Challenging Dogma - Fall 2007

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

Saturday, December 8, 2007

When No One Can Think of Something Better…Blame the Parents: The Metro-West Foundation’s Failed Approach To Childhood Obesity. -Andrew Mastey

Introduction:

TT The Centers for Disease Control and Prevention report various alarming statistics on their website using data from National Health and Nutrition Examination Surveys collected from 1976-1980 and 2003-2004. This just in! The children of America are fat and the problem is getting worse! The prevalence of overweight children aged 2-5 years increased from 5% to 13.9%, 6-11 years from 6.5% to 18.8%, 12-19 years from 5% to 17.4% (1). How is this possible? I do not have any idea what it was like from 1976-1980 but it does seem that today it is not possible to take a breath without first reading the nutrition facts about the air that you are about to inhale.

The FDA reports that Americans spend over 30 billion dollars a year on diet programs in an attempt to lose weight (2). The federal, state and local governments fund various programs designed to encourage weight loss among children and adults. Insurance companies provide discounts for fitness clubs as well as other financial incentives to reduce weight and promote health. In addition, there are countless foundations that aim to promote health through public campaigns. If one considers the statistics provided by the CDC, the valiant efforts by all parties have one thing in common. They are failures.

The initiatives that these groups use rely upon outdated and/or flawed theories of human behavior. Recently, several great initiatives have begun because some of these groups now understand why their campaigns have failed. One foundation however, has not seen the error in its ways. The MetroWest Community Health Care Foundation began a campaign at the beginning of the year that relies upon obsolete theories of behavior. Its obesity campaign was a flawed intervention because it depended on the Health Belief Model, improperly labeled both children and their parents, and disregarded the theory of self-efficacy. (Youtube Video of Commercial)

This campaign was launched through several media outlets. There was a television commercial, a number of billboards, and an advertisement in the Boston Globe. All of these can be found here: MetroWestkids Media. I should note that while I consider all of the components of this campaign flawed I will primarily focus on the television commercial. I do not think that one can understand the critique of such a campaign without seeing the campaign first. For that reason I have included the script of the commercial here: “Please stop. Look at our kids. An increasing number of them are overweight, on the road to obesity. The facts are clear. Obese kids could be facing a lifetime of health problems including depression, heart attack, stroke, and type II diabetes. Yes we know the risks, yet we keep dancing around the issue. It’s time to do something because obesity is robbing our kids of their future. Take a first step.“ The commercial presents an overweight child sitting at a desk with a number of adults, presumably America’s parents, dancing around him to distressing music.

Reliance on the Health Belief Model:

The campaign relies completely on the Health Belief Model. Proponents of such a model suggest that the perceived susceptibility and perceived severity of a behavior are compared to the perceived costs of the behavior. A cost benefit analysis leads to a specific intention that would then lead to a behavior (3). This model is fallible because a strong link between intention and behavior does not exist. This theory enables its supporters to disregard social influences such as socioeconomic status, access, and education. The theme that the campaign portrays is that “If you love your children you will make sure they are not fat. Even if you live in an inner-city neighborhood, work 3 jobs and have no access to healthier foods.” This is obviously an exaggeration but the premise of such a campaign is inappropriate at best. It would be virtually impossible to find a parent that does not know that childhood obesity increases the child’s risks for diseases such as heart attack and diabetes. Even ignorant celebrities, like Halle Berry and David Wells, that have disgracefully misinformed the public about the differences between type I and type II diabetes realize that it may have something to do with weight (4). If we know that obesity causes disease and we know that disease is bad, then why would the levels of overweight children increase if this were a rational process? Remember, U.S. consumers spend over 30 billion dollars a year on weight loss! The commercial even states “we know the risks, yet we keep dancing around the issue.” The reason that such a problem can not be fixed by telling parents that they are simply failing their fat children is that this problem is rooted in issues that have nothing to do with intentions or rational thought. Link and Phelan would suggest we must “contextualize individually-based risk factors by examining what puts people at risk of risks” and understand that “social factors such as socioeconomic status and social support are likely ‘fundamental causes’ of disease that, because they embody access to important resources, affect multiple disease outcomes through multiple mechanisms, and consequently maintain an association with disease even when intervening mechanisms change”(5). Children are obese because their parents lack guidance due to inadequate primary care. Children are obese because while there is a Whole Foods or Trader Joe’s on every corner in Brookline there are only 7-11s or Store 24s in Roxbury and the South End (6).

Improper labeling of both children and their parents:

Labeling Theory states that “the self-identity and behavior of an individual is influenced by how that individual is categorized and described by others in their society” (7). Labeling children as obese without providing parents with information is deconstructive. There are at least three explicit labeling issues depicted in this campaign.

First, if a negligent parent is defined by the weight of their child then traditional labeling theory would suggest that parents may embody this label of “bad parent” leading to even less discretion at the grocery store or when feeding their children. However, I would like to highlight a more substantial issue. If a young child becomes obese and his or her parent believes this is their fault because they are doing nothing but “dancing around” they may hesitate to bring their child to the primary care physician because they do not want to be reminded that they are not responsible parents. This result would have troubling medical implications scoping far beyond obesity.

Second, children that are overweight will be labeled as fat. If peers identify this child as fat then he or she may embody this role of the “fat kid” and fulfill his peers’ expectations. He will perceive sedentary behavior and gluttony as his position in society.

Finally, these campaigns reinforce the stigmatization of obesity. Children and parents may overemphasize or misinterpret the problem and inadvertently encourage unhealthy eating behaviors (8). Even children as young as 5 display a bias towards overweight people (9). This stigma affects the child’s ability to make friends leading to social isolation, low self-esteem, and depression (10,11). One study found that in the last 40 years this stigmatization of a child’s appearance has increased 41% (12). It is reasonable to conclude that if a child is taunted or observes another child taunted about their weight they will do anything to avoid this “fat label”. In many cases this weight teasing leads to a significant increase in the risk of development of eating disorders (13).

This campaign shows a complete disregard towards the Theory of Self-Efficacy:

Albert Bandura taught us that it is our personal expectations of success or failure that determines whether or not we engage in a specific behavior (3). However, this campaign presents obesity as the most daunting problem the children of America will ever battle. The commercial paints a dismal picture using dark lighting and unnerving music to tell parents that even though we know about the ill effects of obesity we are unable to fix the problem and it is getting worse. If a problem is framed in such a way many people will think that they are incapable of overcoming it and their already low level of self-efficacy will be confirmed. The parent thinks, “If we are spending over 30 billion dollars a year to fix this problem but this commercial tells me that it is getting worse and worse then why bother?” If parents do not believe that there is a remedy that is attainable they will convey this message to their children and the problem will persist.

Implications:

This campaign framed the issue of childhood obesity as a choice for parents. “It comes down to parents, ultimately, because they make the decisions" (14). This is at best an unfair approach and at worst harmful to the overall movement to curb obesity. Paul Campos suggested, that such “increasingly hysterical pronouncements about the evils of ‘excess ‘ weight”, are exactly why our countries health continues to deteriorate producing a “culture full of fat people” (15). Future campaigns should focus on elements not obviously linked to obesity such as wealth, access, and education. They should present the issue in a way that encourages weight loss but also promotes a high level of self-efficacy. Other ad campaigns such as these:Better Video 1, Better Video 2

provide simple steps that one can take to lose weight and eat healthy. They are not judgmental and they promote health without scare tactics. These are the types of campaigns that should be promoted by public health officials.

Conclusion:

The campaign promoted by the MetroWest Foundation has failed the public health community. It relies upon the Health Belief Model and disregards social factors such as socioeconomic status. The campaign negatively labels children and their parents. It frames the issue in a highly individualistic way and presents an impossible uphill climb for people to face when battling their weight. The campaign is flawed and insulting. Due to extensive criticism many of the original billboards for this campaign have been removed. (16)

I would like to note one last observation about the MetroWest Foundation PUBLIC HEALTH campaign. On their website they thank the MetroWest Childhood Obesity Task Force. This list contained many highly educated people. In fact, several names were followed by an impressive list of letters. M.P.H however, did not appear after any of them.

References:

  1. Centers for Disease Control and Prevention. Overweight and Obesity. Atlanta, GA : Division of Nutrition, Physical Activity and Obesity. http://www.cdc.gov/nccdphp/dnpa/obesity/index.htm
  2. U.S. Food and Drug Administration. The Facts About Weight Loss Products and Programs. DHHS Publication No (FDA) 92-1189 http://www.cfsan.fda.gov/~dms/wgtloss.html
  3. Salazar MK. Comparison of four behavioral models. AAOHN 1991;39:128-135.
  4. ESPN News. Wells makes major lifestyle changes due to diabetes. http://sports.espn.go.com/mlb/news/story?id=2804147
  5. Link B, Phelan J. Social Conditions as Fundamental Causes of Disease. Journal of Health and Social Behavior 1995;(Extra Issue):80-94
  6. Siegel M. Soft drinks being singled out as cause of obesity problem; analogy to tobacco seems detrimental to public health efforts. The Rest of the Story: Tobacco News Analysis and Commentary (blog), March 7, 2006. Available at: http://tobaccoanalysis.blogspot.com/2006/03/soft-drinks-being-singled-out-as-cause.html.
  7. Wikipedia. Labeling Theory. Wikimedia Foundation Inc. http://en.wikipedia.org/wiki/Labeling_theory
  8. Ikeda et al.
BMI screening in schools: helpful or harmful? Health Educ Res 2006;21:761-769.
  9. Musher-Eizenman DR, Holub SC, Miller AB et al. Body size stigmatization in preschool children: the role of control attributions. J Pediatr Psychol 2004; 29: 613–20
  10. Strauss RS, Pollack HA. Social Marginalization of Overweight Children. Arch Pediatr Adolesc Med 2003;157:746-652.
  11. Lumeng JC, Gannon K, Cabral HJ et al. Association between clinically meaningful behavior problems and over- weight in children. Pediatrics. 2003; 112: 1138–45.
  12. Latner JD, Stunkard AJ. Getting worse: the stigmatization of obese children. Obes Res 2003; 11: 452–6.
  13. Haines J, Neumark-Sztainer D, Eisenberg ME, Hannan PJ. Weight Teasing and Disordered Eating Behaviors in Adolescents: Longitudinal Findings From Project EAT (Eating Among Teans). Pediatrics 2006;117:209-215.
  14. Manuse A. Spotlight on parents of overweight kids MetroWest Daily News http://www.metrowestdailynews.com/archive/x425331818
  15. Campos P. The Obesity Myth: Why America's Obsession with Weight is Hazardous to Your Health. Conclusion (pp. 247-251). New York: Gotham Books, 2004.
  16. Manuse A. Obesity billboard idea yanked. MetroWest Daily News http://www.metrowestdailynews.com/homepage/8998967371255250943

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9 Comments:

  • At December 10, 2007 at 5:36 PM , Blogger Read said...

    This comment has been removed by the author.

     
  • At December 13, 2007 at 12:58 PM , Blogger Read said...

    Great use of Labeling Theory. You pulled out some key insights that weren't evident to me.

    And the ending there cracked me up. I don't think the MPH degree necessarily means you know what you're doing, but a heck of an observation.

     
  • At December 13, 2007 at 4:22 PM , Blogger Victoria said...

    I watched the commercial you posted - it really was flawed! Even if you didn't watch the entire thing (when it finally got the its point at the end) it just didn't make any sense. I really like how you pointed out if parents feel guilt about their children's weight problem, they may be less inclined to bring them to a PCP (because they've been "dancing" around the issue).

     
  • At December 14, 2007 at 9:41 AM , Anonymous Deinera said...

    The two commercials you posted at the end were great, and such a contrast for the MetroWest ad. I also enjoyed the insightful comments of your last paragraph!

     
  • At December 16, 2007 at 8:18 AM , Blogger ER said...

    Great points, especially about the self-efficacy of these individuals. What a creepy comercial, it would make it seem like a hopeless situation

     
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