Challenging Dogma - Fall 2007

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

Thursday, December 13, 2007

Nutritional Interventions in Elementary Schools Fail to Ameliorate Childhood Obesity– Charlotte DeLeo

Childhood obesity and public health’s educational approach
Childhood obesity is arguably the worst health trend our country faces, due in part because of its potential prevention (10). The incidence of overweight and obese children is rising rapidly and there is no indication that it might slow down (17,31). According to the Centers for Disease Control and Prevention, the prevalence of overweight children between the ages of six to eleven years old has risen from 6.5% to 18.8%, and between the ages of twelve and nineteen has risen from 5.0% to 17.4% in the past three decades (21). Childhood and adolescent obesity is a particular concern because at a young age, kids are unconsciously forming their lifelong habits (4). Overweight children are predictably destined to become overweight adults (10). As their waistlines grow, children unknowingly increase their risk factors for a myriad of diseases in their adult life such as heart disease, type-2 diabetes and hypertension. This has devastating implications for future health care costs. Furthermore, children do not realize through their young perspective that unhealthy eating habits and physical inactivity inadvertently affect their energy levels, mood, social relationships, self-confidence and general well-being.
Schools should recognize the great opportunity they have to improve the health of future generations; they provide an ideal setting for implementing public health interventions because kids spend the majority of their day at school (19,26). The current public health approach taken to address the childhood obesity epidemic has been to implement school-based programs where teachers incorporate nutrition education into the curriculum of other classes. The rationale is that programs will teach positive dietary messages and knowledge that will influence the dietary behavior of children (20). Although there are many nutritional based programs nationwide, childhood obesity has reached epidemic proportions.
A recent study assessed the overall effectiveness of school-based prevention programs in reducing obesity and found that only four of 57 programs reported both statistically and clinically significant outcome differences between intervention and comparison groups (28). Although there have been many childhood obesity programs, findings show that these interventions are only producing meager results without meaningful public health impacts (3). Results, if any, are short-term and after a short period of time effects are diminished by personal and social barriers not addressed by current interventions (32).
The current design of educationally based programs is not effective. Educational interventions based on traditional behavioral theories fail because they are too confined to the classroom and assume that knowledge will translate directly into behavior. There is not a goal to improve children’s self-efficacy which is the foundation for individual behavioral change. Finally, school-based programs are too isolated and need to take a more collaborative approach including extending support to families and teaming up with the community to promote active living.
Failure to incorporate physical activity programs alongside nutrition
Public health’s method of educational approaches in elementary schools is flawed because the programs largely draw on Social Learning Theory, which assumes nutritional knowledge will translate into kids changing their health behavior. Social Learning Theory posits that people learn from one another via observation, imitation and modeling (7). The assumption is that children will observe a teacher and be motivated and capable to transfer that knowledge into their own behavior. According to Social Learning Theory, one forms an idea of how new behaviors are performed by observing others, and this coded information serves as a guide for action on future occasions (12). In reality, regardless of what a child learns, there is no way to predict that a child is able to perform that behavior. A child also has no desire to make a change unless they feel motivated to do so. A teacher is not an empowering role model who effectively motivates a child to change his or her attitude towards the issue of nutrition. Having an authority figure dictate good nutrition in a non-enthusiastic, non-engaging tone does not inspire a child to pick fruits or vegetables over more sugary foods they have decided are more tasty and fun to eat. Physical activity programs need to be implemented in schools alongside nutrition, so that children will perform healthy behavior, rather simply observing it. In addition, through sports programs, children can serve as models to their own peers, which may serve as a more effective model than authority figures.
The failure in limiting interventions to the classroom is that exercise is being largely ignored as a factor which will improve childhood obesity. Children need to be given the opportunity to feel the benefits of physical activity. Many factors dictate whether a child will be physically active and a child’s attitude toward the activity will significantly affect their participation (15). Failure to incorporate sports programs tends to misplace the emphasis on weight without the balance of a total health message which can lead to unhealthy and unsustainable dieting (15). When children enjoy exercise, it will demonstrate to them that food is not evil, but a balance should exist between energy input and output. Eating and exercise are both fun and important. School-based policies fail to give adequate opportunity for exercise, and policy is only worsening as schools cut out critical physical activity programs.
Even the most basic program of physical education classes are being sacfrificed more and more due to funding. Faced with shrinking budgets and increased pressure to perform on standardized state tests, physical education (PE) classes have been replaced with classroom nutrition programs that only encourage children to stay active instead of offering them the opportunity to exercise. In 2006, only 4 percent of elementary schools provided daily physical education and overall, 22 percent of schools did not require any physical education (30). If PE classes do exist today, they would be most useful to emphasize the behavioral skills associated with developing an active lifestyle, such as how to become less sedentary (15), rather than simply teaching new sports skills they can only use on certain occasions. In some cases, recess has also been cut out of a child’s school day. In 2005, between 12- 17% of elementary schools in the U.S. reported they did not provide daily recess (9). A survey of Chicago Public Schools found that out of 396 schools, only 43% of those offered recess (6). Recess should be a built into the daily schedule of every elementary school. Studies have shown that children experience more concentration problems on days without recess (11). It is an important break which allows children unstructured physical activity where they can release energy and stress, and restore their concentration for the classroom (11,26).
One strategy is that schools could encourage children to walk and bike to school (24). This would require crossing guards and bike racks outside the school. To make this possible in some areas, states may need to revamp sidewalks to make them safe enough, so parents can feel comfortable allowing their children to have that independence. A Walk or Bike to School Program might have a group of students go together accompanied by an adult to be safe enough. If active commuting programs are feasible and implemented, they have the potential to establish early habits of lifestyle physical activity that can be sustained through adolescence and adulthood (29).
Ideally, schools need to incorporate after school sports programs were children become part of a team, build better relationships with their peers to encourage each other, and let them feel the rewards of physical activity. One intervention tested the efficacy of an after-school dance program to reduce television viewing and weigh gain in African-American girls and the program succeeded with high participation, significantly reduced television viewing and trends towards lower BMI than the control group (22). Expanding after-school sports programs competitive and non-competitive will give kids the incentive to get moving and have fun, instead of going home to watch TV. Nutritional interventions are doomed to be ineffective if they are not paired with interventions to increase energy expenditure through physical activity.
Increasing self-efficacy and fostering positive attitudes towards healthy living
Education-based nutrition interventions have failed to address children’s individual self-efficacy- a major predictor of whether they will succeed or even attempt a new behavior. There needs to be a focus on increasing children’s attitudes, self-confidence, and self-efficacy. Based on Social Cognitive Theory, regardless if a behavior is positively modeled, children have to believe they are able to change their behavior in order to be successful (1,7). Teachers should focus on constantly offering positive affirmations to all children equally.
The concept of BMI “report-cards” that some schools have adopted as a policy for childhood overweight and obesity only breaks down a child’s self-confidence. Labeling a child as “fat” is absolutely detrimental to a child’s self-efficacy. These children are likely to have terrible body image and this strategy is guaranteed to isolate overweight kids, make them feel ashamed of themselves and perpetuates them towards negative self-image. The implications will inevitably lead to decreased academic performance, depression, hopelessness, and social problems with peers, teachers and siblings along with, body dysmorphia, eating disorders and lifelong unhealthy relationships with food (2).
Children will become motivated and be inspired to live healthy if the message comes from a voice that they feel more connected to, one that is less authoritative than that of a teacher (23,25,27). This channel of communication will build their self-confidence and make goals more realistic and appealing. It has been found that overweight youth engage in more intense activity when in the presence of peers (23). The “Peer Power” initiative in Dare County, North Carolina provides an excellent example of an effective peer-driven program that has produced positive health behavior changes in the areas of physical activity and nutrition. This initiative trains high school students to be health educators and mentors for younger elementary and middle school children, thereby making health education more relevant and interesting. Findings indicated that the program improved students’ nutrition and activity-related health choices significantly and also decreased average BMI by 4 percent in two thirds of students (27). Another similar program “Healthy Buddies” found a student-led curriculum which focused on nutrition, physical activity, and healthy body image improved healthy behavior in both the older and younger buddies, and older buddies showed weight loss (25). Peer-peer interactions and support can serve to increase kids’ excitement about getting active, increase energy levels, foster friendships and improve social bonds and feelings of acceptance (23). A positive support-system among classmates is essential for kids to feel mentally healthy and encourage them to participate. Programs that strengthen activity levels and peer-peer support systems will ultimately serve to relieve anxiety, boredom, possibly reduce youth violence and improve social problems, such as being teased, loneliness, or low self-esteem (26). By fostering positive attitudes and a positive social atmosphere, this improves the social environment for children to learn and grow in. In a type of atmosphere where they feel comfortable, children will develop improved self-confidence and feel more internally motivated to try new foods and not be lazy.
Food-policy changes within schools and parental participation to achieve continuity
Educational campaigns are too focused on individual level models and fail to consider the child’s environment as a major factor mediating behavior. Both the school environment and the environment children return to after school need to be considered. Based on the Stages of Change model, the major component that dictates potential relapse is whether the individual can maintain their behavior (7). A revised stages of change model with social influences as a component to the maintenance stage would be more helpful to use. The original Stages of Change model school nutritional programs seem to be based on fails to account for social influences, whether or not resources are available and familial support. The assumption is being made that children have the power to make healthy choices and that necessary resources are available to them, when in reality they often are not. Looking at current nutritional education programs, children are simply unable to maintain the behavioral change, or put what they learn into practice due to social and environmental blocks.
Beyond an educational campaign, this needs to be an institutional-level change, which would include simply replacing foods in cafeterias high in grease, fat, salt and sugar with more moderate ones. States, districts and schools must examine their food-related policies and make healthier alternatives more accessible to students in terms of appearance, taste and cost (16). One study assessed that American students at 86% of high schools, 62% of middle schools, and 21% of elementary schools have access to foods and beverages through vending machines, and there is widespread availability of food high in fat, sodium, and added sugars. The result is a paradox; when students are taught about good nutrition and healthy food choices in the classroom but are surrounded by a school environment offering primarily low nutritive foods, they receive an inconsistent message (18). There needs to be continuity in the message to convince students to change. Vending machines need to be eliminated during school hours to avoid the temptation and habits of snacking on innutritious items throughout the day when children should just wait until lunchtime to eat. Furthermore, the availability of competitive foods sold to children through vending machines and snack bars has been found to negatively correlate with fruit and vegetable consumption, displacing healthy foods and therefore contributing to excess fat and saturated fat intake (13,26). A child cannot be taught one lifestyle in the classroom and then enter a school cafeteria that is full of contradictions. Environmental changes are going to improve the health of children.
Nutrition should be a part of the general operating budget of state funding for schools. Children have to be given healthy food options because at a young age they do not necessarily have the perspective to seek out healthy foods on their own. By changing district policies on what is served in cafeterias, children will become healthier not only in terms of weight, but will also benefit by a decrease in hyperactivity and lethargy that follows a sugar-high and increased ability to focus. One example of the potential impact a change in the food-environment can have is with the Natural Ovens program in Appleton, Wisconsin where there has been a district-wide commitment to healthier eating and lifestyles. Policy makers in Wisconsin have decided to invest in feeding students quality, nutritious foods now, instead of potentially paying for health care costs associated with obesity in the future (5). Prior to the program’s launch in 1997, teens in the pilot school were described as rude, obnoxious and ill-mannered with so discipline problems a police officer was on staff. Since the beginning of the high school program, students became more calm, well-behaved with less angry outbursts and more receptive to learning. In the area middle schools, teachers report students more clam, less bouncy and more alert (5). The number of kids who have dropped out, been expelled, been found using drugs, carrying weapons or who have committed suicide has been zero in every category. Overall, throughout the 200 schools implementing this food-environment change, it is evident that kids enjoy the benefits (5) of better nutrition and how it makes feel both physically and psychologically. This exemplifies the possibility that schools can completely eliminate the grease and kids will learn to appreciate the fresh food. When kids are given the opportunity to eat better and experience positive results, the change will eventually become their habit.
Finally, children can never maintain what they practice for half their day if there is no there is no continuity to the parental sector. Nutritional education interventions fail to address the upstream source of students’ unhealthy lifestyles which starts at the family level and at home (14). Because parents provide a child’s contextual environment (8), they should be key participants in promoting a healthy and active lifestyle for their child. Children may go home and watch television for the rest of the night when some individuals have working parents who cannot be home. If there is a strong effort made at school to change the health behaviors of children then parents need to be aware of that and involved in helping their child maintain eating habits and physical goals. A partnership between teachers and parents should exist to promote realistic approaches for healthful eating for the family and suggestions for physical activities they can do with their kids outside of school. There needs to be family interventions that send home innovative flyers, encourage participation in community-based social and physical events that foster positive attitudes toward healthy living. National, state, and local leaders should encourage citizens to cooperate to establish state and local coalitions to plan and promote physical activity among young people and their whole families on a community-wide level.
Public school nutrition programs are flawed in a number of fundamental ways and therefore have failed to create consistent and lasting effects in kids. The internal motivation for nutrition and activity behavioral change is problematic with current methods of classroom-based nutritional education interventions. Schools need to divert away from solely educational endeavors and move towards taking real action. Simply educating a child is not enough; they need to feel the change of nutritious food themselves and decide it is the better choice. Once children feel the benefits of physical activity, exercise will become something they look forward to, seek out and want to do on their own. Elementary schools should consider this as an opportunity to inspire children to live healthier lifestyles, which will ultimately help kids build self-confidence, improve academic performance and foster better attitudes and support amongst peers.
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