Challenging Dogma - Fall 2007

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

Wednesday, December 12, 2007

The Massachusetts 5-2-1 Healthy Choices Obesity Prevention Program: The Limitations and Failures of this School Based Program- Nicole A. Metes

Childhood Obesity is a growing epidemic around the world and has become an increasingly chronic problem in the United States (1, 2). In the United States, children are classified as being overweight when they have a Body Max Index (BMI) for sex and age over the 85th percentile. It has been proposed that children should be classified as being obese when they are over the 95th percentile, although this is not a universally accepted method of analysis that all researchers use (3, 4). Obesity has become an epidemic according to the Third National Health and Nutrition Examination Surveys (NHANES III). Over the past 20 years childhood obesity has doubled in children from ages 6 to 11 and has tripled in numbers for teenagers (5). Studies have shown that two thirds of children, who are over age 10 and are obese, will become obese adults (6). Childhood obesity is influenced by various factors including genetic predisposition, poor diet, lack of physical activity, family, social factors, and psychological factors (7). The impact of childhood obesity has been linked to various chronic health problems including type II diabetes, coronary heart disease, high blood pressure, asthma, cancer, decreased quality of life and life expectancy (8). The recent rise in childhood overweightness and obesity can be attributed to various complex changes in society and the environment over the past two decades, which have primarily influenced individual’s nutrition and lifestyle (7).

The Healthy Choices 5-2-1 Obesity Prevention Campaign was introduced as a public health intervention for middle school aged children in the state of Massachusetts. This school based initiative was geared to reverse the trend of childhood obesity and was a joint collaboration of the Massachusetts Department of Public Health (MDPH) and the private health care organization, Blue Cross Blue Shield of Massachusetts (BCBSMA). The Healthy Choices 5-2-1 message is that children should eat 5 fruits and vegetables, have less than 2 hours of television and at least 1 hour of activity or exercise daily. The objective of the program is to increase opportunities for children to participate in physical activity programs at school and increase knowledge regarding the health benefits of proper nutrition and increased physical activity (9). The main components of this school based program are geared towards improving nutrition quality in school meals and in vending machines, increasing opportunities for physical activity during the school day, incorporate nutrition and health education into the curriculum, and the 5-2-1 social marketing campaign. Although this public health intervention does include a multifaceted approach, it fails to provide tools to promote self-efficacy, address barriers outside of the classroom, and focus on the importance of children’s attitudes and social norms.

Healthy Choices 5-2-1 lacks tools to promote self-efficacy
The Healthy Choices 5-2-1 approach fails to account for the individual’s promotion of self-efficacy as demonstrated by the Social Cognitive Theory. The concept of self-efficacy is characteristic of a person’s confidence that he or she can perform a behavior regardless of intention. According to Albert Bandura, the originator of the Social Cognitive Theory, “the idea of self-efficacy as a key element in how people change behavior moves beyond the mechanistic conditioning process of behaviorism and gives individuals a role in their own process of change” (10, 11). According to this theory, children must believe that they have control over changing their behavior in order to attain the goals prescribed in the intervention. Self-efficacy will influence the child’s beliefs about the behavior, will determine whether or not the behavior is adopted, how much effort they put towards the behavior once it is adopted, and how long the behavior is sustained over time (12). A child with a high level of self-efficacy for a new behavior will have more confidence and be able to overcome obstacles towards the behavior. On the other hand, a child with a low level of self-efficacy for a new behavior will be less likely to attempt the behavior or believe the change in behavior is too difficult (13). The theory of self-efficacy can be put into practice by promoting that exercise is fun and easy and highlighting the rewards that children will easily grasp, such as feeling great and increasing fitness.

The 5-2-1 Healthy Choices initiative addresses education on healthy lifestyle, promotes healthy nutritional choices, increased physical activity, and proposes limits to television watching in order to encourage physical activity. However, this initiative does not provide the parents with tools for promoting self-efficacy to help them model healthy eating and exercise behaviors to their children at home. Studies show that children’s self-efficacy is strongly influenced by modeling behaviors, the surrounding behaviors of the individuals in their lives that they observe as being positive and rewarding or negative and not rewarding (11). The premise of the 5-2-1 campaign is intended for the child’s entire day; in fact the majority of the components of this program will be occurring after school. However, this program does not address the child’s parents modeling behaviors once they are home, which is important for positive reinforcement and social persuasion.

Studies show that children that have two obese parents are at greater risk of becoming obese, which may be due to genetic factors but most likely due to parental modeling of unhealthy eating and exercising behaviors (16). Additionally, fifty percent of parents of elementary school aged children do not exercise (15). Parents that do not have self-efficacy towards a healthy physical and nutritious lifestyle will have a difficult time supporting and influencing their children towards making healthy choices. Children may bring home educational materials or brochures about the Healthy Choices 5-2-1 program that promotes healthy eating habits and exercise, ultimately the parents are the ones that make the decisions on what types of meals to prepare and make rules regarding television watching and encourage exercise. In research where parents were involved in the intervention and acted as role models in promoting healthy lifestyle and nutrition in children, outcomes were improved and showed an increase in voluntary participation by children in programs (14).

Therefore it is important to provide parents with the proper tools to promote the self-efficacy of children at home to engage in exercise and healthy eating. Receiving a brochure on the campaign hardly merits the promotion of this intervention at home and may give parents a false sense of security since they may consider this to be exclusively a school day program.

Healthy Choices 5-2-1 fails to consider the barriers to behavioral change as set forth by the Health Belief Model
The 5-2-1 Healthy Choices initiative fails to address the barriers to behavioral change, such as access to fresh and nutritious foods, limitations to outdoor & indoor physical activity, and television. The Health Belief Model (HBM) assumes that everyone has access to the same level of knowledge and information to make a rational decision about behavioral change (19). According to the HBM, the likelihood of adopting a healthy behavior is increased if the perceived barriers to the action are low (20).

Addressing the barriers to implementing the Healthy Choices 5-2-1 program are crucial to the success of the campaign since the contributing factors may limit the accessibility and knowledge required for this intervention to occur. The first barrier this intervention fails to address is the accessibility and implementation of a healthy diet which may be influenced by financial, physical, educational, psychological, or cultural factors. The Healthy Choices initiative is provided with financial assistance from the joint collaboration of BCBSMA and MDPH for healthy school lunches, health and nutrition education and increased physical activity as part of the school’s curriculum. However, this does not address the costs associated to extend the healthy meals, health and nutrition education, and physical activity at home. Fresh fruits and vegetables can be exorbitantly costly and time consuming to prepare; therefore, it may be difficult to coordinate a diet for a child that follows the 5 fruits and vegetables a day criterion. In addition, studies have shown that taste, cost, availability, and food preference, are the most important factors people consider when making dietary choices. Nutrition is not on the top of the list (18). Fast foods and prepared meals are less costly and time consuming in contrast to the cost and time associated with making meals from fresh produce and ingredients. However, prepared meals and fast foods are typically higher in sodium, calories, and fats and are not as nutritious as home cooked meals (21). Physical accessibility to healthy food choices may also be a challenge for some families. Fresh fruits and vegetables are more likely to be sold in supermarkets, farmers markets, and grocery stores which are sparse in low income and urban areas (17). Subsequently, the burden of distance, time and costs associated with accessing fresh produce may limit the amounts a family is able to consume.

The second and third barrier’s this campaign fails to address are limiting television watching to 2 hours a day and increasing physical activity to at least one hour a day. This may be challenging for some families where both parents work full time, and may not be home to supervise their children after school, either themselves or through child care. A contributing factor to limiting television may be lack of adult supervision, some families may not be able to afford a babysitter after school or pay for after school activities, sports or programs that would entertain and occupy their children until they get home. Excessive television watching results from children not having other options to pass the time after school, such as toys and indoor games, accessibility to neighborhood youth centers, or recreational centers. These types of barriers to physical activity primarily affect families that live in depressed or urban areas where there are a lack of playgrounds and recreation centers. Often in these neighborhoods, there may also be safety concerns about children being outdoors, such as limited adult supervision, heavy traffic on neighborhood streets, and being exposed to violence or drugs which may keep parents from letting their children play outdoors(22). It is easy to see why children end up playing indoors with video games and watching television, when their outdoor environment is not conducive to child’s play.

Healthy Choices 5-2-1 fails to account for the child’s attitudes and social norms
The Healthy Choices 5-2-1 initiative fails to address children’s attitudes and social norms as set forth by the Theory of Reasoned Action (TRA). TRA proposes that a person’s behavioral intention is dependant upon their attitude towards the behavior and the subjective norms (23, 24). In other words, a child’s voluntary behavior is predicted by his or her attitude towards the behavior and how they feel others will view them if they perform the behavior.

This intervention fails to provide tools to address the child’s attitudes towards a healthy lifestyle as set forth by the Healthy Choices program. The child may be educated on the benefits of eating healthy, limiting television watching and increasing physical activity, but it’s their beliefs about the particular behavior that will dictate action. A child may believe that the goals of the 5-2-1 program are good for them, but they may also believe that losing weight means things that are unpleasant to them, such as cutting back on junk foods and sweets, missing some of their favorite shows, and that exercise is painful or uncomfortable. The theory of reasoned action focuses on rational cognitive decision making involved in adopting or changing a behavior. The child’s attitude concerning healthy lifestyle habits needs to not only be positive, but the child needs to want to make a change and feel that making a change will be beneficial. The child’s attitudes are largely influenced by their social group and influenced by other children having positive attitudes towards the behavior. Since two thirds of middle school aged children are overweight, one can speculate that the social norm is to eat junk food, play computer games or watch television for hours at a time and have low levels of physical activity (6). This intervention is geared towards reversing the current overweigthness and obesity trend, but does not provide adequate tools for parents, teachers, and children to significantly skew children’s attitudes and address social norms. Some necessary tools for this type of intervention to occur would be to encourage parents and teachers to be positive role models and have positive attitudes towards healthy eating and physical activity around children. Children must not only believe in themselves and have self efficacy, but their attitudes towards changing or adopting healthy behaviors must be positive and they have to feel good about making the changes after weighing the other options.

Implications for Future Public Health Programs and Recommendations
The Healthy Choices 5-2-1 program’s multifaceted education strategy that promotes healthy lifestyle habits has some failures that I believe can be detrimental to the success of this public health intervention. I believe that the school based intervention needs to extend its resources to the parents and provide tools and that will help foster these healthy lifestyle choices. An after school component may be a very valuable tool for parents and educators to promote healthy behaviors by providing fun sports or activities that would encourage physical activity amongst other children and minimize the lag time at home where children would be more prone to watch television until a parent comes home. These types of resources and activities require funding; however the implications of not supporting these types of programs have negative consequences that drastically outweigh the costs. Studies show that health care expenditures in child related obesity have increased 3 fold over the past 20 years (25). Obesity in children has also been shown to lower life expectancy by 5-20 years (26). Other studies show that 1 in 4 overweight children have impaired glucose tolerance, and 60% of those children have at least one risk factor for heart disease (27). As the rate of obese children increases, so do the associated medical complications and ultimately medical costs that may become taxing to society.

Obesity has become an epidemic in America, and this condition is perceived as a disease that is linked to other chronic health conditions. The 5-2-1 Healthy Choices campaign could be tailored to account for self efficacy, attitudes and perceived barriers to health and I believe this could drastically improve the outcomes of this public health intervention. I believe that children that have positive attitudes towards healthy lifestyles, and believe they can in fact make the changes in their own lives, in conjunction with addressing the barriers that restrict or limit these healthy choices are critical towards a successful intervention. Having the family and social support, in addition to the support the child receives at school towards changing and adopting these behaviors is crucial for a sustainable and effective intervention to occur.

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