Tuesday, January 1, 2013

The Dangers of ‘Fat Shaming’ and Parent-Child Interventions: Rethinking Obesity Interventions- Emily Hall

There is no denying that obesity has become a public health epidemic that needs immediate attention, especially among America’s youth. Currently, 1 in 3 children ages 11-19 are overweight or obese and nearly 1 in 6 children are obese with a BMI above the 95th percentile of the CDC’s recommended growth charts (1). Overweight and obese children are at an increased risk for many health conditions such as cardiovascular disease, type-2 diabetes in addition to various psychological problems related to the social stigma of being overweight (2- 241S). It is also likely for many children that these health problems will continue into adulthood: overweight children have a 70% chance of becoming obese adults, which rises to 80% if 1 parent is overweight or obese (1).
In order to counteract this dangerous trend, several public health organizations have designed interventions to highlight how parental obesity is related to childhood obesity. However, many of these programs rely on a tactic known as ‘fat shaming’ which relies on the stigma against obesity as motivation for children (and their parents) to adopt healthier lifestyles and lose weight (3-4). Examples of such anti-obesity campaigns include Georgia’s Strong4Life campaign (4) and Blue Cross and Blue Shield of Minnesota’s ‘Better Example’ campaign (5). Both have sparked national debates over the use of fat shaming in their TV and billboard advertisements. Anti-obesity campaigns focusing on the parent-child relationship and using weight stigma as a call to action are detrimental to obesity interventions since they do not take into account the entire ecological model of health promotion, are based on changing attitudes through the Theory of Reasoned Action, and rely on fat shaming to create positive behavior change when in reality it leads to psychological reactance.
Individual-level Interventions and the Ecological Model of Health Promotion
Applied to health promotion by McLeroy et al., ecological models of behavior describe the individual, social and environmental factors that contribute to an individual’s actions (6-351). Although individual factors play a role in the model, social and environmental influences are shown to be greater predictors of behavior. Individual-oriented behavior change interventions, such as child anti-obesity campaigns that use fat shaming, often lead to victim blaming and inaction (6-352). Social and environmental forces maintain and reinforce unhealthy eating behaviors, so intervening only on an individual level ineffective (6-353) and ignores many of the group-level factors contributing to the problem.
            The levels of influence identified within McLeroy et al.’s ecological model for health promotion are intrapersonal factors, interpersonal processes, institutional factors, community factors, and public policy (6-355). Anti-obesity campaigns based on fat shaming are only utilizing intrapersonal and interpersonal factors, as they are specifically aimed at changing the behavior of obese children and their parents (5). Since they are focused on intervening on the individual level, these campaigns assume that the direct causes of behavior come from within the individual or familial influence rather than the larger social and political environment. Concerning most health behaviors, motivation to act is not only the result of an individual’s knowledge and attitudes about health but influence from outside environmental forces out of the individual’s control (6-356).
            This is especially true of the convergence of environmental and social influences that have led to obesity epidemic in the U.S. Rather than just the result of individual lifestyle choices, the growing rate of weight gain can also be attributed to a series of environmental influences stemming from widespread lifestyle changes. These include the overall reduction in physical activity and increase in the availability of inexpensive, energy dense foods (7-853).
For example, obesity rates in the last 30 years have risen in tandem with the increase in restaurant portion sizes. Items at restaurants, especially at fast food establishments, have gotten 2 to 5 times larger since the 1980s. Studies conducted in natural eating environments have illustrated that when presented with a small and large portion choice, individuals are more likely to choose the larger portion (7-905). The amount of food offered to an individual as a portion has a great influence on their caloric intake, which in turn impacts their weight. Children are particularly susceptible to weight gain due resulting from this trend of increasing portion sizes: children with higher BMIs consume portions up to 100% larger than those routinely eaten by children with lower BMIs (8-907).
Changes in overall eating habits of Americans have greatly contributed to the rising trend of childhood obesity. Consuming meals made outside the home is very common due to an increasing number of both two income and single parent households and expansion of the restaurant industry. The increase in portion sizes at restaurants is attributable in part to consumer demand for economic value leading to fast food establishments offering larger portions of calorie dense food for lower costs as a marketing strategy (8-908).
The rise in fast food consumption among families is also attributable to the changes in economic structures and workplace expectations that have occurred in the last two generations—the “9 to 5” workday is disappearing, leaving parents with less time to prepare meals for their children. This emphasis on high productivity in the workplace has also left many adults without the time to engage in physical activity for themselves or encourage it among their children. It is clear that current social norms encourage obesity and are influential forces dictating individual health behaviors (7-854).
Anti-obesity interventions that focus only on individuals and their interpersonal interactions, such as those between parents and their children, fail to address the influences that higher level factors have on health behaviors. According to the ecological model of health promotion, at the community level resources available for health services or encouraging healthy lifestyles may be limited (6-364) and therefore dictate an individual’s eating habits more than personal food preference. This model also states that community power dictates the public agenda and those with the most severe health problems are often have the least access to participating in the community and influencing the agenda. McLeroy et al. describes these disenfranchised groups as the poor, uneducated, unemployed and those with socially stigmatized medical conditions (6-365). 
Across the U.S., childhood obesity is growing the fastest among low income households where levels of parental education are also low, although this relationship is moderated by ethnicity (9-5). Therefore, disregarding the amount of community power that these families wield as compared to more educated and affluent community members has led to interventions that are ineffective due to their ignorance of the community power structure (6-365). The stigmatization of obesity seen in the Strong4Life and Better Example campaigns marginalizes obese children even further (10), making the intervention not only unsuccessful in provoking community level change but may even be harmful to the parents and children whose health they are trying to improve.
Appealing to Parents through the Theory of Reasoned Action
            The Theory of Reasoned Action uses social psychology to explore the relationships between an individual’s behaviors, beliefs, attitudes and intentions. It states that behavioral intention is the most important predictor of action. In this theory, intention is influenced by an individual’s attitude towards performing a behavior and by subjective norms about the behavior within the individual’s peer group. The Theory of Reasoned Action also assumes that all other factors that could influence behavior are experienced only through the model and cannot predict behavior independently. This includes environmental or cultural factors (11-16).
            Blue Cross Blue Shield Minnesota’s ‘Better Example’ campaign uses the Theory of Reasoned Action through trying to change parents’ attitudes towards certain lifestyle habits, such as eating large portions of fast food, and the negative impact that they have on their children. The slogan used in many of their commercials, “Today is the day we set a better example for our kids,” (5) also illustrates that this campaign seeks to address the subjective norms that overweight parents with children who are overweight or obese have about their eating habits and how it influences their children. Through attempting to change parents’ attitudes about how their behavior impacts their children, this campaign seeks to influence their intentions and therefore their health behaviors.
            One flaw in the Theory of Reasoned Action is its emphasis on intention leading directly to behavior. This emphasizes individual cognition above environmental influence when making decisions (11-16). The Theory of Reasoned Action also assumes that individuals systematically process and the information that is presented to them and make decisions based on a rationed thought process (12-253).  When applying these assumptions to other health behaviors such as HIV prevention, research has shown that being informed about protection had little impact on changing the rate of unprotected sex among homosexual men. Instead, socioeconomic status and perceived severity of illness were the biggest predictors of using protection when engaging in risky sexual activity (12-254).  Therefore, individual attitudes and beliefs alone cannot be depended upon to lead to behavioral change, since much of behavior is influenced instead through the social structures that govern everyday actions (12-255).
Similar to the impact of individual attitudes on HIV prevention behavior, parental attitudes towards obesity are not the greatest predictors of a healthy lifestyle for their children that include a balanced diet and adequate physical exercise. Even a person’s food preference is a result of their socioeconomic and cultural environment rather than individual, rational thought considering nutritional benefits and potential impact on weight (13-250S). The externality theory of obesity, supported by many behavioral researchers,  states that obese individuals are more susceptible to overeating since they are more receptive to external cues rather than internal cues such as lack of hunger or attitudes about food consumption (13-251S).
 The Theory of Reasoned Action also postulates that external factors only impact behavior through an individual’s attitudes (11-6), which is clearly illustrated to be false concerning overeating behavior and other activities that lead to obesity. A study conducted by Craeynest et al. on the attitudes of obese and non-obese children concerning food intake and physical activity concluded that obese children did not have a negative attitude towards healthy food or physical activity. However, when given the opportunity they ate larger portions of food and engaged in sedentary activities more often than the non-obese participants. This illustrates the discrepancy between the attitudes of obese children and their behavior (14-1118), which cannot be accounted for by the Theory of Reasoned Action. Since childhood obesity is not only the product of individual or parental attitudes towards a healthy lifestyle (6-356), basing an intervention on this theory will not lead to a substantial change in obesity rates among children or their parents.
Fat Shaming and Psychological Reactance
            Both the Strong4Life and Better Example campaigns have been criticized for fat shaming, or using the societal stigma against being overweight as motivation for parents and children to adopt healthier lifestyles (3-4). Supporters of these campaigns claim that obesity is such a serious and prevalent problem that parents and children need to be confronted with these realities through any means possible (5). However, a recent analysis of anti-obesity public health campaigns conducted at Yale University has determined that weight stigma is not an effective tool for encouraging weight loss. Instead, promoting the stigmatization of obese individuals leads to serious psychological health problems, exacerbates health disparities, and discredits effective obesity interventions (15-1) through provoking psychological reactance.
Psychological reactance results from being pressured by social influence to act in a certain way, which threatens individual autonomy. In response to this perceived threat, individuals feel the need to respond reactively or against the message of the influence to restore their personal freedom (16-277). Fat shaming invokes psychological reactance through stereotyping overweight individuals as lazy, unsuccessful, unintelligent, and lacking in self-discipline as an incentive to change their behavior. A psychologically reactive response ensures that the opposite happens: overweight individuals who are targeted by weight stigmatizing anti-obesity ads actually increase the risk of unhealthy behaviors. This often results in further weight gain and therefore poor physical health outcomes, but also adverse psychological outcomes (15-1). Anti-obesity campaigns that highlight personal responsibility for weight gain have also been shown to be received negatively by the targeted audience rather than inspire motivation for change (15-5).
            Georgia’s Strong4Life campaign has generated significant controversy for its use of fat shaming, with TV ads using dialogue such as, “Being fat takes the fun out of being a kid,” and “It’s hard to be a little girl if you’re not,” and featuring images of overweight and obese children (10).  As discussed in Fat Shame: Stigma and the Fat Body in American Culture, weight stigmatization is especially detrimental to the psychological health of women and girls due to historical gender norms. According to Western cultural ideology, women are weak and lacking in self-discipline as compared to men and are therefore more susceptible to individual blame for being overweight (3-49).The ads used by the Strong4Life campaign perpetuate this idea, presenting images of children, many female, who look depressed and isolated. As Farrell stated to CNN, “[These ads] teach us that we should feel sorry for fat kids and that it’s normal to tease and abuse them” (10).   
            The prejudice against overweight individuals resulting from weight stigma may further marginalize populations that already suffer discrimination due to their race or socioeconomic status. One result of weight stigmatization has been the avoidance of doctors and healthcare providers by obese individuals (17-89). Obesity contributes to many chronic conditions that need significant medical treatment (2-241S), and stress responses to stigmatization can exacerbate these conditions (17-89), so fat shaming is doubly detrimental to overweight and obese individuals. Rather than perpetuating weight stigma, anti-obesity campaigns should focus on creating an atmosphere of empowerment that inspires the target audience to engage healthier behaviors (15-1).
Rethinking Anti-Obesity Campaigns: An Alternative Approach           
In order to combat all of the downfalls of parent-child focused obesity interventions that use fat shaming, many changes need to be made to the theoretical basis and execution of these campaigns. First, the parent-child obesity problem should be addressed in the context of the community while utilizing the upper levels of the ecological model of health promotion. Instead of using an individual level theory such as the Theory of Reasoned action, advertising theory provides the means to present an obesity intervention to parents that makes behavior change look attractive and beneficial. Lastly, instead of using ‘fat shaming’ to encourage behavior change, an effective intervention presents concrete lifestyle change ideas and messages of empowerment for the target audience to use to their benefit.
Community Level Interventions and the Ecological Model of Health Promotion

            There are a multitude of benefits to planning public health interventions at a community level, as the community has often played a central role in public health planning (6-362). Communities include “mediating structures’” such as informal social networks, churches and other voluntary associations that provide social identity to individuals and are an important influence on behavior. McLeroy et al. emphasize the importance of community social structures, asserting that without the support of these mediators convincing individuals to change their behavior is nearly impossible (363). As stated earlier, community structure also dictates the power that certain groups may have to change their behavior which needs to be taken into account when planning public health campaigns and interventions (364).
            Since the current obesity epidemic is being driven primarily by environmental influences (7-853), a community level intervention can better address these factors and their impact on the target population of obese parents and children. Therefore, an intervention aimed at decreasing the prevalence of obesity should begin a long-term campaign for social change that will result in large enough political and economic incentives to change the environment to be more conducive to healthy lifestyle choices. At the same time, the current needs of the growing population of obese parents and children can be addressed through providing individuals with strategies to resist environmental factors that contribute to weight gain (854).
             Some proposed interventions to combat the influence of increasing portion sizes available in fast food and the popularity of sedentary behavior (7-905) as part of a comprehensive anti-obesity include encouraging mindful eating, increasing physical activity and other changes. These methods can be used by entire families, but must be supported by the community in order to be successful (18-71). Communities that already have public spaces such as parks or gardens can encourage an increase in community activity through well designed signage (18-72) or organizing events such as walking clubs with free participation. In addition, community level interventions can advocate for an expansion of nutrition labeling on fast food since many parents are unaware of the contents of what they and their children are eating or the exact caloric content (18-73).
Incorporating Advertising Theory into Anti-Obesity Campaigns
            The two flaws in the Theory of Reasoned Action that make it a poor basis for an anti-obesity campaign is that it assumes that intentions lead directly to behavior and that decisions to change behaviors are shielded from outside environmental forces (11-16). As illustrated by the failure of Georgia’s Strong4Life and Minnesota’s Better Example campaign to lead to actual behavioral change (5), appealing to individual intentions is not an adequate technique to decrease the prevalence of obesity in the U.S. Using a different approach, advertising theory allows anti-obesity campaigns to reach a larger number of people and influence their behavior on a population level.
This is done with presenting the target audience with what they want, or a “promise” that the idea that is being sold will fulfill their desires (20-3). To utilize this idea within anti-obesity campaigns, public health practitioners should realize that the “promise” that individuals are seeking is not health but rather freedom from the burden of being obese (3-4). The target audience of obesity interventions rate public health messages that do not mention the word ‘obese’ or ‘fat’ as more motivating than those that invoke personal responsibility for weight gain, which illustrates the desire for freedom from this stigma (15-5).
Obesity interventions can provide the promise of freedom from the constraints of excess weight by crafting advertisements that focus on the positive promotion of behavioral changes such as eating healthier foods and engaging in regular physical activity (15-6). If presented through actors that appear carefree and happy while doing these and other healthy lifestyle activities, preferably with their family members, obese parents will not only be more motivated to change their behavior, but they will also feel less stigmatized by the intervention (15-6).
The use of advertising theory rather that the Theory of Reasoned Action in anti-obesity campaigning skirts the issue of ignoring environmental influences on behavior and harnesses an important resource that has been traditionally used to promote obesity epidemic rather than prevent it from growing. Analyses of television ads created to sell fast food products to children have concluded that over 50% of the commercials feature high fat, high sugar, and high sodium content foods (19-409). These advertisements have been shown to contribute to the obesity epidemic through reinforcing unhealthy eating habits and making the consumption of larger portion sizes appear to be the social norm (19-411).  If advertising theory is a powerful enough tool to contribute to the rise in obesity rates, it can be harnessed by public health interventions to promote the opposite through “selling” healthy lifestyle changes.
Empowerment and Avoiding Psychological Reactance
            The use of fat shaming in anti-obesity interventions is damaging to the mental health of both parents and children (15-1) and should be abandoned by public health practitioners entirely as a tactic to motivate healthy behavior. Children especially should not be stigmatized through anti-obesity advertisements, as these were found to cause the most extreme negative response to weight loss and diet change messages (15-7) In fact, the public health community should work to eradicate prejudice against overweight and obese individuals to ensure that they feel confident that they can change their lifestyle (15-6). Health practitioners are not immune to the societal stigma against obesity, which impacts the quality of care given to individuals that they deem as ‘fat’ (17-89).
            The link between body size and social standing is especially important to consider when addressing the obesity epidemic, as the experiences of how overweight and obese individuals experience discrimination due to their size have a great impact on how they view their health and ability to change (3-3). Fat shaming is not the result of the health dangers associated with being overweight, but the social connotations associated with fatness: laziness, greed, stupidity, ugliness etc. This has led a cultural stigma against fatness that often supersedes discussion about obesity’s impact on an individual’s physical health (3-4).  It is a societal misconception that obesity is solely the result of poor individual lifestyle choices. Media outlets that perpetuate this idea do not motivate positive behavior change, as discussed earlier, but contribute to the barriers that make fighting obesity a difficult challenge for public health practitioners (17-90).
An approach to anti-obesity interventions that is not supportive of  fat shaming can work against the detrimental impact of weight stigma and also reduce the amount of psychological reactance experienced by the target audience (15-1).  Psychological reactance can also be lessened through communicating the desired message to the target audience through individuals that are similar to the audience, and therefore are perceived as more credible (16-277). Similarity between the communicator and the audience has been shown to not only increase the positive force towards compliance but also reduce the negative force of resistance that leads to reactance (16-278).
Therefore, anti-obesity interventions focusing on families should communicate its messages through actors who are overweight or obese but have chosen to adopt lifestyle changes to improve the health of their families. These could include paying closer attention to nutrition labels and utilizing community spaces for family physical activities (18-72). Featuring resources within community also illustrates that obesity is a problem that impacts the entire community rather than targeting isolated individuals.
Yale University’s analysis of anti-obesity campaigns suggests that best received messages were multivariate, or suggested a multitude of behavior changes to be adopted on a community rather than individual level (15-6). Through combining the use of actors similar to the target audience to deliver positive messages of empowerment, anti-obesity interventions can be used not only to encourage healthy behaviors but also work against weight stigma. This will hopefully begin to reduce the physical, psychological and societal barriers against weight loss experienced by overweight and obese individuals.
            As the rate of obesity continues to rise steadily in the U.S. among children and adults (1), anti-obesity campaigns are a necessary vehicle to providing health education and motivation for lifestyle change on a community level. However, public health interventions should avoid the mistakes made by Georgia’s Strong4Life and Minnesota’s Better Example campaigns (5), including focusing only on the parent-child relationship, depending on the Theory of Reasoned action to cause behavior change, and relying on fat shaming as inspiration for transformation. This approach can be remedied through adopting community-level intervention techniques as described by McLeroy et al.’s ecological model of health promotion (6-355), using advertising theory to promote a healthy lifestyle as the means of gaining freedom from stigma, and using empowerment and rather than shaming as the primary motivation for behavior change.

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