that once in college, female obese students receive less financial support from their parents than their non-obese peers receive, even when parents have similar income, family size, and number of children (19). Negative attitudes about obese patients have been documented among physicians, nurses, and medical students (20). Common perceptions among health professionals include beliefs that obese patients are, “unintelligent,” “unsuccessful,” “weak-willed,” and “lazy” (20). This prejudice may lead to poor medical care for obese patients as physicians admit not intervening as much as they should with obese patients simply because weight loss counseling is “inconvenient” (20). The same study found that nurses were hesitant to “touch” obese patients and 24% of nurses described obese patients as “repulsive” (20). At the college level, educational discrimination based on weight has also been documented (20). Obese students are less likely to be accepted to college than average-weight students, despite having equivalent application rates and academic performance (20).

What is perhaps more concerning is the fact that negative attitudes towards overweight children are learned at a young age. One study found that pre-school children aged 3-5 years old judged an overweight child to be a “mean” and a “less desirable playmate” than another child of average weight (21). The study found that 3 year-olds associate overweight children with the traits of being “mean”, “stupid”, “ugly”, “selfish”, “lazy”, “stupid”, “dishonest”, and “subject to teasing”, while average weight children were considered, “clever”, “healthy”, “attractive”, “kind”, “happy”, “popular” and “desirable playmates” (21). Another study looked at the negative stereotyping associated with overweight among fourth– and sixth-grade students (21). The study found that these children endorsed negative stereotypes of both children and adults who were overweight (22). The beliefs of the fourth- and sixth-graders were also assessed about the controllability of obesity and overweight. The study found that most fourth- and sixth-graders believed that obesity was under personal control and that this belief was positively associated with negative stereotyping (22).

The attitudes expressed by the preschool and middle-school children in these studies are a product of social norms that are widespread in current culture. The early stigmatization of overweight children may explain their lower self-esteem and greater shame, humiliation compared with normal-weight children (23). To make matters worse, the level of negativity in the way overweight children are viewed by their peers, increases as children get older, suggesting a steady rise in the ridicule and prejudice experienced by overweight children throughout their development (23). One study conducted by Adams and colleagues observed the way that parents may subtly convey their stereotypic beliefs about obese children at home (24). In the study parents were given three pictures of children (an average-weight child, a handicapped child, and an obese child) and asked to tell a story about each picture to their own child. In the stories, the parents portrayed the obese child as having the most negative attributes and lowest self-esteem of all three children (24). In addition, there were striking differences in the rate of successful outcomes at the end of the stories. The obese child had 0% successful story outcomes while the handicapped child had 85% successful story outcomes and the average-weight child had 45% successful story outcomes (24). This study supports the idea that parents communicate with their children in ways that endorse stereotypes about obese children. It also shows that parents themselves house the stereotypes that may potentially influence their own treatment of obese children in addition to their children’s treatment of obese children in society.

It is clear from current research that there is a connection between depression and childhood obesity (10-12), but researchers have not clearly determined a path of causality between the two factors. Are overweight children more prone to depression considering the social stigmatization that confronts them on a daily basis, or are depressed children more prone to obesity due to their poor self-esteem and lack of self-efficacy? This is a question that continues to be hotly debated. What can be unequivocally determined is that overweight children are the objects of ridicule, and these children do have higher rates of depression and poor self-esteem than normal-weight children (10). The MCHCF’s public education initiative was flawed because it contributed directly to the ongoing prejudice against overweight children. The use of derogatory pictures to portray overweight children on billboards and on television only added to the negative and prejudicial images present in current society that condone discrimination based on weight. In this way the public education initiative to raise awareness of childhood obesity only served to further stigmatize the population it was seemingly designed to help.

Conclusions

The MCHCF failed to consider several factors when designing their public health initiative. Although the campaign was directed at parents, the derogatory images displayed in the media campaign were easily visible to children, increasing the likelihood that overweight children would identify themselves with the negative images portrayed. In addition, the campaign used fear and blame as methods to motivate parents, and therefore decreased their self-efficacy. Finally, by using deprecating images of children, the initiative to raise awareness of childhood obesity only served to further stigmatize the population it was seemingly designed to help. The childhood obesity public education initiative, launched by the MetroWest Community Health Care Foundation (MCHCF), was flawed because it failed to take into account basic social and behavioral science principles.

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