Saturday, December 15, 2012

A Critique of the FIT Kids Act: Why Simply Reporting Physical Activity is Not Enough and What We Can Do About It– Stephanie Parker

The Fitness Integrated with Teaching Kids Act (FIT Kids Act) is a bill written to “amend the Elementary and Secondary Education Act of 1965 to improve standards for physical education” (1). Representative Ron Kind [D-WI] introduced it to the House of Representatives on March 14, 2011 and Senator Tom Harkin [D-IA] introduced it to the Senate the day afterward. These bills are currently in the committee stage. 
The act begins with a list of Congressional findings regarding physical activity (1). It then contains a “report card” section, which requires schools to add additional information about their health and physical education programs to their annual reports to the government. This additional information includes the following: amount of time their students spend in required physical education compared to the national standards, the percentage of local educational agencies in the State that have a required, age-appropriate physical education curriculum, the percentage of PE teachers who are licensed or certified, the percentage of schools that have a School Health Council, the number of meetings of the council, and the amount of square feet that are used for physical education.
Given the act is a reporting requirement, it suggests that the reason there is not enough physical education in schools is due to a lack of awareness. Based on this assumption, if Congress can make schools, parents, and kids aware of the current state of their schools’ physical education programs, school administrators will be motivated to change their physical education programs to meet national standards.
This paper will go through three major flaws to the thinking behind the FIT Kids Act and show why it is not the best piece of legislation to enact change in regards to sedentary behavior and childhood obesity. These flaws include weak frames, assuming that knowledge changes behavior, and not changing any social norms. The paper will then propose an alternative bill that addresses and overcomes each of these flaws. The proposed bill will use strong frames. It will focus on behavior change and let knowledge and attitudes follow after that. Finally, it will work to change social norms.
Critique 1: The law uses weak frames
The frames of the FIT Kids act are very weak. A frame is “the process by which someone packages a group of facts to create a story…and the basis by which public policy decisions are made” (2). The components of a frame include a core position, metaphors, catch phrases, visual images, sources of the problem, predicted outcomes, and an appeal to principle or core values (3). The strength of a frame depends on how strong the elements of the frame are and how strong the core values are. Strong frames contain a core value that is important to everyone with all the components of a frame working together to contribute to one overall message.
The frame one chooses to use for a message is important because people are influenced simply by how an issue is presented (4). In 1981, Kversky and Kahneman famously demonstrated how changing the way a problem is framed can drastically change the results. In the experiment they analyzed, university students were asked to imagine a scenario of an outbreak of an unusual Asian disease. Two problems were proposed and each problem had a choice between programs with differing probabilities in saving people from the disease. Even though the problems were effectively identical, the different wording between them resulted in opposite responses. They concluded that preferences are susceptible to variations in framing.
The FIT Kids act is predominantly framed using the core values of health and economic livelihood. The first part of the act, entitled “Findings,” gives the reasoning behind the bill and explains why Congress thinks it needs to be enacted (1). It lists 18 different findings starting with “Childhood obesity has reached epidemic proportions in the United States.” The second finding is “Obesity-related diseases cost the United States economy more than $117,000,000,000 every year.” It continues with how many children will eventually suffer from diabetes, how many deaths come from major chronic disease, and how many schools are not meeting the national standards for physical activity. The only finding that uses a core value other than health or economic livelihood is a brief mention of the strong correlation between fitness and academic performance.
The problem is not that this bill includes health statistics. These statistics help lay the groundwork for the bill. However, the bill lacks a stronger drive to change than just health. The bill correctly points out that sedentary lifestyles can lead to obesity, chronic disease, and eventually premature death. The bill neglects to take this one step further and explain how obesity, chronic disease, and premature death rob people of their freedom and control over their life. The reality is that while people value health, they most likely value freedom and control much more. This bill misses the opportunity to build on what people value most.
The best evidence for the weakness of the core value of health is the fact that in spite of a growing awareness of the problems of childhood obesity and physical inactivity, these problems have not been reversed (5,6). A study done by Evans et al. in 2005 found 41.3% of those surveyed believed childhood obesity was a “very serious” problem (5). Additionally, 44.2% believed a lack of exercise in school had contributed “a significant amount” to the increase in childhood obesity. The authors mention how media coverage of obesity has increased as well as health promotion campaigns aimed at obesity awareness and prevention. However, according to the Centers for Disease Control and Prevention, the prevalence of obesity among children has continued to rise (6). NHANES found the prevalence of obesity among US children aged 2-19 to be 15.5% in 2005-2006 and 16.9% in 2007-2008. This is an indicator that the core value of health is weak and has been ineffective in reversing the trend of childhood obesity.

Critique 2: The law assumes knowledge changes behavior
            The FIT Kids act is based upon the assumption that if schools are forced to report their current standing on physical activity, they will automatically be motivated to increase both the amount and quality of physical education classes at their school. This assumption is directly based on the Health Belief Model (HBM). In the 1950s, social psychologists were perplexed why people were not participating in free chest X-ray screens for tuberculosis (7). This led them to develop the HBM, one of the first theories about health behavior ever proposed. The HBM states that health behavior is motivated by four key components: perceived susceptibility, perceived severity, perceived benefits of an action, and perceived barriers to taking that action (7,8). Ensuing years brought the addition of two more elements to the model: cues to action, defined as some kind of external event that motivates people to act, and self-efficacy, a person’s perceived ability to act (8). 
Even though the HBM is one of the most widely used models in public health (8), it has some key flaws that make it an ineffective approach for many public health problems. One of its biggest limitations is that it is an individual-level model, which suggests that individuals are the main sources of their behavior (7). The National Cancer Institute’s “Theory at A Glance: A Guide for Health Promotion Practice” acknowledges, “The individual level is the most basic one in health promotion practice, so planners must be able to explain and influence the behavior of individuals.” However, the guide continues by emphasizing the individual level is only one of many levels when looking at health problems with an ecological perspective. Specifically, it misses interpersonal factors, institutional or organizational factors, community factors, and public policy factors. The guide concludes, “Health promotion programs are more effective when planners consider multiple levels of influence on health problems.”
            Some of the most important factors the HBM ignores are social and environmental factors. An article by Janz and Becker explains how the HBM is problematic “where economic and/or environmental factors prevent the individual from undertaking a preferred course of action” (9). Thomas further critiques the HMB by stating, “This paradigm has been oppressive in nature, depriving persons of value and contextual meanings, which are embedded in cultural practices, skills, and languages. From the HBM perspective, persons are viewed as a collective group, confined and reduced to ‘objective’ data without regard for their sociopolitical and historical experiences” (1o).
            Another major flaw of the Health Belief Model is that it assumes people are rational decision-makers. It essentially says that people make all their health decisions by weighing the costs and benefits. In his book, Predictably Irrational, Dan Ariely gives countless examples of how humans are often irrational when they make decisions (11). Not only are they irrational, but they often claim they will be rational in a decision and then end up acting differently in the heat of the moment.
The HBM is the wrong model to base the FIT Kids Act on because even with all the components of the HBM in their favor, some schools still lack quality physical education. As Critique 1 discussed, the statistics show that childhood obesity is prevalent and people are recognizing it as a major problem (perceived susceptibility and severity). There is ample evidence, even within the FIT Kids Act findings, showing that the physical and academic benefits of physical activity for children outweigh potential costs (perceived benefits and barriers). However, the statistic remains that 22 percent of schools do not require students to take any physical education at all (1).    
            The HBM basis for the FIT Kids act fails because it ignores the other factors of an ecological perspective of health behavior and does not account for irrational decision-making. An analysis by Link points out public health interventions often neglect to contextualize risk factors and consider the fundamental causes of disease such as socioeconomic status (12). Schools may have a great desire to improve their physical activity programs, but lack the access to resources to make it happen. Furthermore, school administrators, teachers, parents, and students may also act irrationally when it comes to physical activity. A prime example is during standardized testing. Moon et al. found that both teachers and students feel a lot of pressure to produce high test scores (13). Teachers might be tempted to cut physical activity in order to allow more time for test preparation. 

Critique 3: The law doesn’t change social norms
            By issuing a set of reporting requirements, the FIT Kids Act does nothing more than add an additional burden to schools that already have too much paperwork to deal with. The law does not change social norms. Social norms are defined as “customary codes of behavior in a group or culture, together with the beliefs about what those codes mean” (8). Social Expectations Theory is based on the premise that when people decide which actions to take, their biggest considerations are the expectations and responses of those around them. DeFleur and Ball-Rokeach explain, “People worry about ‘what other people will think’—about the approvals, disapprovals, rewards, punishments, recognitions, or disgrace that their actions might provoke” (14). Social Expectations Theory teaches that if a health intervention or policy can change social norms, people’s behavior will follow suit.
            There is nothing in the FIT Kids Act that changes social norms. For example, having schools report how much time their students are spending in physical education compared to the national standards does not require schools to change that amount of time at all. In fact, if this law were passed, schools could theoretically decrease their amount and quality of physical education classes and still be 100% compliant with the law.
Another example of not changing social norms comes with the requirement to report the percentage of schools that have a School Health Council that meets monthly and a requirement to report the number of meetings of that council during the school year. Having a School Health Council made up of parents, students, food authority members, school board representatives, school administrators, and members of the public as the FIT Kids Act proposes is not a bad idea. A strong council could potentially bring about a lot of good changes to physical education curriculums. However, the only component of this council the law seems to care about is the number of meetings the council will hold. Instead of creating an incentive to hold quality meetings that accomplish solid outcomes, the law only incentivizes more meetings. In an article by bestselling author Les McKewen, he states, “[What are] the main reasons leaders in growing business lose the ability to create change? More meetings.” He continues, “How many of the meetings you sat through [this past week] could be abolished without harm (and perhaps great benefit) to the organization’s overall decision-making ability?”(15). More meetings of a School Health Council do not change social norms.
The law not only ignores the opportunity to change social norms, but does not provide any way for schools to change the situation themselves. For example, requiring schools to report the amount of square feet of indoor and outdoor facilities that are primarily used for physical education does not do anything to help the school change that situation. The law does not provide funding or suggestions for funding to assist in bettering the facilities. Instead, it asks schools for “a description of how the state educational agency will use funds under this part to provide professional development that is directly related to the fields of physical education and health education” (1, emphasis added). It is impossible to change social norms if there is no call to action and no facilitation for that action.
Proposed alternative legislation—the Finally Free For Fun Act

            The proposed alternative piece of legislation to the FIT Kids Act is the Finally Free For Fun Act (4F Act). This act will contain three sections: a “Why This Matters” section, a “Call to Action” section, and a “Ways to Facilitate Change” section. The “Why This Matters” section of this act will not quote any of the classic obesity health statistics based on the understanding the general public already is aware of the health implications of childhood obesity and physical inactivity. Instead, it will talk about how play and fun can fuel and enhance healthy development of children (16). It will cite research that shows how physical activity enhances vitality (17) and can improve working memory and problem solving skills (18). It will discuss ways physical activity can promote freedom, control, and fun for students, parents, teachers, and school administrators.
            The next section will be the “Call to Action” section. Instead of asking schools to report how their physical activity standards compare to the national standard, the law will actually require schools to meet the national standard. It will ask public schools to provide at least 150 minutes of physical education per week for elementary school students and 225 minutes per week for middle and secondary school students. It will also allow schools to decide appropriate alternatives for students with disabilities. This section will also state that each individual school will have the freedom to implement whatever curriculum it chooses that will best meet the needs of the students at their school.
            The last section of the act will be entitled “Ways to Facilitate Change.” It will have two parts. The first part will be an explanation of a soda tax that will provide the funds for schools to meet the new physical activity standards. The second part will explain a marketing campaign targeting students that will be launched to change the current social norm that physical education classes are a waste of time, boring, or annoying. If the motivation to improve the quality and quantity of physical education classes can come from the students instead of the government, school administrators and teachers will be much more likely to enthusiastically participate in meeting these standards.

Defense 1: The law uses strong frames
            The 4F Act will be framed using the core values of freedom, control, and fun, and will intentionally avoid the core value of health. The chosen core values will penetrate every component of the act. The act’s title uses the words “free” and “fun” in it to get across the idea that physical activity is about much more than health. The findings from the “Why This Matters” section will be carefully chosen and worded to include not only statistics, but images, metaphors, and symbols to make the chosen frames strong and complete.
The act will especially focus on framing the actual physical education requirements and the proposed soda tax in a way to champion freedom, especially because opponents may call these infringements on freedom. It will emphasize the fact that physical activity brings students freedom from the monotony of a difficult school day and that schools will be free to choose the curricula they want to implement. The soda tax will provide the means to allow schools to finally be able to have the quality facilities and programs they want to give their students. The marketing campaign will also play to students’ desires for freedom, control, and fun instead of trying to convince them that health is what they should value the most.   
Research shows that freedom and control are much stronger frames than health when it comes to changing health behavior. In analysis of newspaper coverage of tobacco issues, Claudia Menashe and Michael Siegel found that like childhood obesity interventions, tobacco control interventions have been ineffective in further reducing smoking prevalence (19). However, they found the tobacco industry has been a powerful force in getting kids to smoke. They state, “The tobacco industry’s strategy has been quite successful because of the extent to which the core values of its messages are an inherent part of American thinking: ‘the concept and symbolic importance of individual freedoms are deeply ingrained in American myth, culture, and law.’” They continue, “Findings suggest that although health is an important core value for the public and policy makers, personal freedoms, civil liberties, and individuals rights may be even more compelling values.”
Defense 2: The law starts with behavior change knowing attitudes and knowledge will follow
            Instead of assuming that knowledge will change behavior, the 4F Act will first seek to actually change behavior. The law will be based on the Theory of Cognitive Dissonance instead of the Health Belief Model. The Theory of Cognitive Dissonance proposes that if you can get people to change their behavior, their attitudes will change. Cognitive dissonance is defined as “a state of unpleasant tension that people experience when they hold contradictory attitudes or when their behavior contradicts their state attitudes” (20). When people are in a state of cognitive dissonance, they end up either changing their attitudes or changing their behavior to resolve the tension. A classic cognitive dissonance experiment by Festinger and Carlsmith in 1959 showed that people ended up convincing themselves a very boring activity was enjoyable after they were paid a small amount to tell another participant it was enjoyable (21).
            The behavior change that the 4F Act implements is the requirement of 150 minutes (or 225 minutes depending on age) of physical activity each week in public schools. The Theory of Cognitive Dissonance can be applied to change the attitudes of both those implementing the requirement and those participating in the physical activity. Once school administrators take action to meet the requirements (along with increased funding and a marketing campaign that will be explained below), they will come to realize that these standards are achievable and result in very positive outcomes. As the research in the “Why This Matters” section suggests, they may see increased self-esteem, focus, and quality of academic work in their students. Students may also see the benefits of quality physical education classes and facilities. They may come to realize how much more fun running around with their friends can be than sitting at a desk listening to a lecture.
            Because many schools will have to increase the quality and quantity of their physical education classes to meet the standards of this act, it is essential that the act provide funding to make this possible. This act will propose a soda tax with the dual goal of both reducing consumption of sugary beverages and increasing funding for physical education curriculums and facilities in public schools across the country. Research shows both of these goals can be accomplished with a soda tax (22,23). A recent meta analysis of 32 different studies analyzing the effect of a soda tax on consumption found, “taxes on carbonated drinks…would be associated with beneficial dietary change, with the potential for improved health” (22). A report from the Center for Science in the Public Interest found that a 7 cent tax on sugary drinks could raise a combined $10 billion per year (23). A large portion of this money would be allocated to public schools to help improve their physical education programs.

Defense 3: The law changes social norms
            One of the major goals of the 4F Act is to change social norms. The law will seek to do this by launching a 4F marketing campaign very similar to Florida’s “truth” campaign, an anti-tobacco counter-marketing effort focused on reducing youth smoking prevalence (24). Jeffrey Hicks, the president of the advertising agency that ran the truth campaign, identified seven key principles that allowed their campaign to succeed. These included real money, youth involvement, youth marketing verses social marketing, tone, the anti-manipulation strategy, making ‘truth’ a brand, and focus. Youth were asked to provide feedback about what they did and did not like throughout the entire process. The advertising agency found out that kids were well aware that tobacco kills. However, some kids used tobacco anyway because it was an emotional way to signal they were in control. The campaign decided to take advantage of this rebellion and steer it toward the tobacco industry instead. After the campaign was launched, the percentage of Floridian middle school youth using tobacco declined by 7.4 percentage points in just 30 days.
            While the goal of the 4F campaign will be to do something instead of not do something, it will take advantage of the same lure of rebellion by having kids use physical activity as their time of freedom from the stresses of school to have fun. The 4F campaign will do this by turning to actual students for their advertising and brand ideas. Hicks points out, “In a search to define one’s identity, brands (like piercing, haircuts, and even tobacco use) serve as a shorthand way for youth to identify themselves to the world” (24). Establishing a strong 4F brand that kids are proud of will be key to convincing school administrators and teachers that providing quality physical education classes is the most important thing they can do for their students.
Overall, the central goal of this act will be to change social norms. DeFleur and Ball-Rokeach state, “The mass media, through selective presentations and emphasis of certain themes, create impressions among their audiences that common cultural norms concerning the emphasized topics are structured or defined in some specific way” (14). If this act can be implemented and this marketing campaign launched, it will become the norm for gym class to be the best time of every student’s day.


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