The VERB and Small Step Campaigns: Flawed Approaches to Ending Childhood Obesity in the United States – Erin Migausky

Eighteen percent of children between the ages of 6 and 11 in the United States are overweight, as are 17.4% of adolescents between the ages of 12 and 19 (1). The prevalence of overweight children and adolescents has continued to grow. Since 1971, the prevalence of overweight children between the ages of 6 and 11 years increased from 4% to 18.9% and the prevalence of overweight adolescents between the ages of 12 and 19 increased from 6.1% to 17.4% (2-4). As it does in adults, obesity in children leads to many health complications, including endocrine, cardiovascular, gastrointestinal, pulmonary, orthopedic, neurological, dermatologic, and psychosocial problems (5). These obesity-related problems will plague children into adulthood and result in premature disease and death (6,7).

Childhood obesity is obviously a fast growing problem in the United States, with most obese children going on to become obese adults. The Surgeon General has predicted that obesity will surpass smoking in causing preventable diseases (8) and death and the impact on health care costs continues to skyrocket. The United States recognizes the problem and has taken action with the creation of several government-sponsored campaigns aimed at increasing healthy lifestyles, including two campaigns aimed at reducing childhood obesity - the VERB and Small Step campaigns. The VERB campaign was aimed at increasing physical activity in “tweens” between the ages of 9 and 13 years as well as involving parents and other adult influencers to help them achieve this goal (9). The campaign ended in September 2006. The Small Step campaign, which is ongoing, was originally targeted to adults and a companion campaign targeted to children aged 6 to 11 years was developed in November 2005. The focus of the campaign was on the importance of eating healthy and being physically active and how accomplishing these two things was “simple and free” (10,11). However, the VERB and Small Step campaigns are flawed interventions because they place a heavy emphasis on personal responsibility and do not address important contributors to childhood obesity such as social, community, and environmental factors.

Rational Decision Making

Children are not as capable of rational decision making as are adults, yet the VERB and Small Step campaigns rely largely on models and beliefs that assume children will take personal responsibility for changing their behavior. A large portion of children’s behavior is influenced by their social contacts and experiences, especially by parents and adult role models, yet these campaigns did not take those social factors into account. Although they claimed to incorporate adult involvement, most parents and other adults surveyed were not aware of the VERB campaign (12). Assuming that children would or could choose to lead healthier lifestyles after being exposed to these campaigns is a significant flaw.

According to Social Learning Theory, people learn to do a behavior because they observe others doing that behavior (13). Children, especially, learn to behave in certain ways by modeling their parents, with whom they spend the majority of their time (14,15). On a daily basis, they observe their parents doing everything from eating, drinking, going to work, interacting both with each other and others, arguing, and solving problems. The way that a child behaves in turn is largely related to what they learned from observing their parents. Many parents make unhealthy lifestyle choices, such as leading a sedentary lifestyle and eating poorly, and children learn these behaviors from them and other adults in their life. Most children are not developed enough to be capable of rationally deciding to make large-scale changes to their learned behavior until they move into adolescence. Both campaigns assume that rational decision making is taking place and that children will change their behavior if they learn that eating healthy and exercising is beneficial. However, as most children are learning behaviors related to a healthy lifestyle from observing their parents, the campaign’s messages are not going to influence the behavior if they do not fit into the child’s social context. Children are not going to be able to rationally make a connection that the ads’ messages of eating healthy and exercising may be better than their current behaviors.

A study by Strauss and Knight in 1999 looked at the influence of the home environment on the development of obesity in children and found that “children with obese mothers, low family incomes, and lower cognitive stimulation have significantly elevated risks of developing obesity, independent of other demographic and socioeconomic factors” (16). Since the main goal of the campaigns is to reduce the prevalence of childhood obesity, the target audience is presumably children who are already overweight or who are at high risk of becoming overweight. If the findings of the above study are true, children at risk for becoming overweight are likely not to be learning healthy eating habits at home if their parents are obese and they are not in a position to make a lifestyle change due to both limited socioeconomic and cognitive factors.

In 1998, Birch and Fisher looked at the development of eating behaviors among children and adolescents and found that children’s food preferences developed as result of observing the eating behaviors of their parents (17). Parents generally buy the food that is offered in the household, so children often do not have the option of eating healthy foods if their parents do not buy them. If parents are eating diets high in saturated fat and not exercising, their children are likely to follow suit (18). Furthermore, cultural and socioeconomic factors influence how parents are able to model healthy behavior for their children. Families with two working parents or single parents often do not have the time to prepare nutritious foods and unhealthy meals are eaten on the run. Also, families may not be able to afford to buy healthy foods or do not have an abundant supply of healthy foods available in their neighborhoods. As an example, the San Jose Mercury News/Kaiser Family Foundation Survey on Childhood Obesity done in 2003 found that Hispanic parents believed that price and convenience were the most important factors when buying food for their households (19). Inexpensive and easily obtained foods are generally not healthy foods.

By failing to recognize that children are not as capable of rational thoughts as adults and that their behavior and choices are shaped by modeling those of their parents, the VERB and Small Step campaigns were flawed.

Peer Groups and Social Norms

For children, fitting in with their peer group is extremely important and is a strong predictor of behavior. Making healthy eating and exercise “cool” by changing social norms is NOT what the VERB and Small Step campaigns succeed in doing. They fail to take the peer group into consideration and that is a major absence.
According to Social Network Theory and Social Expectations Theory, people form their beliefs and make decisions about behavior as part of their relationships in their social networks and behavior is largely dictated by social norms (20,21). Outside of the home, a child’s development is influenced by many factors, of which the three most important are peers, play, and television (22). For children, if playing with friends involves eating, watching television, or playing video games, an individual child is more likely to not deviate from the social norms of the group, even if he is aware that his behavior is not always healthy.

In today’s culture, a huge portion of child play involves eating snack food, watching television, playing videogames, and using the computer. Studies have shown that these sedentary activities lead to childhood obesity (23-27). They are the current social norms, with children engaging in these activities alone, with their families, and in peer groups. Children spend an average of 5-and-a-half hours per day using some form of media (28). The VERB and Small Step campaigns had the right idea when they started airing television ads, as this would likely reach their target audience. However, the small-budget campaign ads are far outnumbered by ads for candy, fast food, snack foods, soft drinks, and sweetened breakfast cereals and they cannot compete with those more prevalent, expensive ads, which have a budget of about $1 billion per year (29). In order to succeed in helping to reduce childhood obesity, the VERB and Small Step campaigns should have used on a non-media approach to focus on children’s peer interactions and tried to challenge the social norms that exist surrounding physical inactivity and food consumption. In addition to television ads, both campaigns incorporated an interactive internet aspect, where children could log on to the websites and take quizzes, play games, and watch the ads. The sites also provided links to other websites that children may be interested in perusing. If one of the campaign’s goals is to increase physical activity, providing interactive web tools is only encouraging the social norm of sedentary activities. In addition, it excludes children who do not have computers or internet access. A heavy reliance on media is not the way to challenge the social norms that are leading to childhood obesity.

A 2007 article in the New England Journal of Medicine by Christakis and Fowler found that “obesity appears to spread through social ties” (30). Having obese friends or family members was associated with being obese by affecting one’s perception of the social norms regarding the acceptability of being obese and one’s adoption of specific behaviors such as eating unhealthy foods and not engaging in physical activity. The study concluded that the spread of obesity in social networks appears to be a factor in the obesity epidemic. Although this study was done using adult subjects, the idea can be applied to the issue of childhood obesity. As more and more children are becoming obese, it is becoming more socially acceptable. Obese children are less likely to eat healthy foods or engage in physical activity, which results in an acceptance of sedentary behavior and reinforces the effects of the peer group and social norm influences. Any campaigns aiming to curb the problem of childhood obesity need to take these social trends into consideration. They should use the Social Network and Social Expectations theories to their advantage, by changing the current social norm that is leading to the United States’ childhood obesity epidemic.

Community and Environmental Factors

The VERB and Small Step campaigns focused on the importance of exercise and being active and the Small Step campaign incorporated an additional focus on healthy eating choices. However, many children do not live in neighborhoods were it is safe to play outside unsupervised or to walk/bike to school and healthy food options are not always readily available in their communities. Neighborhood disadvantage is consistently associated with obesity due to the unavailability of stores where healthy food can be purchased and lack of facilities for physical activity (31-34). Community-level factors play a strong role in shaping behavior and the VERB and Small Step campaigns do not address these issues, including the fact that people lacking basic resources have the highest risk for serious illness and premature death, often caused by obesity.

To encourage children to become more physically active, both campaigns have a series of advertisements that show a large group of children actively playing with each other, in settings such as a park and a swimming pool. The majority of these ads do not show any adults, unless the adult is a celebrity being used to promote the ad. Unfortunately, the reality for most children in today’s culture is that they are not free to simply run outside to the park for fun or wander to the local pool for water sports. Even “safe” neighborhoods do not allow children the freedom to be unsupervised, especially younger children. Children do not need to be convinced that playing is fun, but they do have barriers that often make regular physical activity difficult to obtain. The VERB and Small Step campaigns did not address ways to overcome these barriers in their ads.

A study by Gordon-Larsen et al in the journal Pediatrics looked at environmental factors that contribute to health disparities in children, including obesity (34). They found that geographic areas with a low socioeconomic status and a high minority population had fewer physical activity facilities available, which resulted in those groups participating less in physical activity and being more overweight. This indicates that even if children have a strong desire to participate in physical activities, it is often impossible because of socioeconomic or other factors that are out of their control. The campaigns’ ads, which show fit, happy children playing in an idyllic setting do not allow for a child to believe that she can also participate in these types of activities because the ads portray a scene which is far removed from her reality. Further, by only showing physically fit children in the ads, they do not resonate and connect with the large audience of children who are already overweight.

A recent study by Franco et al published in the American Journal of Public Health looked at the association between the availability and price of food and diabetes and obesity in poor Baltimore neighborhoods (33). They found that the price of healthy food (food that was recommended by the 2005 Dietary Guidelines for Americans) was approximately 20% higher, if available at all, in neighborhood grocery or convenience stores than in supermarkets. Supermarkets that offer healthier foods at more reasonable prices are often located nowhere near low SES neighborhoods. This problem is magnified when one considers that most of the people in poor neighborhoods do not have cars and are therefore not able to shop at large supermarkets. Instead, they shop at local grocery or convenience stores, which sell items such as soda, chips, and canned foods rather than fruit, vegetables, whole grains, and fat-free dairy products. This barrier of access to healthy foods was not addressed in any way by the VERB and Small Step campaigns. As mentioned above, obesity has been shown to be linked to the availability of healthy foods and by not addressing this issue, the campaigns are not reaching a large portion of their target audience.

The VERB and Small Step campaigns both noted that they were hoping for collaboration with schools to increase physical activity and promote healthy eating. However, many schools have cut physical education and after-school athletic programs due to cost. Children who were once getting some amount of physical activity through an organized school program are increasingly losing that opportunity. In addition, school vending machines and cafeterias offer unhealthy foods that are easy for children to buy. If schools do not have money to offer physical education programs and do not have policies regarding the type of foods sold on their premises, it seems unlikely that they would be able to provide the sort of collaboration for which the campaigns were hoping. Failing to take community and environmental factors into consideration was a flawed aspect of the VERB and Small Step campaigns.

Implications/Recommendations for Future Public Health Programs

Despite government-sponsored interventions, childhood obesity is a fast-growing problem in the United States. If we do not stop or slow its growth, the implications for our health care system our huge. Future public health interventions must focus on the social factors contributing to childhood obesity in order to be successful. Eating unhealthy foods and not exercising result in obesity, but we must understand the reasons behind eating and exercise choices. Because there are so many factors influencing a child’s behavior, it is not realistic to try to change everyone’s behavior at once. Perhaps more targeted interventions would be more effective. A model on which to base an intervention that might work to fight childhood obesity is the Diffusion of Social Innovations Model. If a campaign could aim to get a few influential people to adopt a healthier lifestyle, these early adopters could perhaps spur on others to assume this lifestyle as well. As noted above, social norms are a big predictor of behavior, so if we could begin to change those, we may see better results. At the same time, since parents and other adults are such influential models when it comes to childhood behavior, a campaign aimed at promoting healthy behavior among adults could be the backbone for campaigns aimed at children. Finally, it is important the childhood obesity remain on the public agenda. This has shown to be effective for anti-smoking efforts and there is no reason to believe that it would be any less effective in helping to curb the country’s childhood obesity epidemic.

Conclusion

Childhood obesity is a huge problem in the Unites States. Evidence shows that despite attempts at interventions, the obesity rate is steadily rising. In order to be successful, an intervention aimed at reducing childhood obesity must address important contributors to childhood obesity such as social and environmental factors. The VERB and Small Step campaigns were good in that their goal was to curb this growing epidemic by promoting healthy eating and physical activity, but both approaches were flawed because they failed to successfully address the major influencers in children’s lives – parents, peers, and community.

REFERENCES

1. NHANES data on the Prevalence of Overweight Among Children and Adolescents: United States, 2003–2004. CDC National Center for Health Statistics, Health E-Stat. http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight.
2. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among U.S. children and adolescents, 1999–2000. JAMA 2002; 288:1728–1732.
3. Hedley AA, Ogden CL, Johnson CL, et al. Prevalence of overweight and obesity among US children, adolescents, and adults, 1999–2002. JAMA 2004; 291:2847–2850.
4. Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of overweight and obesity in the United States, 1999–2004. JAMA 2006; 295:1549–1555.
5. Unger R, Kreeger L, Christoffel KK. Childhood obesity. Medical and familial correlates and age of onset. Clin Pediatr (Phila) 1990; 29:368-73.
6. van Dam RM, Willett WC, Manson JE, Hu FB. The relationship between overweight in adolescence and premature death in women. Ann Intern Med 2006; 145:91-7.
7. Must A, Jacques PF, Dallal GE, et al. Long-term morbidity and mortality of overweight adolescents. A follow-up of the Harvard Growth Study of 1922 to 1935. N Engl J Med 1992; 327:1350-5.
8. US Department of Health and Human Services, The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity (Rockville, MD: US Department of Health and Human Services, Public Health Service, Office of the Surgeon General, 2001).
9. Center’s for Disease Control and Prevention: Youth Media Campaign. www.cdc.gov/youthcampign.
10. Smallstep Adult and Teen. www.smallstep.gov.
11. Smallstep Kids. http://smallstep.gov/kids/flash/index.html.
12. Parker-Pope T. Passing the Ball: Hip Campaign That Got Kids to Be Active Looks for Its Next Move. The Wall Street Journal. September 5, 2006. http://online.wsj.com/article_email/article_print/SB115741165465153226-lMyQjAxMDE2NTA3NjQwMTYxWj.html.
13. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007. p.52.
14. Stanrock JW. Children, 5th edition, Boston, MA: McGraw Hill, 1997. p.67.
15. Westen D. Psychology: Mind, Brain, and Culture, New York: John Wiley & Sons, Inc., 1996. p.206.
16. Strauss RS, Knight J. Influence of the Home Environment on the Development of Obesity in Children. Pediatrics 1999; 103:e85.
17. Birch LL, Fisher JO. Development of Eating Behaviors Among Children and Adolescents. Pediatrics 1998; 101:539-49.
18. Oliveria SA, Ellison RC, Moore LL, et al. Parent–child relationships in nutrient intake: the Framingham children’s study. Am J Clin Nutr 1992; 56:593–598.
19. San Jose Mercury News/ Kaiser Family Foundation: Survey on Childhood Obesity. March 2004.
20. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007. p.56-57.
21. SB721 class notes. October 4, 2007.
22. Stanrock JW. Children, 5th edition, Boston, MA: McGraw Hill, 1997. p.320.
23. Dietz W, Gortmaker S. Do We Fatten Our Children at the TV Set? Obesity and Television Viewing in Children and Adolescents. Pediatrics 1985; 75:807-12.
24. Gortmaker S, Must A, Sobol A, et al. Television Viewing as a Cause of Increasing Obesity among Children in the United States, 1986-1990. Arch Pediatr Adolesc Med 1996; 150:356-62.
25. Crespo CJ, Smit E, Troiano RP. Television watching, energy intake, and obesity in US children: results from the third National Health and Nutrition Examination Survey, 1988-1994. Arch Pediatr Adolesc Med 2001; 155:360-5.
26. Lowry R, Wechsler H, Galuska DA, et al. Television viewing and its associations with overweight, sedentary lifestyle, and insufficient consumption of fruits and vegetables among US high school students: differences by race, ethnicity, and gender. J Sch Health 2002; 72:413-21.
27. Proctor MH, Moore LL, Gao D, et al. Television viewing and change in body fat from preschool to early adolescence: The Framingham Children's Study. Int J Obes Relat Metab Disord 2003; 27:827-33.
28. Kaiser Family Foundation: The Role of Media in Childhood Obesity. February 2004.
29. Advertising, Marketing, and the Media: Improving Messages. Fact Sheet. Institute of Medicine of the National Academies. September 2004.
30. Christakis NA, Fowler JH. The Spread of Obesity in a Large Social Network over 32 Years. N Engl J Med 2007; 357:370.
31. Powell LM, Auld MC, Chaloupka FJ, et al. Associations between access to food stores and adolescent body mass index. Am J Prev Med 2007; 33:S301-7.
32. Galvez MP, Morland K, Raines C, et al. Race and food store availability in an inner-city neighbourhood. Public Health Nutr 2007; :1-8.
33. Franco M, Nandi A, Glass T, Diez-Roux A. Smoke before food: a tale of Baltimore City. Am J Public Health 2007; 97:1178.
34. Gordon-Larsen P, Nelson MC, Page P, Popkin BM. Inequality in the Built Environment Underlies Key Health Disparities in Physical Activity and Obesity. Pediatrics 2006; 117:417-24.