A Critique of Maine’s Childhood Obesity Campaign: Sara Lammert
Introduction: Obesity as a
Public Health Problem
Adult obesity rates have continued to
increase over the past 30 years, leading to major public health concerns not
only for the nation, but also for individual states, including Maine. According to the Behavioral Risk Factors
Surveillance Survey conducted in 2012, 62.9% of Maine adults were considered
overweight (BMI > 25), while 26.8% were considered to be obese (BMI >
30). (1) Although Maine was below the
national obesity levels in 2010 (35.7%), it is estimated that by 2030, 55.2% of
the adult population in Maine will be considered obese. (2,3) These trends are similar in the youth of
Maine as well and are also increasing at an alarming rate. According to the 2009 Youth Risk Behavior
Survey, 15.1% of Maine’s adolescents were considered to be overweight, while
12.5% were considered obese. (1)
Additionally, Maine has the highest prevalence of obesity in high school
students compared to all other states in New England. (4) Children who are overweight or obese are more
likely to be overweight or obese as adults, predicting increase obesity rates
in the future. (5)
There is not one contributing cause of
obesity; it is a multi-dimensional epidemic with genetic, social,
environmental, dietary, and physical factors playing roles in multiple aspects
of daily life. (5) However,
many argue that obesity is most proximately caused by poor nutrition as well as
a lack of physical activity. (6)
Maine adolescents are not eating adequate quantities of healthy foods or
participating in enough physical activity on a daily basis according to the
2009 Youth Risk Behavior Survey (1):
o 66% ate
fruits or drank 100% fruit juice less than 2 times per day
o 86.2% at
vegetables less than 3 times per day
o 29.2%
drank a can, bottle, or glass or soda or pop at least one time per day
o Only
17.9% were physically active for at least 60 minutes per day for a week
o 18.0%
did not participate in at least 60 minutes of physical activity on any day in
the past week (1)
Public health interventions to combat the
rate of childhood obesity are extremely important not only to protect the
health of the children of Maine, but to prevent obesity related disorders in
the future. Obesity related disorders
once rare in children including heart disease, diabetes, high blood pressure,
high cholesterol bone and joint problems, and sleep apnea, are becoming more
frequent in overweight and obese children, indicating longer time diagnosed with
obesity-related disorders. (5,7-8)
Public health interventions are also necessary to prevent the economic
impacts of obesity and obesity related diseases and illness as individuals are
diagnosed with these issues earlier.
According to a study conducted by the University of Maine, medical costs
in Maine related to obesity could reach 1.2 billion dollars through 2034. (3) In order to combat and reverse the childhood
obesity trends, effective public health interventions are necessary in the
state of Maine. One such program is the
Let’s Go! 5-2-1-0 campaign.
Let’s Go!
5-2-1-0
Let’s Go! 5-2-1-0 is a public health
campaign aimed to prevent childhood obesity and was launched in 2006 in
Portland as well as other communities in Cumberland County, Maine. (9) Research has shown that fruit, vegetable and
sugar based drinks consumption as well as the quantity of screen time and
physical activity are four major factors contributing to the obesity epidemic
and should be used when creating targets or goals for childhood obesity prevention
programs. (8) Let’s Go!
5-2-1-0 works in 6 settings (schools, early childhood programs, after school
programs, healthcare offices, workplaces, and communities) to promote the four
dietary and physical activity aims of the campaign through education and
awareness (9)
1.
5 or more fruits and vegetables
2.
2 hours or less of recreational screen time
3.
1 hour or more hour of physical activity every day
4.
0 sugary drinks (9)
Unfortunately, many public health
interventions and campaigns, including the Let’s Go! 5-2-1-0, are flawed in the
design and application. Before launching
this campaign into other cities and counties around the state of Maine, social
and behavioral theories need to be consulted to make necessary changes to
improve the effectiveness of the campaign.
First, Let’s Go! 5-2-1-0 fails to recognize important physical, social,
and financial barriers preventing children and their parents from incorporating
healthy behaviors into their lives on a daily basis regardless how aware individuals
are of the campaigns objectives.
Secondly, Let’s Go! does not take into consideration principles of
psychological reactance: the explicit 5-2-1-0 message of the campaign causes
reactance in children and potentially their parents. Thirdly, the model in which the theory is
based, the Theory of Planned Behavior, models that through awareness and
education, children will intend to follow the guidelines of the Let’s
Go!5-2-1-0 program, increasing their own self-efficacy, and then change their
behavior. However, it does not take into
account other factors that may prevent children from fully participating in the
aims of the campaign regardless of their own self-efficacy.
Socioeconomic,
Geographical Barriers
The Let’s
Go 5-2-1-0 campaign focuses on the most proximal causes of obesity: poor nutrition and lack of physical activity.
(6) However, there are many societal, socioeconomic, and geographical
barriers that may have a more distal effect on childhood obesity as they create
barriers to access to healthy nutrition and physical activity. The Let’s Go! campaign originated in Portland,
Maine, along with other communities in Cumberland County. (9) The median household income in Cumberland
County is $57,267, which is the highest in state, while the median household income
in Maine is $47,898. (10) Individuals,
families, and their schools, on average, have higher socioeconomic levels than
the rest of the state of Maine. When the
Let’s Go! 5-2-1-0 campaign is launched in other parts of the state, it is
assumed that children’s families will have the same financial ability to
purchase healthy foods or the ability to drive farther distances to obtain that
food. However, the ability to provide at
least 5 fruits and vegetables a day to a child has a relationship to the socioeconomic
status of the child’s family, as well as the availability of such food within a
reasonable distance to the family. This
is supported by studies showing that individuals from counties with lower
median household income, on average, have a higher probability of being
overweight or obese than counties with higher median household incomes. (11)
Additionally,
Cumberland county and the Greater Portland area is a larger urban area, while
much of the remainder of the state is considered rural. Studies have indicated that individuals
living in rural areas are more likely to be overweight or obese than individuals
living in urban areas. (11, 12)
A study conducted at the University of Southern Maine in 2009 found that
the prevalence of overweight and obese children in 6 rural areas in Maine were
47.9% and 27.7% respectively, which are above the average levels in the state.
(11) Because Cumberland County is
a mostly urban area, proximity to multiple types of grocery stores in shorter
distances is more common. In order for
the Let’s Go! campaign to be effective in rural parts of the state, dynamics of
rural communities need to be a focus of the intervention. Studies in rural areas have shown that the
most frequent source of food were convenience stores, where fresh fruit,
vegetables, or healthier foods may be limited or non-existent. (11,12) Therefore, children and their families in
rural parts of Maine may not have access to larger supermarkets or grocery
stores where fresh fruit and vegetables and healthy options are more readily
available.
Along
with financial and geographical barriers for access to healthy food, physical
activity may also be prevented in Maine due to climate issues. The only time many children are able to
participate in physical activity is during school hours or during after school
activities. During the summer, fall, and
spring months, it may be warm enough and there may be enough day light hours
for children to obtain physical activity outside. However, during the winter months, more
physical barriers, such as daylight hours and temperature, prevent continuous
physical activity. During the winter
months, the days are shorter so safe physical activity after school hours may
not be conducive. Additionally, if the
weather is too cold, children may be forced to stay indoors for recess or after
school. The relationship between climate
conducive for outdoor physical activity and BMI was conducted by the Department
of Geosciences at the Georgia State University.
In this study, researchers found a relationship between climate allowing
for ample quantity of outdoor physical activity and county-level BMI. (13) This indicates that counties with less time
available outdoors for physical activity, on average, have higher BMI’s. (13) This is because, with less frequent time
available outside of play, children are forced to spend the majority of their
time after school indoors, where there is less mobility to enjoy physical
activity, and more available sedentary activities, such as watching television
or playing video or computer games.
While schools still allow for recess indoors, many schools may not have
the capacity to allow children to run participate in rigorous physical activity
indoors to elevate their heart rate enough to have it count as physical
activity. The Let’s Go! 5-2-1-0 assumes
that children will always have financial and geographical access to fruits,
vegetables, and other healthy food options and have access to an uninterrupted
hour for physical activity; however, due to financial, geographical, and
physical climate barriers, this may not be the case.
Violation of
Psychological Reactance
The
premise of the Let’s Go 5-2-1-0 campaign in Maine focuses on what children
should and should not do, which is similar to the campaign the National Cancer
Institute launched in 1991 called the 5 A Day for Better Health. (14) It educates parents, children, and their
schools about the necessary quantity of fruits and vegetables children should
eat, the maximum number of hours children should watch television or play
computer and video games, the minimum number of hours of physical activity
children should have on a daily basis, and that children should not drink any
carbonated or sugary drinks, such as soda or pop. (9) Because the aims of the campaigns are
directive, the Let’s Go! 5-2-1-0 campaign violates the theory of psychological
reactance. (15) By explicitly
telling people what to do not only in the program aims and name of the
campaign, parents and children may feel as if their control on choosing their
own dietary needs and physical activities is being threatened. Instead of viewing the aims of the program as
goals to be reached, the goals of the program may be perceived as a violation
to individual freedom or autonomy, a highly regarded core value among
Americans. This violation of
psychological reactance may ultimately backfire and children and their families
may actively choose not to follow the aims of the Let’s Go! 5-2-1-0 campaign.
Psychological
reactance, in relation to childhood obesity, theorizes that when children or
their parents become engaged with the Let’s Go! 5-2-1-0 campaign, they may feel
as if their freedom or choice to choose what they eat or drink, how much
physical activity or hours of television watching they participate in has been
taken away from them. (6, 15-16)
Instead of following those recommended behaviors of the Let’s Go!
5-2-1-0 campaign, they will try to gain back that freedom they believe is
threatened by participating in behaviors the Let’s Go! 5-2-1-0 program is
trying to eliminate. (6, 15-16) Even if parents or children know
that eating health and engaging in physical activity is extremely important for
a healthy lifestyle, because they feel as if the campaign is taking away their
sense of freedom or control, they will experience reactance and will try to
gain that freedom back. (15-16)
Although they know that not following the aims of the campaign may be
detrimental to their health, children and their parents may not consume the
necessary amounts of fruits or vegetables, or not participate in enough or
frequent physical activity, in an attempt to gain back control of their
freedom.
This same
phenomenon occurred with the 5 A Day for Better Health campaign. The 5 A Day campaign was started in the
United States in 1991 in order to increase the average daily consumption of
fruits and vegetables to 5 per day. (14) At the time of the launch, the necessity of
this campaign was apparent as the baseline survey conducted by the National
Cancer Institute found that only 23 percent of people consumed 5 or more
servings of fruits or vegetables a day. (14) However, childhood obesity continued to
increase during the 1990’s, even with the introduction of this program. (2) The Let’s Go! 5-2-1-0 campaign has multiple
similarities to the 5 A Day campaign.
Not only does the Let’s Go! 5-2-1-0 campaign put “goals” on the number
of fruits and vegetables children should eat every day and the amount of
physical activity they should receive on a daily basis, it also creates limits
and restrictions on the number of hours children should be watching television,
playing video games, or being on the computer, as well as “forbidding” the
consumption of all types of sugary soft drinks, such as soda. (9) Not only does it have a basis in the failed
5-A day campaign, it also increases the number of limits and regulations on
children’s daily lives ultimately increasing their experience of
reactance. The structure of the
campaign, due to psychological reactance, could backfire completely as children
experience reactance and try to gain the control of what they can and cannot do
from the Let’s Go! 5-2-1-0 campaign.
In
additional to experiencing reactance for the consumption of fruits, vegetables,
and sugary drinks, children will most likely experience reactance when told how
much exercise they should participate in on a daily basis. As children get older, they become more
independent and have more control on their decision making process compared to
younger children. (17)
Research has shown that as children get older, they expect to be able to
make personal decisions in their life, particularly about their physical
activity. (17) Because children are making decisions about their own
physical activity, if they are experiencing reactance, children may be less
likely to participate in sports or other extracurricular activities that may
decrease their likelihood of becoming overweight or obese and participating in
activities where the social norm of fitness is valued regardless of their
knowledge about how important physical activity is for their health.
Limited
Perception to Change Behavior
Lastly, the Let’s Go! 5-2-1-0 campaign in Maine is based on the Theory
of Planned Behavior:
“The program is based on the premise that if families are exposed to
health promotion messages through several settings, and if those settings have
policies and environments that support healthy choices, they will be more
likely to adopt or maintain the behaviors in their daily lives (9).”
The Theory of Planned Behavior is on the
individual level, with both individual and group level factors contributing to
attitudes towards a particular behavior: the individual’s attitude and how the
person perceives what the social norms are towards that behavior. (18) The Let’s Go! 5-2-1-0 program focuses on
childhood obesity in individual children, with influences coming from both the
individual and parents, as well as societal level norms present in local
schools, towns, states, and nationally.
The Theory of Planned Behavior indicates that individuals will balance
both the outcome and expectations along with social norms to formulate an
intention to change behavior. (6, 18) According to the Theory of
Planned Behavior, after balancing particular individual and social norms
regarding a behavior, an individual will form an intention, and as long as the
individual perceives he or she can accomplish that behavior, he or she will
complete that behavior. (18)
However,
as good as the intention to eat healthy or participate in physical activity on
a daily basis, the ability to do so may not be actually feasible, especially in
the public school setting. Therefore,
the policies and environments that are meant to be in place to promote the
transition from intention to behavior are not there. According to the Maine School Health
Profiles, there is still a lot of work to be done at the school level in order
to provide a healthier school environment for children. Among high school students in the state of
Maine, only 48% were required to take 2 or more health education courses, while
only 28% of schools surveyed did not sell less nutritious foods and beverages
anywhere outside the school food service program. (19) Even if the children had the intention to eat
healthy food at school and had the perception they would be able, there are
still barriers to the behavior.
Therefore, in order for the program to be effective, the Let’s Go!
5-2-1-0 needs to work with individuals regarding Maine education policy in
order to create environments that allow for intention and perception of the
ability to eat well and exercise daily in order to change behavior.
In
addition to society level barriers preventing the perception of ability to
change behavior, there are also additional individual barriers preventing the
perception of an ability to change behavior.
The 2010 Pediatric Nutrition Surveillance System found that 17.1% of
Maine’s children between the ages of 2 and 5 were overweight, while 14.3% were
obese. (1) If children and
teenagers have been obese or overweight since their were very young children,
they may feel as if they will never be able to reverse their situation. This may be especially true if they have
overweight or obese parents. Studies
have shown that children’s perceptions of the ability to lose weight is
associated with their parents perception of whether or not the child will be
able to lose weight. (20) If children’s parents don’t indicate that
they believe their child can overcome obesity, the child will not have the
perception that they can lose weight, and therefore, will be unable to change
their behavior. Additionally, studies
have shown that normal weight children and adolescents have higher physical
activity motivation than children who are obese. (17) As children
are becoming obese and overweight at younger ages, their perception that they
have the ability to change their behavior will continue to diminish as the
longer they are overweight or obese.
Conclusion
As previously mentioned, there is
not one cause of obesity. Obesity is a
multi-dimensional public health issue that must be addressed from multiple
different angles. By not taking into
consideration demographic, socioeconomic, and geographical differences between
the demonstration site in Cumberland county and the dissemination sites in
other more rural parts of the state; by violating the theory of psychological
reactance leading to children experiencing reactance; and by not taking into
consideration social and individual barriers to children’s perception to change
behavior, the Let’s Go! 5-2-1-0 campaign will most likely follow in the
footsteps of the 5 A Day for Better Health campaign. Although interventions to prevent childhood
obesity are critically important, especially as researchers expect childhood
and adult obesity rates to continue to increase, these interventions must be
created and framed taking into consideration social factors of different
families and communities, use the theory of psychological reactance to decrease
the experience and reactance, as well as improve children’s perception that
they have the ability to change their behavior. By reframing the issue in a way that
children are able to claim their future and their life and less as a health and
obesity issue, then children may be more willing and open to following the
guidelines of the Let’s Go! 5-2-1-0 campaign.
Proposed Intervention
In order
to best reverse the childhood obesity epidemic in the state of Maine, many
changes and additions need to be made in the Let’s Go! 5-2-1-0 campaign in
order for it to work in reducing the prevalence of childhood obesity in the
state. The proposed intervention will still have the same goals as the initial
campaign, but it will frame and advertise the issue so by participating in the
campaign, children will gain freedom and have control of their freedom, rather
than their freedom and control of their freedom being taken away. First, the proposed intervention will change
it’s name from Let’s Go! 5-2-1-0 to Let ME Move! The program will work with policy and law
makers in the state of Maine as well as health organization to create
environments that are conducive for healthy behaviors, most specifically access
to fresh fruits and vegetables as well as continuous outdoor physical activity. It will allow for remote access for fresh
fruits and vegetables through mobile food trucks throughout parts of rural
Maine where distances to grocery stores with healthy food options are
large. Additionally, it will work with
schools, especially elementary school age children, to create education
policies that promote physical activity in classroom and after school
activities. Additionally, each
elementary and middle school participating in the program will host competition
between all classes or different schools in a community to select a winning
class or school. Every time a student
participates in 60 minutes of physical activity a day, or eats 5 fruits and
vegetables a day will be given a point value.
Every month, the winning class at the school will win a prize from the
Let ME Move! campaign.
Minimizing
Barriers
While
residents of the urban centers of Maine may have more access to and choices for
different grocery venues, residents in more rural areas of the state may have
less venues for healthy grocery shopping, as well as a farther distance to get
to those places. In order to increase
assess to fruit and vegetables for consumption, the initiative will promote the
delivery of fresh produce to town or community centers, specifically in
Northern or Central Maine where the travel time to go to grocery stores would
be too high. The food truck will also
stop at local high schools or middle schools during the day, so if parents are
unable to reach the designated areas of the food truck, orders could be made
and dropped off at the local schools.
Additionally, fruits and vegetables should be subsidized so the prices
of the healthy foods are not a deterrent for parents or schools to purchase.
Additionally,
because much of the children’s physical activity is obtained at school during
recess or school related activities, children should have access to cold
weather gear especially during the winter months. By working with local public health
organizations and charities, donations for winter apparel will be a main
priority. Schools should have access to
extra snow pants and winter weather gear to ensure that children are not
prevented from going outside for recess solely on the fact that they cannot
afford the proper winter weather gear.
Additionally, if forced to have indoor recess, especially during the
winter months, children should have access to large areas where they are
allowed to run around in and play games.
In addition to recess, gym should be a daily requirement for children as
there has been evidence to suggest that the only school-based intervention
programs that significantly affected children’s BMI’s were ones the required
daily physical education. (17) Therefore, the intervention will work
with education policy makers in the state to create legislation and policies
that support daily physical education.
Eliminating
Reactance
The 5 A
Day campaign failed on the premise that children experienced reactance after
being told through the campaigns media and advertisements that they needed to
eat 5 fruits or vegetables on a daily basis.
The Let’s Go! 5-2-1-0 is not only telling children about the necessary
consumption of fruits and vegetables, it is also informing children on the
maximum number of screen time, the amount of physical activity, and the absence
of all types of sugary beverages.
The Let’s
Go! 5-2-1-0 campaign’s name is the first proposed changed to the
intervention. The name itself has
implications that are informing children and their parents what to do. By eliminating the “5-2-1-0” portion of the
name and changing the name to “Let ME Move!”
may reduce the initial experience of reactance after changing the
name. Additionally, the use of “M-E”
also have both individual and state level implications, therefore, children in
the state of Maine will relate to the program on both an individual and a state
level. Instead of the program telling
the children what they need to do, children will feel as if they are in
control; they can tell policy makers, teachers, their parents, to “Let ME
Move!” Parents, additionally, need to be
educated about the effect parents have in creating reactance in children: more pressure from parents regarding eating
habits or physical activity may cause children or adolescents to react in
opposition to the message. (21)
Secondly,
the brochures and pamphlets need to frame the issue in a way that minimizes the
experience of reactance. They need to
show in their media and advertising that Let’s Go! doesn’t eliminate individual
feeling of control, it actually gives children the power to control their lives. By doing this, children and their parents may
be more willing to follow the health suggestions of the program. The Let ME Move! campaign should incorporate
media techniques used by Nike. The
implicit health message should not be state implicitly in the message; instead,
the commercials need to be framed in a way that children feel as if they are
empowered to make changes in their lives in order to gain control of their
future. (22)
Improve Perception
to Change Behavior through Policies
Lastly,
Let ME Move! must focus on bridging the causal pathway between intention and
behavior, by increasing the perception that the children have the ability to
change their behavior regarding healthy nutrition and physical activity. Because of growing rates of obesity in
younger children, specifically between the ages of 2 and 5, the improved
perception to be able to change behavior must be targeted at earlier ages.
(1) One way to improve this is to
work with local city council members to improve or create local parks for
children to play in, as well as increase the numbers of sidewalks in town
centers that promote walking or biking. (23) As the number of opportunities to participate
in recreational physical activity increase, the prevalence of obesity has been
shown to decrease. (24) If
local norms within the city promote outdoor physical, and there are venues that
allow for the participation in that activity, children from a young age and
their parents may be more likely to participate in that behavior.
Additionally,
collaboration with school boards is essential to make the social norm about
healthy behaviors important within the school community. By providing healthy food options over ones
high in calories or fat and promoting physical activity in multiple aspects of
the child’s day will give children the perception that they have the ability to
change their behavior, and there will be a causal pathway between intention and
behavior. By incorporating a competition
between classes or schools, especially at the younger age levels, may lead to
an increased motivation to participate in the campaign, and therefore, increase
participation in the program, increasing fruit and vegetable consumption as
well as physical activity on a daily basis. (25)
Conclusion
By
reframing the issue of childhood obesity from one in which quantified
requirements and limitations are placed in children’s lives to one that gives
children freedom to control their lives, the Let ME Move! campaign will have a
better foundation to make significant improvements in the childhood obesity
epidemic in Maine. However, there is not
just one solution to the problem. Along
with the proposed intervention, policies aimed at minimizing socioeconomic
disparities, improving access to healthy foods, increased infrastructure that
allows to physical activity outdoors, as well as improvements for
self-awareness that the obesity epidemic is reversible. With these improvements on the local, state,
and national level, the prevalence of obesity in the nation’s children will
begin to decrease.
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Labels: Adolescent Health, Maternal and Child Health, Nutrition, Obesity, Physical Activity, Pink, Socioeconomic Status and Health
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