Combating Childhood Obesity One Move At A Time: A Socio-Behavioral Critique of First Lady Michelle Obama’s Let’s Move! Campaign – M. E. L.

Introduction

Childhood obesity has become an epidemic not only in the United States, but around the world (1). Public health practitioners are particularly concerned because of its associated health consequences and increasing prevalence. Obesity and overweight can lead to a number of medical consequences including Type II diabetes, liver disease, and cardiovascular problems (2,3). Other consequences are mechanical such as sleep apnea or psychosocial such as low self-esteem and poor self image (2). Obesity in childhood not only has an immediate impact on a child’s health, but can also significantly increase the risk of morbidities in adulthood, including becoming an obese adult (2). The National Health and Nutrition Examination Survey (NHANES), 2007-2008, gathered data from a nationally representative sample to determine the prevalence of childhood obesity. It collected the heights and weights of school-age children 6-11 years old to calculate their sex-and-age-specific body mass index (BMI). BMIs that are above the 85th percentile and 95th percentile are classified as overweight and obese, respectively. Recent analysis of NHANES estimated that among 6-11 year-olds, almost 40% were overweight (35.5%) and almost 20% were obese (19.6%) (1,3,4). Furthermore, children from low-income families and black and Hispanic backgrounds have a higher prevalence of obesity (5).
What causes obesity? “Although obesity is due in part to certain genetic predispositions and metabolic abnormalities, the huge increases in obesity in the past twenty years have been caused by behavioral and social ecological factors” (6), specifically the increase in energy intake and reduction in energy expenditure. These two contributing factors reflect changes in society’s behavioral patterns over recent decades. Populations are becoming more urban and diets have higher proportions of fats, saturated fats and sugars (3). At the same time, there are large shifts toward less physical activity resulting from less free time in schools, the use of automated transportation, and technology in the home (3).Communities that have no or distant grocery stores, or have an imbalance of healthy food options, will likely have increased premature death and chronic health conditions (7). The two main health behaviors involved in the prevention and treatment of childhood obesity are: increasing physical activity and decreasing the amount of unhealthy food eaten (6). Thus, to combat the rising epidemic, children’s and parents’ behaviors would need to change to reflect these preventive measures. There are a number of policies, programs, services and campaigns aimed at reducing the prevalence and incidence of childhood obesity (5,8). One such campaign is the Let’s Move! campaign.

Let’s Move! Campaign

First Lady Michelle Obama officially launched this campaign on February 9, 2010, with the overarching goal of eliminating childhood obesity within one generation (www.letsmove.org). This campaign is nationwide and brings together the educational, political, family sectors to combat this rising threat to children’s health. Let’s Move! targets school age children 6-11 years old, and has four key components: 1. Making healthy choices, 2. Healthier school lunches, 3. Increased physical activity, 4. Improved access to affordable healthy food. The first area entails improving the information and the tools parents need to make healthy decisions for their families. Among other educational tools, medical providers will be trained and encouraged to give parents prescriptions with simple tips on what they can do to eat healthier and keep their children active. The second is to improve the quality of the foods in schools, which is where children eat most of their meals (9). Schools can participate in the US Department of Agriculture’s HealthierUS School Challenge, which is a voluntary certification program that recognizes excellence in nutrition and physical activity. Also, an additional $1 billion dollars of federal spending yearly for ten years will be invested into the National School Lunch Program. Thirdly, the campaign will also incorporate professional sports figures to get children involved in physical activity and raise awareness of this growing public health issue (10). Lastly, within seven years, the campaign seeks to eliminate “food deserts”, which are areas in the country with no or distant grocery stores. The Health Food Financing Initiative is a federal partnership that will invest $400 million a year to finance grocery stores and farmers markets in underserved areas, as well as healthier food options in local convenience stores (9). Creating a culture of health where each individual takes ownership and leadership of their own health appears to be the direction in which the First Lady desires to go.

Critique of Let’s Move!

Sustainable change in nutrition patterns and physical activity should be the overall goal of interventions combating childhood obesity. A mass campaign is an appropriate and important way to increase awareness of the childhood obesity epidemic (11). However without concrete and personal programming, it is unlikely that it will foster the behavioral change that is necessary to accomplish its ambitious goal of eliminating obesity within one generation (5). Behavior- and ecology-based problems require behavior- and ecology-based solutions (6). While the First Lady’s campaign is very well-intentioned; Let’s Move! will not lead to increased physical activity and decreased eating of unhealthy foods in a manner that will rid our nation of the childhood obesity epidemic due to the following reasons.

Critique 1 - Let’s Move! Assumes Rational-Decision Making

Children are a vulnerable population because they are under the control of their parents. Therefore, parents are an integral force on a child’s success in averting obesity, and it is fitting for a segment of the Let’s Move! campaign to be devoted to parents. Researchers have found that children whose parents are involved in their behavior changing process are more successful at maintaining the behavioral change, than children who are targeted directly to change their behavior without parental support (12). The first component of Let’s Move! involves educating parents about better and simple ways for their families to eat healthier and stay active. Let’s Move! figures that educating and providing tools to parents on easy ways to improve their child’s nutrition will lead them to serve their children healthier foods in appropriate portion sizes. This approach is seemingly based on the Health Belief Model (HBM) of socio-behavioral theory. This theory postulates that individuals make decisions based on a weighing of benefits, and if they know that a situation is bad they will rationally make a decision to not engage in that behavior (obesity research). However, people usually make irrational decisions, and it is upon the irrationality of human decision-making that public health interventions should be based. The HBM also requires that the individuals (e.g. the parents) perceive that they are at risk for the negative outcome (e.g. obesity in their children) and thus will change their behavior (e.g. encourage increased physical activity and reduced unhealthy eating habits in their children) if they deem it is worth it (6). It is unlikely that parents will perceive that their child is at risk of becoming overweight simply because a mass campaign raised their awareness about the issue and provided tips, and then as a result, adopt the proposed behaviors (13). Thus, basing this component on the HBM will not sustainably influence parents’ behaviors in the home.

Critique 2 - Let’s Move! Neglects Key Environmental Factors

There are three key factors in the environment that contribute to childhood obesity: fast food chain zoning, unsafe environments, and accessibility of unhealthy snacks in vending machines at school. Obesogenicity is a fairly recent term that refers to the “sum of influences that the surroundings, opportunities, or conditions of life have on promoting obesity in individuals or populations” (14) Foods deserts tend to exist in communities that are already obesogenic. Let’s Move! doesn’t propose a mechanism by which to combat the obesogenicity of the areas in which many people in the nation are living. It is very honorable that funding has been identified to eliminate the food deserts in our nation’s communities. However, if this addition of grocery stores is not balanced by a subtraction of fast food places, it is likely that the two will be competing for customers and that consumers will continue engaging in the not-so-healthy food purchasing habits to which they are accustomed.
Research shows that limited safe places to walk and engage in recreation contribute to the sedentary lifestyles of children (6). Let’s Move! encourages people to identify safe routes to walk and safe places to play by directing them to websites where they can learn how to do this--without giving any concrete resources. (15) Let’s Move! attempts to counter average of 7 hours (9) in front of the television that children spend by encouraging children to watch fewer hours of TV and to get active and exercise. However, it does not provide a concrete response to the lack of safety in many of the urban neighborhoods where inner-city children live. The third factor involves the intimate school environment, where children spend a significant portion of their day, provides too-easy access to a variety of unhealthy foods, particularly in vending machines. Let’s Move! simply proposes that vending machine companies will one day put the calorie information in their snacks on the front of the package (9), which is unlikely to impact children’s purchasing patterns in a more healthful manner.

Critique 3 - Let’s Move! Does Not Promote Self-Efficacy

According to Albert Bandura’s Social Cognitive Theory, a person must perceive that he or she can successfully complete a given task and also achieve the desired outcome before engaging in a particular behavior and persevering to obtain a goal (6,16,17). This describes the notion of self-efficacy. Let’s Move! does not account for the parents’ self-efficacy, and thus will not be successful in achieving the desired behavioral change of parents influencing their children’s health behaviors. Educating parents and children about the strategies they can employ to achieve healthier lifestyles will not produce sustainable behavior change without accounting for self-efficacy. Essentially, individuals must believe that they are capable of accomplishing a particular task, in order for them to attempt it. It also does not promote self-efficacy on the part of the child, particularly those who are already obese or overweight and may have issues with low self-esteem. It would appear difficult for a wide-scale campaign like this to yield the specific results in behavioral change, particularly because these results are better attained using narrowly focused interventions. The campaign does, however, de-stigmatize obesity by framing it as a nationwide issue that impacts all children, obese or not, rich or poor, and from any racial or ethnic background. Thus it averts negative labeling in this regard. On the other hand, it is not culture-, gender- or race- specific, and research has shown that obesity and overweight differentially impacts different groups of children who would more benefit from cultural and social competency (18). Furthermore, simply suggesting to children that they do something will not necessarily achieve the sought results. A more personal approach, such as a counseling session, would be a more effective way to get the message across (18).

Alternative Approach – Three Separate Initiatives

The campaign is a great way to increase awareness around the childhood obesity epidemic. Overall, a large-scale campaign like Let’s Move! is unlikely to influence the sustained change in physical activity and nutrition behaviors that are necessary to avert or reverse obesity (19). Ergo, I propose that this nationwide initiative would be more successful in altering the related health behaviors if it were three separate initiatives. To ameliorate the flaws in Critique 1, the Social Ecological Model should be employed by using elementary schools and other educational programs as the settings for teaching and facilitating the exchange of information. Secondly, three separate policies that address the environmental contributors to childhood obesity must be enacted and strictly enforced. Each policy would address each environmental factor discussed in Critique 2, thereby attempting to remediate the problem each caused. Thirdly, the nationwide initiative will appropriately address the self-efficacy needs of children and their parents by fostering supportive environments within the school setting that can further follow-through in the home. This way, parents will have the social support of the school nurses, dieticians and even teachers to help engage their children in healthy behaviors.

Bring Parents Back to School

The current intervention, Let’s Move!, bases the parental educational component on the Health Belief Model and provides general tips for parents to employ. The better approach would be to target both parents and children, either together or separately, with the same message and use schools as the setting of choice (20). Repeated messages in a setting that they are accustomed to is more likely to achieve the desired behavior changes that is necessary to reduce childhood obesity. The Social Ecological Model (SEM) posits that bringing the intervention to the targeted individuals—children and their parents—while taking their social ecologies into consideration, will yield successful results (21). This model does not postulate that human behavior is reasoned, which is an important distinction from the previously stated HBM, as it accounts for the fact that people may not have control over their behavior. The social-ecological model takes a societal approach in order to account for the external factors that influence this interaction (18). The SEM also incorporates the interpersonal relationships that people engage in and accounts for these interactions. Research has found that interventions that are targeted to specific groups (i.e. school-age children) and narrowly-tailored around specific results (i.e. increased physical activity, improved nutrition) are more effective (18). Thus, for this educational portion to be effective, it must incorporate the social environment in which these individuals interact. Let’s Move! proposes helping parents make healthy choices at home with their families, which is one of the most important settings where children’s eating and physical activity behaviors are shaped (20). However, children also eat a good portion of their daily foods in school (9), and should be encouraged, with the input of their parents, within the school setting.

Policy-Driven Change

The second critique is regarding the environmental influences that Let’s Move! neglects. Since this effort is to eliminate obesity on the national level, addressing factors within the environment is better suited as policies that will lead to concrete change. These three policies would address the critical need of changing the environment in which people live in order to better facilitate the change in their behaviors. This would be yet another incorporation of the Social Ecological theory that postulates that behavior change can be mediated by changing the environment that people live in (6). Let’s Move! has a plan to increase the accessibility and affordability of healthy foods by making funding available to eliminate food deserts around the nation. However, it is not only this change that will cause to people to change their nutrition seeking behaviors. In particular, the first policy would impose more stringent zoning laws so that fast food chains cannot dominate the areas where low- to middle-income individuals live and shop for food. Reducing access to unhealthy food while increasing access to healthy food can lead to significant improvements in nutrition. The second policy calls for a federal mandate that a particular entity be responsible to identify safe routes to walk to school and engage children in regular (i.e. daily, weekly) outdoor activities, weather-permitting. Various sectors would be involved--schools, local governments, law enforcement--to establish walk-to-school events and other activities that promote physical activity. It is not enough that Let’s Move! will rely on professional sports figures and schools to voluntarily join a competition. The behavioral change will come because the environment has now become more conducive for it to occur.
Within an ecological framework, procedures to enact change could include policy changes such as those proposed here, establishing ecologically sound design of neighborhoods, and making changes to the physical environment such as adding physical activity-promoting playground equipment (6). These alterations to the immediate environment in which children live and interact are likely to yield favorable behavioral changes in their physical activity and nutrition. One study found that children who ate lunches provided by the National School Lunch Program tend to eat more nutritious meals than those who brought their own lunches from outside (6). So it is great that Let’s Move! will be increasing funding to the NSLP. This study also found that vending machines that lowered the cost of low-fat snacks by 50% almost doubled their consumption (6). Therefore, the third policy will mandate that in order for vending machines to be placed inside an elementary school or other educational setting where children 6-11 are, they must contain affordable, low-fat snacks. Above all, the obesogenicity of affected neighborhoods will be impacted by the enactment of these policies, leading to great opportunities for behavioral change to occur.

Self-Efficacy

The Let’s Move! campaign targets the entire nation without controlling for the impact that differences in culture and socio-economic status may have on people. A key element of Social Cognitive Theory is the aspect of self-efficacy (16). Simply understanding the need for healthy foods and having access to it does not lead to overall improved diets, but rather parents and children need to feel as though they can be successful engaging in these behaviors. Demonstrating the healthful behaviors of regularly engaging in physical activity and eating healthy foods in moderate proportions will not be effective alone. Parents and children especially, will need to meet their needs of self-efficacy by fostering a supportive environment in a familiar place (i.e. at school or an after-school program. In this manner they will not only get the exposure to these behaviors in action but they will also receive the encouragement from teachers and even other students. An intervention is likely to be successful at helping adults enact the self-regulatory behaviors essential to buying and eating healthier food if it is effective at: (a) garnering family support, (b) increasing nutrition related self-efficacy, and (c) overcoming negative outcome expectations (16). This could then translate into parents making the essential behavioral changes in encouraging and ensuring that their children stay active and eat healthy and moderate proportions. This third initiative calls for community-level programs across the nation to be established in these settings to give children and their parents the examples and practice they need to build up their confidence in their capabilities.

Conclusion

The Let’s Move campaign has a noble mission of eliminating and raising awareness about childhood obesity using a multifaceted approach. Each of the four components is purposed to contribute to the overall success of the campaign. There are three main flaws that are likely to prohibit Let’s Move! achieve its ambitious goal. Each of these critiques would successfully be addressed by implementing an alternative approach that incorporates social and behavioral theories that have been found to yield favorable results with this constituency around this health outcome. Firstly, the parental education component of the campaign is loosely based on the Health Belief Model, as it assumes rational-decision making; thus, subjecting it to being ineffective, because it ought to be based on the irrationality of human decision-making. The proposed intervention called for repeated targeting of both parents and children with the same message in a common locale in order to facilitate behavior change in spite of their irrationalities. Secondly, Let’s Move! neglects to address key environmental influences on childhood obesity. Policies that would reduce the proximity of fast food chains, improve the safety of neighborhoods and create a physical activity-friendly built environment, and remove unhealthy snacks from vending machines in schools all around the nation would remediate these socio-environmental influences. And finally, to increase the sense of self-efficacy within children and their parents, there should be programs directed towards building capacity within individuals by giving them opportunities to practice the behaviors in a supportive environment such as schools and other educational settings. Campaigns like Let’s Move! are typically successful at influencing social norms to bring about long-term behavior change; and they should not be stand-alone initiatives, but rather part of a larger and broader strategy such as a policy or environmental change (19).

REFERENCES

1. Centers for Disease Control and Prevention (CDC). Childhood Overweight and Obesity. Last Updated 31 March 2010. http://www.cdc.gov/obesity/childhood/index.html. Accessed 4 May 2010.
2. Lee, Yung Seng. Consequences of Childhood Obesity. Ann Acad Med Singapore 2009;38:75-81.
3. World Health Organization (WHO). Obesity and Overweight. http://www.who.int/dietphysicalactivity/publications/facts/obesity/en/. Accessed 30 April 2010.
4. Ogden, Cynthia L., Margaret D. Carroll, Lester R. Curtin, et al. Prevalence of High Body Mass Index in US Children and Adolescents, 2007-2008. JAMA 2010;303(3):242-249.
5. Hadley, Alena M. Elizabeth C. Hair, and Nicole Dreisbach. What Works for the Prevention and Treatment of Obesity Among Children: Lessons from Experimental Evaluations of Programs and Interventions. Fact Sheet. Child Trends 2010. http://www.childtrends.org/Files//Child_Trends_2010_03_25_FS_WWObesity.pdf. Accessed 2 May 2010.
6. Baranowski, Tom, Karen W. Cullen, Theresa Nicklas, Deborah Thompson, and Janice Baranowski. Are current health behavioral change models helpful in guiding prevention of weight gain efforts? Obesity Research 2003;11(10):23S-43S.
7. Gallagher, Mary. Mary Gallagher Research and Consulting Group. Examining the Impact of Food Deserts on Public Health in Chicago. 2006. Executive Summary. Web. Accessed 1 May 2010.
8. Stice, Eric, Heather Shaw, and C. Nathan Marti. A Meta-Analytic Review of Obesity Prevention Programs for Children and Adolescents: The Skinny on Interventions That Work. Psychological Bulletin 2006;132(5):667-691.
9. “Let’s Move!” America’s Move to Raise a Healthier Generation of Kids. 2010. http://letsmove.gov/. Accessed 12 April 2010.
10. Sklar, Bev. “Is Michelle Obama’s ‘Let’s Move’ Plan Enough? 23 February 2010. http://www.thatsfit.com/2010/02/23/michelle-obama-obesity-plan-ratings/. Accessed 2 May 2010.
11. Bauman, Adrian, Ben J. Smith, Edward W. Maibach and Bill Reger-Nash. Evaluation of mass media campaigns for physical activity. Evaluation and Program Planning 2006;29(3):312-322.
12. Lindsay, Ana C., Katarina M. Sussner, Juhee Kim, and Steven Gortmaker. The role of parents in preventing childhood obesity.
13. Beckman, Heidi, Suzanne Hawley, and Thomas Bishop. Application of Theory-Based Health Behavior Change Techniques to the Prevention of Obesity in Children. Journal of Pediatric Nursing 2006;21(4):266-275.
14. Lake, Amelia, and Tim Townshend. Obesogenic environments: exploring the built and food environments. The Journal of the Royal Society for the Promotion of Health 2006;126(6):262-267.
15. Anderson, Patricia M., and Kristin F. Butcher. Childhood Obesity: Trends and Potential Causes. The Future of Children 2006;16(1):19-45.
16. Anderson, Eileen S., Richard A. Winett, and Janet R. Wojcik. Self-regulation, self-efficacy, outcomes expectations, and social support: Social cognitive theory and nutrition. Annals of Behavioral Medicine 2007;34(3):304-312.
17. Salazar MK. Comparison of four behavioral models. AAOHN 1991;39:128-135.
18. Stice, Eric, Heather Shaw, and C. Nathan Marti. A Meta-Analytic Review of Obesity Prevention Programs for Children and Adolescents: The Skinny on Interventions That Work. Psychological Bulletin 2006;132(5):667-691.
19. Cavill, Nick and Adrian Bauman. Changing the way people think about health-enhancing physical activity: do mass media campaigns have a role? Journal of Sports Sciences 2004;22(8):771-790.
20. Golan, M. Parents as agents of change in childhood obesity—from research to practice. Int J Pediatr Obes. 2006;1(2):66-76.
21. Krug, Etienne G., James A. Mercy, Linda L. Dahlberg and Anthony B. Zwi. The world report on violence and health. Lancet 360:2002;1083-1088.