Ten Thousand Steps a Day: An Overly-Simplistic Strategy to Increase Physical Activity – Sandy Askew

Step counting has become a popular means for increasing physical activity. Several studies have used pedometers and step counting as a central component in physical activity and weight control campaigns and interventions (1-6), including those which urge participants to take 10,000 steps a day (7-11). The interest in these types of interventions has grown because walking seems like a simple exercise and monitoring steps doesn’t require large or expensive equipment. In fact, some pedometers are so affordable to produce, McDonald’s restaurants and Kellogg’s cereal company were able to give thousands away in adult happy meals and cereal boxes during their own pedometer campaigns (12-14). Despite this seemingly simple solution, half of all American adults don’t meet current recommendation of 30 minutes or more of moderate physical activity 5 or more days per week for a healthy lifestyle (15, 16). Evidence from intervention studies suggests that most people who try one of these walking programs will be unlikely to maintain it long term (8, 17, 18). Despite their simplicity, or perhaps because of it, these campaigns are not achieving wide spread success. In creating these step count programs, many intervention designers have limited their thinking to individual-oriented approaches to behavioral change which will continue to have limited success. Physical activity interventions focused on a step count recommendation are overly simplistic because they rely heavily on an individual-oriented approach and assume that by changing a person’s attitudes and intentions toward walking, they will change behavior. These interventions seldom consider more complex consider social and behavioral factors like social norms, competing behaviors and perceived behavioral control, which may have a greater impact on physical activity adoption.

Background: 10,000 Steps
One popular pedometer intervention recommendation is to take 10,000 steps a day. Based more on an advertising campaign than scientific research, the popularity of the 10,000 steps figure grew from “Manpo-kei”: the advertising slogan of a 1960’s pedometer which literally means “10,000 steps meter” (19). As the recommendation was not created through research, there was no formal theoretical model used to develop it. Nonetheless, the recommendation is clearly an individual-oriented approach urging each person to walk 10,000 steps a day for better health and focusing on creating positive attitudes about walking and its effects. Like some traditional models, including the Health Belief Model and the Theory of Planned Behavior, the 10,000 steps approach assumes that behavior will follow intention: If people adopt a goal of 10,000 steps a day, they will walk more to reach that goal (20). Like the theoretical framework of the intervention, the step goal did not originate in scientific evidence leaving it open to scientific inquiry and criticism. While the idea of walking 10,000 steps for wellness has spread throughout Japan and to other parts of the world, researchers have been attempting to find evidence to support it.

Is 10,000 Steps an Achievable Goal?
A growing body of research supports the idea of increased walking for health, although no clear consensus has developed regarding the figure of 10,000 steps per day. The Centers for Disease Control and Prevention (CDC) and the American College of Sports Medicine (ACSM) recommend that adults engage in moderate-intensity physical activities, like brisk walking, for at least 30 minutes on 5 or more days of the week (15, 16). Walking as a form of moderate exercise may reduce a person’s risk for cardiovascular disease, diabetes, hypertension certain cancers and obesity (21, 22). Some researchers have found the 10,000 steps recommendation to approximately match the CDC’s and ACSM’s recommendation (19, 23, 24) and that it could lead to improvements in glucose tolerance and lipid profiles, lower body fat and blood pressure as well as other health benefits (25-28). Yet other studies have reported that a 10,000 steps goal may be difficult for some people to achieve and maintain, even with 30 minutes of activity a day (23, 28, 29) and some evidence suggests fewer steps may be needed to achieve some health benefits (26, 30, 31). This raises questions about the impact of the figure of 10,ooo steps on a person’s self-efficacy and if it is wise to promote such a high figure if it is unnecessary or unrealistic. While 10,000 steps a day may be considered an easy to remember, concrete goal (19), if it is too high people may quickly grow discouraged with it or not adopt it at all. Further, if interventions don’t address other influences on self-efficacy and barriers to walking, even a lesser figure may be unattainable.

Although 10,000 steps interventions attempt to improve physical activity self-efficacy by focusing on a simple exercise behavior, they fail to account for an individual’s perceived behavioral control. Even if an individual wants to walk more, he may feel there are barriers beyond his control which prevent him from doing so. Features of the physical environment may serve as barriers to physical activity, including an activity as simple as walking (32-38). Urban sprawl, poor neighborhood aesthetics, poor street connectivity, high traffic, no sidewalks or poorly maintained sidewalks and no streetlights have all been found to have a negative association with walking activity (38-45). Concerns about neighborhood safety may also inhibit people from walking (33, 34, 37). The Theory of Planned Behavior postulates that a person’s attitude toward a given behavior, as well as his perceived and actual behavioral control, will help determine his intention to engage in that behavior (20). However, step count interventions often don’t address environmental barriers which may make a person feel that walking is unpleasant, difficult or even unsafe. Instead, these interventions focus on the simplicity of walking more without realizing that for many people it is not at all simple. On the other hand, some aspects of the environment may encourage walking. For example, the presence of nearby shops, parks, beaches and walking paths is positively associated with walking (39, 41, 45-48). A concept taken from ecological psychology explains that there are “behavioral settings”: places or situations which promote or discourage certain behaviors (38). Living proximal to parks and shopping centers may encourage walking activity through design: They lessen the perceived barriers to walking more. Alternatively, living near one of these settings may also lessen perceived barriers through social mechanisms by providing both social models and social expectations, or norms, to walk because other people are walking there. Unfortunately, these kinds of social influences are also seldom addressed in physical activity interventions built on step counts like 10,000 steps.

The Importance of Social Norms
Ten thousand steps interventions focus largely on the individual and fail to address social norms which may inhibit adoption of physical activity recommendations. According to the Theory of Planned Behavior an individual is more likely to adopt a behavior if it is supported by the norms of their social networks (20). “Nobody walks in L.A.” is an expression popularized by a song in the 1980’s (49), but more than that, it may be an expression of the social or cultural norms of a city and other places like it. A person who lives in a place where walking is not the norm, or is even seen as distasteful, will be less likely to walk. The social acceptability, or unacceptability, of the behavior has a direct effect on a person’s intention because he may feel he will be stigmatized or socially sanctioned for engaging in that behavior. The literature on the impact of neighborhood norms on walking behavior is limited, but some authors have described the influence of these norms through a “contagion” perspective where people are influenced by the behaviors of those around them, copying behaviors, whether they are positive or negative, and thereby creating acceptable norms in the neighborhood (50, 51). This perspective includes ideas presented in Modeling theory where people emulate the behaviors they see in other people, gaining self-efficacy vicariously by observing successful behaviors (20). It also includes aspects of Diffusion of Innovations theory where, as with the spread of some diseases, a few people may initially perform a behavior, but it slowly begins to spread (20). When it reaches a tipping point, it will spread rapidly through a population, becoming normalized. If a physical activity campaign could manipulate these norms and use theories like Diffusion of Innovations to their advantage, physical inactivity could become an oddity. Unfortunately, 10,000 steps and other step count interventions fail to address these norms. While it is easy to recommend that someone take a walk at lunch or use the stairs instead of the elevator, many people may be very uncomfortable deviating from the norms of their peers. They may feel self-conscious walking through a neighborhood where walkers are observed as unusual or the subject of suspicion. Unless interventions find a way to help participants beyond those feelings or to normalize walking, they will continue to have limited success.

Behavioral Principles and 10,000 steps
Step counting interventions fail to consider that although an individual may intend to walk more, competing behaviors may be given higher priority if they seem more equally or more rewarding. Perhaps essential to altering norms or changing individual behaviors is to understand and use basic behavioral learning principles to affect behavior. At the core of the Behavioral paradigm in psychology are the concepts of reinforcement and punishment. Reinforcement is anything which leads to an increase in the performance of a behavior and punishment is anything which leads to a decrease in the performance of a behavior (52). At any given time, a person has a nearly limitless repertoire of behaviors he can perform; however according to Behavioral principles, the behavior he perform s will likely be the one he perceives, consciously or not, to be most rewarding (53, 54). Step count interventions try to lower the costs of increasing physical activity by focusing on an exercise that, for most people, is physically easy to perform and to promote the rewards of better health. Unfortunately, while doing so they usually fail to address behaviors which may more attractive because they are supported by an individual’s attitudes, culture or social norms and perceived as more rewarding. For example in a qualitative study conducted by Airhihenbuwa et al., the cultural beliefs of African Americans about health were explored through a focus group (55). The study observed that the African Americans in the focus group seemed to value rest over exercise, believing it to be as important or more important to health (55). If one’s values conflict with the performance of a behavior central to an intervention, it is unlikely that behavior will be successfully adopted. If two behaviors are believed to serve a similar function, like promoting health or relieving stress, but one perceives one behavior, like rest, as somehow more beneficial or reinforcing, than the other behavior, like walking, it is likely he will chose to rest rather than to walk.

A major difficulty public health interventions have is that health behaviors don’t typically have strong or immediate reinforcers or punishers, so the psychological link between health and the health behavior is relatively weak. This means that other behaviors which are produce faster or stronger feedback are likely to win when they compete with health behaviors. To many people, playing video game, for example is more enjoyable than going out for a walk. Feeling sweaty or tired may seem more important to avoid right now than the possible risk of heart disease a long time from now (56). A person may fully intend to walk and increase their step count in order to lower their health risks, as some theoretical models like the Health Belief Model would predict (20), but that behavior may continually be prioritized under more instantaneously gratifying activities. To be successful, step count interventions would do better to try to pair other types of reinforcement with physical activity along with potential health benefits. Reframing exercise as social or exciting by combining it with other activities or encouraging group activity is one way to do this. The more potential a behavior has to be rewarding, the more likely it is to be adopted and continued.

Conclusion
Step count interventions have some undeniable strengths. They are simple and affordable and therefore can be implemented on a large scale. A 10,000 step goal is concrete and easy to remember and might match CDC and ACSM recommendations for physical activity for many people. For long-term or wide-spread adoption, however, these interventions, as usually presented, are too simplistic to have maximum success. To build on the strengths of these kinds of interventions, intervention and campaign designers need to address a wider range of behavioral determinants, including environmental, social and cultural determinants. They also need to draw on the knowledge of other disciplines like behavioral psychology to understand what motivates behavior and to push beyond creating intention into generating behavior change. By addressing social as well as individual components, step count intervention like 10,000 steps can take a multilevel approach to improving physical fitness and reach far greater levels of success than it will by depending on the simplicity of their goal setting alone.

REFERENCES
1. Chan CB, Ryan DA, Tudor-Locke C. Health benefits of a pedometer-based physical activity intervention in sedentary workers. Prev Med. Dec 2004;39(6):1215-1222.
2. Gilson N, McKenna J, Cooke C, Brown W. Walking towards health in a university community: a feasibility study. Prev Med. Feb 2007;44(2):167-169.
3. Matthews CE, Wilcox S, Hanby CL, et al. Evaluation of a 12-week home-based walking intervention for breast cancer survivors. Support Care Cancer. Feb 2007;15(2):203-211.
4. Toole T, Thorn JE, Panton LB, Kingsley D, Haymes EM. Effects of a 12-month pedometer walking program on gait, body mass index, and lower extremity function in obese women. Percept Mot Skills. Feb 2007;104(1):212-220.
5. Tudor-Locke C, Bell RC, Myers AM, et al. Controlled outcome evaluation of the First Step Program: a daily physical activity intervention for individuals with type II diabetes. Int J Obes Relat Metab Disord. Jan 2004;28(1):113-119.
6. Winett RA, Anderson ES, Wojcik JR, Winett SG, Bowden T. Guide to health: nutrition and physical activity outcomes of a group-randomized trial of an Internet-based intervention in churches. Ann Behav Med. May-Jun 2007;33(3):251-261.
7. Araiza P, Hewes H, Gashetewa C, Vella CA, Burge MR. Efficacy of a pedometer-based physical activity program on parameters of diabetes control in type 2 diabetes mellitus. Metabolism. Oct 2006;55(10):1382-1387.
8. Eakin EG, Mummery K, Reeves MM, et al. Correlates of pedometer use: results from a community-based physical activity intervention trial (10,000 Steps Rockhampton). Int J Behav Nutr Phys Act. 2007;4:31.
9. Hultquist CN, Albright C, Thompson DL. Comparison of walking recommendations in previously inactive women. Med Sci Sports Exerc. Apr 2005;37(4):676-683.
10. Hyman DJ, Pavlik VN, Taylor WC, Goodrick GK, Moye L. Simultaneous vs sequential counseling for multiple behavior change. Arch Intern Med. Jun 11 2007;167(11):1152-1158.
11. Rooney B, Smalley K, Larson J, Havens S. Is knowing enough? Increasing physical activity by wearing a pedometer. Wmj. 2003;102(4):31-36.
12. PR Newswire US. Tony the Tiger Goes to Hollywood to Help Families Get in Step!;Kellogg Company Launches Fitness Program on the Famous Hollywood Walk of Fame. September 27, 2005, 2005.
13. Geoghegan T. The 10,000-step guide to fitness. BBC News Online Magazine Vol October 12,2004; 2004.
14. Ethridge M. Low-cal Happy Meals Target Health-Conscious Consumbers; Mcdonalds reinvents the Box. Akron Beacon Journal May 11, 2004, 2004;business: D1.
15. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2005.
16. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. Feb 1 1995;273(5):402-407.
17. Iwane M, Arita M, Tomimoto S, et al. Walking 10,000 steps/day or more reduces blood pressure and sympathetic nerve activity in mild essential hypertension. Hypertension Research. Nov 2000;23(6):573-580.
18. Rooney BL, Gritt LR, Havens SJ, Mathiason MA, Clough EA. Growing healthy families: family use of pedometers to increase physical activity and slow the rate of obesity. Wmj. Jul 2005;104(5):54-60.
19. Tudor-Locke C, Bassett DR, Jr. How many steps/day are enough? Preliminary pedometer indices for public health. Sports Med. 2004;34(1):1-8.
20. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury: Jones and Bartlett Publishers, Inc; 2007.
21. Walk away from diabetes and heart disease. The most natural of human activities is also the best medicine for these connected health problems. Harv Heart Lett. Sep 2003;14(1):6-7.
22. Morris JN, Hardman AE. Walking to health. Sports Med. May 1997;23(5):306-332.
23. Wilde BE, Sidman CL, Corbin CB. A 10,000-step count as a physical activity target for sedentary women. Res Q Exerc Sport. Dec 2001;72(4):411-414.
24. Welk GJ, Differding JA, Thompson RW, Blair SN, Dziura J, Hart P. The utility of the Digi-walker step counter to assess daily physical activity patterns. Med Sci Sports Exerc. Sep 2000;32(9 Suppl):S481-488.
25. Moreau KL, Degarmo R, Langley J, et al. Increasing daily walking lowers blood pressure in postmenopausal women. Med Sci Sports Exerc. Nov 2001;33(11):1825-1831.
26. Sugiura H, Sugiura H, Kajima K, Mirbod SM, Iwata H, Matsuoka T. Effects of long-term moderate exercise and increase in number of daily steps on serum lipids in women: randomised controlled trial [ISRCTN21921919]. BMC Womens Health. 2002;2(1):3.
27. Tudor-Locke C, Ainsworth BE, Whitt MC, Thompson RW, Addy CL, Jones DA. The relationship between pedometer-determined ambulatory activity and body composition variables. Int J Obes Relat Metab Disord. Nov 2001;25(11):1571-1578.
28. Iwane M, Arita M, Tomimoto S, et al. Walking 10,000 steps/day or more reduces blood pressure and sympathetic nerve activity in mild essential hypertension. Hypertens Res. Nov 2000;23(6):573-580.
29. Tudor-Locke C, Jones R, Myers AM, Paterson DH, Ecclestone NA. Contribution of structured exercise class participation and informal walking for exercise to daily physical activity in community-dwelling older adults. Res Q Exerc Sport. Sep 2002;73(3):350-356.
30. Tudor-Locke C, Ainsworth BE, Thompson RW, Matthews CE. Comparison of pedometer and accelerometer measures of free-living physical activity. Med Sci Sports Exerc. Dec 2002;34(12):2045-2051.
31. Tudor-Locke CE, Myers AM, Bell RC, Harris SB, Wilson Rodger N. Preliminary outcome evaluation of the First Step Program: a daily physical activity intervention for individuals with type 2 diabetes. Patient Educ Couns. May 2002;47(1):23-28.
32. Wilcox S, Castro C, King AC, Housemann R, Brownson RC. Determinants of leisure time physical activity in rural compared with urban older and ethnically diverse women in the United States. J Epidemiol Community Health. Sep 2000;54(9):667-672.
33. Lavizzo-Mourey R, Cox C, Strumpf N, Edwards WF, Stinemon M, Grisso JA. Attitudes and beliefs about exercise among elderly African Americans in an urban community. J Natl Med Assoc. Dec 2001;93(12):475-480.
34. King AC, Castro C, Wilcox S, Eyler AA, Sallis JF, Brownson RC. Personal and environmental factors associated with physical inactivity among different racial-ethnic groups of U.S. middle-aged and older-aged women. Health Psychol. Jul 2000;19(4):354-364.
35. Owen N, Leslie E, Salmon J, Fotheringham MJ. Environmental determinants of physical activity and sedentary behavior. Exerc Sport Sci Rev. Oct 2000;28(4):153-158.
36. Brownson RC, Housemann RA, Brown DR, et al. Promoting physical activity in rural communities: walking trail access, use, and effects. Am J Prev Med. Apr 2000;18(3):235-241.
37. Humpel N, Owen N, Leslie E. Environmental factors associated with adults' participation in physical activity: a review. Am J Prev Med. Apr 2002;22(3):188-199.
38. Owen N, Humpel N, Leslie E, Bauman A, Sallis JF. Understanding environmental influences on walking; Review and research agenda. Am J Prev Med. Jul 2004;27(1):67-76.
39. Giles-Corti B, Donovan RJ. Socioeconomic status differences in recreational physical activity levels and real and perceived access to a supportive physical environment. Prev Med. Dec 2002;35(6):601-611.
40. Eyler AA, Brownson RC, Bacak SJ, Housemann RA. The epidemiology of walking for physical activity in the United States. Med Sci Sports Exerc. Sep 2003;35(9):1529-1536.
41. Ball K, Bauman A, Leslie E, Owen N. Perceived environmental aesthetics and convenience and company are associated with walking for exercise among Australian adults. Prev Med. Nov 2001;33(5):434-440.
42. Ewing R, Schmid T, Killingsworth R, Zlot A, Raudenbush S. Relationship between urban sprawl and physical activity, obesity, and morbidity. Am J Health Promot. Sep-Oct 2003;18(1):47-57.
43. Lopez R. Urban sprawl and risk for being overweight or obese. Am J Public Health. Sep 2004;94(9):1574-1579.
44. Saelens BE, Sallis JF, Black JB, Chen D. Neighborhood-based differences in physical activity: an environment scale evaluation. Am J Public Health. Sep 2003;93(9):1552-1558.
45. Humpel N, Owen N, Leslie E, Marshall AL, Bauman AE, Sallis JF. Associations of location and perceived environmental attributes with walking in neighborhoods. Am J Health Promot. Jan-Feb 2004;18(3):239-242.
46. Lopez RP, Hynes HP. Obesity, physical activity, and the urban environment: public health research needs. Environ Health. 2006;5:25.
47. Wilson DK, Kirtland KA, Ainsworth BE, Addy CL. Socioeconomic status and perceptions of access and safety for physical activity. Ann Behav Med. Aug 2004;28(1):20-28.
48. Seefeldt V, Malina RM, Clark MA. Factors affecting levels of physical activity in adults. Sports Med. 2002;32(3):143-168.
49. Walking in L.A.: One Way; 1982.
50. Ross CE. Walking, exercising, and smoking: does neighborhood matter? Social Science & Medicine. 2000;51(2):265-274.
51. Greiner KA, Li C, Kawachi I, Hunt DC, Ahluwalia JS. The relationships of social participation and community ratings to health and health behaviors in areas with high and low population density. Soc Sci Med. Dec 2004;59(11):2303-2312.
52. Skinner BF. The behavior of organisms: An experimental analysis. New York: Appleton-Century; 1938.
53. Thomdike EL. Animal Intelligence: An Experimental Study of the Associative Process in Animals. Psychology Review Monographs. 1898;2(55):1-553.
54. Horner R, Day H. The effects of response efficiency on functionally equivalent competing behaviors. J Appl Behav Anal. 1991;24(4):719-732.
55. Airhihenbuwa CO, Kumanyika S, Agurs TD, Lowe A. Perceptions and beliefs about exercise, rest, and health among African-Americans. Am J Health Promot. Jul-Aug 1995;9(6):426-429.
56. Laitakari J, Vuori I, Oja P. Is long-term maintenance of health-related physical activity possible? An analysis of concepts and evidence. Health Education Research. 1996;11(4):436-477.

Failures Of The Jump Up & Go Campaign: What is Really Making Adolescents Unhealthy? – Diane Wheaton

Introduction: A rational-empirical approach to solving the nation’s obesity epidemic

The Jump Up & Go campaign is a multidimensional intervention campaign that aims to address some important health issues in today’s youth and adolescents. In recent years, the prevalence of overweight and obesity has reached epidemic proportions. Currently, approximately 66% of American adults aged twenty and above are overweight (BMI > 24.9), while approximately 32% are obese (BMI > 29.9) (1). Of even greater concern is the prevalence of overweight among children and adolescents. Approximately 19% of children aged 6-11 and 17% of adolescents aged 12-19 are overweight (1). All of these statistics have increased dramatically within the last decade (2). These numbers present an area of concern because individuals who are overweight as children or who have overweight parents have a significantly increased risk of being overweight or obese as adults. The comorbidities associated with overweight and obesity present an additional set of issues, which the US healthcare system struggles to address every day. Some of these include increased risks for hypertension, heart disease, diabetes, stroke, poor bone and muscle strength, some types of cancers, and social and emotional problems (3). The economic consequences of these conditions as they relate to overweight and obesity totaled approximately $92.6 billion in 2002 (3). A quick review of these statistics immediately reveals the urgent need to address the nation’s rising obesity epidemic, especially among children and adolescents.

The Jump Up & Go campaign has identified and targeted three factors that are currently contributing to the obesity epidemic among youths. These factors are physical inactivity, poor diet and nutrition, and an overabundance of “screen time” including time spent watching television, playing video games, or using a computer. The Jump Up & Go campaign takes a rational-empirical approach to addressing these issues by attempting to educate children, parents, teachers, and healthcare providers on the importance of establishing healthy lifestyle behaviors at a young age. The focus of the campaign is the ‘5-2-1 philosophy’, which advocates for five or more servings of fruits and vegetables, fewer than two hours of screen time, and one or more hours of activity every day (4). The campaign promotes these behaviors by educating and providing resources to children, parents, teachers, and physicians such as healthy recipe ideas and nutrition tips, activities for the classroom, daily logs, and other materials for evaluating and promoting healthy behaviors within school systems (4). However, this approach does not consider some important implications that are central to public health interventions among children. The Jump Up & Go campaign is inadequate in addressing the public health concerns associated with physical activity, poor nutrition, and excessive “screen time” in children and adolescents because it does not consider the underlying social contributors or behavioral models that are essential in youth development.

Issues associated with access to a healthy lifestyle

One of the most important factors to consider when developing a public health campaign is the availability of resources beyond the control of the target population. The Jump Up & Go campaign fails to address this. When a child or family does not have access to healthy food choices or venues for safe physical activity, these interventions are doomed to fail. Research shows that regardless of the level of knowledge one may have regarding appropriate health behaviors, the inability to access healthy foods and physical activity will remain a constant barrier to behavior interventions (5). These issues are exaggerated especially in low socioeconomic neighborhoods and populations (6).

Access to healthy foods is a key determinant in the success of a nutrition intervention program. The Jump Up & Go campaign encourages children to consume at least five servings of fruits and vegetables every day. The campaign assumes that such fruits and vegetables are readily available. However, increasing costs of fresh produce and increasing prevalence of fast food restaurants have contributed significantly to the decreasing levels of fruit and vegetable intake among children (6). In addition to the rising cost of fresh produce, families may find it difficult to buy fruits and vegetables due to inconvenient locations of grocery stores. The concept of built environment has recently become a topic of discussion among public health professionals due to its contributions to urban sprawl and to many families’ inability to shop at healthful grocery stores (5). In addition to the lack of access to healthy foods, many children and their families find that the plethora of fast food restaurants and unhealthy snack options available in schools and stores offer cheaper and more satisfying meal choices (5). In today’s capitalist society, fast food chains like McDonald’s, Taco Bell, Dunkin Donuts, Domino’s, and Dairy Queen can dominate the food market and offer a wide range of inexpensive food options that are high in fat and sugar, low in vitamins and minerals, and in portions that far exceed the caloric needs of adolescents, directly contributing to the rising rates of pediatric obesity. The Jump Up & Go campaign does not address these issues of access to nutritional food choices and therefore cannot possibly expect to obtain full compliance with their five-a-day recommendation for fruits and vegetables.

Access to physical activity opportunities presents another significant barrier to healthy behaviors, which the Jump Up & Go campaign does not address. The campaign advocates for children to engage in physical activity for at least one hour every day. However, in order to fulfill this requirement, children must have access to safe parks, playgrounds, recreational facilities, and neighborhood streets. These venues are often not available for children on a daily basis. Oftentimes public parks and playgrounds are too far away for children to access by walking or biking. Working parents may not be available to drive their children to such activity centers. Neighborhood streets may be unsafe due to traffic, poor lighting, or crime rates (5). All of these barriers combined result in many children remaining indoors, entertaining themselves with television and video games (5). A study conducted by the Department of Kinesiology and Physical Education at the Wilfrid Laurier University in Canada proved that the leading causes of resistance to behavioral change as it relates to physical activity among adolescents are infrastructural in nature and include low access to proper physical fitness centers (7). In addition to the physical barriers to activity, there exist mental barriers as well. Numerous studies have demonstrated correlations between an individual’s perceptions of their surrounding environments and the levels of physical activity (8). When a child or parent feels that their community is not “activity-friendly” or dangerous, they will often fail to engage in regular physical activity. Contributors to a community’s “activity-friendliness” include crime rates, street lighting, distances between residential and commercial areas (also known as ‘land use’), aesthetics, modes of transportation, traffic, and building and land maintenance (8). The Jump Up & Go campaign does not consider theses barriers to physical activity when they try to promote one hour of physical activity. When a child or parent cannot gain access to physical activity centers, exercise levels cannot increase, regardless of educational and promotional interventions.

The Jump Up & Go campaign attempts to educate children, parents, teachers, and physicians on the necessity of adequate nutrition and activity. However, by simply attempting to educate and inform, the campaign fails to consider issues of access to good nutrition and physical activity. Barriers such as these require more than just a rational-empirical intervention. They require policy change and government involvement. The Jump Up & Go campaign cannot possibly expect children to change their dietary and activity patterns while these barriers remain in place.

The Theory of Self-Efficacy: When is it too much?

Another negative reflection of the Jump Up & Go campaign is its failure to consider the Theory of Self-Efficacy. The Theory of Self-Efficacy centers on the idea that an individual’s personal expectations and perceptions regarding their ability to change will determine how effectively they will make that change (9). If an individual believes with conviction that he or she can successfully execute the necessary processes to make a behavioral change and to obtain the perceived outcomes and benefits, the person is more likely to be successful (9). Many public health interventions have employed the Theory of Self-Efficacy due to its widely applicable standards to almost any population and any behavioral change (10). However, the Jump Up & Go campaign does not utilize the messages of this theory and therefore cannot truly be successful.

The Jump Up & Go campaign establishes the 5-2-1 goal: five servings of fruits and vegetables, two or fewer hours of screen time, and one or more hours of physical activity every day. These changes could indeed contribute to an overall improvement in a child’s lifestyle, however, executing so many changes may be difficult if not impossible for most children and their families to make at the same time. Telling a child to make these changes is not sufficient to make them see the potential benefits, which may deter him or her from trying to make any changes at all (11). Additionally, attempting to enforce so many changes all at once, may overwhelm the child and their family, making them feel that they cannot achieve such lofty goals. This could in turn cause the family to abandon the suggestions entirely (11). In cases such as this, or in cases where the child does attempt to make the changes and fails, the campaign does not offer any suggestions for alternative methods of behavioral change. This could cause the family to relapse into old behaviors rather quickly. By challenging the target population to make so many changes, the campaign may in fact deter children and families from making any positive adjustments (11).

The Jump Up & Go campaign further violates the Theory of Self-Efficacy by involving too many stakeholders in the change process. The campaign provides educational and promotional materials for children, parents, teachers, school administrators, and medical care personnel. All of these materials offer suggestions that pertain to each stakeholder’s role in the child’s life, however, they do not integrate well with each other, nor are there sufficient opportunities for the stakeholders to engage in group decision making. As a result, the child may receive slightly different suggestions from each role model, which can cause conflict (12). A school administrator and a parent may want different things for the child or have different motivations and resources available to them. As a result, conflict and confusion may result within the child causing him or her to ignore the suggestions altogether (7). An example of what happens when too many authority figures are involved in an intervention, will be provided later in this paper. If the campaign took a more active approach to engaging all stakeholders in a group decision process, the result could be a more clear and thorough message for the child, which could enable the child to feel more confident in his or her ability to make the suggested behavioral changes.

The Theory of Self-Efficacy is a widely accepted and utilized behavioral theory in public health. Its implications in a program such as the Jump Up & Go campaign are important to the success of the intervention. This campaign fails to consider the central concepts of the theory by forcing too many changes at once and involving too many individual stakeholders. These factors combined may decrease the child’s self-efficacy resulting in a failure to make a change.

Social Learning Theory: The importance of understanding how children really learn

A second theory that has great implications on public health interventions is the Social Learning Theory. The Social Learning Theory maintains that individuals learn behaviors through their observations of others (10). This theory is especially important among children, who are very impressionable and quickly observe and imitate the habits that parents, siblings, teachers and friends exhibit (12). When public health officials try to promote behavioral change in youth and adolescents, they must consider the ways in which children really learn. The Jump Up & Go campaign contends that the best way to impart a behavioral change is through education and knowledge. This is inconsistent with the messages of the Social Learning Theory. The use of knowledge and education is ineffective by itself in implementing any significant behavioral change because it lacks a modeling component that is essential in youth development (12).

Children learn their behaviors from the individuals around them (12). Therefore, if children are expected to make changes, they must receive consistent signals from their role models. Role models must not only demonstrate the desired behavior, but also must demonstrate the benefits of performing the behavior. The child must see and understand why the desired behavior is important and how they can practice the behavior themselves (11). Additionally, parents, teachers, and friends, must portray the behavior as something that is attainable but also fun; children often do not respond well to harsh instructions. Telling a child that they must do something is inefficient for establishing a desired behavioral change (12).

Additionally, demonstration of behavioral changes must be consistent among all role models. It is essential that parents, teachers, physicians, and friends, exhibit and promote the same behaviors. This will increase the child’s feeling of self-efficacy as previously discussed as well as help to ensure that the desired action is more effectively engrained in the child’s mind. It is important that all role models send the same signals so that the child receives a consistent message that is easy to follow and understand (12). The Wilfrid University study found a striking association between lack of physical activity and mixed messages from authority figures. Many parents of adolescents were telling their children that sports were a waste of time, which detracted from their academic studies. Teacher and school administrators, however, supported athletes and encouraged further leisure time activity for all students. The result was a decrease in behavioral change (7). The Jump Up & Go campaign does not ensure consistencies among authority figures, which can allow for situations such as the one described in the Wilfrid study. There is limited interaction between the many stakeholders in this campaign, which may lead parents, teachers, and other involved members to take individual approaches. When too many stakeholders are involved, as in the Jump Up & Go campaign, it can be extremely difficult to keep everyone on the same page regarding the best course of action to promote behavioral change.

Social Learning Theory can have very important implications in behavioral interventions, especially among children. Until the Jump Up & Go campaign realizes and successfully implements the messages of this theory, the intervention can never reach its full potential. The campaign must go beyond an educative approach to behavioral change and incorporate important modeling theories as well.

Conclusion

Massachusetts’ Jump Up & Go campaign has the potential to impart some excellent behavioral changes in today’s youth, however the campaign comes up short in many aspects. The campaign attempts to promote healthier lifestyles in children at a young age so that they may retain those behaviors through life. These behaviors include increased fruit and vegetable consumption (along with general improved nutrition), decreased “screen time,” and increased physical activity. These three goals are legitimate and well founded however, the Jump Up & Go campaign will be unsuccessful in initiating and maintaining such changes. The campaign does not consider the issues surrounding access to proper nutrition and physical activity opportunities. The campaign also ignores the Theory of Self-Efficacy and the Social Learning Theory, both of which are essential in developing behavioral interventions, especially among children and adolescents.

Public health campaigns that aim to impart behavioral changes must look at the evidence supporting the real ways in which children learn and grow. Rational-empirical approaches will always fall short when they stand on their own, especially when children are involved. Behavioral interventions must go beyond education and move into the domain of teaching by example. They must recognize the inherent capabilities and cognitive limitations of children so as not to enforce too much change at once. Finally, behavioral interventions must recognize the factors affecting behavior that are beyond the control of the individual. Social factors such as built environment and access to proper nutrition require political and governmental resources as well. The Jump Up & Go Campaign has great potential to make changes however, there are serious flaws that the campaign must address if it expects to obtain all of the goals in their 5-2-1 philosophy.

REFERENCES

1. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey. Hyattsvile, MD: National Center for Health Statistics 2004.

2. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Sysetem. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion 2005.

3. Center for Disease Control and Prevention. Overweight and Obesity. Atlanta, GA: Department of Health and Human Services 2007.

4. Blue Cross Massachusetts. Jump Up & Go!. Blue Cross Massachusetts. Bluecrossma.com.

5. Sallis JF, Glanz K. The Role of Built Environments in Physical Activity, Eating, and Obesity in Childhood. The Future of Children 2006; 16(1): 89-108.

6. Burton NW, Turrell G, Oldenburg B. Participation in Recreational Physical Activity: Why do Socioeconomic Groups Differ?. Health Education & Behavior 2003; 30:225-240.

7. Berry T, Naylor PJ, Wharf-Higgins J. Stages of Change in adolescents: an examination of self-efficacy, decisional balance, and reasons for relapse. Journal of Adolescent Health 2005; 37:452-459.

8. Brennan Ramirez LK et al. Indicators of Activity-Friendly Communities: An Evidence-Based Consensus Process. American Journal of Preventive Medicine 2006; 31(6): 515-524.

9. Salazar MK. Comparison of Four Behavioral Theories: A Literature Review. AAOHN Journal 1991; 39(3): 128-135.

10. Choi KH, Yep GA, Kumekawa E. HIV Prevention Among Asian and Pacific Islander American Men Who Have Sex with Men: A Critical Review of Theoretical Models and Directions for Future Research. AIDS Education and Prevention 1998; 10: 19-30.

11. Bradley RH, Corwyn RF. Home Environment and Behavioral Development During Early Adolescences: The Mediating and Moderating Roles of Self-Efficacy Beliefs. Merrill-Palmer Quarterly 2001; 47(2): 165-187.

12. Hoelscher DM, Evans A, Parcel GS, Kelder SH. Designing effective nutrition interventions for adolescents. Journal of the American Dietetic Association 2002; 102(3): S52-S63.

The Crusade of Children Obesity and Fitness by Texan State Government Falls Short: A Critique of Senate Bill 530 Fitnessgram – Chieh Chu

Recent generations of the United States population have experienced high rates of obesity. An increased prevalence of child obesity is associated with a rise in health problems such as diabetes and coronary heart diseases (1). In an effort to address this issue the Texan state government has initiated the “fitnessgram” project (Senate Bill 530), which aims to reduce obesity rates among children. The fitnessgram project mandates a standard fitness test for every student from grades three to twelve, accompanied by a report card which allows parents and teachers to record the child’s progress (4-6). The legislation will take effect in the 2007-2008 school year (4-6). The fitness scores of the students will be collected by the Texas Education Agency (TEA) and used to assess associations between fitness level and student grades, attendance, obesity, disciplinary problems and school meal programs (4-6). The fitnessgram includes tests of aerobic capacity, body composition, muscular strength, muscular endurance and flexibility (4-6).

SB530 mandates a minimum of 30 minutes moderate-to-vigorous daily exercise per child (4-6). However, the curriculum does not provide comprehensive support for a healthy lifestyle, and does not consider students’ motivations for physical exercise. For example, students may be drawn to exercise by conceptualizing it as entertainment or competition, or personal achievement and social participation, rather than maintaining high fitness scores. Another issue is the fact that there is no definite outcome linked to engaging in physical exercise in this project.

The fitnessgram program adopts the traditional, but flawed Health Belief Model (HBM), rather than the more recently proposed Social Behavioral Approach. The HBM frames obesity as an individual’s problem, failing to address the broader context of social factors (7). It requires students to engage in vigorous exercise without addressing the concepts of healthy eating and adequate energy consumption. These factors are largely shaped by social influences and if not appropriately addressed students can become malnourished or initiate inadequate eating behavior. Social factors such as access to exercise facilities, availability of healthy foods, and student attitudes need to be considered for successful behavior change (8). Framing obesity and fitness as an individual responsibility creates stress by imposing high expectancies on students. The program’s ignorance of social factors may lead to low perceived self-efficacy with respect to weight loss, and eventually low self-esteem among students (9). Thus a power coercive approach such as SB530 is inappropriate for solving the current child obesity epidemic (10, 12).

Another issue with SB530 is the TEA’s emphasis on the association between physical fitness and variables such as school grades and disciplinary problems, as this focus implies a causal link (5). The use of fitness report cards may lead to unfit students being labeled lazy or stupid by both parents and teachers, which in turn discourages these students from pursuing desirable behaviors and outcomes (11, 21).

Senate Bill 530 is a Power Coercive Approach which Fails to Promote Self-Efficacy

Senate Bill 530 mandates that grade three to grade twelve students undertake moderate-to-vigorous physical exercise for 30 minutes daily and regularly take a fitnessgram test (4-6). The Texan state government has hence adopted a power coercive approach in an effort to change physical exercise-related behaviors. The power coercive approach refers to the use of laws to mandate certain behavior (12). The goals in this case are to improve health and overall fitness of children and teenagers, and subsequently improve academic performance and discipline (4-6). The power coercive strategy has been successful in several public health campaigns, such as banning smoking in bars and restaurants (18). However, this approach also has limitations, particularly when the desirable change is not achieved and further public health problems are incurred (12-13). For instance, in The Rest of the Story: Tobacco News Analysis and Commentary, Siegel examined the government effort to ban smoking at home (13). He found that use of the coercive approach did not stop children from being exposed to second hand smoke, and indeed prevented children accessing medical treatment for second-hand smoke-induced diseases because parents were afraid of being subject to penalties for their behavior (13).

The power coercive approach to addressing child obesity, exemplified by SB530, is also likely to fail. This approach does not recognize factors such as performance accomplishment, vicarious experience, and verbal persuasion that are major sources of information in shaping perceived self-efficacy (9). Self-efficacy is an individual level theory for predicting behavior. This model suggests that without an expectation of mastery of a task, one is unlikely to persist in executing the action even when the outcome expected is rewarding (9). In the fitnessgram program there is very little incentive provided for performance accomplishment. The project mandates that students engage in vigorous exercise on a daily basis but it does not specify plans of activity or guarantee resources to assist students in meeting this requirement. For example, there is no support provided for the establishment of school sports leagues or competition games. Rather, the program only provides students with a report card of their fitness is kept confidential. In other words, it would be difficult for students to articulate their fitness score in terms of personal achievement.

It is also important to recognize that not all students deem weight or health as a concern. The need to gain a high fitness score may be hard to translate to non-obese students or “cool kids” (14). As a result, students may feel that the mandatory daily exercise is valueless. The vicarious experience thus becomes dimmed or non-existent as students are indifferent of their score and cannot compare their scores (9). Finally, note that self-efficacy is influenced by verbal persuasion, which implies the possible use of a normative re-educative strategy (9). This strategy uses tools to persuade people to change existing social norms to those which support healthy behaviors (9). The fitnessgram has completely disregarded the social norms that shape student motivation and incentive to engage in physical exercise (7,9). Enforcing mandatory physical education classes will only ensure students perceive a higher rate of schoolwork. An alterative approach that should be more effective is the normative-re-educative strategy, such as the “Truth Campaign” for youth tobacco reduction, that seeks to change behavioral norms (15). An advertising strategy could also be used to emphasize the positive outcomes of physical exercise and shape students’ perception of physical education.

It is important to remember that while some students can meet the requirements of the fitnessgram easily, others will have more difficulty improving their fitness level and losing weight. Such students will have to work harder to attain the same scores as their peers. Expectancies of these students are relatively high, which may lead to low perceived self-efficacy and result in low self-esteem (9). Such students are more likely to give up physical education after the introduction of the fitnessgram. In attempt to achieve a desirable body weight, such individuals are also at higher risk of using unhealthy diet strategies, such as inadequate energy intake, purging, or anorexia (19). Teenagers, who are very sensitive to their appearance, are more susceptible to engaging in such behaviors.

In summary, SB530 is likely to fail because it adopts a power coercive approach, forcing students to engage in physical exercise. This strategy fails to address students’ perceived self-efficacy, a critical factor determining whether students will undergo behavior change with respect to physical exercise (9). The use of report cards imposes high expectancy on overweight students and is likely to trigger low self-esteem (9). As a consequence, these students are more likely to engage in unhealthy eating behaviors (19).

Greater Fitness Equals Good Academic Performance? False Causation Engenders Negative Labeling

The original intention of the fitnessgram is to improve health and fitness among children, however the government of Texas has also implied that “improved fitness equals improved academic performance” (4-6). This belief had arisen from a trend study conducted in Texas in 2005 by the Texas Comptroller. The study revealed that obese individuals are more likely to drop out of high school compared to non-obese individuals (drop out rate 67.8% vs. 59.9%) (3). To establish whether this is a causal relationship, the SB530 empowers the TEA to undertake correlative analyses between students’ fitness scores, their academic grades, attendance rates, disciplinary problems, obesity level, and school meal programs (4-6). The findings will be released annually on September 1^st without displaying students’ names (4-6). Teachers and parents can then review individual student’s fitness scores by examining their test report cards (4-6).

Though the trend study does demonstrate a correlation between weight/fitness and education level, this data is still far from sufficient to establish a causal relationship. The trend study assessed students’ weight and education levels at the same point at time. Thus it was not a longitudinal analysis and thus the emergence of an outcome (i.e., education) cannot be situated before or after the proposed exposure factor (i.e., obesity, 8). Indeed, reverse causality could be taking place, such that low education level leads to obesity, given that individuals with low levels of education are more likely to have low “social economic status” (SES) and lack of knowledge of healthy eating patterns. Alternatively, there could be a third factor simultaneously affecting the variables of obesity and education. For instance, students that come from lower SES families may tend to eat more junk foods, and their parents may be too busy or unable to supervise their schoolwork. Therefore, these students would be more likely to become obese and perform less well in school. Thus the results of the trend study do not necessarily suggest that obesity causes low academic performance or vice versa.

The underlying mechanism of how fitness might affect student grades is not well understood. The TEA has essentially taken a theoretical leap from a link between obesity and academic performance to the proposal that improving fitness will improve academic performance. It is highly irresponsible to put forward this message without providing a clear mechanism for such a relationship. The key impact on students from this proposal is the negative labeling effect. Teachers and parents who absorb this message may label students based on their fitness scores and make presumptions with regard to their behaviors and academic performance (21). Emphasis of this relationship could also mean that other factors could be ignored when student issues arise, if parents and teachers assume problems are based on the fitness-academic performance link (21). According to Bigler and Liben, personal characteristics that are perceptually discriminable are more likely to become the basis of stereotyping than other characteristics (11). Nonetheless, appearance alone does not cause stereotyping or stigma, rather it is the labeling of distinguishable groups by adults which forms social stereotypes (11).

Through the fitnessgram project overweight and unfit students may learn that poor academic grades are linked to their fitness level. According to labeling theory, when individuals are named as part of a group they tend to assume the characteristics of that group (20). Therefore, children who are overweight may learn to give up before they even initiate learning at school. That is, they may feel that there is no expectancy of good grades/discipline in their stereotyped group, and that to attain good performance they have to lose weight to escape the stereotyped group. However, losing weight is unlikely to occur in a short period of time. The combined expectancy of high weight loss and good academic performance may stress obese students and further lower their perceived self-efficacy (7,9).

In summary, SB530 is likely to generate a negative labeling effect on overweight and unfit students by stressing an as yet unsubstantiated causation between good academic performance and physical fitness. Such labeling changes both adults’ and peers’ perceptions of the labeled group and self-expectancy of the labeled individuals.

The Fitnessgram and Flaws in the Traditional Health Belief Model

SB530 mandates that students undertake moderate-to-vigorous physical exercise for 30 minutes daily. It assumes that students dislike physical exercise. Students make rational decisions as to whether they engage in exercise (9,16). The implementation of the fitnessgram program is intended to adjust this personal behavior (9,16). The program is a typical instantiation of the Health Belief Model (HBM). According to the HBM, an individual’s readiness to take action is determined by weighing the perceived benefits of the action against perceived costs (9,16). It assumes human behavior is based on objective logical thought processes (9). In the case of physical exercise, students’ perceived benefits (perceived susceptibility and severity) are weight loss or obesity prevention. Perceived costs may be time and energy spent. Students then individually make rational decisions with respect to exercising. SB530 (reflective of the HBM) frames obesity as an individual problem (7), and fails to contextualize social factors such as lack of exercising facilities and social groups that would prompt individuals to engage in exercise (8). In contrast, Social Network Theory suggests an individual’s decision is dependent the social support available to them (17). Access and affordability are seen as crucial for physical exercise and a healthy diet. The HBM disregards these factors, and thus students are missing important information regarding the factors affecting their fitness levels and weight. They will gradually feel loss of control as more individual responsibilities are stressed by SB530.

In summary, SB530 cannot successfully improve students’ fitness because it adopts the flaws of the HBM. By assuming that being overweight is solely an individual responsibility this approach disregards the broader social context that engenders child obesity. Such social barriers will impede students from performing regular exercise to an extent they cannot control.

Conclusion:

Fitnessgram SB530 aims to improve students’ well-being. It mandates that students engage in daily physical exercise and use the fitnessgram for outcome evaluation (4-6). However, the use of a power coercive approach does not support positive perceived self-efficacy (9). Lack of incentives can lead to an indifferent attitude toward physical exercise. For overweight children expectancies are higher than other children, which can lead to low perceived self-efficacy and self-esteem (9). The emphasis on the relationship between fitness and school performance has not yet been scientifically demonstrated. The proposed link may lead to negatively labeling students who perform badly at school as unfit and overweight, and vice versa. Stereotyping may cause these students to be treated differently by adults and peers (11).

The design of the fitnessgram program is based on the HBM, which fails to contextualize the social factors that affect students’ behavior (8). Overall, the program inflicts more personal responsibility on students than can be repaired by the health benefits. To ensure the success of the program, the Texan government should adopt a normative re-education approach to increase students’ awareness of physical exercise (12). The relationship between grades and obesity needs to be carefully examined, and the program should cease labeling unfit and overweight students as having bad grades and behavior problems. Finally, social factors need to be addressed within the program in order to empower students with knowledge of the underlying causes of obesity, which will allow a more efficient strategy to be designed to encourage healthy behaviors (8).

REFERENCES:

1. Tanner L. Doctor Report on Heart Attacks in Kids. New York, NY: Associated Press. http://www.physorg.com/news110442448.html.

2. Carlton J. Texas Unveil Fitness Test for Students. New York, NY: Associated Press. http://www.boston.com/news/education/k_12/articles/2007/09/27/texas_unveils_fitness_test_for_students/.

3. Combs S. Weighing the Costs: Obesity Affects the Work Force. Austin, Tx: Texas Comptroller of Public Accounts. http://www.window.state.tx.us/comptrol/fnotes/fn0705/.

4. Nelson J. et al. Lagislative Update: Latest on SB 530. Austin, Tx: Texas Association for Health, Physical Education, Recreation, and Dance. http://www.tahperd.org/LINKS/SUB_LINKS/ISSUES_LEGISLATIVE/legislative_action.html.

5. Partnership for a Healthy Texas. Physical Education in Texas. Austin, Tx: Texas Health Institute. http://www.tahperd.org/LINKS/SUB_LINKS/ISSUES_LEGISLATIVE/issues_pdfs/PE_Talking_Points.pdf.

6. Nelson J. et al. Student Fitness Legislation (SB 530). Austin, Tx: The Senate of Texas. http://www.tahperd.org/LINKS/SUB_LINKS/ISSUES_LEGISLATIVE/issues_pdfs/SB530_Nelson_Information_Handout.pdf.

7. Edberg M. Individual Health Behavior Theories (pp. 35-49). In: Edberg M, ed. Essentials of Health Behavior. Sudbury, MA: Jones and Barlett Publishers, Inc., 2007.

8. Link B. G. & Phelan J. Social Conditions as Fundamental Causes of Disease 1996; (Extra Issue):80-94.

9. Salazar M. K. Comparison of Four Behavioral Theories: A Literature Review 1991; Vol. 39, NO. 3: 92-99.

10. Benne K. & Chin R. General Strategies For Effecting Changes in Human Systems (pp. 22-45). In: Bennis W, ed. The Planning of Change. New York, NY: Holt, Rinehart And Winston, 1965.

11. Bigler R. S. & Liben L. S. A Developmental Intergroup Theory of Social Stereotypes and Prejudice. Advances in Child Development and Behavior 2006; 34:39-89.

12. Siegel M. Education and Perssuasion Versus Coercion as Public Health Approaches. Boston, MA: The Rest of the Story: Tobacco News Analysis and Commentary. http://tobaccoanalysis.blogspot.com/.

13. Siegel M. Making it Unlawful to Smoke Around Children Could have Detrimental Effect on Children’s Health, Especially among Disavantaged Populations. Boston, MA: The Rest of the Story: Tobacco News Analysis and Commentary. http://tobaccoanalysis.blogspot.com/.

14. Gladwell M. The Tipping Point. New York, NY: Little, Brown and Company, 2002.

15. Hicks J. The Strategy Behind Florida’s “Truth” Campaign. Tobacco Control 2001; 10:3-5.

16. Rosenberg I. Historical Origins of the Health Belief Model. Health Education Monographs; Vol. 2, NO 4:328-335

17. Edberg M. Social, Cultural, and Environmental Theories (Part I) (pp. 51-64). In: Edberg M, ed. Essentials of Health Behavior. Sudbury, MA: Jones and Barlett Publishers, Inc., 2007.

18. Beiner L. & Siegel M. Banning Smoking Could Boost Business for Restaurants and Bars. Boston, MA: American Medical Association’s Science News Department. http://www.wish-wi.org/siegel.html

19. Gilbert P. & Miles J. Eating disorders, shame and pride (pp. 219-255). In: Gilbert P. & Miles J, ed. Body Shame: Conceptualization, Research, and Treatment. New York, NY: Psychology Press, 2002

20. Wikipedia. Labeling Theory. Wikimedia Foundation Inc. http://en.wikipedia.org/wiki/Labeling_theory.

21. Campos P. Why American’s obsession with weight is hazardous to your health (pp.247-251). In: Campos P, ed. The Obesity Myth. New York, NY: Gotham Books, 2004.

“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.

REFERENCES
1. Saelens, Brian E. Neighborhood-Based Differences in Physical Activity: An Environment Scale Evaluation. American Journal of Public Health 2003; 93 (9): 1552-1558
2. Phelps, James R. Physical Activity and Health Maintenance- Exactly What Is Known? The Western Journal of Medicine 1987; 146; 200-206
3. Morant, Helen. BMA demands more responsible media attitude on body image. British Medical Journal 2000; 320; 1495.
4. McKay, A H. Exercise interventions for health: time to focus on dimensions, delivery, and dollars. British Journal of Sports Medicine 2003; 37; 98-99
5. Edberg, M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston, MA: Jones and Bartlett, 2007.
6. Childhood Obesity. Tampa, Florida: Obesity Action Coalition. http://www.obesityaction.org
7. Sack, K. (2007, October 20). Schools Found Improving in Nutrition and Fitness. The New York Times.
8. Centers for Disease Control and Prevention. A New View of Physical Activity, Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion Division of Nutrition and Physical Activity, 1999.
9. Campos, P. The epidemiology of overweight and obesity: public health crisis or moral panic? International Journal of Epidemiology 2006; 35: 55-60.
10. Louis, Margaret. Exploring the Association Between Body Weight, Stigma of Obesity and Health Care Avoidance. Journal of the American Academy of Nurse Practitioners 2002; 14 (12): 554-561.
11. Allison, Kenneth R. Self-Efficacy and Participation in Vigorous Physical Activity by High School Students 1999; 26 (12): 12-24.
12. Greenberg, Bradley S. Portrayals of Overweight and Obese Individuals on Commercial Television 2003; 93 (8):1342-1348.
13. Blendon, Robert J. Understanding The American Public’s Health Priorities: A 2006 Perspective. Journal of Health Affairs 2006; 25: 508-515.
14. Centers for Disease Control and Prevention. Overweight and Obesity. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion, 2007.
15. Kantrowitz, B. Newsweek. Why Women Lose Weight- or Don’t. 2007. www.Newsweek.com