Challenging Dogma - Fall 2007

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

Tuesday, December 11, 2007

“Let’s Get Realistic:” Public Health Has Failed in Implementing Successful Exercise Programs as a Way to Fight the Obesity Epidemic- Shaina Parry

Despite a common belief that change begins within the individual, it is now widely believed that change begins with a society (5). Change does not happen overnight and it is certainly not easy for everyone. Proof of this is the obesity epidemic which has increased within the past thirty years (14). There are many factors which are associated with obesity including environment, lack of physical activity, heredity, dietary patterns and socioeconomic status (6). These factors have more to do with the group rather than the individual. Since forty percent of the American public is physically inactive, obesity can be considered a group problem. Change begins with a community, and then trickles down to the individual.
The change toward an overall healthier lifestyle is one that challenges many and still the dangerous and fatal health consequences of obesity are not taken seriously (5). Public health’s obesity interventions fail because they are not planned with social and behavioral theories in mind. Due to a lack of considering society’s deep- rooted behavioral ideals and norms, physical exercise interventions focused on preventing obesity and its related illnesses have failed to make their mark. Had the following behavioral theories been implemented in exercise campaigns, perhaps these interventions would be effective.
Advertising and agenda theories explain how the media has a profound effect on people’s lives (5). Society chooses to aim for a thin body image rather than a healthy one, and this is seen in the media (12). Society also does not consider physical activity a top priority, and this is because public health has not framed obesity as a serious threat (13). Society’s negative stigma associated with being overweight may play a much more important role than we think. Social theories which help to explain this stigma include self efficacy, social cognitive theory and labeling theory.

Blame the media?
While many fitness magazines promote exercise as a way to become physically healthy, the majority of the media does not. Society chooses to focus on a thin body image rather than a healthy one (3). Agenda setting theory states that people’s behavior depends on what the public talks about, which is directly influenced by the mass media (5). As long as the societal thin image remains, it will be hard to convince Americans to exercise for their health (3). While many blame the media for incorporating the thin image, it is the job of public health campaigns and interventions to challenge the media (3). Individuals may exercise to lose drastic amounts of weight rather than exercise for known health benefits. While exercise for weight loss is beneficial, many individuals may be deterred from exercising because they do not believe they are capable of losing weight or ever reaching a desirable body image (15). Individuals who do not believe they are capable of losing weight would be considered to have low self efficacy.
Self efficacy is the belief that one is capable of performing a certain task and/ or meeting certain goals (5). According to a recent article in Newsweek Magazine, women who are overweight do not set high weight loss goals for themselves because they believe that losing a large amount of weight is unrealistic (15). By beginning a weight-loss program with an already negative outlook it may be hard to reach any goals, even if they are small. Individuals with low self efficacy may not understand or believe that exercise is highly beneficial for them. It is the concept of self efficacy which is not incorporated into obesity interventions.
Self efficacy goes hand in hand with social cognitive theory, which states that people will act on the basis of whether they believe they can do something or not (5). Social cognitive theory combines individual and environmental factors, such as family and cultural influences. According to social expectations theory, individuals’ behavior is dictated by social norms. Because society is so obsessed with image rather than health (3), exercise interventions focusing on health rather than weight loss have not worked. By making society more health conscious, perhaps society will begin to incorporate physical activity as a regular part of life.
Public health practitioners have not incorporated advertising theory into their interventions. Advertising theory is about making a promise between a product and its outcome. The promise that isn’t made clear is that exercise will increase one’s health. There is strong evidence that physical activity lowers the rates of mortality and other diseases, and that it has numerous psychological benefits (11). However, despite its numerous benefits, exercise is not a top priority among Americans, and public health interventions have failed to make it such a priority.

Get your priorities straight
According to a number of polls conducted in 2006, neither healthcare nor exercise was considered a top priority. In fact, healthcare ranked fourth behind war, economy and oil (13). Exercise was nowhere to be found on this list. Among the top five health concerns for 2006 were cancer, HIV, avian flu, heart disease, diabetes and obesity. It is alarming that, while over thirty percent of adults in the United States are obese, obesity is not considered a top priority (14). What is even more alarming is that the cost of health consequences associated with obesity amount to well over two billion dollars annually in the Unites States (4). This cost may increase as more individuals become obese because of a sedentary lifestyle.
Not all people choose to live a sedentary lifestyle, and many life circumstances are often ones which cannot be controlled (5). The decision to take on regular exercise is affected by socioeconomic status, cost, safety, access, environment and free time (5). Priority will vary depending on one’s life circumstances, culture or financial situation. For some, a top priority may be education, making money or feeding their family. For others, keeping their family safe and out of trouble may be more important. Public health practitioners have not taken the above factors into consideration when implementing obesity interventions. By not framing the obesity epidemic as a serious enough threat, and not framing exercise as a priority, public health interventions have been unsuccessful. A mere eleven percent of the public see obesity as a problem, and this is not enough for there to be a significant societal change toward a healthier lifestyle (13). Perhaps if more people recognized obesity as a disease, there would be more focus on what to do about it, rather than on those that are obese.

Negative stigma
There is an unfortunate, negative stigma associated with being overweight. This stigma is seen in the media, and especially on television. In one study in the American Journal of Public Health, researchers found that obese actors on popular television shows were less likely to be thought of as good-looking and also less likely to have romantic relationships, compared to thinner actors (12). While being overweight does have its health consequences, it also has social ramifications. Obese individuals are often considered to be lazy and deceitful and because of this stigma, there is a bias against overweight individuals in important areas of life including education, employment, and education (12). While there has long been discrimination based on race and gender, obesity is now joining the ranks.
The reason why obesity’s stigma is so detrimental is twofold. First, this stigma creates a negative self image for those who are obese. Those who are obese may have a lower self efficacy because of their negative self image. Second, it creates a bias against obese individuals which may have a negative impact on their quality of life. This stigma prevents people from believing that they actually can exercise to become healthier.
According to labeling theory, when individuals are labeled as part of a group, they tend to take on the tendencies of that group (5). When obese people internalize the negative stigma attached to them, they may not even consider exercise or health. Maybe some people think that it is too late to start an exercise regiment, or that there is no point. Public health campaigns have not worked enough to dispel this stigma or to realize how detrimental it can be. Overweight individuals may lack the self efficacy they need in order to feel confident about themselves and the importance of their health. This stigma is part of a social factor which impacts the health of those who are obese (10).

Future Implications
Obesity is considered a preventive disease yet it is the only disease where actions have not been taken to prevent it (4). Many argue that obesity should be treated like any other illness however treatment for it should be prescribed as exercise instead of pills (11). This suggested exercise treatment should be taken as seriously as any other treatment for an illness. The health of the American public is at stake, and it is up to public health interventions to stop this increasing and damaging epidemic. There need to be drastic changes for the future, which include education about nutrition and physical activity.
In the year 2000, one- fifth of schools did not require physical activity at all (7). Education about nutrition and physical activity should be integrated into teaching curriculums around the country. It is important that health behaviors be established at a young age, so that they can be continually practiced throughout life (11). Young children who are obese have a 70 percent greater chance of remaining obese into adulthood (6). Currently, sixty percent of adults in the United States don’t get regular physical activity (6). Had these inactive adults been trained in a healthy lifestyle from a young age, perhaps they would have been more inclined to continue this healthy lifestyle into and throughout adulthood.

So what?
Problems lie within society, within its well-established ideals and norms which are neither perfect nor ideal. The growth of obesity over the past thirty years has created a new and serious health problem which hasn’t yet been dealt with effectively. There are many factors which are related to obesity including family, culture, heredity and general environment. Obesity interventions have not worked well because of the three following reasons.
The media promotes a thin image instead of a healthier image. Advertising and agenda setting theories explain how the media has such a strong influence over people’s actions and beliefs. The mass media is one main outlet through which the public’s ideas are expressed. The media is everywhere and it is sending the wrong ideas about body image. Public health must challenge and change society’s views of body image. Health interventions must be taken seriously and be a part of everyone’s life. Because a thin image is considered better than a healthier one, many individuals who are obese may turn to exercise in order to lose weight, rather than exercise for their health and well-being. Although there are countless benefits of weight loss, what happens to those who do not believe that they are capable of losing weight?
Self efficacy and social cognitive theories are two major behavioral theories which help to explain how individuals from different backgrounds may or not believe they are capable of completing a task- such as exercise (5). Self efficacy is an important predictor of physical activity (11). By giving broader community support and reinforcing a positive self- image, public health interventions can make an impact on health.
However, physical activity is not a top priority among Americans, which is bad news since over thirty percent of adults are obese (14). Successful exercise interventions would take into account that socioeconomic status plays a major role in prioritizing. Interventions must be tailored to different cultures and communities. These interventions must be framed in a way which stresses the benefits of physical activity, and their impact on one’s life.
The negative stigma attached to being obese does more damage than good. Obese individuals are more likely to have a negative self- image than people who are at a normal weight (11). This negative stigma may discourage individuals from seeking out help for their obesity. Labeling theory states that when individuals are labeled as part of a group, they tend to take on the tendencies of that group (5).
Public health as the preventive science hasn’t prevented anything yet. But by taking one’s life circumstances, culture or financial situation into consideration, public health interventions can stress the importance of exercise in a way that reaches individuals from all backgrounds. It is important for everyone to be healthy, not only those who can afford to be.

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15. Kantrowitz, B. Newsweek. Why Women Lose Weight- or Don’t. 2007.

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