Friday, December 21, 2012

Tackling Childhood Obesity in Atlanta: Creating A Movement out Of Controversy- Karan Shergill

Childhood obesity is one of the most serious upcoming public health issues within the United States. According to the World Health Organization, obesity as a disease is defined as the condition of excess body fat to the extent that health is impaired (1). For practical purposes and among both children and adults, BMI is now widely used to assess obesity (2,3). BMI is closely correlated with body fat and obesity related health consequences (2).
 The ‘new’ BMI reference is provided in the 2000 Center for Disease Control and Prevention Growth Charts (3), which was developed for all US children aged 2-19 years. These ‘new’ BMI, 85th and 95th percentiles are recommended by the Centers for Disease Control and Prevention for screening overweight persons. Thus overweight children have their BMI within the range of 85 to 95 percentile, for the children of same age and sex and obese children have BMI greater than 95 percentile.  For children younger than age 2 years, there is no BMI- for-age reference to define overweight, and the weight –for-length 95th percentile has been used(2).
The percentage of children and adolescents between 2- 19 years who are suffering from childhood obesity are estimated to be around 17% (4). The top 3 states where majority of the children are suffering from childhood obesity are Mississippi, Georgia and Kentucky (4). Childhood obesity is a multisystem disease with potentially devastating consequences. Obese youth are more likely to have risk factors for cardiovascular disease, such as high cholesterol or high blood pressure (5). Children and adolescents who are obese are at greater risk for bone and joint problems, sleep apnea, type 2 diabetes and social and psychological problems such as stigmatization and poor self-esteem (6).
Although there are some genetic and hormonal causes of childhood obesity, most of the time, it is caused by kids eating too much and exercising too little (7). Genetic, environmental, social and behavioral factors have been found to be related in determining an individual’s body weight (8,9). Advertising campaigns link food, beverage, candy products with enticing features such as movie and cartoon characters, toys, video games, branded kids clubs, the Internet, and educational materials (10-12).Such advertising is especially influential among children younger than 8 years because they have limited understanding of the advertisers’ persuasive intent (13). Adolescents, on average, get 11% of their calories from soft drinks and consume twice as much soda as milk (14). Low-income families face numerous barriers including food insecurity, lack of safe places for physical activity, and lack of consistent access to healthful food choices, especially fruits and vegetables (15). 
The Atlanta Campaign against Childhood-obesity:
In-order to raise awareness regarding the problems of childhood obesity by making use of billboards and the television media, an anti –obesity campaign was started by Strong4Life, run by Children’s Healthcare of Atlanta. The advertisements and billboard hoardings show obese children telling to the audience how do they feel about being obese and with taglines as "Chubby isn't cute if it leads to type two diabetes"; and "Being fat takes the fun out of being a kid" (16).  These advertisement campaigns are the topic of critique of this paper which will explain why the strategy employed by Strong4Life is ineffective in tackling childhood obesity.
Criticism 1:  Reinforcement of Stigmas
According to chief administrative officer of Children’s Healthcare of Atlanta, "We felt that because there was so much denial that we needed to make people aware that this is a medical crisis. We knew flowery ads don't get people's attention. We wanted to come up with something arresting and hard-hitting to grab people" (17).
 Though the advertisements are aimed to create awareness and attention to the epidemic, it is in a direction that may perpetuate stigmas for obese children. Messages like “Being fat takes the fun out of being a kid,"    accompanied by a picture of an overweight child looking extremely somber singles out obese children (16). This, in turn, makes them an easy target in society. Negative attitudes toward obese persons are pervasive in North American society. Numerous studies have documented harmful weight-based stereotypes that overweight and obese individuals are lazy, weak-willed, unsuccessful, unintelligent, lack self-discipline, have poor willpower, and are noncompliant with weight-loss treatment.(18).
Stigmas arise as a result of misconceptions about a particular aspect or outcome (19). Although Strong4life intended to separate out the obese children from the rest in order to motivate them for weight loss, there are number of reasons to believe that this move might be unhelpful. Attempts at weight loss cannot be achieved just on the basis of diet (20). Thus the message ‘Stop sugar coating- Georgia’ is not completely appropriate. By stigmatizing the obese children, they have ignored the harmful outcomes of stigma which include discrimination and negative impacts on health (19). The individual behavior of these children can be greatly influenced by simply labeling them as obese. According to the Labeling Theory, labeling an individual influences their behavior and more often encourages that individual to behave in a manner that justifies the label assigned with them (8-9). Obese children must endure negative stigma not only from their peers, but also by their teachers and themselves (7). It has been observed that when individuals feel shamed or stigmatized because of weight they're actually more likely to engage in behaviors that reinforce obesity: unhealthy eating, avoidance of physical activity, increased caloric intake (7).
Critique 2:  Lack Of Self-efficacy;
 Warning label like “My fat may be funny to you but its killing me” (16), bring out a sense of incapability, subjugation and melancholy.  There is nothing in this message that arouses a sense of self-efficacy, or the idea that a lower, healthier weight is an attainable goal. Although these ads depict a picture that childhood obesity is a serious concern among the children who suffer from it but the element of how one can manage this situation is missing, hence rendering the audience clueless of what can be done to tackle it. Self-efficacy refers to personal judgments of one’s capability to organize and implement behaviors in specific situations. The concept of self-efficacy is a central component of Social Cognitive Theory. According to the Social Cognitive, behavior of a person is a result of the interaction between one’s environment, the behaviors one witnesses, and the individual themselves (21). Such advertisements convey a pessimistic feeling in the minds of audience by showing worried kids who can’t do anything about their obesity. Hence Strong4Lifr is not sending a positive message of self- efficacy and should not expect other people to change their behavior by watching their advertisements or billboards, instead should expect the opposite to happen.
Critique 3: Employment of Fear Tactics:
In order to come up with an advertisement that is more assertive and hard hitting to the people, the Strong4Life have employed the use of fear tactics.
 By setting fear into the minds of audience, Strong4life want to force people to circumspect on the issue so that the parents can take necessary steps to curb it. The somber expression and direct gaze of the children reads as accusatory in some images and pleading in others.  The children stare down the camera, and the stark black and white of the images serves to emphasize the grim nature of their predicament.  Combined with the inflammatory captions, the ads consciously manipulate feelings of guilt and fear in an effort to capture attention. They are assuming people to make rational decisions by visualizing these children. But fear often results in making decisions which are irrational and tend to negate the intended effect. Fear creates an unnecessary pressure in the mind of the individuals and instead of thinking of a proper way to a quandary people tend to ponder upon the fear itself. Thus this move by Strong4life which although was meant to motivate the audience, instead is more likely to create reverse effect.
From the above discussion it is quite evident that due to serious flaws in the messages being conveyed to the audience this intervention is likely to fail.
The campaign will not work as it targets and separates out an individual in the community and makes him/her belief that they are inefficacious. Thus the Social Network Theory can be employed in such a situation to deal with the problem of segregation and discrimination and make people believe in themselves. It will work in the intended direction of mitigating the above mentioned problems as the social structure of the network will be responsible for determining and predicting individual behavior (22).
 A proposal of three different interventions has been presented below that might be able to remedy Strong4Life’s public health campaign against childhood and adolescent obesity.  To formulate a more effective public health campaign against childhood obesity for Strong4Life, these interventions discuss the elimination of stigmas and labels, encourage self-efficacy and discourage use of fear tactics.
Intervention 1: Elimination Of Stigmas and Stereotyped behavior
The stigmas against obesity created by the advertisements and in the society in general can be encountered with the use of Social Network Theory. By promoting healthy interaction between obese children and their peers and other members of the society, these stigmas can be removed. In one of the advertisements an obese child says,’ Playing video games is what I like to do by myself. I don’t have to be around with other kids because all they want to do is pick on me’ (16). As it not uncommon in for the obese kids to be teased, therefore advertisements showing these kids involved in sports or physical activity will not only convey to other obese children how to reduce weight but will also depict cordial interaction between children from various backgrounds and weights, which will send a positive message to the society.
It has been observed in studies, that sharing beliefs provides a means to affiliate with others and to achieve membership, attention, emotional support, acceptance and security in social groups (23-26). A person’s stigmatizing attitudes are affected by perceptions about whether they are shared by others and may change accordingly (27). Attitude change is more likely when relevant information comes from valued in groups than from other disliked groups (28,29). An example of how social network theory seems to work in real life is the “Peer Power” initiative in North Carolina which was a peer driven program that had produced remarkable positive health behavior changes in areas of health activity and nutrition, leading to decrease in average BMI BY 4% in two thirds of students (30). In this the high school students were trained to be educators and mentors for younger elementary and middle school children. Hence by showing all sorts of kids intermingling with each, Strong4Life can help reduce the discrimination faced by the obese children.
Intervention 2: Encouragement of Self-Efficacy:
Instead of creating a picture of hopelessness and helplessness, the advertisements should focus on positive ways to enhance self -esteem and encouragement of obese children. The tagline of “My fat might be funny to you but it is killing me” can be replaced by “I am killing my fat by dancing everyday- it’s fun”. The later line conveys to the audience that engaging in any sort of physical activity is enjoyable and that the obese children can also participate in any activity they like.
Similarly, if advertisements are developed on the basis of the Social Cognitive Theory, in which the obese children are trying to reduce their weight by working out or playing each day, the audience will witness a particular behavior being performed. Thus by observing the actions of others and the benefits of those actions the people will change their own attitudes from that of being a pessimist to that of an optimist which will promote self -efficacy. Perceived self -efficacy can affect health behavior in number of ways. Self-judgments of efficacy determine choice behavior; that is which actions will be attempted and which avoided. Self-efficacy also affects the amount of effort devoted to a task, and the length of persistence when difficulties are encountered. Realizing that they are self- efficacious, the obese children will feel empowered and that they are capable of achieving any challenges that come in their way.
Intervention 3: Discouraging Scare Tactics:
Instead of instilling fear in the minds of the obese children, Strong4life should come up with advertisements that should focus on healthy behaviors for all children. As opposed to showing children against a dark background in a desolate way, it is necessary that they should exploit the concepts of Social Network Theory. They should depict confidant and bright looking kids who are willing to find a solution to their obesity by keeping themselves involved in sports regularly for fixed duration of hours and eating healthy food. They can also show a child who was obese before and how he can become a role model to other children watching him.
The Strong4Life campaign has some limitations because of which its effectiveness is restricted and rather seems to act in an opposite way. Although it is necessary to address the issue of childhood obesity, but it should not be done in a way which promotes un-equality for these children as they also have the equal rights and freedom enjoyed by every citizen of this country. By eliminating the fear based approach and reinforcement of stigmas and by promoting self -efficacy, it is possible that we can change the behavior of the concerned individuals. The new proposed campaigns would empower the caretakers and children to make a collaborative effort within their familial unit, as well as in the community, to make better and healthier choices for their health.

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