Friday, December 21, 2012

Motivating or Stigmatizing? Addressing the Need for the Public Health Community to Promote Multi-Disciplinary and Motivating Obesity-Related Messages – Katherine Rosa

The National Center for Health Statistics reports that 17 percent of youth under age 20 were obese in 2009-2010 (1).  The statistics are staggering, and the prevalence of obesity among youths in the United States has nearly tripled from 1980, when approximately 6% of the youth population was obese (2). Obesity is a major public health problem in the United States and other developed countries. It is associated with serious consequences for individuals in terms of higher mortality and worse health outcomes, including hypertension, elevated cholesterol levels, and Type 2 diabetes (3). Furthermore, obese children are more likely to be obese as adults, which leads to higher risks of poor health outcomes including heart disease and stroke, and diabetes cases in children have increased by one fifth since 2000 (4).  There are clear, evident, and significant consequences to early-onset obesity. The lasting effects of childhood obesity can be highly detrimental to a child’s future. Consequently, obesity-related public health interventions are needed to hinder the growing problem of childhood obesity.   
Various public health approaches to combatting childhood obesity have been implemented in the United States. One recent intervention was developed by Children’s Healthcare of Atlanta in partnership with the Strong4life campaign. A major component of the intervention was a series of black and white billboards and commercials featuring stark and blunt captions on the individual weight problems of the child in each commercial. Captions included ‘Get healthy, get moving, get a life’, ‘Fat kids become fat adults’ and ‘Being fat takes the fun out of being a kid’ (5). Atlanta’s pediatric health care system has defended these advertisements, insisting that a bold message was needed to convey the urgency of the childhood obesity rate in the state of Georgia, whose overall obesity rate is the second highest in the nation (6). Conversely, critics of this approach claim that the advertisements inadvertently stigmatize the individuals they intend to help; by stigmatizing obesity, the campaign could alienate the audience of children and families it intends to motivate and hinder the behavioral changes it means to encourage (5).
Ultimately, the approach that Children’s Healthcare of Atlanta took in its intervention strategy is based too heavily on the Health Belief Model and simultaneously fails to promote self-efficacy (7). The approach also promotes an incredible amount of weight stigma, and it fails to account for the geographic maldistribution of educational and economic resources.
Critique of the Health Belief Model
Children’s Healthcare of Atlanta’s intervention depends too heavily on the Health Belief Model.  This model primarily focuses on individual decisions and reasoning. It neither accounts for disparities in knowledge nor addresses social, economic, or environmental factors (8). The model also assumes there is a solid arrow from intention to behavior and assumes once an individual makes a decision, he or she will act (8). These assumptions are too unrealistic and simplified for a childhood obesity intervention campaign. Factors aside from individual reasoning must be considered in order to effectively intervene against childhood obesity. These factors include cultural, sociopolitical, and economic conditions which set the context for individual health experience and behavior (9). By only focusing on individual children and behavior, and in some instances including a parent, the commercials individualize the problem and inadvertently create negative implications for the way obese individuals are viewed. The Health Belief Model can taint the way individuals are viewed and, as discussed in the following section, create a stigma associated with unhealthy behavior.
Furthermore, the primary resource for change within the Health Belief Model is self-efficacy. People with greater levels of self-efficacy, or confidence, will more likely engage in a specific behavior, persist until they get it right, and maintain the behavior over time (10). Yet the commercial advertisements do not provide children or families with any tools to promote self-efficacy. Rather, they show startling images to increase the perceived severity and susceptibility of childhood obesity. Perceived severity and specificity are two concepts within the Health Belief Model. The campaign commercials specify the consequences of obesity to increase the perceived severity, but they do not recommend any action (11).  These commercials attempt to startle viewers into action, but they neglect to propose alternative, actionable behavior. They do not build any confidence in the viewer that he or she has the ability to perform an alternative behavior to combat obesity (10). In fact, the commercials entirely fail to propose any alternative behavior.
 Research has shown that messages that obese individuals find least motivating are ones that provided no specific actionable behaviors (5). This finding suggests the importance of testing messages in advance among the general public and ensuring that the responses and perceptions of obese individuals are understood and considered (5). Ultimately, this public health campaign fails because it neglects to propose alternative, actionable behavior, it does not consider the reactions or perceptions of the obese individuals whom it intends to help, and because its underlying assumptions based on the Health Belief Model are flawed.
Critique of Weight Stigma and Attribution Theory
The Children’s Healthcare of Atlanta intervention also fails because it promotes weight stigma. As previously mentioned, the Health Belief Model can negatively affect the way individuals are viewed and can create stigmas. In the case of childhood obesity, children may be viewed as inherently flawed or made to feel a great deal of shame and stigmatization. According to the Centers for Disease Control and Prevention, ‘stigma hampers prevention’ (12). A number or research studies show that experiencing weigh stigma increases the likelihood of engaging in higher calorie intake, unhealthy eating habits, binge eating patterns, and lower levels of exercise, all of which exacerbate weight gain and inhibit weight loss (5, 13). Stigma assumes the condition of obesity is under personal control
Research has also shown that the messages included in the Children’s Healthcare of Atlanta intervention, such as ‘Get healthy, get moving, get a life’, ‘Fat kids become fat adults’, ‘Chubby kids may not outlive their parents’ and ‘Being fat takes the fun out of being a kid’, were viewed as stigmatizing and did not induce motivation to engage in healthy behaviors (5). Therefore, this intervention communicated stigmatizing and shameful messages toward families struggling with obesity. These messages were perceived to be inappropriate and ineffective, and they did not promote any change in behavior among viewers.
 Stigmatization has detrimental effects on both children and adults; experiences with weight stigma negatively impact both psychological and behavioral outcomes (14). Consequently, children who experience weight stigma report they are reluctant to become involved in physical activities at school because of teasing. Teasing about weight among children is also related to lower involvement with physical activity and a preference for sedentary activities (15). A major flaw in this intervention it that it sends messages that promote weight stigma and criticism rather than showing any empathy, understanding, or alternative behaviors to consider. Instead, the message is dark, solitary, isolating, and harsh. These are not elements of a public health campaign that will enable and promote behavioral change.
Additionally, the emotional and social consequences of obesity are less detailed and not well understood. They include ‘low self-esteem, negative body image, clinical depression, and weight bias. Any action or policy that exacerbates these consequences is considered a serious ethical problem’ (16). Weight bias is the inclination of others to form unreasonable judgments based on a person’s weight; it is caused by a general belief that stigma and shame ‘will motivate people to lose weight or the belief that people fail to lose weight as a result of inadequate self-discipline or insufficient willpower’ (16). However, evidence in the literature suggests that weight stigma and bias are not beneficial public health tools for reducing obesity or improving health. Instead, stigmatization of obese individuals ‘poses serious risks to their psychological and physical health, generates health disparities, and interferes with implementation of effective obesity prevention efforts’ (13). Furthermore, because obesity is often viewed as a condition under volitional control, it is a highly stigmatizing condition. This stigmatization is in line with the attribution model of public discrimination. In this model, ‘causal beliefs about the controllability of the condition lead to an emotional response (e.g. stigmatization attitudes). Behavioral consequences in the form of discrimination result’ (17). Negative attributes associated with obesity include labeling obese individuals as unmotivated, unintelligent, and lazy (17).
Given the emotional, behavioral, and social consequences of negative causal attribution and stigmatizing attitudes, it is clear that the Children’s Healthcare of Atlanta intervention is flawed. This approach fails to recognize the detrimental effects obese children face when they are bullied, teased, and judged because of their weight. The campaign’s commercials and billboards exacerbate these problems through their stigmatizing messages.  These messages are aggressive and bullying in nature. Unfortunately, by stigmatizing obese children, this campaign effectively alienates the very children it intended to motivate. Sadly, the psychological consequences these children already face are only heightened by such a divisive public health campaign.
Critique of the Failure to Recognize Social and Environmental Inequality

Society frequently blames the victim rather than addressing environmental conditions that contribute to obesity (16). Atlanta’s public health intervention fails because it assigns blame at the individual level. The intervention fails to account for the geographic maldistribution of food and other resources. This maldistribution is a critical component of childhood obesity that cannot be overlooked.  Because obesity is especially prevalent among poor or minority groups in disadvantaged areas, obese individuals often already belong to marginalized groups and experience multiple stigmatization statuses. Consequently, the stigmatization of obese individuals is inextricably linked to social inequalities (13). Yet social inequality is never referenced in the Children’s Healthcare of Atlanta approach. Instead, the campaign focuses on individual children and families and casts a message of shame and stigma on them. The campaign’s response is limited because it focuses on individual choices regarding nutrition and physical activity and overlooks critical societal and environmental causes of obesity (13).
Research recently reported in an American Heart Association scientific statement concluded that ‘access to supermarkets, rather than only grocery or convenience stores, was 1 of 3 neighborhood factors with the strongest evidence for inverse associations’ with obesity and related lifestyle behaviors in disadvantaged populations. The other factors were availability of places to exercise and safety (18). The authors concluded that disadvantaged populations were more likely to live in neighborhoods with suboptimal availability of food stores, places to exercise, aesthetic characteristics, and traffic or crime-related safety (18). The report indicates that perceptions of overall neighborhood safety and traffic safety (eg, related to aspects of road or pedestrian crossings) were positively associated with children’s physical activity. Similarly, objective measures of neighborhood crime were inversely associated with children’s physical activity (18). Unfortunately, Children’s Healthcare of Atlanta’s public health campaign fails to account for the geographic maldistribution of food or the impact of the community environment on physical activity. The campaign provides no information on the environment in which the documented children live. It neglects to account for the geographic maldistribution of food and lack of accessibility to healthy food in disadvantaged areas. Obesity is more than an individual level problem; it is a multi-faceted problem that cannot be overcome by the stigmatizing slogans and tactics of the Children’s Healthcare of Atlanta campaign.
Introduction to Proposed Intervention
A successful intervention against childhood obesity will emphasize specific health behaviors and personal empowerment for health rather than imply personal blame and stigmatize the obese (2). Additionally, it will take on a multi-faceted approach to intervening in the complex problem of childhood obesity. The proposed alternative intervention will also understand the community it intends to serve and will work to improve environmental and academic factors that affect health behavior. Rather than aiming to achieve a specific weight target, the motivator and outcome of interest for these children will shift to health. This alternative intervention can be applied at the municipal and state levels to specifically target disadvantaged communities where obesity affects poor children disproportionately.
Defense of Intervention Section 1: Altering the Framework and Model of the Campaign from an Individual to a Community Level

Unlike the Children’s Healthcare of Atlanta campaign, the proposed intervention will be based on a general framework for the determinants of health and an ecological perspective that embraces the intrapersonal, interpersonal, and community levels of influence (9, 11).
As Marks states in his research, an effective framework for intervening in childhood obesity must realistically represent the ‘constraints upon, and links between individual, community, and societal levels of change’ (9). Unlike the Health Belief Model, which focuses only on individual level factors, a general framework for the determinants of health provides a more enhanced and nuanced perspective. This framework layers the following factors affecting the determinants of health around the individual: individual lifestyle, social and community influences, living and working conditions, and general socio-economic, cultural, and environmental conditions (9). These factors are overlooked by the Children’s Healthcare of Atlanta campaign. The campaign makes no reference to community or environmental effects. Instead, it places children and families in dark, prison-like settings where they are forced to endure the burden of obesity alone. 
Similarly, an ecological perspective emphasizes the ‘interaction between, and interdependence of, factors within and across all levels of a health problem (11). The ecological perspective accounts for multiple levels of influence beyond the individual level, for the social environment, and for reciprocal causation. The idea of reciprocal causation is critical to addressing the childhood obesity problem because it shifts responsibility away from the child and weakens the attribution model of public discrimination and stigmatization (11, 17). Instead, reciprocal causation suggests that children both influence, and are influenced by, other people and their environment (11).
The alternative intervention will acknowledge the ‘primary determining influence of society through the community, living and working conditions, and the surrounding socio-economic, cultural and environmental conditions’ (9). The alternative intervention will embrace a community setting for its commercial video messages, much like the Bring Change 2 Mind organization’s public service announcement filmed in Grand Central Station (see (19). Bring Change 2 Mind’s public service announcement is effective because of its open and familiar location, because it links the individuals struggling with mental illness with supportive family and friends, and because it creates a sense of community that is caring and compassionate rather than abrasive and biased.  This type of community is not acknowledged in the Children’s Healthcare of Atlanta campaign.
However, the proposed alternative intervention will link obese children with their family and community members in order to create a supportive and self-efficacious message. Messages intended to motivate individuals to be healthier are more effective when they are framed in ways that foster confidence and self-efficacy to engage in healthy behaviors rather than in ways that imply personal blame or solitary effort (5). Thus, the proposed alternative intervention will rely on these alternative models to expand beyond educational campaigns focused on individual behaviors toward larger-scale, coordinated policies that initiate social changes to help reverse the societal and environmental conditions that create obesity in the first place (13). Specifically, family and community members will be included alongside children in any commercial and billboard advertisements. These advertisements will also be colorful and energetic instead of gloomy and depressing. These effects promote the sense of community effort and encouragement in learning and attaining better health. 
Defense of Intervention Section 2: Eliminating Weight Stigma and Shifting the Focus from Weight to Health

 The attribution of obesity to internal causes remains a major source of stigmatization and discrimination of obese individuals. Unfortunately, the Children’s Healthcare of Atlanta campaign negatively labels children and families struggling with obesity and enables this stigma. This approach creates an ideal starting point for the alternative intervention’s approach. Rather than embracing weight stigma and bias, the alternative intervention will introduce a multidimensional concept of the etiology of obesity to the public in order to reduce stigmatization (17).  The alternative intervention will clearly support measures to promote better health behavior and weight control, but it will do so without being anti-obese people.
The idea of achieving better health versus achieving a certain weight is critical to the success of the alternative intervention.  The alternative intervention will use a model that can reduce the distress associated with stigma while simultaneously empowering weight control efforts (13). A growing movement that is currently underway called Health at Every Size shifts the focus from weight management and reduction to health promotion; the primary intent of this movement is to support improved health behaviors for people of all sizes without ‘using weight as a mediator’ (20). The Health at Every Size movement effectively shifts the paradigm from weight to health. This shift is in line with research that suggests individuals, including children, may be more willing to improve their health behaviors when the focus is on health rather than measured body weight (5). The alternative obesity intervention will overcome weight stigma by specifically addressing it directly in its campaign, incorporating anti-stigma messages into its campaign, and by focusing on health as both the primary motivator and desired outcome for behavior change rather than focusing on achieving a set weight (13).
Defense of Intervention Section 3: Ensuring Obesity is Understood as a Community and Environmental Threat Rather than just an Individual Threat

The built environment has decreased opportunities for healthy lifestyle behaviors through factors such as urban design, land use, public transportation availability, density and location of food stores and restaurants, and neighborhood barriers such as safety and walkability (13). There is also increased accessibility of inexpensive foods in disadvantaged areas (13, 18). Unlike the Children’s Healthcare of Atlanta campaign, the alternative intervention understands that environmental change is essential to the solution of obesity; public health efforts must address the multiple forces contributing to the development and maintenance of obesity and recognize that individual behaviors are powerfully shaped by the environment (13).
Research shows that disadvantaged populations are more likely to live in neighborhoods with poor access to and availability of food stores, places to exercise, aesthetic characteristics, and crime prevention and safety (18). Therefore, the alternative intervention proposed will focus on strengthening disadvantaged communities, improving access to essential services, encouraging development, and working with various community and public groups (9). Specifically, this alternative intervention will supplant resources in school cafeterias. Funding will be provided for the purchase of healthier food options that meet calorie and fat guidelines. Food options that do not meet preset nutritional guidelines will be eliminated and replaced with healthy options. Curriculum will include nutrition diagrams as well as tastings of healthy snack options. The tasting is critical because it acquaints students with fruits and vegetables they have previously never seen (4). This curriculum will be a mandatory component of classroom education that all students will be required to participate in and that all teachers must teach. Teachers will be provided basic nutrition education from school nurses or the state’s public health commission office depending on city. Additionally, funding will go to the development of safe parks in these areas so that children have a safe place to play and exercise. Security will be in place to protect children and deter crime. Principals, superintendents, city representatives, mayors, and the state government will work together to oversee this process, and funding will be mandated at the state and federal level.  These tactics are a tacit attack on obesity rather than the outright verbal attack that is used in the Children’s Healthcare of Atlanta campaign. A multi-faceted yet tacit assault is necessary to reverse the trend of childhood obesity. Children, parents, schools and lawmakers need to better understand the environmental effects on health behavior and promote effective alternative behaviors.
Ultimately, unhealthy eating behaviors should be discouraged for all people regardless of weight (13). Policies that make nutritious food more affordable and improve road and landscape design to encourage physical activity are critical to the success of this alternative intervention. Direct funding to support these efforts is critical to the success of this alternative intervention.
1.  Centers for Disease Control and Prevention. Prevalence of Obesity in the United States, 2009-2010. Atlanta, GA: National Center for Health Statistics, 2012.
2.  Moyer C. Stigmatizing Obesity Undercuts Effectiveness of Public Health Campaigns. American Medical News. September 24, 2012 (Accessed December 9, 2012 at 
3.  Sikorski C, Luppa M, Brahler E, Konig H, and Riedel-Heller S. Obese Children, Adults and Senior Citizens in the Eyes of the General Public: Results of a Representative Study on Stigma and Causation of Obesity. PLoS One 2012; 7(10): e46924.
4.  Tavernise S. Obesity in Young is Seen as Falling in Several Cities. New York Times. December 10, 2012.
5.  Puhl R., Peterson JL, and Luedicke J. Fighting Obesity or Obese Persons? Public Perceptions of Obesity-Related Health Messages. International Journal of Obesity 2012; doi:10.1038/ijo.2012.156.
6.  Rubin B. Making the Burden of Childhood Obesity all the More Heavy. Chicago Tribune. January 31, 2012 (Accessed on December 9, 2012 at
7.  Janz NK, Becker MH. The Health Belief Model: A Decade Later. Health Education Quarterly. 1984; 11(1):1-47.
8.  Edberg M. Individual Health Behavior Theories (pp. 35-49). In: Edberg, M. Essentials of Health Behavior: Socials and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
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11.           National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, pp. 9-21 (NIH Publication No. 05-3896).
12.           Centers for Disease Control and Prevention. HIV Prevention Strategic Plan Through 2005. January 2001. (Accessed on December 9, 2012 at
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14.           Piggen J and Lee J. Don’t Mention Obesity: Contradictions and Tensions in the UK Change4Life Health Promotion Campaign. Journal of Health Psychology 2011; 16(8):1151-1164.
15.           Vartanian L and Novak S. Internalized Societal Attitudes Moderate the Impact of Weight Stigma on Avoidance of Exercise. Obesity 2010;19:757-762.
16.           Washington R. Childhood Obesity: Issues of Weight Bias. Preventing Chronic Disease 2011; 8(5):A94 (Accessed on December 9, 2012 at
17.           Sikorski, C, Luppa, M, Glaesmer, H, Schomerus, G, Konig, H, and Rideo-Heller, S. The Stigma of Obesity in the General Public and its Implications for Public Health – a Systematic Review. BMC Public Health 2011; 11:661-669.
18.           American Heart Association. Population Approaches to Improve Diet, Physical Activity, and Smoking Habits: A Scientific Statement. Circulation 2012; 126(12):1514-1563 (Accessed on December 9, 2012 at
19.           Bring Change 2 Mind. Change a Mind About Mental Illness.
20.Bacon L and Aphramor L. Weight Science: Evaluating the Evidence for a Paradigm Shift. Nutrition Journal 2011; 10:9 (Accessed on December 9, 2012 at

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