Does an Apple a Day Keep the Doctor Away? – Vanessa Holley

Does an Apple a Day Keep the Doctor Away? The Failure of the 9 a Day Campaign to Reduce the Risk of Diet Related Diseases in African Americans.

The Center for Disease and Control reports that everyone should consume fruits and vegetables because they contain essential vitamins and minerals needed to protect against chronic diseases such as cardiovascular disease and certain cancers (1). Vitamin A and C, fiber, and potassium are just some of the many nutrients found in fruits and vegetables that may help protect people against these chronic diseases. Studies suggest that those who do not eat fruits and vegetables daily are twice as likely to get cancer and increasing the intake of fruits and vegetables can reduce cancer rates by more than 25% (2). Eating fruits and vegetables is important, but it is the amount you consume that theoretically reduces the risk of certain diseases.

According to the National Institute of Health, on average people consume 2.9 servings of fruits and vegetables daily (2). As an association was clear between fruit and vegetable intake and chronic diseases, the National Institute of Health and the National Cancer Institute developed a program, 5 a Day for Better Health, to increase the awareness of eating more fruits and vegetables daily to reduce the risk of diseases. The 5 a Day program recommends everyone to eat at least 5-9 fruits and vegetables daily to reduce the incidence of chronic diseases. People were encouraged to maintain a healthy lifestyle, diet regularly, and consume at least 5 fruits and vegetables daily to reduce the risk of diseases. As the campaign progressed and continued to address the issue of fruit and vegetable intake and chronic diseases, small populations of Americans were still disproportionately affected by diet related and chronic diseases, especially African American men.

African American men suffer disproportionately in numerous health conditions. African American men have the highest rates of cancer and mortality rates among any other ethnic group (3). They develop diabetes and high blood pressure very young and suffer severe side effects (3). They are also twice as likely to get diabetes than whites. Overall, African American men are 140% more likely to die from cancer than whites (4). African Americans are severely affected by diet related diseases, yet they have the lowest consumption of fruit and vegetable intake overall (4). On average, African American men eat 3.1 fruits and vegetables daily (4). The 5 a Day campaign became concerned with the high rates of diseases among African American men so they extended their program to a 9 a Day campaign, a program designed for African American men to eat 9 fruits and vegetables daily to reduce their risk of diet related disease. The 9 a Day campaign needs to ultimately change the eating habits of African American men to reduce their risk of disease. The U.S. Department of Health and Human Services and the National Cancer Institute 9 a Day Campaign to reduce chronic disease among African American men fails in its attempt to recognize factors that influence eating habits.

Accessibility of Fruits and Vegetables

The 9 a Day campaign does not take into account accessibility of fruits and vegetables. African American men will be unable to eat at least 9 fruits and vegetables daily if they are not readily accessible to them. Geographic location of healthy food stores, lack of transportation and affordability of fruits and vegetables are main components that prohibit African American men from having access to fruits and vegetables.

The campaign fails in its’ attempt to understand how the local environment can influence consumption of fruits and vegetables. Low-income neighborhoods are made up of a disproportionate number of African Americans and predominately white neighborhoods tend to have higher average incomes. Lower income neighborhoods have fewer healthy food stores compared to higher income neighborhoods and therefore is not accessible to many African American men (5). Higher income neighborhoods have 5 times more supermarkets compared to only 8 % of low-income communities made up of African Americans living near at least one supermarket (5). Supermarkets carry more variety of fruits and vegetables than local grocery stores and would be a resource of obtaining needed fruits and vegetables. As more supermarkets continue to migrate to the suburbs and more independently own grocery stores are being built in low-income neighborhoods, a greater proportion of African American households will not have access to essential fruits and vegetables. It is impossible for African American men to eat 9 fruits and vegetables daily if resources (healthy food stores and supermarkets) are not readily available within their specific neighborhoods.

Transportation would also have to be readily accessible to get access of fruits and vegetables needed. If healthy food stores are not located in African American neighborhoods, African Americans would be forced to travel across town to get the food they need. Those without a car rely on public transportation to get around. What father of 3 would waste 2 hours of their time to get on the bus with children in tow to get the necessary 9 fruits and vegetables needed to maintain a healthy lifestyle. Whites have 3 times greater access to transportation than African Americans and have a better chance of purchasing the food they need (5). Those with limited transportation are forced to shop nearby in grocery stores where supermarkets are generally smaller in size, carry a narrower range of products, and are usually more expensive (6). The program cannot be effective unless African American men have access to purchase the fruits and vegetables needed to reduce diet related diseases.

African American men will be unable to eat at least 9 fruits and vegetables daily if they cannot afford to purchase these items. Increasing fruit and vegetable consumption is very difficult because consumer food choice is closely linked to food costs (7). Fruit and vegetable availability decreases in the home as the costs per serving for fruits and vegetables increases (7). As prices steadily rise for fruits and vegetables, African American men will not be able to afford them. The 9 a Day campaign expects all African American men to eat 9 fruits and vegetables daily, but they can eat that many servings if they are unable to afford these items. There is also an association between income and fruits and vegetables. Lower socioeconomic status is linked to the consumption of fruits and vegetables because many cannot afford to purchase fruits and vegetables. There are more African Americans considered within the lower socioeconomic class than whites, which would affect African American men food consumpti0n even more.

Lower income households spend little on fruits and vegetables because they allocate their limited income to other items they deem desirable such as housing, clothing, and other foods (8). Many African American men find that providing for their families essential needs is more important than buying 9 fruits and vegetables a day. A father would first pay rent to provide a roof over his families head than to purchase numerous fruits and vegetables. Although they make less than higher income households, lower income households spend more of their income on food (5). Food is a big part of their budget and they would prefer to buy the necessary food items to feed their family. Many consider fruits and vegetables as an additional expense, and would prefer not to exchange usual food items for healthier options (8). The 9 a Day campaign cannot expect African American men to buy 9 fruits and vegetables if they do not have enough disposable income to actually buy the food items. The campaign cannot be effective unless the men can actually afford to purchase the fruits and vegetables needed to reduce diet related diseases.

Thus, the 9 a Day campaign does not take into account accessibility of fruits and vegetables to African American men. Lower income neighborhoods made up of a disproportionate number of African Americans have fewer healthy food stores. Those without access to transportation are unable to go to the store and buy the recommended fruits and vegetables. Also, many African Americans are unable to afford these items due to their limited incomes, and may opt to prioritize other resources over fruits and vegetables.

Cultural Norms and Fruits and Vegetables

The 9 a Day campaign does not take into account differences in cultural norms of African American men. African American men will not eat 9 fruits and vegetables daily if it is not part of their normal diet. Many cultural differences exist between food consumption and Social Expectations Theory explains how it would be hard for African Americans who are used to consuming the same foods to change their daily eating habits.

African American families purchase fruits and vegetables based on preference, cultural significance and family traditions (7). Food patterns vary according to regional and social influences of each community. African American food patterns have drawn on eating habits of several cultures including seventeenth and eighteenth century West African culture associated with American slavery and post-civil war rural South (9). Slaves had limited access to ingredients and preparation tools to cook food (9). Fruits and vegetables were not readily accessible to many slaves. As a result, many traditional African American families do not eat fruits and vegetables as there food patterns are similar to that of slaves. Many other cultures such as the Haitian community have a high intake of meat, rice, plantains, and beans. Those of Caribbean descent have a high intake of jerk and curry chicken, rice and peas, and sugar cane. Different foods associate with different cultures. Many of these cultures simply may not know how to prepare the fruits and vegetables you find here. These cultures are used to preparing the food of their specific culture. These cultures also have these specific items because they are cash crops of these countries and are easily available to the people of that land (9). Those that migrate to the states are still going to consume those foods of cultural significance. There is deep ethnic variation in the consumption of fruits and vegetables.

The 9 a Day campaign does not consider cultural differences in African American men. The Social Expectations Theory in which behavior is dictated by social norms shows how cultural differences in the consumption of food will change how people feel about consuming 9 fruits and vegetables daily. Those who are used to consuming the same foods within their specific culture will not want to change their daily behavior. Those cultures are not susceptible to change if they are use to their specific social norms. The 9 a Day campaign would have to change the cultural norms of a community in order to change their specific eating habits. The 9 a Day campaign falls short in changing the daily norms of these deeply enriched cultures.

Thus, the 9 a Day campaign does not take into account differences in cultural norms of African American men. Ethnic variations exist between eating habits and fruit and vegetable consumption may not be a big part in their diet. The Social Expectations Theory helps to explain that if the men are use to their specific social norms then consequently they will not be inclined to change their daily diet.

Self-Efficacy and Fruits and Vegetables

African American men will not eat fruits and vegetables if they do not think they can consume 9 fruits and vegetables daily. Social Cognitive Theory helps to address this failure of the 9 a Day campaign. Social Cognitive Theory provides a framework for understanding what influences the mens’ human behavior through self-efficacy.

Within the theory, self-efficacy is a person’s notion that they are capable of performing certain behaviors (10). Those who believe they have the power to change will ultimately change their behavior. People are more inclined to take on a task if they believe they can do it. Likewise, those who believe they cannot change are not inclined to perform a specific task. In Social Cognitive Theory, perceived self-efficacy is a key determinant in changing and inflicting behavior (10). The problem with the 9 a Day campaign is that it does not take into account self-efficacy as a means of changing behavior. African American men will not eat fruits and vegetables if they do not think they can consume 9 fruits and vegetables daily. Many African American men may find that eating 9 servings a day an unattainable goal (11). Simply put, 9 fruits and vegetables are a lot to eat in one day, especially if a person works a 9-5 job and takes care of their children. People may find that they have no time to eat so many fruits and vegetables and opt not to eat any fruits and vegetables all together. Studies indicate that men appear to need increased confidence in their ability to include fruit in their diets as they consider and commit to such a change (11). The 9 a Day campaign fails to recognize the actual ability of these men to change their diets to include 9 fruits and vegetables. Also, accounting for accessibility and affordability, African American men will find it even harder to eat 9 fruits and vegetables. Those who face the barriers to fruit and vegetable access and affordability are discouraged from pursing a healthy behavior according to the Social Cognitive Theory (11). Increased consumption of fruits and vegetables is associated with high levels of self-efficacy (12) and the 9 a Day campaign fails to boost people’s perception that eating 9 fruits and vegetables is an achievable goal. The 9 a Day campaign should just focus on the importance of consuming fruits and vegetables versus mandating 9 fruits and vegetables daily to achieve a healthy lifestyle. Requiring 9 fruits and vegetables seems unattainable to many.

Thus, the 9 a Day Campaign does not take into account self-efficacy as a means of changing behavior. African American men simply do not think that they can consume 9 fruits and vegetables daily. 9 fruits and vegetables is a lot to consume in one day and many African American men find this an unachievable goal.

Conclusion

Overall, the U.S. Department of Health and Human Services and the National Cancer Institute 9 a Day campaign to reduce chronic disease among African American men fails in its attempt to recognize factors that influence eating habits. The 9 a Day campaign does not consider accessibility of fruits and vegetables. A systematic geographic difference exists between those who simply do not have access to healthy food stores and supermarkets. Accessibility is an issue when many do not have transportation to healthy foods stores and supermarkets. Many also simply cannot afford to purchase numerous fruits and vegetables. The 9 a Day campaign does not consider cultural norms of African American men. Ethnic variations exist between eating habits and fruit and vegetable consumption may not be a big part in their diet. The 9 a Day campaign also does not consider self-efficacy as a means of changing behavior. African Americans simply do not believe that they can eat 9 fruits and vegetables daily. The 9 a Day campaign will continue to be a failure unless these factors that influence eating habits are recognized. The 9 a Day campaign can become effective if they work to change the underlying social conditions that cause differences in access, cultural differences, and motivation.

REFERENCES

1. Centers for Disease Control and Prevention. Fruits and Veggies Matter. Atlanta, GA: Centers for Disease Control and Prevention. http://www.fruitsandveggiesmatter.gov/benefits/index.html

2. Produce for Better Health Foundation. 5 a Day for a Better Health Program

Monograph. Wilmington, DE: Produce for Better Health Foundation. http://www.pbhfoundation.org/pdfs/pulse/research/5adayresearch/NCImonograph.pdf

3. The University of Texas MD Anderson Cancer Center. Cancer Wise. Houston, TX: The University of Texas MD Anderson Cancer Center. http://www.cancerwise.org/June_2003/display.cfm?id=D9F10E7A-FCE4-4AF6-9329DF2B425D18D6&method=displayFull&color=green

4. US Department of Health and Human Services. HHS News. Washington D.C.:

http://www.nih.gov/news/pr/apr2003/nci-24.htm

5. Roux A., Moreland K., Wing S. The Contextual Effect of the Local

Food Environment on Residents’ Diets: The Atherosclerosis Risk in Communities Studies. American Journal of Public Health 2002; 92:1761-1767.

6. Krebs-Smith S., Kantor L. Choose a Variety of Fruits and Vegetables

Daily: Understanding the Complexities. The Journal of Nutrition 2001; 22:487-501.

7. Ard J., Fitzpatrick S., Desmond P., et al. The Impact of Cost on

the Availability of Fruits and Vegetables in the Homes of Schoolchildren in Birmingham, Alabama. American Journal of Public Health 2007; 97:376-372.

8. Blisard N., Jolliffe D., Stewart H. Low-Income Households’

Expenditures on Fruits and Vegetables. Agriculture Information Bulletin 2004; 792:1-2.

9. Klassen A., Shankar S. Influences on Fruit and Vegetable Procurement

and Consumption among Urban African-American Public Housing Residents, and Potential Strategies for Intervention. Family Economics and Nutrition Review 2001; 13:34-46.

10. Bandura A. Social Learning Theory. Englewood Cliffs, NJ: Prentice Hall,

1977.

11. Betts N., Greene G., Hoerr Sharon., et al. Self-Efficacy, Perceived

Benefits, and Weight Satisfaction Discriminate Among Stages of Change for Fruit and Vegetable Intakes for Young Men and Women. Journal of the American Dietetic Association 2002; 102:1466-1470.

12. Barbeau E., Dubowitz T., Stoddard A., et al. The Influence of

Social Context on Changes in Fruit and Vegetable Consumption: Results of the Health Directions Studies. American Journal of Public Health 2007; 97: 1216-1227.

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

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


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

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

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

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

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

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

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

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

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

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

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

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

REFERENCES
1. Lobstein T, Baur L, Uauy R for the IOTF Childhood Obesity Working Group. Obesity in children and young people: A crisis in public health. Obesity Reviews 2004; 5 (Suppl 1): 4-85.
2. Ogden Cl, Carroll MD, Curtin LR, McDowell MA, Tabak CJ. Flegal KM. Prevalence of Overweight and Obesity in the United States, 1999-2004. Journal of the American Medical Association (JAMA) 2006; 295:1549-1555
3. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a Standard Definition for Child Overweight and Obesity Worldwide: International Survey, 2000 BMJ; 320:1240-1243
4. Daniels SR, Khoury PR, Morrison JA. The Utility of Body Mass Index as a Measure of Body Fatness in Children and Adolescents: Differences by Race and Gender. Pediatrics. 1997; 99: 804–807
5. Winkleby MA, Robinson TN, Sandquist J, Kramer H. Ethnic Variation in Cardiovascular Disease Risk Factors among Children and Young Adults: Findings from the Third National Health and Nutrition Examination Survey, 1988-1994 JAMA 281(11),1006-1013
6. Must A. Does Overweight in childhood have an impact on adult health? 2003 Nutritional Review 61:139-142
7. Miller J, Rosenbloom A, Silverstein J. Childhood Obesity 2004 Journal of Clinical Endocrinology & Metabolism Vol.89, No. 9 4211-4218
8. U.S. Surgeon General. Overweight and Obesity: Health Consequences. Web site accessed November 11,2007
http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_consequences.htm
9. Association of Health and Territorial Officials & National Institute of Health care Management Organization Report On: Childhood Obesity: Harnessing the Power of Public and Private Partnership. Accessed on 10/26/07 http://www.nihcm.org/pdf/FINAL_report_CDC_CO.pdf
10. Bandura, A. (1994). Self-efficacy. In V. S. Ramachaudran (Ed.), Encyclopedia of human behavior (Vol. 4, pp. 71-81. Accessed on 11/13/07 http://www.des.emory.edu/mfp/BanEncy.html
11. Edberg, M. Social, Cultural, and Environmental Theories (Part I). Essentials of Health Behavior: Social and Behavioral Theory in Public Health. 2007 Ch 5, pg.51-55
12. Schwarxer R, Luszczynska A, Self Efficacy and Health Behavior Theories Accessed on 11/12/07 http://dccps.cancer.gov/brp/constructs/self-efficacy/index.html
13. Pajares Overview of social cognitive theory and of self-efficacy. Accessed 10/26/07, from http://www.emory.edu/EDUCATION/mfp/eff.html
14. Kalakanis L, Moulton B. School-Based Interventions for Childhood Obesity. 2006 Texas Legislative Council. Accessed 10/26/07: http://www.tlc.state.tx.us/pubspol/childobesity.pdf
15. Dietz, W. H., & Gortmaker, S. L. (1985). Do we fatten our children at the television set? Obesity and television viewing in children and adolescents. Pediatrics, 75(5), 807-812.
16. Ross, J. G., & Pate, R. R. (1987). The National Children and Youth Fitness Study II: A summary of findings. Journal of Physical Education, Recreation and Dance, 58(9), 51-56. EJ 364 411. Accessed on 10/26/07 : http://www.kidsource.com/kidsource/content2/obesity.html
17. Weinberg Z. No Place to Shop: Food Acess Lacking in the Inner City. Race, Poverty and the Environment. 2000;7 (2):22-24
18. Glanz K, Basil M, Maibach E Goldberg J Snyder D. Why Americans Eat What They Do: Taste, nutrition, cost ,convenience and weight control concerns as influences on food consumption. Journal of Preventative Health: 22 (1) 23-29
19. Edberg, M. Individual Health Behavior Theories . Essentials of Health Behavior: Social and Behavioral Theory in Public Health. 2007 Ch 4, pg.35-37
20. Emmons KM. Behavioral and social science contributions to the health of adults in the United States. In: Smedley BD, Syme SL, editors. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, DC: National Academy Press; 2000:254-321. Accessed on 10/26/07 : http://www.jmir.org/2005/5/e58#ref20
21. Andrews, Bess. Study Links Fast Food to Overall Nutrition and Obesity Risk. Accessed on 11/11/07 :
http://www.childrenshospital.org/newsroom/Site1339/mainpageS1339P1sublevel42.html
22. Safe Neighborhoods Report, Vision for Children at Risk Website
Accessed on 11/11/07: http://www.visionforchildren.org/content/view/81/38/
23. Edberg, M. Individual Health Behavior Theories . Essentials of Health Behavior: Social and Behavioral Theory in Public Health. 2007 Ch 4, pg.39
24. Wikipedia. Theory of Reasoned Action. Wikimedia Foundation Inc.
Accessed on 10/26/07: http://en.wikipedia.org/wiki/Theory_of_reasoned_action
25. Goran MI, Ball GD, Cruz ML 2003 Obesity and Rish of Type 2 Diabetes and Cardiovasclar Disease in Children and Adolescents. Journal of Clinical Endocrinology and Metabolism: 88 1417-1427
26. Wang G, Dietz WH 2002 Economic Burden of Obesity in Youths Aged 6 to17 years: 1979-1999. Pediatrics 109:E81-1
27. Steinberger J, Daniels SR 2003 Obesity, Insulin resistance, Diabetes, and Cardiovascular Risk in Children: an American Heart Association Scientific Statement from the Atherosclerosis, Hypertension, and Obesity in the Young Committee and the Diabetes Committees. Circulation 107:1448-1453

Will the Commonwealth Truly Connect its Citizens to High-Quality, Safe, Effective, Timely, Efficient, Equitable and Patient-Centered Health Care?

A Critique of the Massachusetts Health Care Reform Legislation - Jahera Otieno

Health Care coverage continues to become an issue of growing importance in the US. As people begin to lose essential health insurance coverage or start having to pay for portions of their health care due of rising costs, health care coverage, or lack thereof, is becoming a topic of increasing significance. As the 2008 presidential race picks up, republican and democratic candidates alike, are sharing their attempts on how they plan address the concerns related to paying for our nation’s health. We are spending more on doctors, prescription drugs and procedures than we ever have before but there are still over 40 million uninsured persons coming from every race, culture, ethnicity and income (3). With health care costs rising to over $2 trillion in 2007, will health care really be a “good” that is accessible to all peoples? This question is one that the state of Massachusetts hopes to answer.

In 2006, Health Care Reform became law in Massachusetts, initiating a national conversation about healthcare. The legislation plans to bring about a healthier Massachusetts with everyone - individuals, government and employers - doing their part and sharing the responsibility to provide all citizens with access to quality health care. While this legislation allegedly makes health care more accessible (mainly by eliminating cost), it also requires, or mandates, that all people have coverage and no longer making it an individual choice. This reform makes Massachusetts the first state in the nation to provide all citizens, if successful, with health care, and in turn, creating a model of universal health care for our country (2,3). Massachusetts becomes the first state in the Nation providing all of it citizens, if successful, High-Quality, Safe, Effective, Timely, Efficient, Equitable and Patient-Centered Health Care (1), creating a model of Universal Health Care for our country (2,3).

As this legislation is working to provide access to hundreds of thousands of people in the state with health care, it is also setting the stage for similar legislation to happen all around the country and in our nation as a whole. In moving forward, it is important that many questions and concerns that key stakeholders have are addressed. Is this legislation truly providing an easier way for all Massachusetts’s residents to access health care? Will there be enough money to support the program while not taking away from current services? Will “affordable” health care really be affordable? With there being an increased demand those primary healthcare services being, will the quality of care that is received here remain cutting-edge or suffer? The Massachusetts Health Care Reform Legislation claims to be providing “affordable” care to Massachusetts’s residents, but its citizens still will not access to affordable health care services.

Argument I: Massachusetts Health Care Reform Legislation does not account for other barriers, outside of cost to health care.

The Massachusetts Health Care Reform Legislation claims that it will provide all it citizens with access to affordable high quality health care but there are some known implicit and explicit barriers to health care that prohibit many people from using health care services. The cost of care will always discourage people from getting regular health care, but there are also many non-financial barriers to health care like culture, race and ethnicity that may deter someone from accessing basic and preventative health care. While the legislation does address some of these issues, there are key elements that have not been addressed throughout the policy.

First and foremost, the cost of health care is the primary reason that health care is not accessed by many people. According to Bodenheimer and Grumbach, Understanding Health Policy, “Access to care has two major components. First and most frequently discussed is the ability to pay”(4). The cost of health care, and its persistent rise, is the primary reason that many do not access care and one of the primary issues addressed by the legislation. By potentially eliminating cost as the barrier to care, it is believed that people should have no major hindrance to accessing health care. Past attempts at controlling cost and political unwillingness to stop the rising cost of health care continue to promote the inaccessibility of health care for many people. For some, health care is still out of reach. The legislation included a caveat that exempts some from having to obtain health insurance coverage (5). Even with the reform aiming for universal coverage, it is still out of reach for some 60,000 people. With Massachusetts having approximately 500,000 uninsured, there is still a large portion of the population for which coverage remains out of reach (5). The cost of care needs to reach a place where care is within reach so that all can access it.

But there are a variety of other reasons, which inhibit people from accessing necessary healthcare services. First, there are major cultural and language barriers that may stop a person from accessing services. "The availability of culturally competent services can make a real difference in whether a patient comes in for care or returns for a second visit (6)." For example, if a woman can’t speak English and is being seen by a male physician, it may be an uncomfortable experience for her and stop her from seeing that doctor, or any doctor, in the future. A New England journal of medicine article states that language barriers can have deleterious effects. Patients who face such barriers are less likely than others to have a usual source of medical care; they receive preventive services at reduced rates; and they have an increased risk of non-adherence to medication (7).

Additionally, issues regarding race, may also stop a person from accessing health care. It has been shown that persons of color are less likely to receive primary health care services when compared to whites (8). According to the report from HRSA, racial and ethnic minorities face significant health disparities. Compared with white infants, infant mortality rates among blacks and Native Americans are 2.5 and 1.5 times higher, respectively. Black men less than 65 years of age have double the rate of prostate cancer compared with white men. The prevalence of diabetes is 70 percent higher among blacks and nearly 50 percent higher among Hispanics than among whites (7). On CommonHealth, WBUR’s blog, about health care in the commonwealth, Elmer Freeman talks about how it is not a matter of how you’re covered but it’s how you’re treated (9). Mr. Freeman states that while it may be unhealthy to be uninsured, health insurance is no assurance of better health, particularly for the diverse racial and ethnic minority groups across the Commonwealth (9). It is true that insurance doesn’t equal access because if a person is not comfortable accessing services, simply having insurance will not open that door.

While, the legislation has established a statewide Racial and Ethnic Health Disparities Council to track disparities data but it does not seem likely that this new legislation will achieve significant results in addresses issues that will persist in baring people for essential care. There are many issues that affect a person’s ability access to health care, regardless of having insurance. It is imperative that the commonwealth continues to watch these issues and others as they arise and work to address.

Argument II: By using the Power-Coercive Model, the MA Health Care Reform Legislation will not increase use of health care through its individual mandate.

There are a variety of strategies that Public Health professionals use when developing interventions to address health care issues. “When a person or group is entrenched in power in a social system, in command of political legitimacy and of political and economic sanctions, that a person or group can use power coercive strategies in effecting changes, which they consider desirable, with much awareness on the part of those out of power in the system” (10) and people are often aware when something is being pushed on them. The Power-Coercive Model can be effective when implementing system-wide change, but it can also make some feel powerless when an initiative, program or policy, be it beneficial or not, is being forced upon them to accept.

One particular troublesome element to the Massachusetts Health Care Reform are the individual and employer mandates. The mandate is being enforced through the use of a penalty system. By working to create change by using a mandate-penalty strategy, the state is use of a Power-Coercive technique will hopefully create state wide social change in regards to health. Unfortunately, by using the Power-Coercive technique to enact a policy that Massachusetts feels is most beneficial to all it citizens, the reform may not be as successful as hoped. The Power-coercive model places emphasis on political and economic sanctions in the exercise of power (10) and it can have a detrimental effect on the change desired. Some may fight back or simply “opt-out” of the requirement.

“A mandate is critical, however, to helping the state (MA) achieve near-universal coverage and it is hard to force people to buy coverage, especially when some people do not think they need it” (11,12). By enacting an individual mandate into the legislation, it shifts the responsibility to the person to find their own health care and “as most people in the United States rely on their employers or a government program for coverage, and individuals seeking insurance on their own are faced with a difficult, sometimes impossible, task” (11,12). Having that responsibility can be an overwhelming task, even for those who have an understanding of health care. And for some MA residents, it may just be easier and cheaper to pay the penalty than to get health insurance (14). Easier, because looking for and accessing care can be a daunting task, even for those who have their coverage paid for. And for a family that is not eligible for the free or less expensive health care coverage options, the cost to provide care simply may not be affordable and a penalty may be the only reasonably priced option.

Argument III: MA Health Care Reform Legislation will not decrease or contain the spiraling cost of healthcare in Massachusetts.

The cost of health care in America continues to rise. With the US forecasted to spend over two and a half trillion dollars on health care in 2007, the cost of basic and essential health services are slowly moving out of reach of individuals, government and employers. But there are a variety of ways to slow down these rising costs including increasing efficiency of health care delivery or limiting the resources available to the health care system (13). The health reform legislation created a Quality and Cost Council which is responsible for setting benchmarks for quality improvement and cost containment, but there was no central focus in the legislation on containing cost overall.

There is a major need for health care accountability for the rising cost of care, particularly on the part care providers. In article by Jon Hurst, he states that “we need answers and accountability from health care providers and that we need to put health care under the microscope to truly examine where the money is going for all this health care (17). As health insurance premiums could cost up to 20% of a total compensation (15), the commonwealth needs to examine where all this money is going to come from to pay for the coverage it has promised it citizens. “What we need is a revolution through which we can replace our resignation with hope -- and our disengagement with a new community-based activism driven not by partisan politics but by an unwillingness to accept a system that has become obsessed with the delivery of health care as an economic commodity at the expense of health for the American people (16). If the state is able to effectively control costs, consumers will get more value for their money while still providing exceptional care. In moving forward, ee as a commonwealth need to collaborate with all stakeholders to control these costs before they get out of hand.

Massachusetts claims that it will address concerns of all it citizens and provide High-Quality, Safe, Effective, Timely, Efficient, Equitable and Patient-Centered Health Care (1)? And while there have been many strides towards providing all citizens with health insurance, it is unlikely that it will provide the highest quality and affordable care possible. It is unlikely that all people will access health care with insurance now even if they have it or if they are being forced to use the services. According to the World Health Organization Constitution, “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition” (18) but this is not a belief held by all. As the state moves into year two of this legislation, it will need to stay in control of the service they are providing. It will need to continue to provide affordable care to all those who need it. It will need to look closer at the beliefs, ideas and expectations of all it peoples that it had that may not have been examined closely before.

References

1. The 185th General Court of The Commonwealth of Massachusetts Chapter 58 of the Acts of 2006. An Act Providing Access to Affordable, Quality, Accountable Health Care. http://www.mass.gov/legis/laws/seslaw06/sl060058.htm
2. “Health Care Reform: An Overview”. Massachusetts Commonwealth Connector www.mahealthconnector.org/portal/site/connector/menuitem.d7b34e88a23468a2dbef6f47d7468a0c?fiShown=default
3. Lee, C. Massachusetts Begins Universal Health Care. The Washington Post. 2007 www.washingtonpost.com/wp-dyn/content/article/2007/06/30/AR2007063000248.html
4. Bodenheimer, Thomas S. , Grumbach, Kevin. Understanding Health Policy. 2001.
5. Families USA. Massachusetts Health Reform of 2006 PDF. August 2007
6. Preboth, Monica. Breaking Cultural Barriers in Health Care. American Family Physician, http://findarticles.com/p/articles/mi_m3225/is_6_61/ai_61432844
7. Flores, G. Language Barriers to Health Care in the United States. New England Journal of Medicine. 2006;355;229-231.
8. Altman, S., Doonan, M. Can Massachusetts Lead the Way in Health Care Reform? New England Journal of Medicine. 2006;354:2093-2095 M
9. Freeman, E. It’s Not How You’re Covered…It’s How You’re Treated. CommonHealth, 2007. http://www.wbur.org/weblogs/commonhealth/?p=36
10. Chin R, Benne KD. General strategies for effective change in human systems. In Bennis W et al. (eds.): The Planning of Change (3rd edition), pp. 22-45. New York: Holt, Rinehart and Winston, 1976.
11. McDonough, J. The Individual Mandate is about to get serious. CommonHealth, 2007. http://www.wbur.org/weblogs/commonhealth/?p=238
12. Abelson, R. Mandatory Coverage Is Easier Said Than Done. New York Times. 2007 http://www.nytimes.com/2007/06/11/business/businessspecial3/11insure.html?emc=eta1&pagewanted=all
13. Controlling Health Care Cost. New England Journal of Medicine .Volume 351:1591-1593 October 14, 2004
14. Lawmakers Say Employer Mandate Key To Massachusetts Health Reform Law

http://www.medicalnewstoday.com/articles/42013.php

15. A cure for spiraling healthcare costs .By Stuart H. Altman | January 2, 2007 http://www.boston.com/news/globe/editorial_opinion/oped/articles/2007/01/02/a_cure_for_spiraling_healthcare_costs/?p1=email_to_a_friend
16. Kitzhaber, J Health care system lacks accountability. October 7, 2005. Seattle Post-Intelligencer http://seattlepi.nwsource.com/opinion/243676_codeblue07.htm
17. Hurst, J. When will we just say no to big health care. Commonhealth. 2007 http://www.wbur.org/weblogs/commonhealth/?p=223
18. Constitution of the World Health Organization.. Basic Documents, Forty-fifth edition, Supplement, October 2006

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.