Sunday, May 9, 2010

The Coalition for Healthy Children’s Reliance on Individual Behavior Change and Social Marketing to Combat Childhood Obesity - Virginia Lijewski

The Coalition for Healthy Children is an Ad Council initiative whose goal is to “help address the obesity crisis that confronts our nation and its children” with a mission to “provide clear, consistent, research-based messages to children and parents on the importance of practicing a healthier lifestyle and offer them the means to do it” (1). They feel fighting the childhood obesity epidemic can be achieved by communicating directly to children, and their parents, about the importance of physical activity and healthy eating. They have crafted five main messages to promote healthy lifestyles: 1) physical activity; 2) food choice; 3) food portions; 4) balance between food and activity; and 5) role modeling.

The five basic messages are broken down into messages tailored to kids and to parents. Messages to kids are 1) Physical activity: Be a player. Get up and play and hour a day; 2) Balance: Eat well. Play hard. Make it balance; 3) Food choices: Are you eating a home run or a strikeout?; 4) Food portions: The amount counts. Keep portions under control. Messages to parents are 1) Encourage your kid to be a player. Get up and play an hour a day; 2) food choice: Tell your kids to eat well, play hard, and make it balance; 3) Food choices: is your kid eating a home run or a strikeout? 4) food portions: The amount counts. Keep portions under control; and 5) Set the example: When it comes to activity and eating right kids take their lead from you.

Organizations and companies have the options to become members of the Coalition for Healthy Children and help in the promotion of the campaign’s health messages. By becoming a member of the Coalition, these groups have made a commitment to incorporate the “strategic messages” into their marketing materials including advertisements, packaging, websites, and in-store promotions (1).

The Ad Council’s Coalition for Healthy Children is using social marketing strategies to deliver their health messages to children and adults. Social marketing has been defined as “the design, implementation, and control of programs seeking to increase the acceptability of a social idea or practice in a target group” (2) Social marketing tactics persuade an individual to change their behavior in order to improve their own health and often work to alter an individual’s perceptions and attitudes about their health (3).

Traditional social marketing campaigns, like that of the Coalition for Healthy Children, develop a short-lived mass advertising campaigns to encourage individuals to exercise more and eat more fruits and vegetables. The Coalition for Healthy Children focuses on the individual as being in complete control of his or her health and ignores the social, environmental, and economic causes of childhood obesity. The campaign recognizes the important role parents play in the health of their children but it fails to provide parents with the tools they need to make a positive change in their child’s health. Obesity disproportionately effects minority populations who have limited access to healthy foods and places to engage in physical activity. The campaign fails to acknowledge the racial and ethnic health disparities that exist and does not target a particular population nor does it try to reduce disparities in health and access to health promoting activities.

Critique 1: Providing parents with the tools needed to promote healthy behaviors in their children

Parents play a vital role in the health of their children and are critical to the success of any intervention to combat childhood obesity. The Coalition understands the important role parents play in the health of their child and through their targeted messages advise them to be a role model for healthy behavior, to play with their children and hour a day, encourage their kids to eat smaller portions and healthy foods, and convince them that being healthier now will pay off in the end. The Coalition however, does not provide parents with the tools they need to make a positive change in their child’s health.

Research has been done to determine the barriers parents face in helping their child eat healthy and be more physically active. The main barriers that have been identified are family schedules, lack of money/transportation, safety, and availability and desirability of healthy foods. Hectic family and work schedules and the convenience and accessibility to unhealthy foods lead parents to make unhealthy food choices for their families. There is a lack of desirability among children for healthy foods, which also makes it hard for parents to encourage healthy eating in their children (4).

A study by Tyler and Horner (5) analyzed an intervention aimed at collaboration between parents, children, and medical providers. Through discussions with parents and children, the medical providers created individualized health plans for each family. The most frequent barriers parents reported were a lack time and safe recreational facilities for their children to play. Most parents understood that their children needed to become more physically active and eat healthier foods but did not know how to implement a healthier lifestyle into their family’s routine. The intervention’s focus was on helping parents make positive changes in their children’s health by providing them with ideas and strategies to improve their families’ health.

Interventions designed to increase physical activity may be more effective if they are designed to accommodate the multiple competing demands of a family and provide affordable and diverse activities that families can do together (6). Parental involvement in obesity prevention programs has been proven to be effective in reducing the rates of childhood obesity (7) but telling parents what to do through health messages isn’t enough. Parents already know the importance of physical activity and healthy food choices but need to be provided with the tools required to accommodate lifestyle change. Effective interventions should provide parents with the ability to work around the barriers they face by encouraging families to work together to improve their health and come up with create ways to be active together.

Critique 2: Failure to consider social determinants of health

The Coalition for Healthy Children’s campaign fails to acknowledge the lack of resources available to certain subsets of the population. They encourage individual behavior change without recognizing that minorities groups, and people in disadvantaged populations, disproportionately lack access to the resources they need to create personal change.

The highest rates of obesity occur in the most disadvantaged populations, including minority groups, and populations with the highest poverty rates and least education (8). Socioeconomic status has been viewed as one possible explanation for the disproportionate rates of obesity among these populations (9). Studies evaluating the effects of socioeconomic status and health have found that poor health is directly correlated to low socioeconomic status. Improvement in health of disadvantaged people includes providing material conditions for good health and a control of life circumstances or empowerment. In the United States material conditions for good health include things like the availability of healthy foods and opportunities for exercise. Empowerment is both an individual and community level phenomenon and at the community level involves securing resources for health (10).

Some research suggests that racial and ethnic disparities in obesity rates can be explained by a lack of access to activity- friendly environments. Rates of physical activity among youth are higher in communities where there are sidewalks, parks, and indoor recreation facilities (11). Access to supermarkets is associated with improved dietary quality, higher intake of fruits and vegetables, and lower rates of obesity. There is a disparity in access to these resources among predominantly white neighborhoods and those of minority populations. High income and white communities tend to have more access to sources of healthy foods and places to engage in physical activity. Low-income communities, and communities with a high percentage of racial and ethnic minorities, tend to have less access to supermarkets and a higher availability of corner convenience stores and inexpensive high-calorie foods (12). The Coalition for Healthy Children fails to recognize that people may have a hard time making a positive health change because they lack access to the resources they need to improve their health. The Coalition is not addressing the larger social issues that may be part of the cause of childhood obesity rates. Instead, the Coalition is sending health messages to children and parents encouraging them to make a change without addressing the specific needs or the barriers to health.

Critique 3: Individual approach

The Coalition’s strategy for achieving its goals is through sending messages to children and parents about health behaviors and physical activity. By creating targeted messages the Coalition is fostering the notion that eating healthy and being more physically active is all within an individual’s control. The Coalition is ignoring the social, economic, and environmental factors that also contribute to obesity and lack of physical activity in children.

Historically, obesity as been blamed on the individual and it is still the case today that a failure of personal responsibility is thought to be the its cause (13). The concept of personal responsibility, especially for one’s health, is highly ingrained in American society and can even be seen in the political structure of the United States (14). While taking personal responsibility for one’s health can lead to positive changes in behavior and heath, emphasizing this as the only way to achieve optimal health can foster victim blaming. Victim blaming occurs when someone is blamed for his or her ill health and negative characteristics are ascribed to the person because they did not make the positive health behavior changes expected by society (14). Societal focus on the individual diverts attention from the social influences that affect health.

Individual level approaches to health behavior change have been criticized in recent years and the field of public health has begun to shift its focus from the individual to the group level. Group level approaches to behavior change emphasize that an individual’s behavior is the result of one’s intentions and abilities to act on those intentions. Factors acting on the individual level like self-efficacy, confidence, and personal beliefs, determine an individual’s intention. Factors acting in the wider environment like access to healthy food and socioeconomic status, determine whether a person acts on their intentions (15). Focusing on group level interventions requires creating environments that will foster behavior change.

People seek good health and the ability to pursue it; however, traditional individual level approaches to behavior change do not capture the importance of both needs. Rugar (16), in an attempt to shift the focus from the individual to the group, defined the concept of health capability. Health capability incorporates the conditions that affect one’s health as well as the person’s ability to make healthy choices; it is the ability to be healthy. Individual health capability is dependent on how someone’s external environment enhances or detracts from his or her health.


The Coalition for Healthy Children uses a social marketing approach in an attempt to communicate health messages to parents and children about the importance of eating healthy and exercising. Their goal is to reduce obesity on the individual level; however, by doing so they neglect the environmental causes of childhood obesity. Current social science research has shown “diet and physical activity interventions that build knowledge, motivation, and behavior change skills in individuals without changing the environments in which they live are unlikely to be effective” (17). An individual can make the choice to be more physically active and eat healthier foods but they cannot act on these decisions if their wider environment is preventing them from living a healthy lifestyle. An intervention designed to address an individual’s barriers to health behaviors would be a more effective approach to reducing the rates of childhood obesity. In designing an intervention it is important to understand the population being targeted and the specific needs of the communities within that population to enable the individual to make personal changes in his or her health. I propose an intervention that corrects the shortcomings of the Coalition for Healthy Children’s campaign to combat childhood obesity by using the combined concepts of social marketing, community organization, and policy change. By incorporating these approaches, the intervention can address the environmental and societal barriers that children and their parents face, sustain a level of personal accomplishment, and address the disparities in health that are the underlying cause of childhood obesity.

Socioeconomic status is a strongly correlated with health and interventions created to focus on changing disparities in health, especially those that disproportionately effect minorities and low-income populations, will have the greatest population benefit. Achieving social and economic change would require major societal change and interventions aimed at addressing social determinants of health need the support of the government and society. A successful intervention should include government and policy makers and should work to promote change in the social system in the United States.

The Health Impact Pyramid is one example of how public health is trying to shift its attention to the population and not the individual to make positive health changes. At the base of the pyramid are efforts to address socioeconomic factors (i.e. poverty and education levels), followed by public health interventions that change the context for health to make individuals’ default decisions healthy (i.e. clean water, safe roads), then long-lasting protective interventions (i.e. immunizations), clinical interventions, and at the top counseling interventions. Public health interventions at the base of the model require the least individual effort and have the greatest population impact. The focus of public health interventions should be at the first and second levels of the pyramid (18).

Parents play a vital role in the success of childhood obesity prevention interventions but they cannot help their child if they are not provided with the information necessary to assist them in making healthy decisions for their family. A good example of a current campaign that involves parents and provides them with the appropriate tools to make a positive change is the “Let’s Move” campaign (19) created by First Lady Michelle Obama. The campaign’s website provides links to services and resources parents can use to make a positive change in their child’s health (20). Part of the campaign’s website focuses on access to affordable healthy food which provides links to the National Policy and Legal Analysis Network to Prevent Childhood Obesity (21) where parents can learn how to increase the access to fresh fruits and vegetables in their particular neighborhood, the Farmer’s Market Coalition (22) where parents can learn how to start a farmer’s market in their community, and the Food Trust (23) where parents can learn what community and school-based access plans there are in their community. The intervention combines individual approaches with group level approaches by providing individuals with the tools they need improve not only their health, but also the health of their family their community. The “Let’s Move” campaign also focuses on making broader social changes through the use of policy changes and government initiatives. The campaign highlights the Healthy Food Financing Initiative, which as part of the president’s 2011 budget, will put $400 million dollars a year towards increasing access to healthy foods in underserved areas (20) By combining the efforts of individuals, communities, and the government, “Let’s Move” has the potential to reduce health disparities related to access to healthy food as well as reduce the rates of childhood obesity.

Several ecological models combining public health, health psychology, consumer psychology, and urban planning, have identified four types of food environments (community, consumer, organizational, and information) that should be understood when trying to reduce obesity in minority populations (17). Community food environments refer to places where food can be obtained (grocery stores, restaurants, etc). Consumer environments refer to what people are exposed to; more specifically the availability, prices, and promotions of certain foods. Information environments include places in the built environment (school and work) that directly and indirectly encourage unhealthy eating habits and sedentary lifestyles and do not encourage healthy eating behavior (24). Schools are one type of information environment that can easily be changed to promote positive health behaviors. Schools are a major setting in a child’s life and should become active in developing obesity prevention programs. Communities, schools, and governmental agencies should work together to design and implement obesity prevention programs (25).

By changing the environments in which children interact through a combination of efforts, positive health behaviors, like increased physical activity and healthy eating habits, can be formed. Interventions aimed at addressing the barriers individual’s face in access to healthy food and the health disparities that exist in the United States would be more effective in combating childhood obesity. A successful intervention should combine the concepts of social marketing, policy change, and community change that will allow the individual (both parents and children) to make the necessary steps to improve their health.


1. The Advertising Council Inc. (2008). Coalition for Healthy Children.

2. Goldberg, Marvin E. (1995). Social Marketing: Are we Fiddling while Rome Burns? Journal of Consumer Psychology 4(4), 347-370

3. Yancey, AK, Cole, BL., Brown, R, Williams, JD. Hillier, A, Randolph, KS, Ashe, M, Grier, SA, Backman, D, and McCarthy, WJ. (2009). A Cross-sectional Prevalence Study of Ethnically Targeted and General Audience Outdoor Obesity-Related Advertising. The Milbank Quarterly 87(1), 155-184.

4. Power, TG, Bindler, RC., Goetz, S, and Daratha, KB. (2010). Obesity Prevention in Early Adolescence: Student, Parent, and Teacher Views. Journal of School Health 8(1), 13-19.

5. Tyler, Diane and Horner, Sharon. (2008). Collaborating with Low-Income Families and Their Overweight Children to Improve Weight-Related Behaviors: An Intervention Process Evaluation. Journal for Specialists in Pediatric Nursing 13(4), 263-274.

6. Thompson, J.L., Jago, R., Brockman, R., Cartwright, K., Page, A.S., Fox, K.R. Physically Active Families- de-bunking the myth? A Qualitative Study of Family Participation in Physical Activity. Child: Care, Health, and Development 36(2), 265-274.

7. Kitzmann, KM, Dalton, WT, Stanley, CM, Beech, CM, Reeves, TP, Buscemi, J, Egli, CJ, Gamble, HL, Midgett, EL. (2010). Lifestyle Interventions for Youth Who are Overweight: A Meta-Analytic Review. Health Psychology 29(1), 91-101.

8. Flegal, Katherine M., Margaret D. Carroll, Cynthia L. Ogden and Clifford L. Johnson. 2002. "Prevalence and Trends in Obesity Among US Adults, 1999-2000." Journal of the American Medical Association 288(14): 1723-1727.

9. LaVeist, Thomas, A. (2005). Minority Populations and Health: An Introduction to Health Disparities in the United States. Preventing Chronic Disease: Public Health Research, Practice, and Policy 2(4).

10. Marmot, Michael. (2006). Health in an Unequal World. The Lancet 368.

11. Whitt-Glover, Melicia C, Taylor, Wendell C, Floyd, Myrone F, Yore, Michelle M, Yancey, Antronette K, and Matthews, Charles E. (2009). Disparities in Physical Activity and Sedentary Behaviors Among US Children and Adolescents: Prevalence, Correlations, and Intervention Implications. Journal of Public Health Policy 30, 309-334.

12. Odoms-Young, AM, Zenk, Shannon and Mason, M. (2009). Measuring Food Availability and Access in African-American Communities. Implications for Intervention and Policy. American Journal of Preventative Medicine 36, 145-149.

13. Schwartz, Marlene and Brownwell, Kelly D. (2007). Actions Necessary to Prevent Childhood Obesity: Creating the Climate for Change. Journal of Law, Medicine, and Ethics 35(1).

14. Brownwell, Kelly D. (1991). Personal Responsibly and Control Over Our Bodies: When Expectation Exceeds Reality. Health Psychology 105(5), 303-310.

15. Maziak, Wasim and Ward, Kenneth. (2009). From Health as a Rational Choice to Health as an Affordable Choice. American Journal of Public Health 99(12), 2134-2139.

16. Ruger, Jennifer Prah. (2010). Health Capability: Conceptualization and Operationalization. American Journal of Public Health 100(1), 41-49.

17.Sallis, James F. and Glanz, Karen. Physical Activity and Food Environments: Solutions to the Obesity Epidemic. The Milbank Quarterly 87(1), 123-154.

18. Frieden, Thomas R. (2010). A Framework for Public Health Action: The Health Impact Pyramid. The American Journal of Public Health 100(4), 590-595.

19. U.S. Department of Health and Human Services. “Let’s Move” (January 2009).

20. U.S. Department of Health and Human Services. (2009).“Access to Affordable Healthy Food.”

21. National Policy and Legal Analysis Network to Prevent Childhood Obesity. (2010).

22. Farmer’s Market Coalition. (2008).

23. USDA Supplemental Assistance Nutrition Program. The Food Trust (2004).

24. Wechsler, H., Devereaux, RS, Davis, M, and Collins, J. (2000). Using the School Environment to Promote Physical Activity and Healthy Eating. Preventative Medicine 31, 122-134.

25. Li, Ji and Hooker, Neal. (2010). Childhood Obesity and Schools: Evidence from the National Survey of Children’s Health. Journal of School Health 8(2), 96-103.

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