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Hispanic and African-American Children Are Target Audiences for Junk Food TV Commercials, Study Says

Hispanic and African-American Children Are Target Audiences for Junk Food TV Commercials, Study Says


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The study shows that minority children are more likely to see ads for unhealthy foods

McDonald's spent $113 million on all Hispanic-targeted media and $33 million on all black-targeted media.

Hispanic and African-American children are the target audience for television commercials for sugary drinks and junk food, according to a study published by the Rudd Center for Food Policy and Obesity at the University of Connecticut.

Researchers found that African-American children and teenagers are 70 percent more likely to see food-related television commercials than Caucasians. They also see twice as many commercials for junk food and sugary drinks.

The researchers noted that some media companies spend more money to specifically target Hispanic and African-American audiences. In 2013, McDonald’s spent $113 million on all Hispanic-targeted media and $33 million on all black-targeted media. Hershey’s spent $42.1 million for Hispanics and $41 million on African-Americans in 2013.

Rates of childhood obesity have been climbing in recent years, according to the Centers for Disease Control and Prevention. Twenty-two and four tenths percent of Hispanic children and 20.2 percent of African-American children were obese in 2011 to 2012.

Researchers concluded that companies should directly address their current racial-ethnic-targeted marketing practices because they contribute to poor diet among people with higher risk for obesity and diet-related diseases. They also noted that there should be more of an effort to educate these children about nutrition and healthy eating.


Challenging Dogma - Spring 2011

Today over one third of U.S. adults and 17% of U.S. children are obese. In the last three decades, obesity rates for adults have doubled and rates for children have tripled. However, the burden of obesity is not evenly distributed, and falls heavily on minorities. The 2009 Behavioral Risk Factor Surveillance System report showed that “blacks were 51% more likely and Hispanics were 21% more likely than non-Hispanic whites to be obese” (1). It is also geographically unevenly distributed with the American Midwest suffering higher obesity prevalence rates than the rest of the country. Cincinnati, Ohio is a beautiful Midwestern city situated at the southern edge of Ohio, across the Ohio River from Kentucky. However, like many Midwestern cities and states, Cincinnati has seen an alarming increase in obesity among adults and children in the last few decades. According to CDC 29.6% of Ohioans were obese in 2009. This increase has serious health consequences for adults and children. Obesity related diseases like type 2 diabetes, which previously only affected adults, is now affecting children (1). Obese children are also at higher risk of suffering cardiovascular disease. Obesity, including childhood obesity, is known to be a risk factor for a number of diseases including cancers, stroke, respiratory problems and reproductive health problems. The annual hospital costs related to childhood obesity increased from $35 million in the period from 1979-1981 to $127 million in the period from 1997-1999 (1).

In 2008 the nonprofit Center for Closing the Health Gap (2) in Greater Cincinnati began a campaign aimed at preventing childhood obesity. Childhood obesity prevention is a goal that fits perfectly within CCHG’s mission, which includes increasing awareness about health disparities (2). The childhood obesity epidemic in the Greater Cincinnati area disproportionately affects minority children. CCHG’s website reports that the rate of overweight and obesity in Hamilton County is 43% among Black, Non-Hispanic children and 21% among White, Non-Hispanic children. The negative consequences to health that may result from obesity are grave. The city was seeing children with hypertension and worrying rates of type II diabetes. Secondly CCHG saw that obesity disproportionately affected children of low-income parents and minority children, particularly Black, Hispanic and Appalachian children. To work toward preventing childhood obesity the organization initiated a campaign called “Do Right!” The specific target of the childhood prevention portion of the program aimed at “improving the health and well-being of children at Rockdale Elementary that are overweight and obese” (2). Rockdale Elementary is part of the Cincinnati Public Schools system and enrolls about 500 preschool and elementary school students from grades PK-8.

The “Do Right!” children’s program is multi-faceted. Its in school components include screening for BMI to identify overweight and obese children, referral for obese children to an after school physical activity and nutrition program. The program includes nutrition every other week by a dietician, physical activity and bi-weekly parent education and information sessions to discuss nutrition. The program also included 1-minute health tips on the radio, parent workshops in development and City School Awareness Presentations (2). Finally, the program ran a concurrent obesity awareness campaign that included billboards, bus shelters, radio advertisements, ads in minority newspapers and the website: www.dorightcincy.org. They feature obese children mowing down on big, greasy burgers in front of plates of onion rings with the words “Are we feeding our kids to death?” in large print. Below, they provide the Do Right! campaign’s website and phone number with the words “for information on how to combat obesity.” These ads are the focus of this critique.

First and foremost it alienates the very population it aims to help. Dwight Tillery, the executive director of CCHG, purports that the campaign was designed to serve as a wake-up call for families. It aims to incentivize parents to take the health of their children more seriously by showing them just how serious obesity is. Tillery said, “We can’t afford to be politically correct on this issue” (3). Political correctness or lack thereof aside the means simply do not justify the end. Whether or not parents are shocked into understanding the gravity of childhood obesity, children who see these ads are sure to feel alienated. The ads effectuate a pervasive sense of hopelessness, powerlessness and defeat. They say, “you’re obese and you’re being fed to death.” There is nothing in this message that engenders a sense of self-efficacy, or the idea that a lower, healthier weight is an attainable goal. This deficiency is the ad’s primary shortcoming. Self-efficacy as defined by psychologist and father of Social Cognitive Theory, Albert Bandura, is one's belief in one's ability to succeed in specific situations. The concept of self-efficacy is central to Social Cognitive Theory (4). Social Cognitive Theory asserts that behavior is based on the interaction between one’s environment, the behaviors one witnesses, and the individual themselves. Ads like these posted by CCHG construct a negative outcome expectation and in so doing dismantle whatever self-efficacy they could otherwise have fostered. It simply isn’t enough to provide a website and helpline when the ad itself effectively destroys self-efficacy.

Labeling and Normalizing Obesity

Not only do these ads beget powerlessness as shown in the last paragraph, but they concurrently label and normalize childhood obesity. The relationship between labeling and normalizing obesity presents a double-edged sword for potential public health interventions aimed at preventing childhood obesity. The normalizing of obesity comes with a hefty price tag including rising economic costs. According to the Brookings Institution, “the total costs of obesity in the U.S. alone may exceed $215 billion annually” (5). The direct medical costs resulting from obesity in the U.S. have been estimated to account for over 9% of the national medical bill (6). Societal costs are also extensive. Obese children are less likely to be sent to college by their parents (6). Obese adults are less likely to be given jobs, and miss more work, overall costing employers something on the order of $4 billion. Obese children are at much higher risk of becoming obese adults than their thinner peers (7 - 8). In sum, normalizing obesity, particularly in children, presents a great hazard to personal health and has a major negative impact on costs at the society level.

On the flip side of normalizing, labeling obese children forces them to contend with the heavy stigma associated with obesity, decreasing the likelihood that they will overcome the many hurdles to health and wellness placed on them by society. Obesity is the fourth most common type of discrimination people report experiencing in the U.S. (9). Simply labeling children as obese has the potential to greatly influence their behavior. While the ads don’t literally use the word “obese”, they make it visually quite clear that they’re targeting obese children, and point a finger at poor eating habits. Labeling Theory (which is also known as Social Reactance Theory) posits that labeling an individual influences their behavior and more often than not causes them to conform to the stereotypes of the label in a self-fulfilling prophecy (10 - 11). Obese children must endure negative stigma not only from their peers, but also by their teachers and themselves (9). They are often ascribed negative characteristics including mean, stupid, loud, sloppy, ugly, lazy, sad, and lacking in friends (12 - 14). Obese children can become trapped within this self-fulfilling prophecy and may thus accept these traits as part of their role in society as an “obese child”. Studies have shown that the stigma associated with obesity causes an increase in coping methods like binge eating instead of being a contributing factor to motivation to lose weight and stay healthy (9, 15).

Not only are the children taught how to act by the characteristics attached to their label, but they learn through cognition in conjunction with observing behaviors within their environment. These elements operate reciprocally. For example, the environment in which one is raised affects one’s cognition and perceptions of behaviors that one witnesses. In state where approximately 30% of people are obese and where television stations air shows like “More to Love” or “Ruby” (in which the star, Ruby, spends three seasons trying lose weight only to end the third season having gained over 50 pounds) obesity is not likely to be perceived as abnormal (1). It is likely seen simply as the status quo. Posting health billboards featuring obese children eating is wading into dangerous territory. It risks adding more obesity normalizing media to the local environment and simultaneously reinforces the stereotypes and stigma associated with obesity, particularly qualities like lack of self-control.

Proponents of the campaign cite the fact that 93% of parents of obese children didn’t perceive their kids as being an abnormal weight (16). Research backs up this frightening assertion and shows that parents of overweight children consistently underestimated their children's weight (17 - 18). CCHG’s Childhood Obesity Awareness Campaign aims to inform parents that their children are at risk for serious health outcomes and the organization has deemed that shocking parents is necessary to do so. This scaremongering tactic assumes that by informing parents that their children are at risk of very serious health outcomes like death, they will be moved to act. This assumption takes for granted that people are rational decision makers. Rational decision-making generally entails defining the problem, identifying criteria relevant to the problem, considering all possible solutions, calculating the potential consequences of each solution, and choosing the best option. Many public health interventions are based on this same assumption. It is in fact the very basis of the Health Belief Model, which is commonly used in public health interventions. This model postulates that a behavioral change at the individual level depends on a person’s attitudes toward expected outcomes, the strength of those attitudes and the resulting outcome expectancies, as well as the individual’s perceptions of how others see them, and what the societal norms are (4). All of these factors meld to produce intention, which is followed by behavior. When applied to a parent’s role in preventing childhood obesity, as CCHG has done, the model suggests that if parents become aware of the potential hazardous heath outcomes of obesity and their attitudes toward obesity change, they will intend to prevent or reverse obesity in their children and that intention will lead to a change in behavior. This progression assumes rationalism prevails. Unfortunately assuming rationality fails to account for an individual’s subconscious thought process, irrational decision-making, group behavior and societal and environmental factors, all of which are crucial variables guiding behavior (4, 19, 20).
Irrational decision-making often relies upon the way that a particular issue is introduced or framed. Framing is a method of presenting a fact, topic or idea in a specific light so as to change how it is received among the audience to whom it is being presented. The concept of framing is central to Prospect Theory. Put simply, Prospect Theory states that people value gains and losses differently and that individuals make decisions based on perceived gains rather than perceived losses (21). Given two options with equal outcomes, an individual would choose the outcome expressed in terms of possible gains instead of the one expressed in possible losses. CCHG’s billboard frames childhood obesity in terms of the expected health outcome as a loss. Presenting the issue of childhood obesity by framing it within the context of not only a negative outcome but its most terrifying potential outcome, premature death from obesity related health problems, sets the campaign up for failure.

DO RIGHT! SUCCESSES: A SPRINGBOARD

While CCHGs program’s billboard and ad campaign are majorly flawed, there are a number of things the Do Right! campaign as a whole has gotten right. The organization was correct to take multi-faceted and all-encompassing approach to targeting childhood obesity prevention. Research suggests that families, schools and communities should all be included in programs aimed at preventing and reducing childhood obesity (22). Targeting parents exclusively has also been shown to be effective in reducing the BMI of overweight and obese children. A recent study from the United Kingdom showed that the BMI percentile of children whose parents were provided with eight sessions of cognitive-behavioral therapy for weight loss decreased significantly by 2.4% in the treatment group (23). Community involvement or not, targeting parents is crucial childhood obesity prevention programs. Children of obese parents are more likely to be obese themselves. Children aged 15 to 17 years old with at least one obese parent are over twice as likely as children with no obese parents to be obese adults. Children aged 1 to 2 years old were three times as likely to be obese as their peers who didn’t have an obese parent (24). Beyond the nuclear family, recent research has shown that obesity also spreads through social networks. A study conducted using data from Framingham, MA found that the chances of someone becoming obese increase 57% if they had a long-term friend who was obese (25). However, succeeding in utilizing parent and community involvement in childhood obesity prevention programs is challenging. As anyone who has ever tried to lose even a few pounds knows, attempting to lose weight can be daunting. For an obese person the barriers to weight loss, potentially including difficulty engaging in physical activity, addiction and lack of social support, can often seem indomitable. At any rate, with at minimum an adequate level of support within the environment and from family and community members, childhood obesity can be overcome. Methods to resolve each of the previously outlined failings within the billboard and ad campaign are presented in the following three sections.

As addressed in a previous section of this paper, the Health Belief Model as a champion of rational decision-making, and as it was implemented, was not an effective archetype from which to create the childhood obesity prevention billboard and ad campaign. On the other hand, framing, as delineated within Prospect Theory, can be an incredibly useful tool with which to begin to reconstruct this intervention. Bearing in mind that the original intent of the ad was to create awareness of childhood obesity as a serious problem among parents of obese children, the following proposed ad is aimed at both parents and children who will inevitably see the ads as well. This approach utilizes an entirely novel angle that frames health, with regard to weight, as a desirable and attainable outcome.

The proposed billboards will feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This sends the following messages physical activity is fun obese children are also entitled to fun obese children can do sports. In this way fighting childhood obesity through physical activity is framed in a positive light, as a fun and attainable goal. Making weight-loss and health attainable completely reverses the billboards, taking them from negative to positive and fomenting self-efficacy in children.

ENGENDERING SELF-EFFICACY BY NORMALIZING HEALTH

Labeling and normalizing obesity both have serious negative consequences at the individual and thus also societal level. They contribute to lower levels of self-esteem among obese children, and contribute to extensive monetary costs at the national level. A good public health campaign will succeed in achieving improved health and preventing obesity without further contributing to the extensive and damaging effects of labeling. While the billboard proposed in the prior section may be argued as normalizing obesity, it should be seen as normalizing activity among children of all shapes and sizes. Obese children are usually stereotyped as stupid, sloppy, ugly and lazy. In personal stories shared on blogs obese adults recount experiences that, in line with research published in peer reviewed journals, illustrate the cyclical nature of the self-fulfilling prophecy. In a blog published on Newsweek, Leslie Kinzel wrote,

“Prior to being told I was fat by my well-intentioned pediatrician … I'd spent my life as an active and athletic child, my fatness no obstacle in keeping up with my peers (and frequently besting them). As I got older I came to understand what being fat meant: fat kids were lousy at sports, and those who tried to play were to be mocked for it. Fat kids were always picked last, and though I was never picked last, I came to fear that it would inevitably happen. So I stopped playing. I backed away from sports and games altogether.” (26)

Her account is unfortunately not uncommon and characterizes the major negative impacts that labeling has on obese children. Obesity carries such stigma that for many children it becomes the single characteristic by which they feel most defined. At the end of her post Kinzel pleads,
“Call it a campaign against childhood couch-sitting. Call it a drive to get kids to go outside and play. Call it a movement to educate children on basic nutrition and how their amazing growing bodies work for them. But don't single out the fat kids. If I am any indication, doing this will only ensure that this generation will be fatter than ever, dragging behind them some heavy baggage around food issues and low self-esteem.” (26)

Kinzel’s well-put conclusion holds true given what has been learned from the failures of the Health Belief Model and the potential outcomes associated with Label Theory and Social Reactance Theory. It is absolutely necessary to change the personal characteristics associated with the obesity label. Getting obese children re-involved in sports and other physical activities will help to get rid of the stereotype that obese children can’t play sports. This will serve a dual purpose. It will encourage other obese children to take up arms so to speak and join the revolt against stereotypes. At the same time becoming involved in sports once again or perhaps for the first time will have positive health effects. While these effects certainly can’t be expected to be immediate they will have a positive effect on the local environment that should grow exponentially.

ENGENDERING SELF-EFFICACY BY REVOLTING AGAINST THE LABEL

Inciting obese children in Cincinnati to rise up against the fat label takes advantage of the mechanisms described in Psychological Reactance Theory. This theory asserts that perceived limitations to freedom or autonomy provoke an aversive affective reaction in people (27). In other words, if an individual perceives that their freedom has somehow been limited they will become provoked to regain it. A wonderful example of psychological reactance at work is the Truth campaign, which aims to curb youth use of tobacco by inciting a rebellion of sorts among young people. The campaign’s theme is “truth, a generation united against tobacco” (28). The Truth campaign successfully framed the tobacco industry as a liar that was hiding the truth from teens. In doing so they provoked teens to rebel against big tobacco and its lies, successfully decreasing youth smoking initiation rates.

The proposed alternative billboards showing obese children standing up to the labels and stereotypes associated with childhood obesity will do the same. This reaction is particularly common when individuals feel obliged to adopt a particular opinion or engage in a specific behavior (27). The billboards will bring to light these expectations and the violation of freedom that they cause for obese children, inspiring rebellion. In inciting this silent, healthy insurrection the campaign will be rekindling self-efficacy in obese children, which has a powerful effect on an individual’s level of motivation. “Boredom and apathy occur when a challenge is too small anxiety and withdrawal occur when a challenge is too great curiosity and engagement occur when the challenge is optimal” (29). If children don’t feel like they will succeed in losing weight or getting healthy they are much less likely to try to do so. Engendering self-efficacy through these billboards is an indispensible component of a successful childhood obesity prevention public health campaign. Recent work has found that “exercise’s association with weight loss was better explained through psychological, rather than physiological (ie, caloric expenditure), pathways” proving even further the importance of self-efficacy in weight loss (30). Giving obese children a common cause and an enemy to take down will help to create this self-efficacy, aiding in reducing and preventing childhood obesity over time.

Childhood obesity is a serious public health threat that requires sincere and practical interventions. The potential health consequences that are associated with childhood obesity are grave. They are harmful both to the individual and at the national level. Obese children are at increased risk for type II diabetes, cardiovascular disease, respiratory problems and future reproductive problems. They have added to increased medical costs at the national level, and as childhood obesity prevalence rates are higher among lower income quintiles the increased prevalence of childhood obesity has contributed to growing government expenditures on health (1). Practical, effective solutions are crucial in the fight to prevent and decrease childhood obesity.

In order to create a billboard campaign that effectively reduces and prevents childhood obesity while carefully avoiding potential adverse affects that such a billboard could so easily have, as evidenced by the one used by CCHG, social and behavioral sciences theories should be employed. Social Cognitive Theory, Labeling Theory (which is also known as Social Reactance Theory), the Health Belief Model, Framing Theory (as well as Prospect Theory) and Psychological Reactance Theory were used to analyze and critique CCHG’s billboard and ad intervention. CCHG’s billboard intervention was found to be inappropriate on the grounds that it contributed to defeating self-efficacy among obese children, added to labeling and normalizing childhood obesity and resorted to terrorizing parents in an effort to create awareness and incite a behavior change among parents and children. These same theories were then employed to suggest an appropriate intervention to replace CCHG’s billboard ads. The proposed replacement intervention consists of billboards that feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This intervention is based on engendering self-efficacy by reframing the childhood obesity issue in a positive light, normalizing healthy choices among obese children and using Psychological Reactance Theory to empower children to fight against the labels associated with childhood obesity. Casting a glow of optimism on the problem will help to bring back to life self-efficacy that has been squashed by labeling and stigma. Social and behavioral sciences theories were instrumental tools in understanding the effects that the Cincinnati CHG’s billboards could be expected to have on the target population, as well as any projected externalities, and in creating a better alternative.

REFERENCES
1. Overweight and Obesity. U.S. Obesity Trends. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/obesity/data/trends.html.
2. Do Right!. The Crisis. Cincinnati, OH: The Center for Closing the Health Gap in Greater Cincinnati. http://dorightcincy.org/the-crisis.
3. Childhood Obesity. Ohio Childhood Obesity Prevention Campaign Stirs Controversy. Princeton, NJ: Robert Wood Johnson Foundation. http://www.rwjf.org/childhoodobesity/digest.jsp?id=8398&c=OTC-RSS&attr=DI.
4. Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 200152:1-26.
5. Hammond R. The Economic Costs of Obesity. Brookings Institution. May 4, 2011. http://www.brookings.edu/multimedia/video/2010/0914_obesity_hammond.aspx.
6. Herper M. The Hidden Cost of Obesity. Forbes [online]. November 24, 2006. http://www.forbes.com/2006/07/19/obesity-fat-costs_cx_mh_0720obesity.html.
7. Epstein LH, Wing RR, Valoski A. Childhood obesity. Pediatr. Clin. North Am. 198532(2):363-379.
8. Krassas GE, Tzotzas T. Do obese children become obese adults: childhood predictors of adult disease. Pediatr Endocrinol Rev. 20041 Suppl 3:455-459.
9. Puhl RM, Latner JD. Stigma, obesity, and the health of the nation’s children. Psychol Bull. 2007133(4):557-580.
10. Laslett B, Warren CAB. Losing Weight: The Organizational Promotion of Behavior Change. Social Problems. 197523(1):69-80.
11. Link BG, Phelan JC. Conceptualizing Stigma. Annual Review of Sociology. 200127:363-385.
12. Holub SC. Individual differences in the anti-fat attitudes of preschool-children: The importance of perceived body size. Body Image. 20085(3):317-321.
13. Musher-Eizenman DR, Holub SC, Miller AB, Goldstein SE, Edwards-Leeper L. Body Size Stigmatization in Preschool Children: The Role of Control Attributions. Journal of Pediatric Psychology. 200429(8):613 -620.
14. Iobst EA. The Relationship Among Gender, Age, Blame, and Children’s Attributions about an Overweight Peer. 2007. Available at: http://etd.ohiolink.edu/view.cgi?acc_num=ucin1242390002. Accessed May 4, 2011.
15. Bensley K. Obesity and Perceptions of the Body in Teenage American Girls. UCL Centre for Applied Global Citizenship [online]. December 17, 2010. London, U.K.: . http://www.ucl.ac.uk/network-for-student-activism/w/Obesity_and_Perceptions_of_the_Body_in_Teenage_American_Girls.
16. Orr K. Provacative local campaign to target childhood obesity. WVXU Radio [online]. July 31, 2008. http://www.wvxu.org/news/wvxunews_article.asp?ID=5421.
17. Etelson D, Brand DA, Patrick PA, Shirali A. Childhood Obesity: Do Parents Recognize This Health Risk? Obesity. 200311(11):1362-1368.
18. Health & Parenting. Many Parents Don’t See Child Obesity. Web MD. http://www.webmd.com/parenting/news/20071211/many-parents-dont-see-child-obesity.
19. Janz NK, Becker MH. The Health Belief Model: A Decade Later. Health Education & Behavior. 198411(1):1 -47.
20. Rosenstock IM, Strecher VJ, Becker MH. Social Learning Theory and the Health Belief Model. Health Education & Behavior. 198815(2):175-183.
21. Kahneman D, Tversky A. Prospect Theory: An Analysis of Decision under Risk. Econometrica. 197947(2):263-291.
22. Lindsay AC, Sussner KM, Kim J, Gortmaker S. The role of parents in preventing childhood obesity. Future Child. 200616(1):169-186.
23. Jansen E, Mulkens S, Jansen A. Tackling childhood overweight: treating parents exclusively is effective. Int J Obes (Lond). 201135(4):501-509.
24. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N. Engl. J. Med. 1997337(13):869-873.
25. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N. Engl. J. Med. 2007357(4):370-379.
26. Kinzel L. Why the first lady's fight to end childhood obesity does damage to the children it's trying to help. Newsweek [online]. April 20, 2010. http://www.newsweek.com/2010/04/19/fat-kids-cruel-world.html.
27. Burke WW, Lake DG, Paine JW. Organization Change: A Comprehensive Reader. John Wiley and Sons 2008.
28. Truth. http://www.thetruth.com/.
29. Snyder CR, Lopez SJ. Oxford handbook of positive psychology. Oxford University Press US 2009 (P573).
30. Annesi JJ. Behaviorally supported exercise predicts weight loss in obese adults through improvements in mood, self-efficacy, and self-regulation, rather than by caloric expenditure. Perm J. 201115(1):23-27.


Challenging Dogma - Spring 2011

Today over one third of U.S. adults and 17% of U.S. children are obese. In the last three decades, obesity rates for adults have doubled and rates for children have tripled. However, the burden of obesity is not evenly distributed, and falls heavily on minorities. The 2009 Behavioral Risk Factor Surveillance System report showed that “blacks were 51% more likely and Hispanics were 21% more likely than non-Hispanic whites to be obese” (1). It is also geographically unevenly distributed with the American Midwest suffering higher obesity prevalence rates than the rest of the country. Cincinnati, Ohio is a beautiful Midwestern city situated at the southern edge of Ohio, across the Ohio River from Kentucky. However, like many Midwestern cities and states, Cincinnati has seen an alarming increase in obesity among adults and children in the last few decades. According to CDC 29.6% of Ohioans were obese in 2009. This increase has serious health consequences for adults and children. Obesity related diseases like type 2 diabetes, which previously only affected adults, is now affecting children (1). Obese children are also at higher risk of suffering cardiovascular disease. Obesity, including childhood obesity, is known to be a risk factor for a number of diseases including cancers, stroke, respiratory problems and reproductive health problems. The annual hospital costs related to childhood obesity increased from $35 million in the period from 1979-1981 to $127 million in the period from 1997-1999 (1).

In 2008 the nonprofit Center for Closing the Health Gap (2) in Greater Cincinnati began a campaign aimed at preventing childhood obesity. Childhood obesity prevention is a goal that fits perfectly within CCHG’s mission, which includes increasing awareness about health disparities (2). The childhood obesity epidemic in the Greater Cincinnati area disproportionately affects minority children. CCHG’s website reports that the rate of overweight and obesity in Hamilton County is 43% among Black, Non-Hispanic children and 21% among White, Non-Hispanic children. The negative consequences to health that may result from obesity are grave. The city was seeing children with hypertension and worrying rates of type II diabetes. Secondly CCHG saw that obesity disproportionately affected children of low-income parents and minority children, particularly Black, Hispanic and Appalachian children. To work toward preventing childhood obesity the organization initiated a campaign called “Do Right!” The specific target of the childhood prevention portion of the program aimed at “improving the health and well-being of children at Rockdale Elementary that are overweight and obese” (2). Rockdale Elementary is part of the Cincinnati Public Schools system and enrolls about 500 preschool and elementary school students from grades PK-8.

The “Do Right!” children’s program is multi-faceted. Its in school components include screening for BMI to identify overweight and obese children, referral for obese children to an after school physical activity and nutrition program. The program includes nutrition every other week by a dietician, physical activity and bi-weekly parent education and information sessions to discuss nutrition. The program also included 1-minute health tips on the radio, parent workshops in development and City School Awareness Presentations (2). Finally, the program ran a concurrent obesity awareness campaign that included billboards, bus shelters, radio advertisements, ads in minority newspapers and the website: www.dorightcincy.org. They feature obese children mowing down on big, greasy burgers in front of plates of onion rings with the words “Are we feeding our kids to death?” in large print. Below, they provide the Do Right! campaign’s website and phone number with the words “for information on how to combat obesity.” These ads are the focus of this critique.

First and foremost it alienates the very population it aims to help. Dwight Tillery, the executive director of CCHG, purports that the campaign was designed to serve as a wake-up call for families. It aims to incentivize parents to take the health of their children more seriously by showing them just how serious obesity is. Tillery said, “We can’t afford to be politically correct on this issue” (3). Political correctness or lack thereof aside the means simply do not justify the end. Whether or not parents are shocked into understanding the gravity of childhood obesity, children who see these ads are sure to feel alienated. The ads effectuate a pervasive sense of hopelessness, powerlessness and defeat. They say, “you’re obese and you’re being fed to death.” There is nothing in this message that engenders a sense of self-efficacy, or the idea that a lower, healthier weight is an attainable goal. This deficiency is the ad’s primary shortcoming. Self-efficacy as defined by psychologist and father of Social Cognitive Theory, Albert Bandura, is one's belief in one's ability to succeed in specific situations. The concept of self-efficacy is central to Social Cognitive Theory (4). Social Cognitive Theory asserts that behavior is based on the interaction between one’s environment, the behaviors one witnesses, and the individual themselves. Ads like these posted by CCHG construct a negative outcome expectation and in so doing dismantle whatever self-efficacy they could otherwise have fostered. It simply isn’t enough to provide a website and helpline when the ad itself effectively destroys self-efficacy.

Labeling and Normalizing Obesity

Not only do these ads beget powerlessness as shown in the last paragraph, but they concurrently label and normalize childhood obesity. The relationship between labeling and normalizing obesity presents a double-edged sword for potential public health interventions aimed at preventing childhood obesity. The normalizing of obesity comes with a hefty price tag including rising economic costs. According to the Brookings Institution, “the total costs of obesity in the U.S. alone may exceed $215 billion annually” (5). The direct medical costs resulting from obesity in the U.S. have been estimated to account for over 9% of the national medical bill (6). Societal costs are also extensive. Obese children are less likely to be sent to college by their parents (6). Obese adults are less likely to be given jobs, and miss more work, overall costing employers something on the order of $4 billion. Obese children are at much higher risk of becoming obese adults than their thinner peers (7 - 8). In sum, normalizing obesity, particularly in children, presents a great hazard to personal health and has a major negative impact on costs at the society level.

On the flip side of normalizing, labeling obese children forces them to contend with the heavy stigma associated with obesity, decreasing the likelihood that they will overcome the many hurdles to health and wellness placed on them by society. Obesity is the fourth most common type of discrimination people report experiencing in the U.S. (9). Simply labeling children as obese has the potential to greatly influence their behavior. While the ads don’t literally use the word “obese”, they make it visually quite clear that they’re targeting obese children, and point a finger at poor eating habits. Labeling Theory (which is also known as Social Reactance Theory) posits that labeling an individual influences their behavior and more often than not causes them to conform to the stereotypes of the label in a self-fulfilling prophecy (10 - 11). Obese children must endure negative stigma not only from their peers, but also by their teachers and themselves (9). They are often ascribed negative characteristics including mean, stupid, loud, sloppy, ugly, lazy, sad, and lacking in friends (12 - 14). Obese children can become trapped within this self-fulfilling prophecy and may thus accept these traits as part of their role in society as an “obese child”. Studies have shown that the stigma associated with obesity causes an increase in coping methods like binge eating instead of being a contributing factor to motivation to lose weight and stay healthy (9, 15).

Not only are the children taught how to act by the characteristics attached to their label, but they learn through cognition in conjunction with observing behaviors within their environment. These elements operate reciprocally. For example, the environment in which one is raised affects one’s cognition and perceptions of behaviors that one witnesses. In state where approximately 30% of people are obese and where television stations air shows like “More to Love” or “Ruby” (in which the star, Ruby, spends three seasons trying lose weight only to end the third season having gained over 50 pounds) obesity is not likely to be perceived as abnormal (1). It is likely seen simply as the status quo. Posting health billboards featuring obese children eating is wading into dangerous territory. It risks adding more obesity normalizing media to the local environment and simultaneously reinforces the stereotypes and stigma associated with obesity, particularly qualities like lack of self-control.

Proponents of the campaign cite the fact that 93% of parents of obese children didn’t perceive their kids as being an abnormal weight (16). Research backs up this frightening assertion and shows that parents of overweight children consistently underestimated their children's weight (17 - 18). CCHG’s Childhood Obesity Awareness Campaign aims to inform parents that their children are at risk for serious health outcomes and the organization has deemed that shocking parents is necessary to do so. This scaremongering tactic assumes that by informing parents that their children are at risk of very serious health outcomes like death, they will be moved to act. This assumption takes for granted that people are rational decision makers. Rational decision-making generally entails defining the problem, identifying criteria relevant to the problem, considering all possible solutions, calculating the potential consequences of each solution, and choosing the best option. Many public health interventions are based on this same assumption. It is in fact the very basis of the Health Belief Model, which is commonly used in public health interventions. This model postulates that a behavioral change at the individual level depends on a person’s attitudes toward expected outcomes, the strength of those attitudes and the resulting outcome expectancies, as well as the individual’s perceptions of how others see them, and what the societal norms are (4). All of these factors meld to produce intention, which is followed by behavior. When applied to a parent’s role in preventing childhood obesity, as CCHG has done, the model suggests that if parents become aware of the potential hazardous heath outcomes of obesity and their attitudes toward obesity change, they will intend to prevent or reverse obesity in their children and that intention will lead to a change in behavior. This progression assumes rationalism prevails. Unfortunately assuming rationality fails to account for an individual’s subconscious thought process, irrational decision-making, group behavior and societal and environmental factors, all of which are crucial variables guiding behavior (4, 19, 20).
Irrational decision-making often relies upon the way that a particular issue is introduced or framed. Framing is a method of presenting a fact, topic or idea in a specific light so as to change how it is received among the audience to whom it is being presented. The concept of framing is central to Prospect Theory. Put simply, Prospect Theory states that people value gains and losses differently and that individuals make decisions based on perceived gains rather than perceived losses (21). Given two options with equal outcomes, an individual would choose the outcome expressed in terms of possible gains instead of the one expressed in possible losses. CCHG’s billboard frames childhood obesity in terms of the expected health outcome as a loss. Presenting the issue of childhood obesity by framing it within the context of not only a negative outcome but its most terrifying potential outcome, premature death from obesity related health problems, sets the campaign up for failure.

DO RIGHT! SUCCESSES: A SPRINGBOARD

While CCHGs program’s billboard and ad campaign are majorly flawed, there are a number of things the Do Right! campaign as a whole has gotten right. The organization was correct to take multi-faceted and all-encompassing approach to targeting childhood obesity prevention. Research suggests that families, schools and communities should all be included in programs aimed at preventing and reducing childhood obesity (22). Targeting parents exclusively has also been shown to be effective in reducing the BMI of overweight and obese children. A recent study from the United Kingdom showed that the BMI percentile of children whose parents were provided with eight sessions of cognitive-behavioral therapy for weight loss decreased significantly by 2.4% in the treatment group (23). Community involvement or not, targeting parents is crucial childhood obesity prevention programs. Children of obese parents are more likely to be obese themselves. Children aged 15 to 17 years old with at least one obese parent are over twice as likely as children with no obese parents to be obese adults. Children aged 1 to 2 years old were three times as likely to be obese as their peers who didn’t have an obese parent (24). Beyond the nuclear family, recent research has shown that obesity also spreads through social networks. A study conducted using data from Framingham, MA found that the chances of someone becoming obese increase 57% if they had a long-term friend who was obese (25). However, succeeding in utilizing parent and community involvement in childhood obesity prevention programs is challenging. As anyone who has ever tried to lose even a few pounds knows, attempting to lose weight can be daunting. For an obese person the barriers to weight loss, potentially including difficulty engaging in physical activity, addiction and lack of social support, can often seem indomitable. At any rate, with at minimum an adequate level of support within the environment and from family and community members, childhood obesity can be overcome. Methods to resolve each of the previously outlined failings within the billboard and ad campaign are presented in the following three sections.

As addressed in a previous section of this paper, the Health Belief Model as a champion of rational decision-making, and as it was implemented, was not an effective archetype from which to create the childhood obesity prevention billboard and ad campaign. On the other hand, framing, as delineated within Prospect Theory, can be an incredibly useful tool with which to begin to reconstruct this intervention. Bearing in mind that the original intent of the ad was to create awareness of childhood obesity as a serious problem among parents of obese children, the following proposed ad is aimed at both parents and children who will inevitably see the ads as well. This approach utilizes an entirely novel angle that frames health, with regard to weight, as a desirable and attainable outcome.

The proposed billboards will feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This sends the following messages physical activity is fun obese children are also entitled to fun obese children can do sports. In this way fighting childhood obesity through physical activity is framed in a positive light, as a fun and attainable goal. Making weight-loss and health attainable completely reverses the billboards, taking them from negative to positive and fomenting self-efficacy in children.

ENGENDERING SELF-EFFICACY BY NORMALIZING HEALTH

Labeling and normalizing obesity both have serious negative consequences at the individual and thus also societal level. They contribute to lower levels of self-esteem among obese children, and contribute to extensive monetary costs at the national level. A good public health campaign will succeed in achieving improved health and preventing obesity without further contributing to the extensive and damaging effects of labeling. While the billboard proposed in the prior section may be argued as normalizing obesity, it should be seen as normalizing activity among children of all shapes and sizes. Obese children are usually stereotyped as stupid, sloppy, ugly and lazy. In personal stories shared on blogs obese adults recount experiences that, in line with research published in peer reviewed journals, illustrate the cyclical nature of the self-fulfilling prophecy. In a blog published on Newsweek, Leslie Kinzel wrote,

“Prior to being told I was fat by my well-intentioned pediatrician … I'd spent my life as an active and athletic child, my fatness no obstacle in keeping up with my peers (and frequently besting them). As I got older I came to understand what being fat meant: fat kids were lousy at sports, and those who tried to play were to be mocked for it. Fat kids were always picked last, and though I was never picked last, I came to fear that it would inevitably happen. So I stopped playing. I backed away from sports and games altogether.” (26)

Her account is unfortunately not uncommon and characterizes the major negative impacts that labeling has on obese children. Obesity carries such stigma that for many children it becomes the single characteristic by which they feel most defined. At the end of her post Kinzel pleads,
“Call it a campaign against childhood couch-sitting. Call it a drive to get kids to go outside and play. Call it a movement to educate children on basic nutrition and how their amazing growing bodies work for them. But don't single out the fat kids. If I am any indication, doing this will only ensure that this generation will be fatter than ever, dragging behind them some heavy baggage around food issues and low self-esteem.” (26)

Kinzel’s well-put conclusion holds true given what has been learned from the failures of the Health Belief Model and the potential outcomes associated with Label Theory and Social Reactance Theory. It is absolutely necessary to change the personal characteristics associated with the obesity label. Getting obese children re-involved in sports and other physical activities will help to get rid of the stereotype that obese children can’t play sports. This will serve a dual purpose. It will encourage other obese children to take up arms so to speak and join the revolt against stereotypes. At the same time becoming involved in sports once again or perhaps for the first time will have positive health effects. While these effects certainly can’t be expected to be immediate they will have a positive effect on the local environment that should grow exponentially.

ENGENDERING SELF-EFFICACY BY REVOLTING AGAINST THE LABEL

Inciting obese children in Cincinnati to rise up against the fat label takes advantage of the mechanisms described in Psychological Reactance Theory. This theory asserts that perceived limitations to freedom or autonomy provoke an aversive affective reaction in people (27). In other words, if an individual perceives that their freedom has somehow been limited they will become provoked to regain it. A wonderful example of psychological reactance at work is the Truth campaign, which aims to curb youth use of tobacco by inciting a rebellion of sorts among young people. The campaign’s theme is “truth, a generation united against tobacco” (28). The Truth campaign successfully framed the tobacco industry as a liar that was hiding the truth from teens. In doing so they provoked teens to rebel against big tobacco and its lies, successfully decreasing youth smoking initiation rates.

The proposed alternative billboards showing obese children standing up to the labels and stereotypes associated with childhood obesity will do the same. This reaction is particularly common when individuals feel obliged to adopt a particular opinion or engage in a specific behavior (27). The billboards will bring to light these expectations and the violation of freedom that they cause for obese children, inspiring rebellion. In inciting this silent, healthy insurrection the campaign will be rekindling self-efficacy in obese children, which has a powerful effect on an individual’s level of motivation. “Boredom and apathy occur when a challenge is too small anxiety and withdrawal occur when a challenge is too great curiosity and engagement occur when the challenge is optimal” (29). If children don’t feel like they will succeed in losing weight or getting healthy they are much less likely to try to do so. Engendering self-efficacy through these billboards is an indispensible component of a successful childhood obesity prevention public health campaign. Recent work has found that “exercise’s association with weight loss was better explained through psychological, rather than physiological (ie, caloric expenditure), pathways” proving even further the importance of self-efficacy in weight loss (30). Giving obese children a common cause and an enemy to take down will help to create this self-efficacy, aiding in reducing and preventing childhood obesity over time.

Childhood obesity is a serious public health threat that requires sincere and practical interventions. The potential health consequences that are associated with childhood obesity are grave. They are harmful both to the individual and at the national level. Obese children are at increased risk for type II diabetes, cardiovascular disease, respiratory problems and future reproductive problems. They have added to increased medical costs at the national level, and as childhood obesity prevalence rates are higher among lower income quintiles the increased prevalence of childhood obesity has contributed to growing government expenditures on health (1). Practical, effective solutions are crucial in the fight to prevent and decrease childhood obesity.

In order to create a billboard campaign that effectively reduces and prevents childhood obesity while carefully avoiding potential adverse affects that such a billboard could so easily have, as evidenced by the one used by CCHG, social and behavioral sciences theories should be employed. Social Cognitive Theory, Labeling Theory (which is also known as Social Reactance Theory), the Health Belief Model, Framing Theory (as well as Prospect Theory) and Psychological Reactance Theory were used to analyze and critique CCHG’s billboard and ad intervention. CCHG’s billboard intervention was found to be inappropriate on the grounds that it contributed to defeating self-efficacy among obese children, added to labeling and normalizing childhood obesity and resorted to terrorizing parents in an effort to create awareness and incite a behavior change among parents and children. These same theories were then employed to suggest an appropriate intervention to replace CCHG’s billboard ads. The proposed replacement intervention consists of billboards that feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This intervention is based on engendering self-efficacy by reframing the childhood obesity issue in a positive light, normalizing healthy choices among obese children and using Psychological Reactance Theory to empower children to fight against the labels associated with childhood obesity. Casting a glow of optimism on the problem will help to bring back to life self-efficacy that has been squashed by labeling and stigma. Social and behavioral sciences theories were instrumental tools in understanding the effects that the Cincinnati CHG’s billboards could be expected to have on the target population, as well as any projected externalities, and in creating a better alternative.

REFERENCES
1. Overweight and Obesity. U.S. Obesity Trends. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/obesity/data/trends.html.
2. Do Right!. The Crisis. Cincinnati, OH: The Center for Closing the Health Gap in Greater Cincinnati. http://dorightcincy.org/the-crisis.
3. Childhood Obesity. Ohio Childhood Obesity Prevention Campaign Stirs Controversy. Princeton, NJ: Robert Wood Johnson Foundation. http://www.rwjf.org/childhoodobesity/digest.jsp?id=8398&c=OTC-RSS&attr=DI.
4. Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 200152:1-26.
5. Hammond R. The Economic Costs of Obesity. Brookings Institution. May 4, 2011. http://www.brookings.edu/multimedia/video/2010/0914_obesity_hammond.aspx.
6. Herper M. The Hidden Cost of Obesity. Forbes [online]. November 24, 2006. http://www.forbes.com/2006/07/19/obesity-fat-costs_cx_mh_0720obesity.html.
7. Epstein LH, Wing RR, Valoski A. Childhood obesity. Pediatr. Clin. North Am. 198532(2):363-379.
8. Krassas GE, Tzotzas T. Do obese children become obese adults: childhood predictors of adult disease. Pediatr Endocrinol Rev. 20041 Suppl 3:455-459.
9. Puhl RM, Latner JD. Stigma, obesity, and the health of the nation’s children. Psychol Bull. 2007133(4):557-580.
10. Laslett B, Warren CAB. Losing Weight: The Organizational Promotion of Behavior Change. Social Problems. 197523(1):69-80.
11. Link BG, Phelan JC. Conceptualizing Stigma. Annual Review of Sociology. 200127:363-385.
12. Holub SC. Individual differences in the anti-fat attitudes of preschool-children: The importance of perceived body size. Body Image. 20085(3):317-321.
13. Musher-Eizenman DR, Holub SC, Miller AB, Goldstein SE, Edwards-Leeper L. Body Size Stigmatization in Preschool Children: The Role of Control Attributions. Journal of Pediatric Psychology. 200429(8):613 -620.
14. Iobst EA. The Relationship Among Gender, Age, Blame, and Children’s Attributions about an Overweight Peer. 2007. Available at: http://etd.ohiolink.edu/view.cgi?acc_num=ucin1242390002. Accessed May 4, 2011.
15. Bensley K. Obesity and Perceptions of the Body in Teenage American Girls. UCL Centre for Applied Global Citizenship [online]. December 17, 2010. London, U.K.: . http://www.ucl.ac.uk/network-for-student-activism/w/Obesity_and_Perceptions_of_the_Body_in_Teenage_American_Girls.
16. Orr K. Provacative local campaign to target childhood obesity. WVXU Radio [online]. July 31, 2008. http://www.wvxu.org/news/wvxunews_article.asp?ID=5421.
17. Etelson D, Brand DA, Patrick PA, Shirali A. Childhood Obesity: Do Parents Recognize This Health Risk? Obesity. 200311(11):1362-1368.
18. Health & Parenting. Many Parents Don’t See Child Obesity. Web MD. http://www.webmd.com/parenting/news/20071211/many-parents-dont-see-child-obesity.
19. Janz NK, Becker MH. The Health Belief Model: A Decade Later. Health Education & Behavior. 198411(1):1 -47.
20. Rosenstock IM, Strecher VJ, Becker MH. Social Learning Theory and the Health Belief Model. Health Education & Behavior. 198815(2):175-183.
21. Kahneman D, Tversky A. Prospect Theory: An Analysis of Decision under Risk. Econometrica. 197947(2):263-291.
22. Lindsay AC, Sussner KM, Kim J, Gortmaker S. The role of parents in preventing childhood obesity. Future Child. 200616(1):169-186.
23. Jansen E, Mulkens S, Jansen A. Tackling childhood overweight: treating parents exclusively is effective. Int J Obes (Lond). 201135(4):501-509.
24. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N. Engl. J. Med. 1997337(13):869-873.
25. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N. Engl. J. Med. 2007357(4):370-379.
26. Kinzel L. Why the first lady's fight to end childhood obesity does damage to the children it's trying to help. Newsweek [online]. April 20, 2010. http://www.newsweek.com/2010/04/19/fat-kids-cruel-world.html.
27. Burke WW, Lake DG, Paine JW. Organization Change: A Comprehensive Reader. John Wiley and Sons 2008.
28. Truth. http://www.thetruth.com/.
29. Snyder CR, Lopez SJ. Oxford handbook of positive psychology. Oxford University Press US 2009 (P573).
30. Annesi JJ. Behaviorally supported exercise predicts weight loss in obese adults through improvements in mood, self-efficacy, and self-regulation, rather than by caloric expenditure. Perm J. 201115(1):23-27.


Challenging Dogma - Spring 2011

Today over one third of U.S. adults and 17% of U.S. children are obese. In the last three decades, obesity rates for adults have doubled and rates for children have tripled. However, the burden of obesity is not evenly distributed, and falls heavily on minorities. The 2009 Behavioral Risk Factor Surveillance System report showed that “blacks were 51% more likely and Hispanics were 21% more likely than non-Hispanic whites to be obese” (1). It is also geographically unevenly distributed with the American Midwest suffering higher obesity prevalence rates than the rest of the country. Cincinnati, Ohio is a beautiful Midwestern city situated at the southern edge of Ohio, across the Ohio River from Kentucky. However, like many Midwestern cities and states, Cincinnati has seen an alarming increase in obesity among adults and children in the last few decades. According to CDC 29.6% of Ohioans were obese in 2009. This increase has serious health consequences for adults and children. Obesity related diseases like type 2 diabetes, which previously only affected adults, is now affecting children (1). Obese children are also at higher risk of suffering cardiovascular disease. Obesity, including childhood obesity, is known to be a risk factor for a number of diseases including cancers, stroke, respiratory problems and reproductive health problems. The annual hospital costs related to childhood obesity increased from $35 million in the period from 1979-1981 to $127 million in the period from 1997-1999 (1).

In 2008 the nonprofit Center for Closing the Health Gap (2) in Greater Cincinnati began a campaign aimed at preventing childhood obesity. Childhood obesity prevention is a goal that fits perfectly within CCHG’s mission, which includes increasing awareness about health disparities (2). The childhood obesity epidemic in the Greater Cincinnati area disproportionately affects minority children. CCHG’s website reports that the rate of overweight and obesity in Hamilton County is 43% among Black, Non-Hispanic children and 21% among White, Non-Hispanic children. The negative consequences to health that may result from obesity are grave. The city was seeing children with hypertension and worrying rates of type II diabetes. Secondly CCHG saw that obesity disproportionately affected children of low-income parents and minority children, particularly Black, Hispanic and Appalachian children. To work toward preventing childhood obesity the organization initiated a campaign called “Do Right!” The specific target of the childhood prevention portion of the program aimed at “improving the health and well-being of children at Rockdale Elementary that are overweight and obese” (2). Rockdale Elementary is part of the Cincinnati Public Schools system and enrolls about 500 preschool and elementary school students from grades PK-8.

The “Do Right!” children’s program is multi-faceted. Its in school components include screening for BMI to identify overweight and obese children, referral for obese children to an after school physical activity and nutrition program. The program includes nutrition every other week by a dietician, physical activity and bi-weekly parent education and information sessions to discuss nutrition. The program also included 1-minute health tips on the radio, parent workshops in development and City School Awareness Presentations (2). Finally, the program ran a concurrent obesity awareness campaign that included billboards, bus shelters, radio advertisements, ads in minority newspapers and the website: www.dorightcincy.org. They feature obese children mowing down on big, greasy burgers in front of plates of onion rings with the words “Are we feeding our kids to death?” in large print. Below, they provide the Do Right! campaign’s website and phone number with the words “for information on how to combat obesity.” These ads are the focus of this critique.

First and foremost it alienates the very population it aims to help. Dwight Tillery, the executive director of CCHG, purports that the campaign was designed to serve as a wake-up call for families. It aims to incentivize parents to take the health of their children more seriously by showing them just how serious obesity is. Tillery said, “We can’t afford to be politically correct on this issue” (3). Political correctness or lack thereof aside the means simply do not justify the end. Whether or not parents are shocked into understanding the gravity of childhood obesity, children who see these ads are sure to feel alienated. The ads effectuate a pervasive sense of hopelessness, powerlessness and defeat. They say, “you’re obese and you’re being fed to death.” There is nothing in this message that engenders a sense of self-efficacy, or the idea that a lower, healthier weight is an attainable goal. This deficiency is the ad’s primary shortcoming. Self-efficacy as defined by psychologist and father of Social Cognitive Theory, Albert Bandura, is one's belief in one's ability to succeed in specific situations. The concept of self-efficacy is central to Social Cognitive Theory (4). Social Cognitive Theory asserts that behavior is based on the interaction between one’s environment, the behaviors one witnesses, and the individual themselves. Ads like these posted by CCHG construct a negative outcome expectation and in so doing dismantle whatever self-efficacy they could otherwise have fostered. It simply isn’t enough to provide a website and helpline when the ad itself effectively destroys self-efficacy.

Labeling and Normalizing Obesity

Not only do these ads beget powerlessness as shown in the last paragraph, but they concurrently label and normalize childhood obesity. The relationship between labeling and normalizing obesity presents a double-edged sword for potential public health interventions aimed at preventing childhood obesity. The normalizing of obesity comes with a hefty price tag including rising economic costs. According to the Brookings Institution, “the total costs of obesity in the U.S. alone may exceed $215 billion annually” (5). The direct medical costs resulting from obesity in the U.S. have been estimated to account for over 9% of the national medical bill (6). Societal costs are also extensive. Obese children are less likely to be sent to college by their parents (6). Obese adults are less likely to be given jobs, and miss more work, overall costing employers something on the order of $4 billion. Obese children are at much higher risk of becoming obese adults than their thinner peers (7 - 8). In sum, normalizing obesity, particularly in children, presents a great hazard to personal health and has a major negative impact on costs at the society level.

On the flip side of normalizing, labeling obese children forces them to contend with the heavy stigma associated with obesity, decreasing the likelihood that they will overcome the many hurdles to health and wellness placed on them by society. Obesity is the fourth most common type of discrimination people report experiencing in the U.S. (9). Simply labeling children as obese has the potential to greatly influence their behavior. While the ads don’t literally use the word “obese”, they make it visually quite clear that they’re targeting obese children, and point a finger at poor eating habits. Labeling Theory (which is also known as Social Reactance Theory) posits that labeling an individual influences their behavior and more often than not causes them to conform to the stereotypes of the label in a self-fulfilling prophecy (10 - 11). Obese children must endure negative stigma not only from their peers, but also by their teachers and themselves (9). They are often ascribed negative characteristics including mean, stupid, loud, sloppy, ugly, lazy, sad, and lacking in friends (12 - 14). Obese children can become trapped within this self-fulfilling prophecy and may thus accept these traits as part of their role in society as an “obese child”. Studies have shown that the stigma associated with obesity causes an increase in coping methods like binge eating instead of being a contributing factor to motivation to lose weight and stay healthy (9, 15).

Not only are the children taught how to act by the characteristics attached to their label, but they learn through cognition in conjunction with observing behaviors within their environment. These elements operate reciprocally. For example, the environment in which one is raised affects one’s cognition and perceptions of behaviors that one witnesses. In state where approximately 30% of people are obese and where television stations air shows like “More to Love” or “Ruby” (in which the star, Ruby, spends three seasons trying lose weight only to end the third season having gained over 50 pounds) obesity is not likely to be perceived as abnormal (1). It is likely seen simply as the status quo. Posting health billboards featuring obese children eating is wading into dangerous territory. It risks adding more obesity normalizing media to the local environment and simultaneously reinforces the stereotypes and stigma associated with obesity, particularly qualities like lack of self-control.

Proponents of the campaign cite the fact that 93% of parents of obese children didn’t perceive their kids as being an abnormal weight (16). Research backs up this frightening assertion and shows that parents of overweight children consistently underestimated their children's weight (17 - 18). CCHG’s Childhood Obesity Awareness Campaign aims to inform parents that their children are at risk for serious health outcomes and the organization has deemed that shocking parents is necessary to do so. This scaremongering tactic assumes that by informing parents that their children are at risk of very serious health outcomes like death, they will be moved to act. This assumption takes for granted that people are rational decision makers. Rational decision-making generally entails defining the problem, identifying criteria relevant to the problem, considering all possible solutions, calculating the potential consequences of each solution, and choosing the best option. Many public health interventions are based on this same assumption. It is in fact the very basis of the Health Belief Model, which is commonly used in public health interventions. This model postulates that a behavioral change at the individual level depends on a person’s attitudes toward expected outcomes, the strength of those attitudes and the resulting outcome expectancies, as well as the individual’s perceptions of how others see them, and what the societal norms are (4). All of these factors meld to produce intention, which is followed by behavior. When applied to a parent’s role in preventing childhood obesity, as CCHG has done, the model suggests that if parents become aware of the potential hazardous heath outcomes of obesity and their attitudes toward obesity change, they will intend to prevent or reverse obesity in their children and that intention will lead to a change in behavior. This progression assumes rationalism prevails. Unfortunately assuming rationality fails to account for an individual’s subconscious thought process, irrational decision-making, group behavior and societal and environmental factors, all of which are crucial variables guiding behavior (4, 19, 20).
Irrational decision-making often relies upon the way that a particular issue is introduced or framed. Framing is a method of presenting a fact, topic or idea in a specific light so as to change how it is received among the audience to whom it is being presented. The concept of framing is central to Prospect Theory. Put simply, Prospect Theory states that people value gains and losses differently and that individuals make decisions based on perceived gains rather than perceived losses (21). Given two options with equal outcomes, an individual would choose the outcome expressed in terms of possible gains instead of the one expressed in possible losses. CCHG’s billboard frames childhood obesity in terms of the expected health outcome as a loss. Presenting the issue of childhood obesity by framing it within the context of not only a negative outcome but its most terrifying potential outcome, premature death from obesity related health problems, sets the campaign up for failure.

DO RIGHT! SUCCESSES: A SPRINGBOARD

While CCHGs program’s billboard and ad campaign are majorly flawed, there are a number of things the Do Right! campaign as a whole has gotten right. The organization was correct to take multi-faceted and all-encompassing approach to targeting childhood obesity prevention. Research suggests that families, schools and communities should all be included in programs aimed at preventing and reducing childhood obesity (22). Targeting parents exclusively has also been shown to be effective in reducing the BMI of overweight and obese children. A recent study from the United Kingdom showed that the BMI percentile of children whose parents were provided with eight sessions of cognitive-behavioral therapy for weight loss decreased significantly by 2.4% in the treatment group (23). Community involvement or not, targeting parents is crucial childhood obesity prevention programs. Children of obese parents are more likely to be obese themselves. Children aged 15 to 17 years old with at least one obese parent are over twice as likely as children with no obese parents to be obese adults. Children aged 1 to 2 years old were three times as likely to be obese as their peers who didn’t have an obese parent (24). Beyond the nuclear family, recent research has shown that obesity also spreads through social networks. A study conducted using data from Framingham, MA found that the chances of someone becoming obese increase 57% if they had a long-term friend who was obese (25). However, succeeding in utilizing parent and community involvement in childhood obesity prevention programs is challenging. As anyone who has ever tried to lose even a few pounds knows, attempting to lose weight can be daunting. For an obese person the barriers to weight loss, potentially including difficulty engaging in physical activity, addiction and lack of social support, can often seem indomitable. At any rate, with at minimum an adequate level of support within the environment and from family and community members, childhood obesity can be overcome. Methods to resolve each of the previously outlined failings within the billboard and ad campaign are presented in the following three sections.

As addressed in a previous section of this paper, the Health Belief Model as a champion of rational decision-making, and as it was implemented, was not an effective archetype from which to create the childhood obesity prevention billboard and ad campaign. On the other hand, framing, as delineated within Prospect Theory, can be an incredibly useful tool with which to begin to reconstruct this intervention. Bearing in mind that the original intent of the ad was to create awareness of childhood obesity as a serious problem among parents of obese children, the following proposed ad is aimed at both parents and children who will inevitably see the ads as well. This approach utilizes an entirely novel angle that frames health, with regard to weight, as a desirable and attainable outcome.

The proposed billboards will feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This sends the following messages physical activity is fun obese children are also entitled to fun obese children can do sports. In this way fighting childhood obesity through physical activity is framed in a positive light, as a fun and attainable goal. Making weight-loss and health attainable completely reverses the billboards, taking them from negative to positive and fomenting self-efficacy in children.

ENGENDERING SELF-EFFICACY BY NORMALIZING HEALTH

Labeling and normalizing obesity both have serious negative consequences at the individual and thus also societal level. They contribute to lower levels of self-esteem among obese children, and contribute to extensive monetary costs at the national level. A good public health campaign will succeed in achieving improved health and preventing obesity without further contributing to the extensive and damaging effects of labeling. While the billboard proposed in the prior section may be argued as normalizing obesity, it should be seen as normalizing activity among children of all shapes and sizes. Obese children are usually stereotyped as stupid, sloppy, ugly and lazy. In personal stories shared on blogs obese adults recount experiences that, in line with research published in peer reviewed journals, illustrate the cyclical nature of the self-fulfilling prophecy. In a blog published on Newsweek, Leslie Kinzel wrote,

“Prior to being told I was fat by my well-intentioned pediatrician … I'd spent my life as an active and athletic child, my fatness no obstacle in keeping up with my peers (and frequently besting them). As I got older I came to understand what being fat meant: fat kids were lousy at sports, and those who tried to play were to be mocked for it. Fat kids were always picked last, and though I was never picked last, I came to fear that it would inevitably happen. So I stopped playing. I backed away from sports and games altogether.” (26)

Her account is unfortunately not uncommon and characterizes the major negative impacts that labeling has on obese children. Obesity carries such stigma that for many children it becomes the single characteristic by which they feel most defined. At the end of her post Kinzel pleads,
“Call it a campaign against childhood couch-sitting. Call it a drive to get kids to go outside and play. Call it a movement to educate children on basic nutrition and how their amazing growing bodies work for them. But don't single out the fat kids. If I am any indication, doing this will only ensure that this generation will be fatter than ever, dragging behind them some heavy baggage around food issues and low self-esteem.” (26)

Kinzel’s well-put conclusion holds true given what has been learned from the failures of the Health Belief Model and the potential outcomes associated with Label Theory and Social Reactance Theory. It is absolutely necessary to change the personal characteristics associated with the obesity label. Getting obese children re-involved in sports and other physical activities will help to get rid of the stereotype that obese children can’t play sports. This will serve a dual purpose. It will encourage other obese children to take up arms so to speak and join the revolt against stereotypes. At the same time becoming involved in sports once again or perhaps for the first time will have positive health effects. While these effects certainly can’t be expected to be immediate they will have a positive effect on the local environment that should grow exponentially.

ENGENDERING SELF-EFFICACY BY REVOLTING AGAINST THE LABEL

Inciting obese children in Cincinnati to rise up against the fat label takes advantage of the mechanisms described in Psychological Reactance Theory. This theory asserts that perceived limitations to freedom or autonomy provoke an aversive affective reaction in people (27). In other words, if an individual perceives that their freedom has somehow been limited they will become provoked to regain it. A wonderful example of psychological reactance at work is the Truth campaign, which aims to curb youth use of tobacco by inciting a rebellion of sorts among young people. The campaign’s theme is “truth, a generation united against tobacco” (28). The Truth campaign successfully framed the tobacco industry as a liar that was hiding the truth from teens. In doing so they provoked teens to rebel against big tobacco and its lies, successfully decreasing youth smoking initiation rates.

The proposed alternative billboards showing obese children standing up to the labels and stereotypes associated with childhood obesity will do the same. This reaction is particularly common when individuals feel obliged to adopt a particular opinion or engage in a specific behavior (27). The billboards will bring to light these expectations and the violation of freedom that they cause for obese children, inspiring rebellion. In inciting this silent, healthy insurrection the campaign will be rekindling self-efficacy in obese children, which has a powerful effect on an individual’s level of motivation. “Boredom and apathy occur when a challenge is too small anxiety and withdrawal occur when a challenge is too great curiosity and engagement occur when the challenge is optimal” (29). If children don’t feel like they will succeed in losing weight or getting healthy they are much less likely to try to do so. Engendering self-efficacy through these billboards is an indispensible component of a successful childhood obesity prevention public health campaign. Recent work has found that “exercise’s association with weight loss was better explained through psychological, rather than physiological (ie, caloric expenditure), pathways” proving even further the importance of self-efficacy in weight loss (30). Giving obese children a common cause and an enemy to take down will help to create this self-efficacy, aiding in reducing and preventing childhood obesity over time.

Childhood obesity is a serious public health threat that requires sincere and practical interventions. The potential health consequences that are associated with childhood obesity are grave. They are harmful both to the individual and at the national level. Obese children are at increased risk for type II diabetes, cardiovascular disease, respiratory problems and future reproductive problems. They have added to increased medical costs at the national level, and as childhood obesity prevalence rates are higher among lower income quintiles the increased prevalence of childhood obesity has contributed to growing government expenditures on health (1). Practical, effective solutions are crucial in the fight to prevent and decrease childhood obesity.

In order to create a billboard campaign that effectively reduces and prevents childhood obesity while carefully avoiding potential adverse affects that such a billboard could so easily have, as evidenced by the one used by CCHG, social and behavioral sciences theories should be employed. Social Cognitive Theory, Labeling Theory (which is also known as Social Reactance Theory), the Health Belief Model, Framing Theory (as well as Prospect Theory) and Psychological Reactance Theory were used to analyze and critique CCHG’s billboard and ad intervention. CCHG’s billboard intervention was found to be inappropriate on the grounds that it contributed to defeating self-efficacy among obese children, added to labeling and normalizing childhood obesity and resorted to terrorizing parents in an effort to create awareness and incite a behavior change among parents and children. These same theories were then employed to suggest an appropriate intervention to replace CCHG’s billboard ads. The proposed replacement intervention consists of billboards that feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This intervention is based on engendering self-efficacy by reframing the childhood obesity issue in a positive light, normalizing healthy choices among obese children and using Psychological Reactance Theory to empower children to fight against the labels associated with childhood obesity. Casting a glow of optimism on the problem will help to bring back to life self-efficacy that has been squashed by labeling and stigma. Social and behavioral sciences theories were instrumental tools in understanding the effects that the Cincinnati CHG’s billboards could be expected to have on the target population, as well as any projected externalities, and in creating a better alternative.

REFERENCES
1. Overweight and Obesity. U.S. Obesity Trends. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/obesity/data/trends.html.
2. Do Right!. The Crisis. Cincinnati, OH: The Center for Closing the Health Gap in Greater Cincinnati. http://dorightcincy.org/the-crisis.
3. Childhood Obesity. Ohio Childhood Obesity Prevention Campaign Stirs Controversy. Princeton, NJ: Robert Wood Johnson Foundation. http://www.rwjf.org/childhoodobesity/digest.jsp?id=8398&c=OTC-RSS&attr=DI.
4. Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 200152:1-26.
5. Hammond R. The Economic Costs of Obesity. Brookings Institution. May 4, 2011. http://www.brookings.edu/multimedia/video/2010/0914_obesity_hammond.aspx.
6. Herper M. The Hidden Cost of Obesity. Forbes [online]. November 24, 2006. http://www.forbes.com/2006/07/19/obesity-fat-costs_cx_mh_0720obesity.html.
7. Epstein LH, Wing RR, Valoski A. Childhood obesity. Pediatr. Clin. North Am. 198532(2):363-379.
8. Krassas GE, Tzotzas T. Do obese children become obese adults: childhood predictors of adult disease. Pediatr Endocrinol Rev. 20041 Suppl 3:455-459.
9. Puhl RM, Latner JD. Stigma, obesity, and the health of the nation’s children. Psychol Bull. 2007133(4):557-580.
10. Laslett B, Warren CAB. Losing Weight: The Organizational Promotion of Behavior Change. Social Problems. 197523(1):69-80.
11. Link BG, Phelan JC. Conceptualizing Stigma. Annual Review of Sociology. 200127:363-385.
12. Holub SC. Individual differences in the anti-fat attitudes of preschool-children: The importance of perceived body size. Body Image. 20085(3):317-321.
13. Musher-Eizenman DR, Holub SC, Miller AB, Goldstein SE, Edwards-Leeper L. Body Size Stigmatization in Preschool Children: The Role of Control Attributions. Journal of Pediatric Psychology. 200429(8):613 -620.
14. Iobst EA. The Relationship Among Gender, Age, Blame, and Children’s Attributions about an Overweight Peer. 2007. Available at: http://etd.ohiolink.edu/view.cgi?acc_num=ucin1242390002. Accessed May 4, 2011.
15. Bensley K. Obesity and Perceptions of the Body in Teenage American Girls. UCL Centre for Applied Global Citizenship [online]. December 17, 2010. London, U.K.: . http://www.ucl.ac.uk/network-for-student-activism/w/Obesity_and_Perceptions_of_the_Body_in_Teenage_American_Girls.
16. Orr K. Provacative local campaign to target childhood obesity. WVXU Radio [online]. July 31, 2008. http://www.wvxu.org/news/wvxunews_article.asp?ID=5421.
17. Etelson D, Brand DA, Patrick PA, Shirali A. Childhood Obesity: Do Parents Recognize This Health Risk? Obesity. 200311(11):1362-1368.
18. Health & Parenting. Many Parents Don’t See Child Obesity. Web MD. http://www.webmd.com/parenting/news/20071211/many-parents-dont-see-child-obesity.
19. Janz NK, Becker MH. The Health Belief Model: A Decade Later. Health Education & Behavior. 198411(1):1 -47.
20. Rosenstock IM, Strecher VJ, Becker MH. Social Learning Theory and the Health Belief Model. Health Education & Behavior. 198815(2):175-183.
21. Kahneman D, Tversky A. Prospect Theory: An Analysis of Decision under Risk. Econometrica. 197947(2):263-291.
22. Lindsay AC, Sussner KM, Kim J, Gortmaker S. The role of parents in preventing childhood obesity. Future Child. 200616(1):169-186.
23. Jansen E, Mulkens S, Jansen A. Tackling childhood overweight: treating parents exclusively is effective. Int J Obes (Lond). 201135(4):501-509.
24. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N. Engl. J. Med. 1997337(13):869-873.
25. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N. Engl. J. Med. 2007357(4):370-379.
26. Kinzel L. Why the first lady's fight to end childhood obesity does damage to the children it's trying to help. Newsweek [online]. April 20, 2010. http://www.newsweek.com/2010/04/19/fat-kids-cruel-world.html.
27. Burke WW, Lake DG, Paine JW. Organization Change: A Comprehensive Reader. John Wiley and Sons 2008.
28. Truth. http://www.thetruth.com/.
29. Snyder CR, Lopez SJ. Oxford handbook of positive psychology. Oxford University Press US 2009 (P573).
30. Annesi JJ. Behaviorally supported exercise predicts weight loss in obese adults through improvements in mood, self-efficacy, and self-regulation, rather than by caloric expenditure. Perm J. 201115(1):23-27.


Challenging Dogma - Spring 2011

Today over one third of U.S. adults and 17% of U.S. children are obese. In the last three decades, obesity rates for adults have doubled and rates for children have tripled. However, the burden of obesity is not evenly distributed, and falls heavily on minorities. The 2009 Behavioral Risk Factor Surveillance System report showed that “blacks were 51% more likely and Hispanics were 21% more likely than non-Hispanic whites to be obese” (1). It is also geographically unevenly distributed with the American Midwest suffering higher obesity prevalence rates than the rest of the country. Cincinnati, Ohio is a beautiful Midwestern city situated at the southern edge of Ohio, across the Ohio River from Kentucky. However, like many Midwestern cities and states, Cincinnati has seen an alarming increase in obesity among adults and children in the last few decades. According to CDC 29.6% of Ohioans were obese in 2009. This increase has serious health consequences for adults and children. Obesity related diseases like type 2 diabetes, which previously only affected adults, is now affecting children (1). Obese children are also at higher risk of suffering cardiovascular disease. Obesity, including childhood obesity, is known to be a risk factor for a number of diseases including cancers, stroke, respiratory problems and reproductive health problems. The annual hospital costs related to childhood obesity increased from $35 million in the period from 1979-1981 to $127 million in the period from 1997-1999 (1).

In 2008 the nonprofit Center for Closing the Health Gap (2) in Greater Cincinnati began a campaign aimed at preventing childhood obesity. Childhood obesity prevention is a goal that fits perfectly within CCHG’s mission, which includes increasing awareness about health disparities (2). The childhood obesity epidemic in the Greater Cincinnati area disproportionately affects minority children. CCHG’s website reports that the rate of overweight and obesity in Hamilton County is 43% among Black, Non-Hispanic children and 21% among White, Non-Hispanic children. The negative consequences to health that may result from obesity are grave. The city was seeing children with hypertension and worrying rates of type II diabetes. Secondly CCHG saw that obesity disproportionately affected children of low-income parents and minority children, particularly Black, Hispanic and Appalachian children. To work toward preventing childhood obesity the organization initiated a campaign called “Do Right!” The specific target of the childhood prevention portion of the program aimed at “improving the health and well-being of children at Rockdale Elementary that are overweight and obese” (2). Rockdale Elementary is part of the Cincinnati Public Schools system and enrolls about 500 preschool and elementary school students from grades PK-8.

The “Do Right!” children’s program is multi-faceted. Its in school components include screening for BMI to identify overweight and obese children, referral for obese children to an after school physical activity and nutrition program. The program includes nutrition every other week by a dietician, physical activity and bi-weekly parent education and information sessions to discuss nutrition. The program also included 1-minute health tips on the radio, parent workshops in development and City School Awareness Presentations (2). Finally, the program ran a concurrent obesity awareness campaign that included billboards, bus shelters, radio advertisements, ads in minority newspapers and the website: www.dorightcincy.org. They feature obese children mowing down on big, greasy burgers in front of plates of onion rings with the words “Are we feeding our kids to death?” in large print. Below, they provide the Do Right! campaign’s website and phone number with the words “for information on how to combat obesity.” These ads are the focus of this critique.

First and foremost it alienates the very population it aims to help. Dwight Tillery, the executive director of CCHG, purports that the campaign was designed to serve as a wake-up call for families. It aims to incentivize parents to take the health of their children more seriously by showing them just how serious obesity is. Tillery said, “We can’t afford to be politically correct on this issue” (3). Political correctness or lack thereof aside the means simply do not justify the end. Whether or not parents are shocked into understanding the gravity of childhood obesity, children who see these ads are sure to feel alienated. The ads effectuate a pervasive sense of hopelessness, powerlessness and defeat. They say, “you’re obese and you’re being fed to death.” There is nothing in this message that engenders a sense of self-efficacy, or the idea that a lower, healthier weight is an attainable goal. This deficiency is the ad’s primary shortcoming. Self-efficacy as defined by psychologist and father of Social Cognitive Theory, Albert Bandura, is one's belief in one's ability to succeed in specific situations. The concept of self-efficacy is central to Social Cognitive Theory (4). Social Cognitive Theory asserts that behavior is based on the interaction between one’s environment, the behaviors one witnesses, and the individual themselves. Ads like these posted by CCHG construct a negative outcome expectation and in so doing dismantle whatever self-efficacy they could otherwise have fostered. It simply isn’t enough to provide a website and helpline when the ad itself effectively destroys self-efficacy.

Labeling and Normalizing Obesity

Not only do these ads beget powerlessness as shown in the last paragraph, but they concurrently label and normalize childhood obesity. The relationship between labeling and normalizing obesity presents a double-edged sword for potential public health interventions aimed at preventing childhood obesity. The normalizing of obesity comes with a hefty price tag including rising economic costs. According to the Brookings Institution, “the total costs of obesity in the U.S. alone may exceed $215 billion annually” (5). The direct medical costs resulting from obesity in the U.S. have been estimated to account for over 9% of the national medical bill (6). Societal costs are also extensive. Obese children are less likely to be sent to college by their parents (6). Obese adults are less likely to be given jobs, and miss more work, overall costing employers something on the order of $4 billion. Obese children are at much higher risk of becoming obese adults than their thinner peers (7 - 8). In sum, normalizing obesity, particularly in children, presents a great hazard to personal health and has a major negative impact on costs at the society level.

On the flip side of normalizing, labeling obese children forces them to contend with the heavy stigma associated with obesity, decreasing the likelihood that they will overcome the many hurdles to health and wellness placed on them by society. Obesity is the fourth most common type of discrimination people report experiencing in the U.S. (9). Simply labeling children as obese has the potential to greatly influence their behavior. While the ads don’t literally use the word “obese”, they make it visually quite clear that they’re targeting obese children, and point a finger at poor eating habits. Labeling Theory (which is also known as Social Reactance Theory) posits that labeling an individual influences their behavior and more often than not causes them to conform to the stereotypes of the label in a self-fulfilling prophecy (10 - 11). Obese children must endure negative stigma not only from their peers, but also by their teachers and themselves (9). They are often ascribed negative characteristics including mean, stupid, loud, sloppy, ugly, lazy, sad, and lacking in friends (12 - 14). Obese children can become trapped within this self-fulfilling prophecy and may thus accept these traits as part of their role in society as an “obese child”. Studies have shown that the stigma associated with obesity causes an increase in coping methods like binge eating instead of being a contributing factor to motivation to lose weight and stay healthy (9, 15).

Not only are the children taught how to act by the characteristics attached to their label, but they learn through cognition in conjunction with observing behaviors within their environment. These elements operate reciprocally. For example, the environment in which one is raised affects one’s cognition and perceptions of behaviors that one witnesses. In state where approximately 30% of people are obese and where television stations air shows like “More to Love” or “Ruby” (in which the star, Ruby, spends three seasons trying lose weight only to end the third season having gained over 50 pounds) obesity is not likely to be perceived as abnormal (1). It is likely seen simply as the status quo. Posting health billboards featuring obese children eating is wading into dangerous territory. It risks adding more obesity normalizing media to the local environment and simultaneously reinforces the stereotypes and stigma associated with obesity, particularly qualities like lack of self-control.

Proponents of the campaign cite the fact that 93% of parents of obese children didn’t perceive their kids as being an abnormal weight (16). Research backs up this frightening assertion and shows that parents of overweight children consistently underestimated their children's weight (17 - 18). CCHG’s Childhood Obesity Awareness Campaign aims to inform parents that their children are at risk for serious health outcomes and the organization has deemed that shocking parents is necessary to do so. This scaremongering tactic assumes that by informing parents that their children are at risk of very serious health outcomes like death, they will be moved to act. This assumption takes for granted that people are rational decision makers. Rational decision-making generally entails defining the problem, identifying criteria relevant to the problem, considering all possible solutions, calculating the potential consequences of each solution, and choosing the best option. Many public health interventions are based on this same assumption. It is in fact the very basis of the Health Belief Model, which is commonly used in public health interventions. This model postulates that a behavioral change at the individual level depends on a person’s attitudes toward expected outcomes, the strength of those attitudes and the resulting outcome expectancies, as well as the individual’s perceptions of how others see them, and what the societal norms are (4). All of these factors meld to produce intention, which is followed by behavior. When applied to a parent’s role in preventing childhood obesity, as CCHG has done, the model suggests that if parents become aware of the potential hazardous heath outcomes of obesity and their attitudes toward obesity change, they will intend to prevent or reverse obesity in their children and that intention will lead to a change in behavior. This progression assumes rationalism prevails. Unfortunately assuming rationality fails to account for an individual’s subconscious thought process, irrational decision-making, group behavior and societal and environmental factors, all of which are crucial variables guiding behavior (4, 19, 20).
Irrational decision-making often relies upon the way that a particular issue is introduced or framed. Framing is a method of presenting a fact, topic or idea in a specific light so as to change how it is received among the audience to whom it is being presented. The concept of framing is central to Prospect Theory. Put simply, Prospect Theory states that people value gains and losses differently and that individuals make decisions based on perceived gains rather than perceived losses (21). Given two options with equal outcomes, an individual would choose the outcome expressed in terms of possible gains instead of the one expressed in possible losses. CCHG’s billboard frames childhood obesity in terms of the expected health outcome as a loss. Presenting the issue of childhood obesity by framing it within the context of not only a negative outcome but its most terrifying potential outcome, premature death from obesity related health problems, sets the campaign up for failure.

DO RIGHT! SUCCESSES: A SPRINGBOARD

While CCHGs program’s billboard and ad campaign are majorly flawed, there are a number of things the Do Right! campaign as a whole has gotten right. The organization was correct to take multi-faceted and all-encompassing approach to targeting childhood obesity prevention. Research suggests that families, schools and communities should all be included in programs aimed at preventing and reducing childhood obesity (22). Targeting parents exclusively has also been shown to be effective in reducing the BMI of overweight and obese children. A recent study from the United Kingdom showed that the BMI percentile of children whose parents were provided with eight sessions of cognitive-behavioral therapy for weight loss decreased significantly by 2.4% in the treatment group (23). Community involvement or not, targeting parents is crucial childhood obesity prevention programs. Children of obese parents are more likely to be obese themselves. Children aged 15 to 17 years old with at least one obese parent are over twice as likely as children with no obese parents to be obese adults. Children aged 1 to 2 years old were three times as likely to be obese as their peers who didn’t have an obese parent (24). Beyond the nuclear family, recent research has shown that obesity also spreads through social networks. A study conducted using data from Framingham, MA found that the chances of someone becoming obese increase 57% if they had a long-term friend who was obese (25). However, succeeding in utilizing parent and community involvement in childhood obesity prevention programs is challenging. As anyone who has ever tried to lose even a few pounds knows, attempting to lose weight can be daunting. For an obese person the barriers to weight loss, potentially including difficulty engaging in physical activity, addiction and lack of social support, can often seem indomitable. At any rate, with at minimum an adequate level of support within the environment and from family and community members, childhood obesity can be overcome. Methods to resolve each of the previously outlined failings within the billboard and ad campaign are presented in the following three sections.

As addressed in a previous section of this paper, the Health Belief Model as a champion of rational decision-making, and as it was implemented, was not an effective archetype from which to create the childhood obesity prevention billboard and ad campaign. On the other hand, framing, as delineated within Prospect Theory, can be an incredibly useful tool with which to begin to reconstruct this intervention. Bearing in mind that the original intent of the ad was to create awareness of childhood obesity as a serious problem among parents of obese children, the following proposed ad is aimed at both parents and children who will inevitably see the ads as well. This approach utilizes an entirely novel angle that frames health, with regard to weight, as a desirable and attainable outcome.

The proposed billboards will feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This sends the following messages physical activity is fun obese children are also entitled to fun obese children can do sports. In this way fighting childhood obesity through physical activity is framed in a positive light, as a fun and attainable goal. Making weight-loss and health attainable completely reverses the billboards, taking them from negative to positive and fomenting self-efficacy in children.

ENGENDERING SELF-EFFICACY BY NORMALIZING HEALTH

Labeling and normalizing obesity both have serious negative consequences at the individual and thus also societal level. They contribute to lower levels of self-esteem among obese children, and contribute to extensive monetary costs at the national level. A good public health campaign will succeed in achieving improved health and preventing obesity without further contributing to the extensive and damaging effects of labeling. While the billboard proposed in the prior section may be argued as normalizing obesity, it should be seen as normalizing activity among children of all shapes and sizes. Obese children are usually stereotyped as stupid, sloppy, ugly and lazy. In personal stories shared on blogs obese adults recount experiences that, in line with research published in peer reviewed journals, illustrate the cyclical nature of the self-fulfilling prophecy. In a blog published on Newsweek, Leslie Kinzel wrote,

“Prior to being told I was fat by my well-intentioned pediatrician … I'd spent my life as an active and athletic child, my fatness no obstacle in keeping up with my peers (and frequently besting them). As I got older I came to understand what being fat meant: fat kids were lousy at sports, and those who tried to play were to be mocked for it. Fat kids were always picked last, and though I was never picked last, I came to fear that it would inevitably happen. So I stopped playing. I backed away from sports and games altogether.” (26)

Her account is unfortunately not uncommon and characterizes the major negative impacts that labeling has on obese children. Obesity carries such stigma that for many children it becomes the single characteristic by which they feel most defined. At the end of her post Kinzel pleads,
“Call it a campaign against childhood couch-sitting. Call it a drive to get kids to go outside and play. Call it a movement to educate children on basic nutrition and how their amazing growing bodies work for them. But don't single out the fat kids. If I am any indication, doing this will only ensure that this generation will be fatter than ever, dragging behind them some heavy baggage around food issues and low self-esteem.” (26)

Kinzel’s well-put conclusion holds true given what has been learned from the failures of the Health Belief Model and the potential outcomes associated with Label Theory and Social Reactance Theory. It is absolutely necessary to change the personal characteristics associated with the obesity label. Getting obese children re-involved in sports and other physical activities will help to get rid of the stereotype that obese children can’t play sports. This will serve a dual purpose. It will encourage other obese children to take up arms so to speak and join the revolt against stereotypes. At the same time becoming involved in sports once again or perhaps for the first time will have positive health effects. While these effects certainly can’t be expected to be immediate they will have a positive effect on the local environment that should grow exponentially.

ENGENDERING SELF-EFFICACY BY REVOLTING AGAINST THE LABEL

Inciting obese children in Cincinnati to rise up against the fat label takes advantage of the mechanisms described in Psychological Reactance Theory. This theory asserts that perceived limitations to freedom or autonomy provoke an aversive affective reaction in people (27). In other words, if an individual perceives that their freedom has somehow been limited they will become provoked to regain it. A wonderful example of psychological reactance at work is the Truth campaign, which aims to curb youth use of tobacco by inciting a rebellion of sorts among young people. The campaign’s theme is “truth, a generation united against tobacco” (28). The Truth campaign successfully framed the tobacco industry as a liar that was hiding the truth from teens. In doing so they provoked teens to rebel against big tobacco and its lies, successfully decreasing youth smoking initiation rates.

The proposed alternative billboards showing obese children standing up to the labels and stereotypes associated with childhood obesity will do the same. This reaction is particularly common when individuals feel obliged to adopt a particular opinion or engage in a specific behavior (27). The billboards will bring to light these expectations and the violation of freedom that they cause for obese children, inspiring rebellion. In inciting this silent, healthy insurrection the campaign will be rekindling self-efficacy in obese children, which has a powerful effect on an individual’s level of motivation. “Boredom and apathy occur when a challenge is too small anxiety and withdrawal occur when a challenge is too great curiosity and engagement occur when the challenge is optimal” (29). If children don’t feel like they will succeed in losing weight or getting healthy they are much less likely to try to do so. Engendering self-efficacy through these billboards is an indispensible component of a successful childhood obesity prevention public health campaign. Recent work has found that “exercise’s association with weight loss was better explained through psychological, rather than physiological (ie, caloric expenditure), pathways” proving even further the importance of self-efficacy in weight loss (30). Giving obese children a common cause and an enemy to take down will help to create this self-efficacy, aiding in reducing and preventing childhood obesity over time.

Childhood obesity is a serious public health threat that requires sincere and practical interventions. The potential health consequences that are associated with childhood obesity are grave. They are harmful both to the individual and at the national level. Obese children are at increased risk for type II diabetes, cardiovascular disease, respiratory problems and future reproductive problems. They have added to increased medical costs at the national level, and as childhood obesity prevalence rates are higher among lower income quintiles the increased prevalence of childhood obesity has contributed to growing government expenditures on health (1). Practical, effective solutions are crucial in the fight to prevent and decrease childhood obesity.

In order to create a billboard campaign that effectively reduces and prevents childhood obesity while carefully avoiding potential adverse affects that such a billboard could so easily have, as evidenced by the one used by CCHG, social and behavioral sciences theories should be employed. Social Cognitive Theory, Labeling Theory (which is also known as Social Reactance Theory), the Health Belief Model, Framing Theory (as well as Prospect Theory) and Psychological Reactance Theory were used to analyze and critique CCHG’s billboard and ad intervention. CCHG’s billboard intervention was found to be inappropriate on the grounds that it contributed to defeating self-efficacy among obese children, added to labeling and normalizing childhood obesity and resorted to terrorizing parents in an effort to create awareness and incite a behavior change among parents and children. These same theories were then employed to suggest an appropriate intervention to replace CCHG’s billboard ads. The proposed replacement intervention consists of billboards that feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This intervention is based on engendering self-efficacy by reframing the childhood obesity issue in a positive light, normalizing healthy choices among obese children and using Psychological Reactance Theory to empower children to fight against the labels associated with childhood obesity. Casting a glow of optimism on the problem will help to bring back to life self-efficacy that has been squashed by labeling and stigma. Social and behavioral sciences theories were instrumental tools in understanding the effects that the Cincinnati CHG’s billboards could be expected to have on the target population, as well as any projected externalities, and in creating a better alternative.

REFERENCES
1. Overweight and Obesity. U.S. Obesity Trends. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/obesity/data/trends.html.
2. Do Right!. The Crisis. Cincinnati, OH: The Center for Closing the Health Gap in Greater Cincinnati. http://dorightcincy.org/the-crisis.
3. Childhood Obesity. Ohio Childhood Obesity Prevention Campaign Stirs Controversy. Princeton, NJ: Robert Wood Johnson Foundation. http://www.rwjf.org/childhoodobesity/digest.jsp?id=8398&c=OTC-RSS&attr=DI.
4. Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 200152:1-26.
5. Hammond R. The Economic Costs of Obesity. Brookings Institution. May 4, 2011. http://www.brookings.edu/multimedia/video/2010/0914_obesity_hammond.aspx.
6. Herper M. The Hidden Cost of Obesity. Forbes [online]. November 24, 2006. http://www.forbes.com/2006/07/19/obesity-fat-costs_cx_mh_0720obesity.html.
7. Epstein LH, Wing RR, Valoski A. Childhood obesity. Pediatr. Clin. North Am. 198532(2):363-379.
8. Krassas GE, Tzotzas T. Do obese children become obese adults: childhood predictors of adult disease. Pediatr Endocrinol Rev. 20041 Suppl 3:455-459.
9. Puhl RM, Latner JD. Stigma, obesity, and the health of the nation’s children. Psychol Bull. 2007133(4):557-580.
10. Laslett B, Warren CAB. Losing Weight: The Organizational Promotion of Behavior Change. Social Problems. 197523(1):69-80.
11. Link BG, Phelan JC. Conceptualizing Stigma. Annual Review of Sociology. 200127:363-385.
12. Holub SC. Individual differences in the anti-fat attitudes of preschool-children: The importance of perceived body size. Body Image. 20085(3):317-321.
13. Musher-Eizenman DR, Holub SC, Miller AB, Goldstein SE, Edwards-Leeper L. Body Size Stigmatization in Preschool Children: The Role of Control Attributions. Journal of Pediatric Psychology. 200429(8):613 -620.
14. Iobst EA. The Relationship Among Gender, Age, Blame, and Children’s Attributions about an Overweight Peer. 2007. Available at: http://etd.ohiolink.edu/view.cgi?acc_num=ucin1242390002. Accessed May 4, 2011.
15. Bensley K. Obesity and Perceptions of the Body in Teenage American Girls. UCL Centre for Applied Global Citizenship [online]. December 17, 2010. London, U.K.: . http://www.ucl.ac.uk/network-for-student-activism/w/Obesity_and_Perceptions_of_the_Body_in_Teenage_American_Girls.
16. Orr K. Provacative local campaign to target childhood obesity. WVXU Radio [online]. July 31, 2008. http://www.wvxu.org/news/wvxunews_article.asp?ID=5421.
17. Etelson D, Brand DA, Patrick PA, Shirali A. Childhood Obesity: Do Parents Recognize This Health Risk? Obesity. 200311(11):1362-1368.
18. Health & Parenting. Many Parents Don’t See Child Obesity. Web MD. http://www.webmd.com/parenting/news/20071211/many-parents-dont-see-child-obesity.
19. Janz NK, Becker MH. The Health Belief Model: A Decade Later. Health Education & Behavior. 198411(1):1 -47.
20. Rosenstock IM, Strecher VJ, Becker MH. Social Learning Theory and the Health Belief Model. Health Education & Behavior. 198815(2):175-183.
21. Kahneman D, Tversky A. Prospect Theory: An Analysis of Decision under Risk. Econometrica. 197947(2):263-291.
22. Lindsay AC, Sussner KM, Kim J, Gortmaker S. The role of parents in preventing childhood obesity. Future Child. 200616(1):169-186.
23. Jansen E, Mulkens S, Jansen A. Tackling childhood overweight: treating parents exclusively is effective. Int J Obes (Lond). 201135(4):501-509.
24. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N. Engl. J. Med. 1997337(13):869-873.
25. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N. Engl. J. Med. 2007357(4):370-379.
26. Kinzel L. Why the first lady's fight to end childhood obesity does damage to the children it's trying to help. Newsweek [online]. April 20, 2010. http://www.newsweek.com/2010/04/19/fat-kids-cruel-world.html.
27. Burke WW, Lake DG, Paine JW. Organization Change: A Comprehensive Reader. John Wiley and Sons 2008.
28. Truth. http://www.thetruth.com/.
29. Snyder CR, Lopez SJ. Oxford handbook of positive psychology. Oxford University Press US 2009 (P573).
30. Annesi JJ. Behaviorally supported exercise predicts weight loss in obese adults through improvements in mood, self-efficacy, and self-regulation, rather than by caloric expenditure. Perm J. 201115(1):23-27.


Challenging Dogma - Spring 2011

Today over one third of U.S. adults and 17% of U.S. children are obese. In the last three decades, obesity rates for adults have doubled and rates for children have tripled. However, the burden of obesity is not evenly distributed, and falls heavily on minorities. The 2009 Behavioral Risk Factor Surveillance System report showed that “blacks were 51% more likely and Hispanics were 21% more likely than non-Hispanic whites to be obese” (1). It is also geographically unevenly distributed with the American Midwest suffering higher obesity prevalence rates than the rest of the country. Cincinnati, Ohio is a beautiful Midwestern city situated at the southern edge of Ohio, across the Ohio River from Kentucky. However, like many Midwestern cities and states, Cincinnati has seen an alarming increase in obesity among adults and children in the last few decades. According to CDC 29.6% of Ohioans were obese in 2009. This increase has serious health consequences for adults and children. Obesity related diseases like type 2 diabetes, which previously only affected adults, is now affecting children (1). Obese children are also at higher risk of suffering cardiovascular disease. Obesity, including childhood obesity, is known to be a risk factor for a number of diseases including cancers, stroke, respiratory problems and reproductive health problems. The annual hospital costs related to childhood obesity increased from $35 million in the period from 1979-1981 to $127 million in the period from 1997-1999 (1).

In 2008 the nonprofit Center for Closing the Health Gap (2) in Greater Cincinnati began a campaign aimed at preventing childhood obesity. Childhood obesity prevention is a goal that fits perfectly within CCHG’s mission, which includes increasing awareness about health disparities (2). The childhood obesity epidemic in the Greater Cincinnati area disproportionately affects minority children. CCHG’s website reports that the rate of overweight and obesity in Hamilton County is 43% among Black, Non-Hispanic children and 21% among White, Non-Hispanic children. The negative consequences to health that may result from obesity are grave. The city was seeing children with hypertension and worrying rates of type II diabetes. Secondly CCHG saw that obesity disproportionately affected children of low-income parents and minority children, particularly Black, Hispanic and Appalachian children. To work toward preventing childhood obesity the organization initiated a campaign called “Do Right!” The specific target of the childhood prevention portion of the program aimed at “improving the health and well-being of children at Rockdale Elementary that are overweight and obese” (2). Rockdale Elementary is part of the Cincinnati Public Schools system and enrolls about 500 preschool and elementary school students from grades PK-8.

The “Do Right!” children’s program is multi-faceted. Its in school components include screening for BMI to identify overweight and obese children, referral for obese children to an after school physical activity and nutrition program. The program includes nutrition every other week by a dietician, physical activity and bi-weekly parent education and information sessions to discuss nutrition. The program also included 1-minute health tips on the radio, parent workshops in development and City School Awareness Presentations (2). Finally, the program ran a concurrent obesity awareness campaign that included billboards, bus shelters, radio advertisements, ads in minority newspapers and the website: www.dorightcincy.org. They feature obese children mowing down on big, greasy burgers in front of plates of onion rings with the words “Are we feeding our kids to death?” in large print. Below, they provide the Do Right! campaign’s website and phone number with the words “for information on how to combat obesity.” These ads are the focus of this critique.

First and foremost it alienates the very population it aims to help. Dwight Tillery, the executive director of CCHG, purports that the campaign was designed to serve as a wake-up call for families. It aims to incentivize parents to take the health of their children more seriously by showing them just how serious obesity is. Tillery said, “We can’t afford to be politically correct on this issue” (3). Political correctness or lack thereof aside the means simply do not justify the end. Whether or not parents are shocked into understanding the gravity of childhood obesity, children who see these ads are sure to feel alienated. The ads effectuate a pervasive sense of hopelessness, powerlessness and defeat. They say, “you’re obese and you’re being fed to death.” There is nothing in this message that engenders a sense of self-efficacy, or the idea that a lower, healthier weight is an attainable goal. This deficiency is the ad’s primary shortcoming. Self-efficacy as defined by psychologist and father of Social Cognitive Theory, Albert Bandura, is one's belief in one's ability to succeed in specific situations. The concept of self-efficacy is central to Social Cognitive Theory (4). Social Cognitive Theory asserts that behavior is based on the interaction between one’s environment, the behaviors one witnesses, and the individual themselves. Ads like these posted by CCHG construct a negative outcome expectation and in so doing dismantle whatever self-efficacy they could otherwise have fostered. It simply isn’t enough to provide a website and helpline when the ad itself effectively destroys self-efficacy.

Labeling and Normalizing Obesity

Not only do these ads beget powerlessness as shown in the last paragraph, but they concurrently label and normalize childhood obesity. The relationship between labeling and normalizing obesity presents a double-edged sword for potential public health interventions aimed at preventing childhood obesity. The normalizing of obesity comes with a hefty price tag including rising economic costs. According to the Brookings Institution, “the total costs of obesity in the U.S. alone may exceed $215 billion annually” (5). The direct medical costs resulting from obesity in the U.S. have been estimated to account for over 9% of the national medical bill (6). Societal costs are also extensive. Obese children are less likely to be sent to college by their parents (6). Obese adults are less likely to be given jobs, and miss more work, overall costing employers something on the order of $4 billion. Obese children are at much higher risk of becoming obese adults than their thinner peers (7 - 8). In sum, normalizing obesity, particularly in children, presents a great hazard to personal health and has a major negative impact on costs at the society level.

On the flip side of normalizing, labeling obese children forces them to contend with the heavy stigma associated with obesity, decreasing the likelihood that they will overcome the many hurdles to health and wellness placed on them by society. Obesity is the fourth most common type of discrimination people report experiencing in the U.S. (9). Simply labeling children as obese has the potential to greatly influence their behavior. While the ads don’t literally use the word “obese”, they make it visually quite clear that they’re targeting obese children, and point a finger at poor eating habits. Labeling Theory (which is also known as Social Reactance Theory) posits that labeling an individual influences their behavior and more often than not causes them to conform to the stereotypes of the label in a self-fulfilling prophecy (10 - 11). Obese children must endure negative stigma not only from their peers, but also by their teachers and themselves (9). They are often ascribed negative characteristics including mean, stupid, loud, sloppy, ugly, lazy, sad, and lacking in friends (12 - 14). Obese children can become trapped within this self-fulfilling prophecy and may thus accept these traits as part of their role in society as an “obese child”. Studies have shown that the stigma associated with obesity causes an increase in coping methods like binge eating instead of being a contributing factor to motivation to lose weight and stay healthy (9, 15).

Not only are the children taught how to act by the characteristics attached to their label, but they learn through cognition in conjunction with observing behaviors within their environment. These elements operate reciprocally. For example, the environment in which one is raised affects one’s cognition and perceptions of behaviors that one witnesses. In state where approximately 30% of people are obese and where television stations air shows like “More to Love” or “Ruby” (in which the star, Ruby, spends three seasons trying lose weight only to end the third season having gained over 50 pounds) obesity is not likely to be perceived as abnormal (1). It is likely seen simply as the status quo. Posting health billboards featuring obese children eating is wading into dangerous territory. It risks adding more obesity normalizing media to the local environment and simultaneously reinforces the stereotypes and stigma associated with obesity, particularly qualities like lack of self-control.

Proponents of the campaign cite the fact that 93% of parents of obese children didn’t perceive their kids as being an abnormal weight (16). Research backs up this frightening assertion and shows that parents of overweight children consistently underestimated their children's weight (17 - 18). CCHG’s Childhood Obesity Awareness Campaign aims to inform parents that their children are at risk for serious health outcomes and the organization has deemed that shocking parents is necessary to do so. This scaremongering tactic assumes that by informing parents that their children are at risk of very serious health outcomes like death, they will be moved to act. This assumption takes for granted that people are rational decision makers. Rational decision-making generally entails defining the problem, identifying criteria relevant to the problem, considering all possible solutions, calculating the potential consequences of each solution, and choosing the best option. Many public health interventions are based on this same assumption. It is in fact the very basis of the Health Belief Model, which is commonly used in public health interventions. This model postulates that a behavioral change at the individual level depends on a person’s attitudes toward expected outcomes, the strength of those attitudes and the resulting outcome expectancies, as well as the individual’s perceptions of how others see them, and what the societal norms are (4). All of these factors meld to produce intention, which is followed by behavior. When applied to a parent’s role in preventing childhood obesity, as CCHG has done, the model suggests that if parents become aware of the potential hazardous heath outcomes of obesity and their attitudes toward obesity change, they will intend to prevent or reverse obesity in their children and that intention will lead to a change in behavior. This progression assumes rationalism prevails. Unfortunately assuming rationality fails to account for an individual’s subconscious thought process, irrational decision-making, group behavior and societal and environmental factors, all of which are crucial variables guiding behavior (4, 19, 20).
Irrational decision-making often relies upon the way that a particular issue is introduced or framed. Framing is a method of presenting a fact, topic or idea in a specific light so as to change how it is received among the audience to whom it is being presented. The concept of framing is central to Prospect Theory. Put simply, Prospect Theory states that people value gains and losses differently and that individuals make decisions based on perceived gains rather than perceived losses (21). Given two options with equal outcomes, an individual would choose the outcome expressed in terms of possible gains instead of the one expressed in possible losses. CCHG’s billboard frames childhood obesity in terms of the expected health outcome as a loss. Presenting the issue of childhood obesity by framing it within the context of not only a negative outcome but its most terrifying potential outcome, premature death from obesity related health problems, sets the campaign up for failure.

DO RIGHT! SUCCESSES: A SPRINGBOARD

While CCHGs program’s billboard and ad campaign are majorly flawed, there are a number of things the Do Right! campaign as a whole has gotten right. The organization was correct to take multi-faceted and all-encompassing approach to targeting childhood obesity prevention. Research suggests that families, schools and communities should all be included in programs aimed at preventing and reducing childhood obesity (22). Targeting parents exclusively has also been shown to be effective in reducing the BMI of overweight and obese children. A recent study from the United Kingdom showed that the BMI percentile of children whose parents were provided with eight sessions of cognitive-behavioral therapy for weight loss decreased significantly by 2.4% in the treatment group (23). Community involvement or not, targeting parents is crucial childhood obesity prevention programs. Children of obese parents are more likely to be obese themselves. Children aged 15 to 17 years old with at least one obese parent are over twice as likely as children with no obese parents to be obese adults. Children aged 1 to 2 years old were three times as likely to be obese as their peers who didn’t have an obese parent (24). Beyond the nuclear family, recent research has shown that obesity also spreads through social networks. A study conducted using data from Framingham, MA found that the chances of someone becoming obese increase 57% if they had a long-term friend who was obese (25). However, succeeding in utilizing parent and community involvement in childhood obesity prevention programs is challenging. As anyone who has ever tried to lose even a few pounds knows, attempting to lose weight can be daunting. For an obese person the barriers to weight loss, potentially including difficulty engaging in physical activity, addiction and lack of social support, can often seem indomitable. At any rate, with at minimum an adequate level of support within the environment and from family and community members, childhood obesity can be overcome. Methods to resolve each of the previously outlined failings within the billboard and ad campaign are presented in the following three sections.

As addressed in a previous section of this paper, the Health Belief Model as a champion of rational decision-making, and as it was implemented, was not an effective archetype from which to create the childhood obesity prevention billboard and ad campaign. On the other hand, framing, as delineated within Prospect Theory, can be an incredibly useful tool with which to begin to reconstruct this intervention. Bearing in mind that the original intent of the ad was to create awareness of childhood obesity as a serious problem among parents of obese children, the following proposed ad is aimed at both parents and children who will inevitably see the ads as well. This approach utilizes an entirely novel angle that frames health, with regard to weight, as a desirable and attainable outcome.

The proposed billboards will feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This sends the following messages physical activity is fun obese children are also entitled to fun obese children can do sports. In this way fighting childhood obesity through physical activity is framed in a positive light, as a fun and attainable goal. Making weight-loss and health attainable completely reverses the billboards, taking them from negative to positive and fomenting self-efficacy in children.

ENGENDERING SELF-EFFICACY BY NORMALIZING HEALTH

Labeling and normalizing obesity both have serious negative consequences at the individual and thus also societal level. They contribute to lower levels of self-esteem among obese children, and contribute to extensive monetary costs at the national level. A good public health campaign will succeed in achieving improved health and preventing obesity without further contributing to the extensive and damaging effects of labeling. While the billboard proposed in the prior section may be argued as normalizing obesity, it should be seen as normalizing activity among children of all shapes and sizes. Obese children are usually stereotyped as stupid, sloppy, ugly and lazy. In personal stories shared on blogs obese adults recount experiences that, in line with research published in peer reviewed journals, illustrate the cyclical nature of the self-fulfilling prophecy. In a blog published on Newsweek, Leslie Kinzel wrote,

“Prior to being told I was fat by my well-intentioned pediatrician … I'd spent my life as an active and athletic child, my fatness no obstacle in keeping up with my peers (and frequently besting them). As I got older I came to understand what being fat meant: fat kids were lousy at sports, and those who tried to play were to be mocked for it. Fat kids were always picked last, and though I was never picked last, I came to fear that it would inevitably happen. So I stopped playing. I backed away from sports and games altogether.” (26)

Her account is unfortunately not uncommon and characterizes the major negative impacts that labeling has on obese children. Obesity carries such stigma that for many children it becomes the single characteristic by which they feel most defined. At the end of her post Kinzel pleads,
“Call it a campaign against childhood couch-sitting. Call it a drive to get kids to go outside and play. Call it a movement to educate children on basic nutrition and how their amazing growing bodies work for them. But don't single out the fat kids. If I am any indication, doing this will only ensure that this generation will be fatter than ever, dragging behind them some heavy baggage around food issues and low self-esteem.” (26)

Kinzel’s well-put conclusion holds true given what has been learned from the failures of the Health Belief Model and the potential outcomes associated with Label Theory and Social Reactance Theory. It is absolutely necessary to change the personal characteristics associated with the obesity label. Getting obese children re-involved in sports and other physical activities will help to get rid of the stereotype that obese children can’t play sports. This will serve a dual purpose. It will encourage other obese children to take up arms so to speak and join the revolt against stereotypes. At the same time becoming involved in sports once again or perhaps for the first time will have positive health effects. While these effects certainly can’t be expected to be immediate they will have a positive effect on the local environment that should grow exponentially.

ENGENDERING SELF-EFFICACY BY REVOLTING AGAINST THE LABEL

Inciting obese children in Cincinnati to rise up against the fat label takes advantage of the mechanisms described in Psychological Reactance Theory. This theory asserts that perceived limitations to freedom or autonomy provoke an aversive affective reaction in people (27). In other words, if an individual perceives that their freedom has somehow been limited they will become provoked to regain it. A wonderful example of psychological reactance at work is the Truth campaign, which aims to curb youth use of tobacco by inciting a rebellion of sorts among young people. The campaign’s theme is “truth, a generation united against tobacco” (28). The Truth campaign successfully framed the tobacco industry as a liar that was hiding the truth from teens. In doing so they provoked teens to rebel against big tobacco and its lies, successfully decreasing youth smoking initiation rates.

The proposed alternative billboards showing obese children standing up to the labels and stereotypes associated with childhood obesity will do the same. This reaction is particularly common when individuals feel obliged to adopt a particular opinion or engage in a specific behavior (27). The billboards will bring to light these expectations and the violation of freedom that they cause for obese children, inspiring rebellion. In inciting this silent, healthy insurrection the campaign will be rekindling self-efficacy in obese children, which has a powerful effect on an individual’s level of motivation. “Boredom and apathy occur when a challenge is too small anxiety and withdrawal occur when a challenge is too great curiosity and engagement occur when the challenge is optimal” (29). If children don’t feel like they will succeed in losing weight or getting healthy they are much less likely to try to do so. Engendering self-efficacy through these billboards is an indispensible component of a successful childhood obesity prevention public health campaign. Recent work has found that “exercise’s association with weight loss was better explained through psychological, rather than physiological (ie, caloric expenditure), pathways” proving even further the importance of self-efficacy in weight loss (30). Giving obese children a common cause and an enemy to take down will help to create this self-efficacy, aiding in reducing and preventing childhood obesity over time.

Childhood obesity is a serious public health threat that requires sincere and practical interventions. The potential health consequences that are associated with childhood obesity are grave. They are harmful both to the individual and at the national level. Obese children are at increased risk for type II diabetes, cardiovascular disease, respiratory problems and future reproductive problems. They have added to increased medical costs at the national level, and as childhood obesity prevalence rates are higher among lower income quintiles the increased prevalence of childhood obesity has contributed to growing government expenditures on health (1). Practical, effective solutions are crucial in the fight to prevent and decrease childhood obesity.

In order to create a billboard campaign that effectively reduces and prevents childhood obesity while carefully avoiding potential adverse affects that such a billboard could so easily have, as evidenced by the one used by CCHG, social and behavioral sciences theories should be employed. Social Cognitive Theory, Labeling Theory (which is also known as Social Reactance Theory), the Health Belief Model, Framing Theory (as well as Prospect Theory) and Psychological Reactance Theory were used to analyze and critique CCHG’s billboard and ad intervention. CCHG’s billboard intervention was found to be inappropriate on the grounds that it contributed to defeating self-efficacy among obese children, added to labeling and normalizing childhood obesity and resorted to terrorizing parents in an effort to create awareness and incite a behavior change among parents and children. These same theories were then employed to suggest an appropriate intervention to replace CCHG’s billboard ads. The proposed replacement intervention consists of billboards that feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This intervention is based on engendering self-efficacy by reframing the childhood obesity issue in a positive light, normalizing healthy choices among obese children and using Psychological Reactance Theory to empower children to fight against the labels associated with childhood obesity. Casting a glow of optimism on the problem will help to bring back to life self-efficacy that has been squashed by labeling and stigma. Social and behavioral sciences theories were instrumental tools in understanding the effects that the Cincinnati CHG’s billboards could be expected to have on the target population, as well as any projected externalities, and in creating a better alternative.

REFERENCES
1. Overweight and Obesity. U.S. Obesity Trends. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/obesity/data/trends.html.
2. Do Right!. The Crisis. Cincinnati, OH: The Center for Closing the Health Gap in Greater Cincinnati. http://dorightcincy.org/the-crisis.
3. Childhood Obesity. Ohio Childhood Obesity Prevention Campaign Stirs Controversy. Princeton, NJ: Robert Wood Johnson Foundation. http://www.rwjf.org/childhoodobesity/digest.jsp?id=8398&c=OTC-RSS&attr=DI.
4. Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 200152:1-26.
5. Hammond R. The Economic Costs of Obesity. Brookings Institution. May 4, 2011. http://www.brookings.edu/multimedia/video/2010/0914_obesity_hammond.aspx.
6. Herper M. The Hidden Cost of Obesity. Forbes [online]. November 24, 2006. http://www.forbes.com/2006/07/19/obesity-fat-costs_cx_mh_0720obesity.html.
7. Epstein LH, Wing RR, Valoski A. Childhood obesity. Pediatr. Clin. North Am. 198532(2):363-379.
8. Krassas GE, Tzotzas T. Do obese children become obese adults: childhood predictors of adult disease. Pediatr Endocrinol Rev. 20041 Suppl 3:455-459.
9. Puhl RM, Latner JD. Stigma, obesity, and the health of the nation’s children. Psychol Bull. 2007133(4):557-580.
10. Laslett B, Warren CAB. Losing Weight: The Organizational Promotion of Behavior Change. Social Problems. 197523(1):69-80.
11. Link BG, Phelan JC. Conceptualizing Stigma. Annual Review of Sociology. 200127:363-385.
12. Holub SC. Individual differences in the anti-fat attitudes of preschool-children: The importance of perceived body size. Body Image. 20085(3):317-321.
13. Musher-Eizenman DR, Holub SC, Miller AB, Goldstein SE, Edwards-Leeper L. Body Size Stigmatization in Preschool Children: The Role of Control Attributions. Journal of Pediatric Psychology. 200429(8):613 -620.
14. Iobst EA. The Relationship Among Gender, Age, Blame, and Children’s Attributions about an Overweight Peer. 2007. Available at: http://etd.ohiolink.edu/view.cgi?acc_num=ucin1242390002. Accessed May 4, 2011.
15. Bensley K. Obesity and Perceptions of the Body in Teenage American Girls. UCL Centre for Applied Global Citizenship [online]. December 17, 2010. London, U.K.: . http://www.ucl.ac.uk/network-for-student-activism/w/Obesity_and_Perceptions_of_the_Body_in_Teenage_American_Girls.
16. Orr K. Provacative local campaign to target childhood obesity. WVXU Radio [online]. July 31, 2008. http://www.wvxu.org/news/wvxunews_article.asp?ID=5421.
17. Etelson D, Brand DA, Patrick PA, Shirali A. Childhood Obesity: Do Parents Recognize This Health Risk? Obesity. 200311(11):1362-1368.
18. Health & Parenting. Many Parents Don’t See Child Obesity. Web MD. http://www.webmd.com/parenting/news/20071211/many-parents-dont-see-child-obesity.
19. Janz NK, Becker MH. The Health Belief Model: A Decade Later. Health Education & Behavior. 198411(1):1 -47.
20. Rosenstock IM, Strecher VJ, Becker MH. Social Learning Theory and the Health Belief Model. Health Education & Behavior. 198815(2):175-183.
21. Kahneman D, Tversky A. Prospect Theory: An Analysis of Decision under Risk. Econometrica. 197947(2):263-291.
22. Lindsay AC, Sussner KM, Kim J, Gortmaker S. The role of parents in preventing childhood obesity. Future Child. 200616(1):169-186.
23. Jansen E, Mulkens S, Jansen A. Tackling childhood overweight: treating parents exclusively is effective. Int J Obes (Lond). 201135(4):501-509.
24. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N. Engl. J. Med. 1997337(13):869-873.
25. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N. Engl. J. Med. 2007357(4):370-379.
26. Kinzel L. Why the first lady's fight to end childhood obesity does damage to the children it's trying to help. Newsweek [online]. April 20, 2010. http://www.newsweek.com/2010/04/19/fat-kids-cruel-world.html.
27. Burke WW, Lake DG, Paine JW. Organization Change: A Comprehensive Reader. John Wiley and Sons 2008.
28. Truth. http://www.thetruth.com/.
29. Snyder CR, Lopez SJ. Oxford handbook of positive psychology. Oxford University Press US 2009 (P573).
30. Annesi JJ. Behaviorally supported exercise predicts weight loss in obese adults through improvements in mood, self-efficacy, and self-regulation, rather than by caloric expenditure. Perm J. 201115(1):23-27.


Challenging Dogma - Spring 2011

Today over one third of U.S. adults and 17% of U.S. children are obese. In the last three decades, obesity rates for adults have doubled and rates for children have tripled. However, the burden of obesity is not evenly distributed, and falls heavily on minorities. The 2009 Behavioral Risk Factor Surveillance System report showed that “blacks were 51% more likely and Hispanics were 21% more likely than non-Hispanic whites to be obese” (1). It is also geographically unevenly distributed with the American Midwest suffering higher obesity prevalence rates than the rest of the country. Cincinnati, Ohio is a beautiful Midwestern city situated at the southern edge of Ohio, across the Ohio River from Kentucky. However, like many Midwestern cities and states, Cincinnati has seen an alarming increase in obesity among adults and children in the last few decades. According to CDC 29.6% of Ohioans were obese in 2009. This increase has serious health consequences for adults and children. Obesity related diseases like type 2 diabetes, which previously only affected adults, is now affecting children (1). Obese children are also at higher risk of suffering cardiovascular disease. Obesity, including childhood obesity, is known to be a risk factor for a number of diseases including cancers, stroke, respiratory problems and reproductive health problems. The annual hospital costs related to childhood obesity increased from $35 million in the period from 1979-1981 to $127 million in the period from 1997-1999 (1).

In 2008 the nonprofit Center for Closing the Health Gap (2) in Greater Cincinnati began a campaign aimed at preventing childhood obesity. Childhood obesity prevention is a goal that fits perfectly within CCHG’s mission, which includes increasing awareness about health disparities (2). The childhood obesity epidemic in the Greater Cincinnati area disproportionately affects minority children. CCHG’s website reports that the rate of overweight and obesity in Hamilton County is 43% among Black, Non-Hispanic children and 21% among White, Non-Hispanic children. The negative consequences to health that may result from obesity are grave. The city was seeing children with hypertension and worrying rates of type II diabetes. Secondly CCHG saw that obesity disproportionately affected children of low-income parents and minority children, particularly Black, Hispanic and Appalachian children. To work toward preventing childhood obesity the organization initiated a campaign called “Do Right!” The specific target of the childhood prevention portion of the program aimed at “improving the health and well-being of children at Rockdale Elementary that are overweight and obese” (2). Rockdale Elementary is part of the Cincinnati Public Schools system and enrolls about 500 preschool and elementary school students from grades PK-8.

The “Do Right!” children’s program is multi-faceted. Its in school components include screening for BMI to identify overweight and obese children, referral for obese children to an after school physical activity and nutrition program. The program includes nutrition every other week by a dietician, physical activity and bi-weekly parent education and information sessions to discuss nutrition. The program also included 1-minute health tips on the radio, parent workshops in development and City School Awareness Presentations (2). Finally, the program ran a concurrent obesity awareness campaign that included billboards, bus shelters, radio advertisements, ads in minority newspapers and the website: www.dorightcincy.org. They feature obese children mowing down on big, greasy burgers in front of plates of onion rings with the words “Are we feeding our kids to death?” in large print. Below, they provide the Do Right! campaign’s website and phone number with the words “for information on how to combat obesity.” These ads are the focus of this critique.

First and foremost it alienates the very population it aims to help. Dwight Tillery, the executive director of CCHG, purports that the campaign was designed to serve as a wake-up call for families. It aims to incentivize parents to take the health of their children more seriously by showing them just how serious obesity is. Tillery said, “We can’t afford to be politically correct on this issue” (3). Political correctness or lack thereof aside the means simply do not justify the end. Whether or not parents are shocked into understanding the gravity of childhood obesity, children who see these ads are sure to feel alienated. The ads effectuate a pervasive sense of hopelessness, powerlessness and defeat. They say, “you’re obese and you’re being fed to death.” There is nothing in this message that engenders a sense of self-efficacy, or the idea that a lower, healthier weight is an attainable goal. This deficiency is the ad’s primary shortcoming. Self-efficacy as defined by psychologist and father of Social Cognitive Theory, Albert Bandura, is one's belief in one's ability to succeed in specific situations. The concept of self-efficacy is central to Social Cognitive Theory (4). Social Cognitive Theory asserts that behavior is based on the interaction between one’s environment, the behaviors one witnesses, and the individual themselves. Ads like these posted by CCHG construct a negative outcome expectation and in so doing dismantle whatever self-efficacy they could otherwise have fostered. It simply isn’t enough to provide a website and helpline when the ad itself effectively destroys self-efficacy.

Labeling and Normalizing Obesity

Not only do these ads beget powerlessness as shown in the last paragraph, but they concurrently label and normalize childhood obesity. The relationship between labeling and normalizing obesity presents a double-edged sword for potential public health interventions aimed at preventing childhood obesity. The normalizing of obesity comes with a hefty price tag including rising economic costs. According to the Brookings Institution, “the total costs of obesity in the U.S. alone may exceed $215 billion annually” (5). The direct medical costs resulting from obesity in the U.S. have been estimated to account for over 9% of the national medical bill (6). Societal costs are also extensive. Obese children are less likely to be sent to college by their parents (6). Obese adults are less likely to be given jobs, and miss more work, overall costing employers something on the order of $4 billion. Obese children are at much higher risk of becoming obese adults than their thinner peers (7 - 8). In sum, normalizing obesity, particularly in children, presents a great hazard to personal health and has a major negative impact on costs at the society level.

On the flip side of normalizing, labeling obese children forces them to contend with the heavy stigma associated with obesity, decreasing the likelihood that they will overcome the many hurdles to health and wellness placed on them by society. Obesity is the fourth most common type of discrimination people report experiencing in the U.S. (9). Simply labeling children as obese has the potential to greatly influence their behavior. While the ads don’t literally use the word “obese”, they make it visually quite clear that they’re targeting obese children, and point a finger at poor eating habits. Labeling Theory (which is also known as Social Reactance Theory) posits that labeling an individual influences their behavior and more often than not causes them to conform to the stereotypes of the label in a self-fulfilling prophecy (10 - 11). Obese children must endure negative stigma not only from their peers, but also by their teachers and themselves (9). They are often ascribed negative characteristics including mean, stupid, loud, sloppy, ugly, lazy, sad, and lacking in friends (12 - 14). Obese children can become trapped within this self-fulfilling prophecy and may thus accept these traits as part of their role in society as an “obese child”. Studies have shown that the stigma associated with obesity causes an increase in coping methods like binge eating instead of being a contributing factor to motivation to lose weight and stay healthy (9, 15).

Not only are the children taught how to act by the characteristics attached to their label, but they learn through cognition in conjunction with observing behaviors within their environment. These elements operate reciprocally. For example, the environment in which one is raised affects one’s cognition and perceptions of behaviors that one witnesses. In state where approximately 30% of people are obese and where television stations air shows like “More to Love” or “Ruby” (in which the star, Ruby, spends three seasons trying lose weight only to end the third season having gained over 50 pounds) obesity is not likely to be perceived as abnormal (1). It is likely seen simply as the status quo. Posting health billboards featuring obese children eating is wading into dangerous territory. It risks adding more obesity normalizing media to the local environment and simultaneously reinforces the stereotypes and stigma associated with obesity, particularly qualities like lack of self-control.

Proponents of the campaign cite the fact that 93% of parents of obese children didn’t perceive their kids as being an abnormal weight (16). Research backs up this frightening assertion and shows that parents of overweight children consistently underestimated their children's weight (17 - 18). CCHG’s Childhood Obesity Awareness Campaign aims to inform parents that their children are at risk for serious health outcomes and the organization has deemed that shocking parents is necessary to do so. This scaremongering tactic assumes that by informing parents that their children are at risk of very serious health outcomes like death, they will be moved to act. This assumption takes for granted that people are rational decision makers. Rational decision-making generally entails defining the problem, identifying criteria relevant to the problem, considering all possible solutions, calculating the potential consequences of each solution, and choosing the best option. Many public health interventions are based on this same assumption. It is in fact the very basis of the Health Belief Model, which is commonly used in public health interventions. This model postulates that a behavioral change at the individual level depends on a person’s attitudes toward expected outcomes, the strength of those attitudes and the resulting outcome expectancies, as well as the individual’s perceptions of how others see them, and what the societal norms are (4). All of these factors meld to produce intention, which is followed by behavior. When applied to a parent’s role in preventing childhood obesity, as CCHG has done, the model suggests that if parents become aware of the potential hazardous heath outcomes of obesity and their attitudes toward obesity change, they will intend to prevent or reverse obesity in their children and that intention will lead to a change in behavior. This progression assumes rationalism prevails. Unfortunately assuming rationality fails to account for an individual’s subconscious thought process, irrational decision-making, group behavior and societal and environmental factors, all of which are crucial variables guiding behavior (4, 19, 20).
Irrational decision-making often relies upon the way that a particular issue is introduced or framed. Framing is a method of presenting a fact, topic or idea in a specific light so as to change how it is received among the audience to whom it is being presented. The concept of framing is central to Prospect Theory. Put simply, Prospect Theory states that people value gains and losses differently and that individuals make decisions based on perceived gains rather than perceived losses (21). Given two options with equal outcomes, an individual would choose the outcome expressed in terms of possible gains instead of the one expressed in possible losses. CCHG’s billboard frames childhood obesity in terms of the expected health outcome as a loss. Presenting the issue of childhood obesity by framing it within the context of not only a negative outcome but its most terrifying potential outcome, premature death from obesity related health problems, sets the campaign up for failure.

DO RIGHT! SUCCESSES: A SPRINGBOARD

While CCHGs program’s billboard and ad campaign are majorly flawed, there are a number of things the Do Right! campaign as a whole has gotten right. The organization was correct to take multi-faceted and all-encompassing approach to targeting childhood obesity prevention. Research suggests that families, schools and communities should all be included in programs aimed at preventing and reducing childhood obesity (22). Targeting parents exclusively has also been shown to be effective in reducing the BMI of overweight and obese children. A recent study from the United Kingdom showed that the BMI percentile of children whose parents were provided with eight sessions of cognitive-behavioral therapy for weight loss decreased significantly by 2.4% in the treatment group (23). Community involvement or not, targeting parents is crucial childhood obesity prevention programs. Children of obese parents are more likely to be obese themselves. Children aged 15 to 17 years old with at least one obese parent are over twice as likely as children with no obese parents to be obese adults. Children aged 1 to 2 years old were three times as likely to be obese as their peers who didn’t have an obese parent (24). Beyond the nuclear family, recent research has shown that obesity also spreads through social networks. A study conducted using data from Framingham, MA found that the chances of someone becoming obese increase 57% if they had a long-term friend who was obese (25). However, succeeding in utilizing parent and community involvement in childhood obesity prevention programs is challenging. As anyone who has ever tried to lose even a few pounds knows, attempting to lose weight can be daunting. For an obese person the barriers to weight loss, potentially including difficulty engaging in physical activity, addiction and lack of social support, can often seem indomitable. At any rate, with at minimum an adequate level of support within the environment and from family and community members, childhood obesity can be overcome. Methods to resolve each of the previously outlined failings within the billboard and ad campaign are presented in the following three sections.

As addressed in a previous section of this paper, the Health Belief Model as a champion of rational decision-making, and as it was implemented, was not an effective archetype from which to create the childhood obesity prevention billboard and ad campaign. On the other hand, framing, as delineated within Prospect Theory, can be an incredibly useful tool with which to begin to reconstruct this intervention. Bearing in mind that the original intent of the ad was to create awareness of childhood obesity as a serious problem among parents of obese children, the following proposed ad is aimed at both parents and children who will inevitably see the ads as well. This approach utilizes an entirely novel angle that frames health, with regard to weight, as a desirable and attainable outcome.

The proposed billboards will feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This sends the following messages physical activity is fun obese children are also entitled to fun obese children can do sports. In this way fighting childhood obesity through physical activity is framed in a positive light, as a fun and attainable goal. Making weight-loss and health attainable completely reverses the billboards, taking them from negative to positive and fomenting self-efficacy in children.

ENGENDERING SELF-EFFICACY BY NORMALIZING HEALTH

Labeling and normalizing obesity both have serious negative consequences at the individual and thus also societal level. They contribute to lower levels of self-esteem among obese children, and contribute to extensive monetary costs at the national level. A good public health campaign will succeed in achieving improved health and preventing obesity without further contributing to the extensive and damaging effects of labeling. While the billboard proposed in the prior section may be argued as normalizing obesity, it should be seen as normalizing activity among children of all shapes and sizes. Obese children are usually stereotyped as stupid, sloppy, ugly and lazy. In personal stories shared on blogs obese adults recount experiences that, in line with research published in peer reviewed journals, illustrate the cyclical nature of the self-fulfilling prophecy. In a blog published on Newsweek, Leslie Kinzel wrote,

“Prior to being told I was fat by my well-intentioned pediatrician … I'd spent my life as an active and athletic child, my fatness no obstacle in keeping up with my peers (and frequently besting them). As I got older I came to understand what being fat meant: fat kids were lousy at sports, and those who tried to play were to be mocked for it. Fat kids were always picked last, and though I was never picked last, I came to fear that it would inevitably happen. So I stopped playing. I backed away from sports and games altogether.” (26)

Her account is unfortunately not uncommon and characterizes the major negative impacts that labeling has on obese children. Obesity carries such stigma that for many children it becomes the single characteristic by which they feel most defined. At the end of her post Kinzel pleads,
“Call it a campaign against childhood couch-sitting. Call it a drive to get kids to go outside and play. Call it a movement to educate children on basic nutrition and how their amazing growing bodies work for them. But don't single out the fat kids. If I am any indication, doing this will only ensure that this generation will be fatter than ever, dragging behind them some heavy baggage around food issues and low self-esteem.” (26)

Kinzel’s well-put conclusion holds true given what has been learned from the failures of the Health Belief Model and the potential outcomes associated with Label Theory and Social Reactance Theory. It is absolutely necessary to change the personal characteristics associated with the obesity label. Getting obese children re-involved in sports and other physical activities will help to get rid of the stereotype that obese children can’t play sports. This will serve a dual purpose. It will encourage other obese children to take up arms so to speak and join the revolt against stereotypes. At the same time becoming involved in sports once again or perhaps for the first time will have positive health effects. While these effects certainly can’t be expected to be immediate they will have a positive effect on the local environment that should grow exponentially.

ENGENDERING SELF-EFFICACY BY REVOLTING AGAINST THE LABEL

Inciting obese children in Cincinnati to rise up against the fat label takes advantage of the mechanisms described in Psychological Reactance Theory. This theory asserts that perceived limitations to freedom or autonomy provoke an aversive affective reaction in people (27). In other words, if an individual perceives that their freedom has somehow been limited they will become provoked to regain it. A wonderful example of psychological reactance at work is the Truth campaign, which aims to curb youth use of tobacco by inciting a rebellion of sorts among young people. The campaign’s theme is “truth, a generation united against tobacco” (28). The Truth campaign successfully framed the tobacco industry as a liar that was hiding the truth from teens. In doing so they provoked teens to rebel against big tobacco and its lies, successfully decreasing youth smoking initiation rates.

The proposed alternative billboards showing obese children standing up to the labels and stereotypes associated with childhood obesity will do the same. This reaction is particularly common when individuals feel obliged to adopt a particular opinion or engage in a specific behavior (27). The billboards will bring to light these expectations and the violation of freedom that they cause for obese children, inspiring rebellion. In inciting this silent, healthy insurrection the campaign will be rekindling self-efficacy in obese children, which has a powerful effect on an individual’s level of motivation. “Boredom and apathy occur when a challenge is too small anxiety and withdrawal occur when a challenge is too great curiosity and engagement occur when the challenge is optimal” (29). If children don’t feel like they will succeed in losing weight or getting healthy they are much less likely to try to do so. Engendering self-efficacy through these billboards is an indispensible component of a successful childhood obesity prevention public health campaign. Recent work has found that “exercise’s association with weight loss was better explained through psychological, rather than physiological (ie, caloric expenditure), pathways” proving even further the importance of self-efficacy in weight loss (30). Giving obese children a common cause and an enemy to take down will help to create this self-efficacy, aiding in reducing and preventing childhood obesity over time.

Childhood obesity is a serious public health threat that requires sincere and practical interventions. The potential health consequences that are associated with childhood obesity are grave. They are harmful both to the individual and at the national level. Obese children are at increased risk for type II diabetes, cardiovascular disease, respiratory problems and future reproductive problems. They have added to increased medical costs at the national level, and as childhood obesity prevalence rates are higher among lower income quintiles the increased prevalence of childhood obesity has contributed to growing government expenditures on health (1). Practical, effective solutions are crucial in the fight to prevent and decrease childhood obesity.

In order to create a billboard campaign that effectively reduces and prevents childhood obesity while carefully avoiding potential adverse affects that such a billboard could so easily have, as evidenced by the one used by CCHG, social and behavioral sciences theories should be employed. Social Cognitive Theory, Labeling Theory (which is also known as Social Reactance Theory), the Health Belief Model, Framing Theory (as well as Prospect Theory) and Psychological Reactance Theory were used to analyze and critique CCHG’s billboard and ad intervention. CCHG’s billboard intervention was found to be inappropriate on the grounds that it contributed to defeating self-efficacy among obese children, added to labeling and normalizing childhood obesity and resorted to terrorizing parents in an effort to create awareness and incite a behavior change among parents and children. These same theories were then employed to suggest an appropriate intervention to replace CCHG’s billboard ads. The proposed replacement intervention consists of billboards that feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This intervention is based on engendering self-efficacy by reframing the childhood obesity issue in a positive light, normalizing healthy choices among obese children and using Psychological Reactance Theory to empower children to fight against the labels associated with childhood obesity. Casting a glow of optimism on the problem will help to bring back to life self-efficacy that has been squashed by labeling and stigma. Social and behavioral sciences theories were instrumental tools in understanding the effects that the Cincinnati CHG’s billboards could be expected to have on the target population, as well as any projected externalities, and in creating a better alternative.

REFERENCES
1. Overweight and Obesity. U.S. Obesity Trends. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/obesity/data/trends.html.
2. Do Right!. The Crisis. Cincinnati, OH: The Center for Closing the Health Gap in Greater Cincinnati. http://dorightcincy.org/the-crisis.
3. Childhood Obesity. Ohio Childhood Obesity Prevention Campaign Stirs Controversy. Princeton, NJ: Robert Wood Johnson Foundation. http://www.rwjf.org/childhoodobesity/digest.jsp?id=8398&c=OTC-RSS&attr=DI.
4. Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 200152:1-26.
5. Hammond R. The Economic Costs of Obesity. Brookings Institution. May 4, 2011. http://www.brookings.edu/multimedia/video/2010/0914_obesity_hammond.aspx.
6. Herper M. The Hidden Cost of Obesity. Forbes [online]. November 24, 2006. http://www.forbes.com/2006/07/19/obesity-fat-costs_cx_mh_0720obesity.html.
7. Epstein LH, Wing RR, Valoski A. Childhood obesity. Pediatr. Clin. North Am. 198532(2):363-379.
8. Krassas GE, Tzotzas T. Do obese children become obese adults: childhood predictors of adult disease. Pediatr Endocrinol Rev. 20041 Suppl 3:455-459.
9. Puhl RM, Latner JD. Stigma, obesity, and the health of the nation’s children. Psychol Bull. 2007133(4):557-580.
10. Laslett B, Warren CAB. Losing Weight: The Organizational Promotion of Behavior Change. Social Problems. 197523(1):69-80.
11. Link BG, Phelan JC. Conceptualizing Stigma. Annual Review of Sociology. 200127:363-385.
12. Holub SC. Individual differences in the anti-fat attitudes of preschool-children: The importance of perceived body size. Body Image. 20085(3):317-321.
13. Musher-Eizenman DR, Holub SC, Miller AB, Goldstein SE, Edwards-Leeper L. Body Size Stigmatization in Preschool Children: The Role of Control Attributions. Journal of Pediatric Psychology. 200429(8):613 -620.
14. Iobst EA. The Relationship Among Gender, Age, Blame, and Children’s Attributions about an Overweight Peer. 2007. Available at: http://etd.ohiolink.edu/view.cgi?acc_num=ucin1242390002. Accessed May 4, 2011.
15. Bensley K. Obesity and Perceptions of the Body in Teenage American Girls. UCL Centre for Applied Global Citizenship [online]. December 17, 2010. London, U.K.: . http://www.ucl.ac.uk/network-for-student-activism/w/Obesity_and_Perceptions_of_the_Body_in_Teenage_American_Girls.
16. Orr K. Provacative local campaign to target childhood obesity. WVXU Radio [online]. July 31, 2008. http://www.wvxu.org/news/wvxunews_article.asp?ID=5421.
17. Etelson D, Brand DA, Patrick PA, Shirali A. Childhood Obesity: Do Parents Recognize This Health Risk? Obesity. 200311(11):1362-1368.
18. Health & Parenting. Many Parents Don’t See Child Obesity. Web MD. http://www.webmd.com/parenting/news/20071211/many-parents-dont-see-child-obesity.
19. Janz NK, Becker MH. The Health Belief Model: A Decade Later. Health Education & Behavior. 198411(1):1 -47.
20. Rosenstock IM, Strecher VJ, Becker MH. Social Learning Theory and the Health Belief Model. Health Education & Behavior. 198815(2):175-183.
21. Kahneman D, Tversky A. Prospect Theory: An Analysis of Decision under Risk. Econometrica. 197947(2):263-291.
22. Lindsay AC, Sussner KM, Kim J, Gortmaker S. The role of parents in preventing childhood obesity. Future Child. 200616(1):169-186.
23. Jansen E, Mulkens S, Jansen A. Tackling childhood overweight: treating parents exclusively is effective. Int J Obes (Lond). 201135(4):501-509.
24. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N. Engl. J. Med. 1997337(13):869-873.
25. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N. Engl. J. Med. 2007357(4):370-379.
26. Kinzel L. Why the first lady's fight to end childhood obesity does damage to the children it's trying to help. Newsweek [online]. April 20, 2010. http://www.newsweek.com/2010/04/19/fat-kids-cruel-world.html.
27. Burke WW, Lake DG, Paine JW. Organization Change: A Comprehensive Reader. John Wiley and Sons 2008.
28. Truth. http://www.thetruth.com/.
29. Snyder CR, Lopez SJ. Oxford handbook of positive psychology. Oxford University Press US 2009 (P573).
30. Annesi JJ. Behaviorally supported exercise predicts weight loss in obese adults through improvements in mood, self-efficacy, and self-regulation, rather than by caloric expenditure. Perm J. 201115(1):23-27.


Challenging Dogma - Spring 2011

Today over one third of U.S. adults and 17% of U.S. children are obese. In the last three decades, obesity rates for adults have doubled and rates for children have tripled. However, the burden of obesity is not evenly distributed, and falls heavily on minorities. The 2009 Behavioral Risk Factor Surveillance System report showed that “blacks were 51% more likely and Hispanics were 21% more likely than non-Hispanic whites to be obese” (1). It is also geographically unevenly distributed with the American Midwest suffering higher obesity prevalence rates than the rest of the country. Cincinnati, Ohio is a beautiful Midwestern city situated at the southern edge of Ohio, across the Ohio River from Kentucky. However, like many Midwestern cities and states, Cincinnati has seen an alarming increase in obesity among adults and children in the last few decades. According to CDC 29.6% of Ohioans were obese in 2009. This increase has serious health consequences for adults and children. Obesity related diseases like type 2 diabetes, which previously only affected adults, is now affecting children (1). Obese children are also at higher risk of suffering cardiovascular disease. Obesity, including childhood obesity, is known to be a risk factor for a number of diseases including cancers, stroke, respiratory problems and reproductive health problems. The annual hospital costs related to childhood obesity increased from $35 million in the period from 1979-1981 to $127 million in the period from 1997-1999 (1).

In 2008 the nonprofit Center for Closing the Health Gap (2) in Greater Cincinnati began a campaign aimed at preventing childhood obesity. Childhood obesity prevention is a goal that fits perfectly within CCHG’s mission, which includes increasing awareness about health disparities (2). The childhood obesity epidemic in the Greater Cincinnati area disproportionately affects minority children. CCHG’s website reports that the rate of overweight and obesity in Hamilton County is 43% among Black, Non-Hispanic children and 21% among White, Non-Hispanic children. The negative consequences to health that may result from obesity are grave. The city was seeing children with hypertension and worrying rates of type II diabetes. Secondly CCHG saw that obesity disproportionately affected children of low-income parents and minority children, particularly Black, Hispanic and Appalachian children. To work toward preventing childhood obesity the organization initiated a campaign called “Do Right!” The specific target of the childhood prevention portion of the program aimed at “improving the health and well-being of children at Rockdale Elementary that are overweight and obese” (2). Rockdale Elementary is part of the Cincinnati Public Schools system and enrolls about 500 preschool and elementary school students from grades PK-8.

The “Do Right!” children’s program is multi-faceted. Its in school components include screening for BMI to identify overweight and obese children, referral for obese children to an after school physical activity and nutrition program. The program includes nutrition every other week by a dietician, physical activity and bi-weekly parent education and information sessions to discuss nutrition. The program also included 1-minute health tips on the radio, parent workshops in development and City School Awareness Presentations (2). Finally, the program ran a concurrent obesity awareness campaign that included billboards, bus shelters, radio advertisements, ads in minority newspapers and the website: www.dorightcincy.org. They feature obese children mowing down on big, greasy burgers in front of plates of onion rings with the words “Are we feeding our kids to death?” in large print. Below, they provide the Do Right! campaign’s website and phone number with the words “for information on how to combat obesity.” These ads are the focus of this critique.

First and foremost it alienates the very population it aims to help. Dwight Tillery, the executive director of CCHG, purports that the campaign was designed to serve as a wake-up call for families. It aims to incentivize parents to take the health of their children more seriously by showing them just how serious obesity is. Tillery said, “We can’t afford to be politically correct on this issue” (3). Political correctness or lack thereof aside the means simply do not justify the end. Whether or not parents are shocked into understanding the gravity of childhood obesity, children who see these ads are sure to feel alienated. The ads effectuate a pervasive sense of hopelessness, powerlessness and defeat. They say, “you’re obese and you’re being fed to death.” There is nothing in this message that engenders a sense of self-efficacy, or the idea that a lower, healthier weight is an attainable goal. This deficiency is the ad’s primary shortcoming. Self-efficacy as defined by psychologist and father of Social Cognitive Theory, Albert Bandura, is one's belief in one's ability to succeed in specific situations. The concept of self-efficacy is central to Social Cognitive Theory (4). Social Cognitive Theory asserts that behavior is based on the interaction between one’s environment, the behaviors one witnesses, and the individual themselves. Ads like these posted by CCHG construct a negative outcome expectation and in so doing dismantle whatever self-efficacy they could otherwise have fostered. It simply isn’t enough to provide a website and helpline when the ad itself effectively destroys self-efficacy.

Labeling and Normalizing Obesity

Not only do these ads beget powerlessness as shown in the last paragraph, but they concurrently label and normalize childhood obesity. The relationship between labeling and normalizing obesity presents a double-edged sword for potential public health interventions aimed at preventing childhood obesity. The normalizing of obesity comes with a hefty price tag including rising economic costs. According to the Brookings Institution, “the total costs of obesity in the U.S. alone may exceed $215 billion annually” (5). The direct medical costs resulting from obesity in the U.S. have been estimated to account for over 9% of the national medical bill (6). Societal costs are also extensive. Obese children are less likely to be sent to college by their parents (6). Obese adults are less likely to be given jobs, and miss more work, overall costing employers something on the order of $4 billion. Obese children are at much higher risk of becoming obese adults than their thinner peers (7 - 8). In sum, normalizing obesity, particularly in children, presents a great hazard to personal health and has a major negative impact on costs at the society level.

On the flip side of normalizing, labeling obese children forces them to contend with the heavy stigma associated with obesity, decreasing the likelihood that they will overcome the many hurdles to health and wellness placed on them by society. Obesity is the fourth most common type of discrimination people report experiencing in the U.S. (9). Simply labeling children as obese has the potential to greatly influence their behavior. While the ads don’t literally use the word “obese”, they make it visually quite clear that they’re targeting obese children, and point a finger at poor eating habits. Labeling Theory (which is also known as Social Reactance Theory) posits that labeling an individual influences their behavior and more often than not causes them to conform to the stereotypes of the label in a self-fulfilling prophecy (10 - 11). Obese children must endure negative stigma not only from their peers, but also by their teachers and themselves (9). They are often ascribed negative characteristics including mean, stupid, loud, sloppy, ugly, lazy, sad, and lacking in friends (12 - 14). Obese children can become trapped within this self-fulfilling prophecy and may thus accept these traits as part of their role in society as an “obese child”. Studies have shown that the stigma associated with obesity causes an increase in coping methods like binge eating instead of being a contributing factor to motivation to lose weight and stay healthy (9, 15).

Not only are the children taught how to act by the characteristics attached to their label, but they learn through cognition in conjunction with observing behaviors within their environment. These elements operate reciprocally. For example, the environment in which one is raised affects one’s cognition and perceptions of behaviors that one witnesses. In state where approximately 30% of people are obese and where television stations air shows like “More to Love” or “Ruby” (in which the star, Ruby, spends three seasons trying lose weight only to end the third season having gained over 50 pounds) obesity is not likely to be perceived as abnormal (1). It is likely seen simply as the status quo. Posting health billboards featuring obese children eating is wading into dangerous territory. It risks adding more obesity normalizing media to the local environment and simultaneously reinforces the stereotypes and stigma associated with obesity, particularly qualities like lack of self-control.

Proponents of the campaign cite the fact that 93% of parents of obese children didn’t perceive their kids as being an abnormal weight (16). Research backs up this frightening assertion and shows that parents of overweight children consistently underestimated their children's weight (17 - 18). CCHG’s Childhood Obesity Awareness Campaign aims to inform parents that their children are at risk for serious health outcomes and the organization has deemed that shocking parents is necessary to do so. This scaremongering tactic assumes that by informing parents that their children are at risk of very serious health outcomes like death, they will be moved to act. This assumption takes for granted that people are rational decision makers. Rational decision-making generally entails defining the problem, identifying criteria relevant to the problem, considering all possible solutions, calculating the potential consequences of each solution, and choosing the best option. Many public health interventions are based on this same assumption. It is in fact the very basis of the Health Belief Model, which is commonly used in public health interventions. This model postulates that a behavioral change at the individual level depends on a person’s attitudes toward expected outcomes, the strength of those attitudes and the resulting outcome expectancies, as well as the individual’s perceptions of how others see them, and what the societal norms are (4). All of these factors meld to produce intention, which is followed by behavior. When applied to a parent’s role in preventing childhood obesity, as CCHG has done, the model suggests that if parents become aware of the potential hazardous heath outcomes of obesity and their attitudes toward obesity change, they will intend to prevent or reverse obesity in their children and that intention will lead to a change in behavior. This progression assumes rationalism prevails. Unfortunately assuming rationality fails to account for an individual’s subconscious thought process, irrational decision-making, group behavior and societal and environmental factors, all of which are crucial variables guiding behavior (4, 19, 20).
Irrational decision-making often relies upon the way that a particular issue is introduced or framed. Framing is a method of presenting a fact, topic or idea in a specific light so as to change how it is received among the audience to whom it is being presented. The concept of framing is central to Prospect Theory. Put simply, Prospect Theory states that people value gains and losses differently and that individuals make decisions based on perceived gains rather than perceived losses (21). Given two options with equal outcomes, an individual would choose the outcome expressed in terms of possible gains instead of the one expressed in possible losses. CCHG’s billboard frames childhood obesity in terms of the expected health outcome as a loss. Presenting the issue of childhood obesity by framing it within the context of not only a negative outcome but its most terrifying potential outcome, premature death from obesity related health problems, sets the campaign up for failure.

DO RIGHT! SUCCESSES: A SPRINGBOARD

While CCHGs program’s billboard and ad campaign are majorly flawed, there are a number of things the Do Right! campaign as a whole has gotten right. The organization was correct to take multi-faceted and all-encompassing approach to targeting childhood obesity prevention. Research suggests that families, schools and communities should all be included in programs aimed at preventing and reducing childhood obesity (22). Targeting parents exclusively has also been shown to be effective in reducing the BMI of overweight and obese children. A recent study from the United Kingdom showed that the BMI percentile of children whose parents were provided with eight sessions of cognitive-behavioral therapy for weight loss decreased significantly by 2.4% in the treatment group (23). Community involvement or not, targeting parents is crucial childhood obesity prevention programs. Children of obese parents are more likely to be obese themselves. Children aged 15 to 17 years old with at least one obese parent are over twice as likely as children with no obese parents to be obese adults. Children aged 1 to 2 years old were three times as likely to be obese as their peers who didn’t have an obese parent (24). Beyond the nuclear family, recent research has shown that obesity also spreads through social networks. A study conducted using data from Framingham, MA found that the chances of someone becoming obese increase 57% if they had a long-term friend who was obese (25). However, succeeding in utilizing parent and community involvement in childhood obesity prevention programs is challenging. As anyone who has ever tried to lose even a few pounds knows, attempting to lose weight can be daunting. For an obese person the barriers to weight loss, potentially including difficulty engaging in physical activity, addiction and lack of social support, can often seem indomitable. At any rate, with at minimum an adequate level of support within the environment and from family and community members, childhood obesity can be overcome. Methods to resolve each of the previously outlined failings within the billboard and ad campaign are presented in the following three sections.

As addressed in a previous section of this paper, the Health Belief Model as a champion of rational decision-making, and as it was implemented, was not an effective archetype from which to create the childhood obesity prevention billboard and ad campaign. On the other hand, framing, as delineated within Prospect Theory, can be an incredibly useful tool with which to begin to reconstruct this intervention. Bearing in mind that the original intent of the ad was to create awareness of childhood obesity as a serious problem among parents of obese children, the following proposed ad is aimed at both parents and children who will inevitably see the ads as well. This approach utilizes an entirely novel angle that frames health, with regard to weight, as a desirable and attainable outcome.

The proposed billboards will feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This sends the following messages physical activity is fun obese children are also entitled to fun obese children can do sports. In this way fighting childhood obesity through physical activity is framed in a positive light, as a fun and attainable goal. Making weight-loss and health attainable completely reverses the billboards, taking them from negative to positive and fomenting self-efficacy in children.

ENGENDERING SELF-EFFICACY BY NORMALIZING HEALTH

Labeling and normalizing obesity both have serious negative consequences at the individual and thus also societal level. They contribute to lower levels of self-esteem among obese children, and contribute to extensive monetary costs at the national level. A good public health campaign will succeed in achieving improved health and preventing obesity without further contributing to the extensive and damaging effects of labeling. While the billboard proposed in the prior section may be argued as normalizing obesity, it should be seen as normalizing activity among children of all shapes and sizes. Obese children are usually stereotyped as stupid, sloppy, ugly and lazy. In personal stories shared on blogs obese adults recount experiences that, in line with research published in peer reviewed journals, illustrate the cyclical nature of the self-fulfilling prophecy. In a blog published on Newsweek, Leslie Kinzel wrote,

“Prior to being told I was fat by my well-intentioned pediatrician … I'd spent my life as an active and athletic child, my fatness no obstacle in keeping up with my peers (and frequently besting them). As I got older I came to understand what being fat meant: fat kids were lousy at sports, and those who tried to play were to be mocked for it. Fat kids were always picked last, and though I was never picked last, I came to fear that it would inevitably happen. So I stopped playing. I backed away from sports and games altogether.” (26)

Her account is unfortunately not uncommon and characterizes the major negative impacts that labeling has on obese children. Obesity carries such stigma that for many children it becomes the single characteristic by which they feel most defined. At the end of her post Kinzel pleads,
“Call it a campaign against childhood couch-sitting. Call it a drive to get kids to go outside and play. Call it a movement to educate children on basic nutrition and how their amazing growing bodies work for them. But don't single out the fat kids. If I am any indication, doing this will only ensure that this generation will be fatter than ever, dragging behind them some heavy baggage around food issues and low self-esteem.” (26)

Kinzel’s well-put conclusion holds true given what has been learned from the failures of the Health Belief Model and the potential outcomes associated with Label Theory and Social Reactance Theory. It is absolutely necessary to change the personal characteristics associated with the obesity label. Getting obese children re-involved in sports and other physical activities will help to get rid of the stereotype that obese children can’t play sports. This will serve a dual purpose. It will encourage other obese children to take up arms so to speak and join the revolt against stereotypes. At the same time becoming involved in sports once again or perhaps for the first time will have positive health effects. While these effects certainly can’t be expected to be immediate they will have a positive effect on the local environment that should grow exponentially.

ENGENDERING SELF-EFFICACY BY REVOLTING AGAINST THE LABEL

Inciting obese children in Cincinnati to rise up against the fat label takes advantage of the mechanisms described in Psychological Reactance Theory. This theory asserts that perceived limitations to freedom or autonomy provoke an aversive affective reaction in people (27). In other words, if an individual perceives that their freedom has somehow been limited they will become provoked to regain it. A wonderful example of psychological reactance at work is the Truth campaign, which aims to curb youth use of tobacco by inciting a rebellion of sorts among young people. The campaign’s theme is “truth, a generation united against tobacco” (28). The Truth campaign successfully framed the tobacco industry as a liar that was hiding the truth from teens. In doing so they provoked teens to rebel against big tobacco and its lies, successfully decreasing youth smoking initiation rates.

The proposed alternative billboards showing obese children standing up to the labels and stereotypes associated with childhood obesity will do the same. This reaction is particularly common when individuals feel obliged to adopt a particular opinion or engage in a specific behavior (27). The billboards will bring to light these expectations and the violation of freedom that they cause for obese children, inspiring rebellion. In inciting this silent, healthy insurrection the campaign will be rekindling self-efficacy in obese children, which has a powerful effect on an individual’s level of motivation. “Boredom and apathy occur when a challenge is too small anxiety and withdrawal occur when a challenge is too great curiosity and engagement occur when the challenge is optimal” (29). If children don’t feel like they will succeed in losing weight or getting healthy they are much less likely to try to do so. Engendering self-efficacy through these billboards is an indispensible component of a successful childhood obesity prevention public health campaign. Recent work has found that “exercise’s association with weight loss was better explained through psychological, rather than physiological (ie, caloric expenditure), pathways” proving even further the importance of self-efficacy in weight loss (30). Giving obese children a common cause and an enemy to take down will help to create this self-efficacy, aiding in reducing and preventing childhood obesity over time.

Childhood obesity is a serious public health threat that requires sincere and practical interventions. The potential health consequences that are associated with childhood obesity are grave. They are harmful both to the individual and at the national level. Obese children are at increased risk for type II diabetes, cardiovascular disease, respiratory problems and future reproductive problems. They have added to increased medical costs at the national level, and as childhood obesity prevalence rates are higher among lower income quintiles the increased prevalence of childhood obesity has contributed to growing government expenditures on health (1). Practical, effective solutions are crucial in the fight to prevent and decrease childhood obesity.

In order to create a billboard campaign that effectively reduces and prevents childhood obesity while carefully avoiding potential adverse affects that such a billboard could so easily have, as evidenced by the one used by CCHG, social and behavioral sciences theories should be employed. Social Cognitive Theory, Labeling Theory (which is also known as Social Reactance Theory), the Health Belief Model, Framing Theory (as well as Prospect Theory) and Psychological Reactance Theory were used to analyze and critique CCHG’s billboard and ad intervention. CCHG’s billboard intervention was found to be inappropriate on the grounds that it contributed to defeating self-efficacy among obese children, added to labeling and normalizing childhood obesity and resorted to terrorizing parents in an effort to create awareness and incite a behavior change among parents and children. These same theories were then employed to suggest an appropriate intervention to replace CCHG’s billboard ads. The proposed replacement intervention consists of billboards that feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This intervention is based on engendering self-efficacy by reframing the childhood obesity issue in a positive light, normalizing healthy choices among obese children and using Psychological Reactance Theory to empower children to fight against the labels associated with childhood obesity. Casting a glow of optimism on the problem will help to bring back to life self-efficacy that has been squashed by labeling and stigma. Social and behavioral sciences theories were instrumental tools in understanding the effects that the Cincinnati CHG’s billboards could be expected to have on the target population, as well as any projected externalities, and in creating a better alternative.

REFERENCES
1. Overweight and Obesity. U.S. Obesity Trends. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/obesity/data/trends.html.
2. Do Right!. The Crisis. Cincinnati, OH: The Center for Closing the Health Gap in Greater Cincinnati. http://dorightcincy.org/the-crisis.
3. Childhood Obesity. Ohio Childhood Obesity Prevention Campaign Stirs Controversy. Princeton, NJ: Robert Wood Johnson Foundation. http://www.rwjf.org/childhoodobesity/digest.jsp?id=8398&c=OTC-RSS&attr=DI.
4. Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 200152:1-26.
5. Hammond R. The Economic Costs of Obesity. Brookings Institution. May 4, 2011. http://www.brookings.edu/multimedia/video/2010/0914_obesity_hammond.aspx.
6. Herper M. The Hidden Cost of Obesity. Forbes [online]. November 24, 2006. http://www.forbes.com/2006/07/19/obesity-fat-costs_cx_mh_0720obesity.html.
7. Epstein LH, Wing RR, Valoski A. Childhood obesity. Pediatr. Clin. North Am. 198532(2):363-379.
8. Krassas GE, Tzotzas T. Do obese children become obese adults: childhood predictors of adult disease. Pediatr Endocrinol Rev. 20041 Suppl 3:455-459.
9. Puhl RM, Latner JD. Stigma, obesity, and the health of the nation’s children. Psychol Bull. 2007133(4):557-580.
10. Laslett B, Warren CAB. Losing Weight: The Organizational Promotion of Behavior Change. Social Problems. 197523(1):69-80.
11. Link BG, Phelan JC. Conceptualizing Stigma. Annual Review of Sociology. 200127:363-385.
12. Holub SC. Individual differences in the anti-fat attitudes of preschool-children: The importance of perceived body size. Body Image. 20085(3):317-321.
13. Musher-Eizenman DR, Holub SC, Miller AB, Goldstein SE, Edwards-Leeper L. Body Size Stigmatization in Preschool Children: The Role of Control Attributions. Journal of Pediatric Psychology. 200429(8):613 -620.
14. Iobst EA. The Relationship Among Gender, Age, Blame, and Children’s Attributions about an Overweight Peer. 2007. Available at: http://etd.ohiolink.edu/view.cgi?acc_num=ucin1242390002. Accessed May 4, 2011.
15. Bensley K. Obesity and Perceptions of the Body in Teenage American Girls. UCL Centre for Applied Global Citizenship [online]. December 17, 2010. London, U.K.: . http://www.ucl.ac.uk/network-for-student-activism/w/Obesity_and_Perceptions_of_the_Body_in_Teenage_American_Girls.
16. Orr K. Provacative local campaign to target childhood obesity. WVXU Radio [online]. July 31, 2008. http://www.wvxu.org/news/wvxunews_article.asp?ID=5421.
17. Etelson D, Brand DA, Patrick PA, Shirali A. Childhood Obesity: Do Parents Recognize This Health Risk? Obesity. 200311(11):1362-1368.
18. Health & Parenting. Many Parents Don’t See Child Obesity. Web MD. http://www.webmd.com/parenting/news/20071211/many-parents-dont-see-child-obesity.
19. Janz NK, Becker MH. The Health Belief Model: A Decade Later. Health Education & Behavior. 198411(1):1 -47.
20. Rosenstock IM, Strecher VJ, Becker MH. Social Learning Theory and the Health Belief Model. Health Education & Behavior. 198815(2):175-183.
21. Kahneman D, Tversky A. Prospect Theory: An Analysis of Decision under Risk. Econometrica. 197947(2):263-291.
22. Lindsay AC, Sussner KM, Kim J, Gortmaker S. The role of parents in preventing childhood obesity. Future Child. 200616(1):169-186.
23. Jansen E, Mulkens S, Jansen A. Tackling childhood overweight: treating parents exclusively is effective. Int J Obes (Lond). 201135(4):501-509.
24. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N. Engl. J. Med. 1997337(13):869-873.
25. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N. Engl. J. Med. 2007357(4):370-379.
26. Kinzel L. Why the first lady's fight to end childhood obesity does damage to the children it's trying to help. Newsweek [online]. April 20, 2010. http://www.newsweek.com/2010/04/19/fat-kids-cruel-world.html.
27. Burke WW, Lake DG, Paine JW. Organization Change: A Comprehensive Reader. John Wiley and Sons 2008.
28. Truth. http://www.thetruth.com/.
29. Snyder CR, Lopez SJ. Oxford handbook of positive psychology. Oxford University Press US 2009 (P573).
30. Annesi JJ. Behaviorally supported exercise predicts weight loss in obese adults through improvements in mood, self-efficacy, and self-regulation, rather than by caloric expenditure. Perm J. 201115(1):23-27.


Challenging Dogma - Spring 2011

Today over one third of U.S. adults and 17% of U.S. children are obese. In the last three decades, obesity rates for adults have doubled and rates for children have tripled. However, the burden of obesity is not evenly distributed, and falls heavily on minorities. The 2009 Behavioral Risk Factor Surveillance System report showed that “blacks were 51% more likely and Hispanics were 21% more likely than non-Hispanic whites to be obese” (1). It is also geographically unevenly distributed with the American Midwest suffering higher obesity prevalence rates than the rest of the country. Cincinnati, Ohio is a beautiful Midwestern city situated at the southern edge of Ohio, across the Ohio River from Kentucky. However, like many Midwestern cities and states, Cincinnati has seen an alarming increase in obesity among adults and children in the last few decades. According to CDC 29.6% of Ohioans were obese in 2009. This increase has serious health consequences for adults and children. Obesity related diseases like type 2 diabetes, which previously only affected adults, is now affecting children (1). Obese children are also at higher risk of suffering cardiovascular disease. Obesity, including childhood obesity, is known to be a risk factor for a number of diseases including cancers, stroke, respiratory problems and reproductive health problems. The annual hospital costs related to childhood obesity increased from $35 million in the period from 1979-1981 to $127 million in the period from 1997-1999 (1).

In 2008 the nonprofit Center for Closing the Health Gap (2) in Greater Cincinnati began a campaign aimed at preventing childhood obesity. Childhood obesity prevention is a goal that fits perfectly within CCHG’s mission, which includes increasing awareness about health disparities (2). The childhood obesity epidemic in the Greater Cincinnati area disproportionately affects minority children. CCHG’s website reports that the rate of overweight and obesity in Hamilton County is 43% among Black, Non-Hispanic children and 21% among White, Non-Hispanic children. The negative consequences to health that may result from obesity are grave. The city was seeing children with hypertension and worrying rates of type II diabetes. Secondly CCHG saw that obesity disproportionately affected children of low-income parents and minority children, particularly Black, Hispanic and Appalachian children. To work toward preventing childhood obesity the organization initiated a campaign called “Do Right!” The specific target of the childhood prevention portion of the program aimed at “improving the health and well-being of children at Rockdale Elementary that are overweight and obese” (2). Rockdale Elementary is part of the Cincinnati Public Schools system and enrolls about 500 preschool and elementary school students from grades PK-8.

The “Do Right!” children’s program is multi-faceted. Its in school components include screening for BMI to identify overweight and obese children, referral for obese children to an after school physical activity and nutrition program. The program includes nutrition every other week by a dietician, physical activity and bi-weekly parent education and information sessions to discuss nutrition. The program also included 1-minute health tips on the radio, parent workshops in development and City School Awareness Presentations (2). Finally, the program ran a concurrent obesity awareness campaign that included billboards, bus shelters, radio advertisements, ads in minority newspapers and the website: www.dorightcincy.org. They feature obese children mowing down on big, greasy burgers in front of plates of onion rings with the words “Are we feeding our kids to death?” in large print. Below, they provide the Do Right! campaign’s website and phone number with the words “for information on how to combat obesity.” These ads are the focus of this critique.

First and foremost it alienates the very population it aims to help. Dwight Tillery, the executive director of CCHG, purports that the campaign was designed to serve as a wake-up call for families. It aims to incentivize parents to take the health of their children more seriously by showing them just how serious obesity is. Tillery said, “We can’t afford to be politically correct on this issue” (3). Political correctness or lack thereof aside the means simply do not justify the end. Whether or not parents are shocked into understanding the gravity of childhood obesity, children who see these ads are sure to feel alienated. The ads effectuate a pervasive sense of hopelessness, powerlessness and defeat. They say, “you’re obese and you’re being fed to death.” There is nothing in this message that engenders a sense of self-efficacy, or the idea that a lower, healthier weight is an attainable goal. This deficiency is the ad’s primary shortcoming. Self-efficacy as defined by psychologist and father of Social Cognitive Theory, Albert Bandura, is one's belief in one's ability to succeed in specific situations. The concept of self-efficacy is central to Social Cognitive Theory (4). Social Cognitive Theory asserts that behavior is based on the interaction between one’s environment, the behaviors one witnesses, and the individual themselves. Ads like these posted by CCHG construct a negative outcome expectation and in so doing dismantle whatever self-efficacy they could otherwise have fostered. It simply isn’t enough to provide a website and helpline when the ad itself effectively destroys self-efficacy.

Labeling and Normalizing Obesity

Not only do these ads beget powerlessness as shown in the last paragraph, but they concurrently label and normalize childhood obesity. The relationship between labeling and normalizing obesity presents a double-edged sword for potential public health interventions aimed at preventing childhood obesity. The normalizing of obesity comes with a hefty price tag including rising economic costs. According to the Brookings Institution, “the total costs of obesity in the U.S. alone may exceed $215 billion annually” (5). The direct medical costs resulting from obesity in the U.S. have been estimated to account for over 9% of the national medical bill (6). Societal costs are also extensive. Obese children are less likely to be sent to college by their parents (6). Obese adults are less likely to be given jobs, and miss more work, overall costing employers something on the order of $4 billion. Obese children are at much higher risk of becoming obese adults than their thinner peers (7 - 8). In sum, normalizing obesity, particularly in children, presents a great hazard to personal health and has a major negative impact on costs at the society level.

On the flip side of normalizing, labeling obese children forces them to contend with the heavy stigma associated with obesity, decreasing the likelihood that they will overcome the many hurdles to health and wellness placed on them by society. Obesity is the fourth most common type of discrimination people report experiencing in the U.S. (9). Simply labeling children as obese has the potential to greatly influence their behavior. While the ads don’t literally use the word “obese”, they make it visually quite clear that they’re targeting obese children, and point a finger at poor eating habits. Labeling Theory (which is also known as Social Reactance Theory) posits that labeling an individual influences their behavior and more often than not causes them to conform to the stereotypes of the label in a self-fulfilling prophecy (10 - 11). Obese children must endure negative stigma not only from their peers, but also by their teachers and themselves (9). They are often ascribed negative characteristics including mean, stupid, loud, sloppy, ugly, lazy, sad, and lacking in friends (12 - 14). Obese children can become trapped within this self-fulfilling prophecy and may thus accept these traits as part of their role in society as an “obese child”. Studies have shown that the stigma associated with obesity causes an increase in coping methods like binge eating instead of being a contributing factor to motivation to lose weight and stay healthy (9, 15).

Not only are the children taught how to act by the characteristics attached to their label, but they learn through cognition in conjunction with observing behaviors within their environment. These elements operate reciprocally. For example, the environment in which one is raised affects one’s cognition and perceptions of behaviors that one witnesses. In state where approximately 30% of people are obese and where television stations air shows like “More to Love” or “Ruby” (in which the star, Ruby, spends three seasons trying lose weight only to end the third season having gained over 50 pounds) obesity is not likely to be perceived as abnormal (1). It is likely seen simply as the status quo. Posting health billboards featuring obese children eating is wading into dangerous territory. It risks adding more obesity normalizing media to the local environment and simultaneously reinforces the stereotypes and stigma associated with obesity, particularly qualities like lack of self-control.

Proponents of the campaign cite the fact that 93% of parents of obese children didn’t perceive their kids as being an abnormal weight (16). Research backs up this frightening assertion and shows that parents of overweight children consistently underestimated their children's weight (17 - 18). CCHG’s Childhood Obesity Awareness Campaign aims to inform parents that their children are at risk for serious health outcomes and the organization has deemed that shocking parents is necessary to do so. This scaremongering tactic assumes that by informing parents that their children are at risk of very serious health outcomes like death, they will be moved to act. This assumption takes for granted that people are rational decision makers. Rational decision-making generally entails defining the problem, identifying criteria relevant to the problem, considering all possible solutions, calculating the potential consequences of each solution, and choosing the best option. Many public health interventions are based on this same assumption. It is in fact the very basis of the Health Belief Model, which is commonly used in public health interventions. This model postulates that a behavioral change at the individual level depends on a person’s attitudes toward expected outcomes, the strength of those attitudes and the resulting outcome expectancies, as well as the individual’s perceptions of how others see them, and what the societal norms are (4). All of these factors meld to produce intention, which is followed by behavior. When applied to a parent’s role in preventing childhood obesity, as CCHG has done, the model suggests that if parents become aware of the potential hazardous heath outcomes of obesity and their attitudes toward obesity change, they will intend to prevent or reverse obesity in their children and that intention will lead to a change in behavior. This progression assumes rationalism prevails. Unfortunately assuming rationality fails to account for an individual’s subconscious thought process, irrational decision-making, group behavior and societal and environmental factors, all of which are crucial variables guiding behavior (4, 19, 20).
Irrational decision-making often relies upon the way that a particular issue is introduced or framed. Framing is a method of presenting a fact, topic or idea in a specific light so as to change how it is received among the audience to whom it is being presented. The concept of framing is central to Prospect Theory. Put simply, Prospect Theory states that people value gains and losses differently and that individuals make decisions based on perceived gains rather than perceived losses (21). Given two options with equal outcomes, an individual would choose the outcome expressed in terms of possible gains instead of the one expressed in possible losses. CCHG’s billboard frames childhood obesity in terms of the expected health outcome as a loss. Presenting the issue of childhood obesity by framing it within the context of not only a negative outcome but its most terrifying potential outcome, premature death from obesity related health problems, sets the campaign up for failure.

DO RIGHT! SUCCESSES: A SPRINGBOARD

While CCHGs program’s billboard and ad campaign are majorly flawed, there are a number of things the Do Right! campaign as a whole has gotten right. The organization was correct to take multi-faceted and all-encompassing approach to targeting childhood obesity prevention. Research suggests that families, schools and communities should all be included in programs aimed at preventing and reducing childhood obesity (22). Targeting parents exclusively has also been shown to be effective in reducing the BMI of overweight and obese children. A recent study from the United Kingdom showed that the BMI percentile of children whose parents were provided with eight sessions of cognitive-behavioral therapy for weight loss decreased significantly by 2.4% in the treatment group (23). Community involvement or not, targeting parents is crucial childhood obesity prevention programs. Children of obese parents are more likely to be obese themselves. Children aged 15 to 17 years old with at least one obese parent are over twice as likely as children with no obese parents to be obese adults. Children aged 1 to 2 years old were three times as likely to be obese as their peers who didn’t have an obese parent (24). Beyond the nuclear family, recent research has shown that obesity also spreads through social networks. A study conducted using data from Framingham, MA found that the chances of someone becoming obese increase 57% if they had a long-term friend who was obese (25). However, succeeding in utilizing parent and community involvement in childhood obesity prevention programs is challenging. As anyone who has ever tried to lose even a few pounds knows, attempting to lose weight can be daunting. For an obese person the barriers to weight loss, potentially including difficulty engaging in physical activity, addiction and lack of social support, can often seem indomitable. At any rate, with at minimum an adequate level of support within the environment and from family and community members, childhood obesity can be overcome. Methods to resolve each of the previously outlined failings within the billboard and ad campaign are presented in the following three sections.

As addressed in a previous section of this paper, the Health Belief Model as a champion of rational decision-making, and as it was implemented, was not an effective archetype from which to create the childhood obesity prevention billboard and ad campaign. On the other hand, framing, as delineated within Prospect Theory, can be an incredibly useful tool with which to begin to reconstruct this intervention. Bearing in mind that the original intent of the ad was to create awareness of childhood obesity as a serious problem among parents of obese children, the following proposed ad is aimed at both parents and children who will inevitably see the ads as well. This approach utilizes an entirely novel angle that frames health, with regard to weight, as a desirable and attainable outcome.

The proposed billboards will feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This sends the following messages physical activity is fun obese children are also entitled to fun obese children can do sports. In this way fighting childhood obesity through physical activity is framed in a positive light, as a fun and attainable goal. Making weight-loss and health attainable completely reverses the billboards, taking them from negative to positive and fomenting self-efficacy in children.

ENGENDERING SELF-EFFICACY BY NORMALIZING HEALTH

Labeling and normalizing obesity both have serious negative consequences at the individual and thus also societal level. They contribute to lower levels of self-esteem among obese children, and contribute to extensive monetary costs at the national level. A good public health campaign will succeed in achieving improved health and preventing obesity without further contributing to the extensive and damaging effects of labeling. While the billboard proposed in the prior section may be argued as normalizing obesity, it should be seen as normalizing activity among children of all shapes and sizes. Obese children are usually stereotyped as stupid, sloppy, ugly and lazy. In personal stories shared on blogs obese adults recount experiences that, in line with research published in peer reviewed journals, illustrate the cyclical nature of the self-fulfilling prophecy. In a blog published on Newsweek, Leslie Kinzel wrote,

“Prior to being told I was fat by my well-intentioned pediatrician … I'd spent my life as an active and athletic child, my fatness no obstacle in keeping up with my peers (and frequently besting them). As I got older I came to understand what being fat meant: fat kids were lousy at sports, and those who tried to play were to be mocked for it. Fat kids were always picked last, and though I was never picked last, I came to fear that it would inevitably happen. So I stopped playing. I backed away from sports and games altogether.” (26)

Her account is unfortunately not uncommon and characterizes the major negative impacts that labeling has on obese children. Obesity carries such stigma that for many children it becomes the single characteristic by which they feel most defined. At the end of her post Kinzel pleads,
“Call it a campaign against childhood couch-sitting. Call it a drive to get kids to go outside and play. Call it a movement to educate children on basic nutrition and how their amazing growing bodies work for them. But don't single out the fat kids. If I am any indication, doing this will only ensure that this generation will be fatter than ever, dragging behind them some heavy baggage around food issues and low self-esteem.” (26)

Kinzel’s well-put conclusion holds true given what has been learned from the failures of the Health Belief Model and the potential outcomes associated with Label Theory and Social Reactance Theory. It is absolutely necessary to change the personal characteristics associated with the obesity label. Getting obese children re-involved in sports and other physical activities will help to get rid of the stereotype that obese children can’t play sports. This will serve a dual purpose. It will encourage other obese children to take up arms so to speak and join the revolt against stereotypes. At the same time becoming involved in sports once again or perhaps for the first time will have positive health effects. While these effects certainly can’t be expected to be immediate they will have a positive effect on the local environment that should grow exponentially.

ENGENDERING SELF-EFFICACY BY REVOLTING AGAINST THE LABEL

Inciting obese children in Cincinnati to rise up against the fat label takes advantage of the mechanisms described in Psychological Reactance Theory. This theory asserts that perceived limitations to freedom or autonomy provoke an aversive affective reaction in people (27). In other words, if an individual perceives that their freedom has somehow been limited they will become provoked to regain it. A wonderful example of psychological reactance at work is the Truth campaign, which aims to curb youth use of tobacco by inciting a rebellion of sorts among young people. The campaign’s theme is “truth, a generation united against tobacco” (28). The Truth campaign successfully framed the tobacco industry as a liar that was hiding the truth from teens. In doing so they provoked teens to rebel against big tobacco and its lies, successfully decreasing youth smoking initiation rates.

The proposed alternative billboards showing obese children standing up to the labels and stereotypes associated with childhood obesity will do the same. This reaction is particularly common when individuals feel obliged to adopt a particular opinion or engage in a specific behavior (27). The billboards will bring to light these expectations and the violation of freedom that they cause for obese children, inspiring rebellion. In inciting this silent, healthy insurrection the campaign will be rekindling self-efficacy in obese children, which has a powerful effect on an individual’s level of motivation. “Boredom and apathy occur when a challenge is too small anxiety and withdrawal occur when a challenge is too great curiosity and engagement occur when the challenge is optimal” (29). If children don’t feel like they will succeed in losing weight or getting healthy they are much less likely to try to do so. Engendering self-efficacy through these billboards is an indispensible component of a successful childhood obesity prevention public health campaign. Recent work has found that “exercise’s association with weight loss was better explained through psychological, rather than physiological (ie, caloric expenditure), pathways” proving even further the importance of self-efficacy in weight loss (30). Giving obese children a common cause and an enemy to take down will help to create this self-efficacy, aiding in reducing and preventing childhood obesity over time.

Childhood obesity is a serious public health threat that requires sincere and practical interventions. The potential health consequences that are associated with childhood obesity are grave. They are harmful both to the individual and at the national level. Obese children are at increased risk for type II diabetes, cardiovascular disease, respiratory problems and future reproductive problems. They have added to increased medical costs at the national level, and as childhood obesity prevalence rates are higher among lower income quintiles the increased prevalence of childhood obesity has contributed to growing government expenditures on health (1). Practical, effective solutions are crucial in the fight to prevent and decrease childhood obesity.

In order to create a billboard campaign that effectively reduces and prevents childhood obesity while carefully avoiding potential adverse affects that such a billboard could so easily have, as evidenced by the one used by CCHG, social and behavioral sciences theories should be employed. Social Cognitive Theory, Labeling Theory (which is also known as Social Reactance Theory), the Health Belief Model, Framing Theory (as well as Prospect Theory) and Psychological Reactance Theory were used to analyze and critique CCHG’s billboard and ad intervention. CCHG’s billboard intervention was found to be inappropriate on the grounds that it contributed to defeating self-efficacy among obese children, added to labeling and normalizing childhood obesity and resorted to terrorizing parents in an effort to create awareness and incite a behavior change among parents and children. These same theories were then employed to suggest an appropriate intervention to replace CCHG’s billboard ads. The proposed replacement intervention consists of billboards that feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This intervention is based on engendering self-efficacy by reframing the childhood obesity issue in a positive light, normalizing healthy choices among obese children and using Psychological Reactance Theory to empower children to fight against the labels associated with childhood obesity. Casting a glow of optimism on the problem will help to bring back to life self-efficacy that has been squashed by labeling and stigma. Social and behavioral sciences theories were instrumental tools in understanding the effects that the Cincinnati CHG’s billboards could be expected to have on the target population, as well as any projected externalities, and in creating a better alternative.

REFERENCES
1. Overweight and Obesity. U.S. Obesity Trends. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/obesity/data/trends.html.
2. Do Right!. The Crisis. Cincinnati, OH: The Center for Closing the Health Gap in Greater Cincinnati. http://dorightcincy.org/the-crisis.
3. Childhood Obesity. Ohio Childhood Obesity Prevention Campaign Stirs Controversy. Princeton, NJ: Robert Wood Johnson Foundation. http://www.rwjf.org/childhoodobesity/digest.jsp?id=8398&c=OTC-RSS&attr=DI.
4. Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 200152:1-26.
5. Hammond R. The Economic Costs of Obesity. Brookings Institution. May 4, 2011. http://www.brookings.edu/multimedia/video/2010/0914_obesity_hammond.aspx.
6. Herper M. The Hidden Cost of Obesity. Forbes [online]. November 24, 2006. http://www.forbes.com/2006/07/19/obesity-fat-costs_cx_mh_0720obesity.html.
7. Epstein LH, Wing RR, Valoski A. Childhood obesity. Pediatr. Clin. North Am. 198532(2):363-379.
8. Krassas GE, Tzotzas T. Do obese children become obese adults: childhood predictors of adult disease. Pediatr Endocrinol Rev. 20041 Suppl 3:455-459.
9. Puhl RM, Latner JD. Stigma, obesity, and the health of the nation’s children. Psychol Bull. 2007133(4):557-580.
10. Laslett B, Warren CAB. Losing Weight: The Organizational Promotion of Behavior Change. Social Problems. 197523(1):69-80.
11. Link BG, Phelan JC. Conceptualizing Stigma. Annual Review of Sociology. 200127:363-385.
12. Holub SC. Individual differences in the anti-fat attitudes of preschool-children: The importance of perceived body size. Body Image. 20085(3):317-321.
13. Musher-Eizenman DR, Holub SC, Miller AB, Goldstein SE, Edwards-Leeper L. Body Size Stigmatization in Preschool Children: The Role of Control Attributions. Journal of Pediatric Psychology. 200429(8):613 -620.
14. Iobst EA. The Relationship Among Gender, Age, Blame, and Children’s Attributions about an Overweight Peer. 2007. Available at: http://etd.ohiolink.edu/view.cgi?acc_num=ucin1242390002. Accessed May 4, 2011.
15. Bensley K. Obesity and Perceptions of the Body in Teenage American Girls. UCL Centre for Applied Global Citizenship [online]. December 17, 2010. London, U.K.: . http://www.ucl.ac.uk/network-for-student-activism/w/Obesity_and_Perceptions_of_the_Body_in_Teenage_American_Girls.
16. Orr K. Provacative local campaign to target childhood obesity. WVXU Radio [online]. July 31, 2008. http://www.wvxu.org/news/wvxunews_article.asp?ID=5421.
17. Etelson D, Brand DA, Patrick PA, Shirali A. Childhood Obesity: Do Parents Recognize This Health Risk? Obesity. 200311(11):1362-1368.
18. Health & Parenting. Many Parents Don’t See Child Obesity. Web MD. http://www.webmd.com/parenting/news/20071211/many-parents-dont-see-child-obesity.
19. Janz NK, Becker MH. The Health Belief Model: A Decade Later. Health Education & Behavior. 198411(1):1 -47.
20. Rosenstock IM, Strecher VJ, Becker MH. Social Learning Theory and the Health Belief Model. Health Education & Behavior. 198815(2):175-183.
21. Kahneman D, Tversky A. Prospect Theory: An Analysis of Decision under Risk. Econometrica. 197947(2):263-291.
22. Lindsay AC, Sussner KM, Kim J, Gortmaker S. The role of parents in preventing childhood obesity. Future Child. 200616(1):169-186.
23. Jansen E, Mulkens S, Jansen A. Tackling childhood overweight: treating parents exclusively is effective. Int J Obes (Lond). 201135(4):501-509.
24. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N. Engl. J. Med. 1997337(13):869-873.
25. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N. Engl. J. Med. 2007357(4):370-379.
26. Kinzel L. Why the first lady's fight to end childhood obesity does damage to the children it's trying to help. Newsweek [online]. April 20, 2010. http://www.newsweek.com/2010/04/19/fat-kids-cruel-world.html.
27. Burke WW, Lake DG, Paine JW. Organization Change: A Comprehensive Reader. John Wiley and Sons 2008.
28. Truth. http://www.thetruth.com/.
29. Snyder CR, Lopez SJ. Oxford handbook of positive psychology. Oxford University Press US 2009 (P573).
30. Annesi JJ. Behaviorally supported exercise predicts weight loss in obese adults through improvements in mood, self-efficacy, and self-regulation, rather than by caloric expenditure. Perm J. 201115(1):23-27.


Challenging Dogma - Spring 2011

Today over one third of U.S. adults and 17% of U.S. children are obese. In the last three decades, obesity rates for adults have doubled and rates for children have tripled. However, the burden of obesity is not evenly distributed, and falls heavily on minorities. The 2009 Behavioral Risk Factor Surveillance System report showed that “blacks were 51% more likely and Hispanics were 21% more likely than non-Hispanic whites to be obese” (1). It is also geographically unevenly distributed with the American Midwest suffering higher obesity prevalence rates than the rest of the country. Cincinnati, Ohio is a beautiful Midwestern city situated at the southern edge of Ohio, across the Ohio River from Kentucky. However, like many Midwestern cities and states, Cincinnati has seen an alarming increase in obesity among adults and children in the last few decades. According to CDC 29.6% of Ohioans were obese in 2009. This increase has serious health consequences for adults and children. Obesity related diseases like type 2 diabetes, which previously only affected adults, is now affecting children (1). Obese children are also at higher risk of suffering cardiovascular disease. Obesity, including childhood obesity, is known to be a risk factor for a number of diseases including cancers, stroke, respiratory problems and reproductive health problems. The annual hospital costs related to childhood obesity increased from $35 million in the period from 1979-1981 to $127 million in the period from 1997-1999 (1).

In 2008 the nonprofit Center for Closing the Health Gap (2) in Greater Cincinnati began a campaign aimed at preventing childhood obesity. Childhood obesity prevention is a goal that fits perfectly within CCHG’s mission, which includes increasing awareness about health disparities (2). The childhood obesity epidemic in the Greater Cincinnati area disproportionately affects minority children. CCHG’s website reports that the rate of overweight and obesity in Hamilton County is 43% among Black, Non-Hispanic children and 21% among White, Non-Hispanic children. The negative consequences to health that may result from obesity are grave. The city was seeing children with hypertension and worrying rates of type II diabetes. Secondly CCHG saw that obesity disproportionately affected children of low-income parents and minority children, particularly Black, Hispanic and Appalachian children. To work toward preventing childhood obesity the organization initiated a campaign called “Do Right!” The specific target of the childhood prevention portion of the program aimed at “improving the health and well-being of children at Rockdale Elementary that are overweight and obese” (2). Rockdale Elementary is part of the Cincinnati Public Schools system and enrolls about 500 preschool and elementary school students from grades PK-8.

The “Do Right!” children’s program is multi-faceted. Its in school components include screening for BMI to identify overweight and obese children, referral for obese children to an after school physical activity and nutrition program. The program includes nutrition every other week by a dietician, physical activity and bi-weekly parent education and information sessions to discuss nutrition. The program also included 1-minute health tips on the radio, parent workshops in development and City School Awareness Presentations (2). Finally, the program ran a concurrent obesity awareness campaign that included billboards, bus shelters, radio advertisements, ads in minority newspapers and the website: www.dorightcincy.org. They feature obese children mowing down on big, greasy burgers in front of plates of onion rings with the words “Are we feeding our kids to death?” in large print. Below, they provide the Do Right! campaign’s website and phone number with the words “for information on how to combat obesity.” These ads are the focus of this critique.

First and foremost it alienates the very population it aims to help. Dwight Tillery, the executive director of CCHG, purports that the campaign was designed to serve as a wake-up call for families. It aims to incentivize parents to take the health of their children more seriously by showing them just how serious obesity is. Tillery said, “We can’t afford to be politically correct on this issue” (3). Political correctness or lack thereof aside the means simply do not justify the end. Whether or not parents are shocked into understanding the gravity of childhood obesity, children who see these ads are sure to feel alienated. The ads effectuate a pervasive sense of hopelessness, powerlessness and defeat. They say, “you’re obese and you’re being fed to death.” There is nothing in this message that engenders a sense of self-efficacy, or the idea that a lower, healthier weight is an attainable goal. This deficiency is the ad’s primary shortcoming. Self-efficacy as defined by psychologist and father of Social Cognitive Theory, Albert Bandura, is one's belief in one's ability to succeed in specific situations. The concept of self-efficacy is central to Social Cognitive Theory (4). Social Cognitive Theory asserts that behavior is based on the interaction between one’s environment, the behaviors one witnesses, and the individual themselves. Ads like these posted by CCHG construct a negative outcome expectation and in so doing dismantle whatever self-efficacy they could otherwise have fostered. It simply isn’t enough to provide a website and helpline when the ad itself effectively destroys self-efficacy.

Labeling and Normalizing Obesity

Not only do these ads beget powerlessness as shown in the last paragraph, but they concurrently label and normalize childhood obesity. The relationship between labeling and normalizing obesity presents a double-edged sword for potential public health interventions aimed at preventing childhood obesity. The normalizing of obesity comes with a hefty price tag including rising economic costs. According to the Brookings Institution, “the total costs of obesity in the U.S. alone may exceed $215 billion annually” (5). The direct medical costs resulting from obesity in the U.S. have been estimated to account for over 9% of the national medical bill (6). Societal costs are also extensive. Obese children are less likely to be sent to college by their parents (6). Obese adults are less likely to be given jobs, and miss more work, overall costing employers something on the order of $4 billion. Obese children are at much higher risk of becoming obese adults than their thinner peers (7 - 8). In sum, normalizing obesity, particularly in children, presents a great hazard to personal health and has a major negative impact on costs at the society level.

On the flip side of normalizing, labeling obese children forces them to contend with the heavy stigma associated with obesity, decreasing the likelihood that they will overcome the many hurdles to health and wellness placed on them by society. Obesity is the fourth most common type of discrimination people report experiencing in the U.S. (9). Simply labeling children as obese has the potential to greatly influence their behavior. While the ads don’t literally use the word “obese”, they make it visually quite clear that they’re targeting obese children, and point a finger at poor eating habits. Labeling Theory (which is also known as Social Reactance Theory) posits that labeling an individual influences their behavior and more often than not causes them to conform to the stereotypes of the label in a self-fulfilling prophecy (10 - 11). Obese children must endure negative stigma not only from their peers, but also by their teachers and themselves (9). They are often ascribed negative characteristics including mean, stupid, loud, sloppy, ugly, lazy, sad, and lacking in friends (12 - 14). Obese children can become trapped within this self-fulfilling prophecy and may thus accept these traits as part of their role in society as an “obese child”. Studies have shown that the stigma associated with obesity causes an increase in coping methods like binge eating instead of being a contributing factor to motivation to lose weight and stay healthy (9, 15).

Not only are the children taught how to act by the characteristics attached to their label, but they learn through cognition in conjunction with observing behaviors within their environment. These elements operate reciprocally. For example, the environment in which one is raised affects one’s cognition and perceptions of behaviors that one witnesses. In state where approximately 30% of people are obese and where television stations air shows like “More to Love” or “Ruby” (in which the star, Ruby, spends three seasons trying lose weight only to end the third season having gained over 50 pounds) obesity is not likely to be perceived as abnormal (1). It is likely seen simply as the status quo. Posting health billboards featuring obese children eating is wading into dangerous territory. It risks adding more obesity normalizing media to the local environment and simultaneously reinforces the stereotypes and stigma associated with obesity, particularly qualities like lack of self-control.

Proponents of the campaign cite the fact that 93% of parents of obese children didn’t perceive their kids as being an abnormal weight (16). Research backs up this frightening assertion and shows that parents of overweight children consistently underestimated their children's weight (17 - 18). CCHG’s Childhood Obesity Awareness Campaign aims to inform parents that their children are at risk for serious health outcomes and the organization has deemed that shocking parents is necessary to do so. This scaremongering tactic assumes that by informing parents that their children are at risk of very serious health outcomes like death, they will be moved to act. This assumption takes for granted that people are rational decision makers. Rational decision-making generally entails defining the problem, identifying criteria relevant to the problem, considering all possible solutions, calculating the potential consequences of each solution, and choosing the best option. Many public health interventions are based on this same assumption. It is in fact the very basis of the Health Belief Model, which is commonly used in public health interventions. This model postulates that a behavioral change at the individual level depends on a person’s attitudes toward expected outcomes, the strength of those attitudes and the resulting outcome expectancies, as well as the individual’s perceptions of how others see them, and what the societal norms are (4). All of these factors meld to produce intention, which is followed by behavior. When applied to a parent’s role in preventing childhood obesity, as CCHG has done, the model suggests that if parents become aware of the potential hazardous heath outcomes of obesity and their attitudes toward obesity change, they will intend to prevent or reverse obesity in their children and that intention will lead to a change in behavior. This progression assumes rationalism prevails. Unfortunately assuming rationality fails to account for an individual’s subconscious thought process, irrational decision-making, group behavior and societal and environmental factors, all of which are crucial variables guiding behavior (4, 19, 20).
Irrational decision-making often relies upon the way that a particular issue is introduced or framed. Framing is a method of presenting a fact, topic or idea in a specific light so as to change how it is received among the audience to whom it is being presented. The concept of framing is central to Prospect Theory. Put simply, Prospect Theory states that people value gains and losses differently and that individuals make decisions based on perceived gains rather than perceived losses (21). Given two options with equal outcomes, an individual would choose the outcome expressed in terms of possible gains instead of the one expressed in possible losses. CCHG’s billboard frames childhood obesity in terms of the expected health outcome as a loss. Presenting the issue of childhood obesity by framing it within the context of not only a negative outcome but its most terrifying potential outcome, premature death from obesity related health problems, sets the campaign up for failure.

DO RIGHT! SUCCESSES: A SPRINGBOARD

While CCHGs program’s billboard and ad campaign are majorly flawed, there are a number of things the Do Right! campaign as a whole has gotten right. The organization was correct to take multi-faceted and all-encompassing approach to targeting childhood obesity prevention. Research suggests that families, schools and communities should all be included in programs aimed at preventing and reducing childhood obesity (22). Targeting parents exclusively has also been shown to be effective in reducing the BMI of overweight and obese children. A recent study from the United Kingdom showed that the BMI percentile of children whose parents were provided with eight sessions of cognitive-behavioral therapy for weight loss decreased significantly by 2.4% in the treatment group (23). Community involvement or not, targeting parents is crucial childhood obesity prevention programs. Children of obese parents are more likely to be obese themselves. Children aged 15 to 17 years old with at least one obese parent are over twice as likely as children with no obese parents to be obese adults. Children aged 1 to 2 years old were three times as likely to be obese as their peers who didn’t have an obese parent (24). Beyond the nuclear family, recent research has shown that obesity also spreads through social networks. A study conducted using data from Framingham, MA found that the chances of someone becoming obese increase 57% if they had a long-term friend who was obese (25). However, succeeding in utilizing parent and community involvement in childhood obesity prevention programs is challenging. As anyone who has ever tried to lose even a few pounds knows, attempting to lose weight can be daunting. For an obese person the barriers to weight loss, potentially including difficulty engaging in physical activity, addiction and lack of social support, can often seem indomitable. At any rate, with at minimum an adequate level of support within the environment and from family and community members, childhood obesity can be overcome. Methods to resolve each of the previously outlined failings within the billboard and ad campaign are presented in the following three sections.

As addressed in a previous section of this paper, the Health Belief Model as a champion of rational decision-making, and as it was implemented, was not an effective archetype from which to create the childhood obesity prevention billboard and ad campaign. On the other hand, framing, as delineated within Prospect Theory, can be an incredibly useful tool with which to begin to reconstruct this intervention. Bearing in mind that the original intent of the ad was to create awareness of childhood obesity as a serious problem among parents of obese children, the following proposed ad is aimed at both parents and children who will inevitably see the ads as well. This approach utilizes an entirely novel angle that frames health, with regard to weight, as a desirable and attainable outcome.

The proposed billboards will feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This sends the following messages physical activity is fun obese children are also entitled to fun obese children can do sports. In this way fighting childhood obesity through physical activity is framed in a positive light, as a fun and attainable goal. Making weight-loss and health attainable completely reverses the billboards, taking them from negative to positive and fomenting self-efficacy in children.

ENGENDERING SELF-EFFICACY BY NORMALIZING HEALTH

Labeling and normalizing obesity both have serious negative consequences at the individual and thus also societal level. They contribute to lower levels of self-esteem among obese children, and contribute to extensive monetary costs at the national level. A good public health campaign will succeed in achieving improved health and preventing obesity without further contributing to the extensive and damaging effects of labeling. While the billboard proposed in the prior section may be argued as normalizing obesity, it should be seen as normalizing activity among children of all shapes and sizes. Obese children are usually stereotyped as stupid, sloppy, ugly and lazy. In personal stories shared on blogs obese adults recount experiences that, in line with research published in peer reviewed journals, illustrate the cyclical nature of the self-fulfilling prophecy. In a blog published on Newsweek, Leslie Kinzel wrote,

“Prior to being told I was fat by my well-intentioned pediatrician … I'd spent my life as an active and athletic child, my fatness no obstacle in keeping up with my peers (and frequently besting them). As I got older I came to understand what being fat meant: fat kids were lousy at sports, and those who tried to play were to be mocked for it. Fat kids were always picked last, and though I was never picked last, I came to fear that it would inevitably happen. So I stopped playing. I backed away from sports and games altogether.” (26)

Her account is unfortunately not uncommon and characterizes the major negative impacts that labeling has on obese children. Obesity carries such stigma that for many children it becomes the single characteristic by which they feel most defined. At the end of her post Kinzel pleads,
“Call it a campaign against childhood couch-sitting. Call it a drive to get kids to go outside and play. Call it a movement to educate children on basic nutrition and how their amazing growing bodies work for them. But don't single out the fat kids. If I am any indication, doing this will only ensure that this generation will be fatter than ever, dragging behind them some heavy baggage around food issues and low self-esteem.” (26)

Kinzel’s well-put conclusion holds true given what has been learned from the failures of the Health Belief Model and the potential outcomes associated with Label Theory and Social Reactance Theory. It is absolutely necessary to change the personal characteristics associated with the obesity label. Getting obese children re-involved in sports and other physical activities will help to get rid of the stereotype that obese children can’t play sports. This will serve a dual purpose. It will encourage other obese children to take up arms so to speak and join the revolt against stereotypes. At the same time becoming involved in sports once again or perhaps for the first time will have positive health effects. While these effects certainly can’t be expected to be immediate they will have a positive effect on the local environment that should grow exponentially.

ENGENDERING SELF-EFFICACY BY REVOLTING AGAINST THE LABEL

Inciting obese children in Cincinnati to rise up against the fat label takes advantage of the mechanisms described in Psychological Reactance Theory. This theory asserts that perceived limitations to freedom or autonomy provoke an aversive affective reaction in people (27). In other words, if an individual perceives that their freedom has somehow been limited they will become provoked to regain it. A wonderful example of psychological reactance at work is the Truth campaign, which aims to curb youth use of tobacco by inciting a rebellion of sorts among young people. The campaign’s theme is “truth, a generation united against tobacco” (28). The Truth campaign successfully framed the tobacco industry as a liar that was hiding the truth from teens. In doing so they provoked teens to rebel against big tobacco and its lies, successfully decreasing youth smoking initiation rates.

The proposed alternative billboards showing obese children standing up to the labels and stereotypes associated with childhood obesity will do the same. This reaction is particularly common when individuals feel obliged to adopt a particular opinion or engage in a specific behavior (27). The billboards will bring to light these expectations and the violation of freedom that they cause for obese children, inspiring rebellion. In inciting this silent, healthy insurrection the campaign will be rekindling self-efficacy in obese children, which has a powerful effect on an individual’s level of motivation. “Boredom and apathy occur when a challenge is too small anxiety and withdrawal occur when a challenge is too great curiosity and engagement occur when the challenge is optimal” (29). If children don’t feel like they will succeed in losing weight or getting healthy they are much less likely to try to do so. Engendering self-efficacy through these billboards is an indispensible component of a successful childhood obesity prevention public health campaign. Recent work has found that “exercise’s association with weight loss was better explained through psychological, rather than physiological (ie, caloric expenditure), pathways” proving even further the importance of self-efficacy in weight loss (30). Giving obese children a common cause and an enemy to take down will help to create this self-efficacy, aiding in reducing and preventing childhood obesity over time.

Childhood obesity is a serious public health threat that requires sincere and practical interventions. The potential health consequences that are associated with childhood obesity are grave. They are harmful both to the individual and at the national level. Obese children are at increased risk for type II diabetes, cardiovascular disease, respiratory problems and future reproductive problems. They have added to increased medical costs at the national level, and as childhood obesity prevalence rates are higher among lower income quintiles the increased prevalence of childhood obesity has contributed to growing government expenditures on health (1). Practical, effective solutions are crucial in the fight to prevent and decrease childhood obesity.

In order to create a billboard campaign that effectively reduces and prevents childhood obesity while carefully avoiding potential adverse affects that such a billboard could so easily have, as evidenced by the one used by CCHG, social and behavioral sciences theories should be employed. Social Cognitive Theory, Labeling Theory (which is also known as Social Reactance Theory), the Health Belief Model, Framing Theory (as well as Prospect Theory) and Psychological Reactance Theory were used to analyze and critique CCHG’s billboard and ad intervention. CCHG’s billboard intervention was found to be inappropriate on the grounds that it contributed to defeating self-efficacy among obese children, added to labeling and normalizing childhood obesity and resorted to terrorizing parents in an effort to create awareness and incite a behavior change among parents and children. These same theories were then employed to suggest an appropriate intervention to replace CCHG’s billboard ads. The proposed replacement intervention consists of billboards that feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This intervention is based on engendering self-efficacy by reframing the childhood obesity issue in a positive light, normalizing healthy choices among obese children and using Psychological Reactance Theory to empower children to fight against the labels associated with childhood obesity. Casting a glow of optimism on the problem will help to bring back to life self-efficacy that has been squashed by labeling and stigma. Social and behavioral sciences theories were instrumental tools in understanding the effects that the Cincinnati CHG’s billboards could be expected to have on the target population, as well as any projected externalities, and in creating a better alternative.

REFERENCES
1. Overweight and Obesity. U.S. Obesity Trends. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/obesity/data/trends.html.
2. Do Right!. The Crisis. Cincinnati, OH: The Center for Closing the Health Gap in Greater Cincinnati. http://dorightcincy.org/the-crisis.
3. Childhood Obesity. Ohio Childhood Obesity Prevention Campaign Stirs Controversy. Princeton, NJ: Robert Wood Johnson Foundation. http://www.rwjf.org/childhoodobesity/digest.jsp?id=8398&c=OTC-RSS&attr=DI.
4. Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 200152:1-26.
5. Hammond R. The Economic Costs of Obesity. Brookings Institution. May 4, 2011. http://www.brookings.edu/multimedia/video/2010/0914_obesity_hammond.aspx.
6. Herper M. The Hidden Cost of Obesity. Forbes [online]. November 24, 2006. http://www.forbes.com/2006/07/19/obesity-fat-costs_cx_mh_0720obesity.html.
7. Epstein LH, Wing RR, Valoski A. Childhood obesity. Pediatr. Clin. North Am. 198532(2):363-379.
8. Krassas GE, Tzotzas T. Do obese children become obese adults: childhood predictors of adult disease. Pediatr Endocrinol Rev. 20041 Suppl 3:455-459.
9. Puhl RM, Latner JD. Stigma, obesity, and the health of the nation’s children. Psychol Bull. 2007133(4):557-580.
10. Laslett B, Warren CAB. Losing Weight: The Organizational Promotion of Behavior Change. Social Problems. 197523(1):69-80.
11. Link BG, Phelan JC. Conceptualizing Stigma. Annual Review of Sociology. 200127:363-385.
12. Holub SC. Individual differences in the anti-fat attitudes of preschool-children: The importance of perceived body size. Body Image. 20085(3):317-321.
13. Musher-Eizenman DR, Holub SC, Miller AB, Goldstein SE, Edwards-Leeper L. Body Size Stigmatization in Preschool Children: The Role of Control Attributions. Journal of Pediatric Psychology. 200429(8):613 -620.
14. Iobst EA. The Relationship Among Gender, Age, Blame, and Children’s Attributions about an Overweight Peer. 2007. Available at: http://etd.ohiolink.edu/view.cgi?acc_num=ucin1242390002. Accessed May 4, 2011.
15. Bensley K. Obesity and Perceptions of the Body in Teenage American Girls. UCL Centre for Applied Global Citizenship [online]. December 17, 2010. London, U.K.: . http://www.ucl.ac.uk/network-for-student-activism/w/Obesity_and_Perceptions_of_the_Body_in_Teenage_American_Girls.
16. Orr K. Provacative local campaign to target childhood obesity. WVXU Radio [online]. July 31, 2008. http://www.wvxu.org/news/wvxunews_article.asp?ID=5421.
17. Etelson D, Brand DA, Patrick PA, Shirali A. Childhood Obesity: Do Parents Recognize This Health Risk? Obesity. 200311(11):1362-1368.
18. Health & Parenting. Many Parents Don’t See Child Obesity. Web MD. http://www.webmd.com/parenting/news/20071211/many-parents-dont-see-child-obesity.
19. Janz NK, Becker MH. The Health Belief Model: A Decade Later. Health Education & Behavior. 198411(1):1 -47.
20. Rosenstock IM, Strecher VJ, Becker MH. Social Learning Theory and the Health Belief Model. Health Education & Behavior. 198815(2):175-183.
21. Kahneman D, Tversky A. Prospect Theory: An Analysis of Decision under Risk. Econometrica. 197947(2):263-291.
22. Lindsay AC, Sussner KM, Kim J, Gortmaker S. The role of parents in preventing childhood obesity. Future Child. 200616(1):169-186.
23. Jansen E, Mulkens S, Jansen A. Tackling childhood overweight: treating parents exclusively is effective. Int J Obes (Lond). 201135(4):501-509.
24. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N. Engl. J. Med. 1997337(13):869-873.
25. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N. Engl. J. Med. 2007357(4):370-379.
26. Kinzel L. Why the first lady's fight to end childhood obesity does damage to the children it's trying to help. Newsweek [online]. April 20, 2010. http://www.newsweek.com/2010/04/19/fat-kids-cruel-world.html.
27. Burke WW, Lake DG, Paine JW. Organization Change: A Comprehensive Reader. John Wiley and Sons 2008.
28. Truth. http://www.thetruth.com/.
29. Snyder CR, Lopez SJ. Oxford handbook of positive psychology. Oxford University Press US 2009 (P573).
30. Annesi JJ. Behaviorally supported exercise predicts weight loss in obese adults through improvements in mood, self-efficacy, and self-regulation, rather than by caloric expenditure. Perm J. 201115(1):23-27.


Challenging Dogma - Spring 2011

Today over one third of U.S. adults and 17% of U.S. children are obese. In the last three decades, obesity rates for adults have doubled and rates for children have tripled. However, the burden of obesity is not evenly distributed, and falls heavily on minorities. The 2009 Behavioral Risk Factor Surveillance System report showed that “blacks were 51% more likely and Hispanics were 21% more likely than non-Hispanic whites to be obese” (1). It is also geographically unevenly distributed with the American Midwest suffering higher obesity prevalence rates than the rest of the country. Cincinnati, Ohio is a beautiful Midwestern city situated at the southern edge of Ohio, across the Ohio River from Kentucky. However, like many Midwestern cities and states, Cincinnati has seen an alarming increase in obesity among adults and children in the last few decades. According to CDC 29.6% of Ohioans were obese in 2009. This increase has serious health consequences for adults and children. Obesity related diseases like type 2 diabetes, which previously only affected adults, is now affecting children (1). Obese children are also at higher risk of suffering cardiovascular disease. Obesity, including childhood obesity, is known to be a risk factor for a number of diseases including cancers, stroke, respiratory problems and reproductive health problems. The annual hospital costs related to childhood obesity increased from $35 million in the period from 1979-1981 to $127 million in the period from 1997-1999 (1).

In 2008 the nonprofit Center for Closing the Health Gap (2) in Greater Cincinnati began a campaign aimed at preventing childhood obesity. Childhood obesity prevention is a goal that fits perfectly within CCHG’s mission, which includes increasing awareness about health disparities (2). The childhood obesity epidemic in the Greater Cincinnati area disproportionately affects minority children. CCHG’s website reports that the rate of overweight and obesity in Hamilton County is 43% among Black, Non-Hispanic children and 21% among White, Non-Hispanic children. The negative consequences to health that may result from obesity are grave. The city was seeing children with hypertension and worrying rates of type II diabetes. Secondly CCHG saw that obesity disproportionately affected children of low-income parents and minority children, particularly Black, Hispanic and Appalachian children. To work toward preventing childhood obesity the organization initiated a campaign called “Do Right!” The specific target of the childhood prevention portion of the program aimed at “improving the health and well-being of children at Rockdale Elementary that are overweight and obese” (2). Rockdale Elementary is part of the Cincinnati Public Schools system and enrolls about 500 preschool and elementary school students from grades PK-8.

The “Do Right!” children’s program is multi-faceted. Its in school components include screening for BMI to identify overweight and obese children, referral for obese children to an after school physical activity and nutrition program. The program includes nutrition every other week by a dietician, physical activity and bi-weekly parent education and information sessions to discuss nutrition. The program also included 1-minute health tips on the radio, parent workshops in development and City School Awareness Presentations (2). Finally, the program ran a concurrent obesity awareness campaign that included billboards, bus shelters, radio advertisements, ads in minority newspapers and the website: www.dorightcincy.org. They feature obese children mowing down on big, greasy burgers in front of plates of onion rings with the words “Are we feeding our kids to death?” in large print. Below, they provide the Do Right! campaign’s website and phone number with the words “for information on how to combat obesity.” These ads are the focus of this critique.

First and foremost it alienates the very population it aims to help. Dwight Tillery, the executive director of CCHG, purports that the campaign was designed to serve as a wake-up call for families. It aims to incentivize parents to take the health of their children more seriously by showing them just how serious obesity is. Tillery said, “We can’t afford to be politically correct on this issue” (3). Political correctness or lack thereof aside the means simply do not justify the end. Whether or not parents are shocked into understanding the gravity of childhood obesity, children who see these ads are sure to feel alienated. The ads effectuate a pervasive sense of hopelessness, powerlessness and defeat. They say, “you’re obese and you’re being fed to death.” There is nothing in this message that engenders a sense of self-efficacy, or the idea that a lower, healthier weight is an attainable goal. This deficiency is the ad’s primary shortcoming. Self-efficacy as defined by psychologist and father of Social Cognitive Theory, Albert Bandura, is one's belief in one's ability to succeed in specific situations. The concept of self-efficacy is central to Social Cognitive Theory (4). Social Cognitive Theory asserts that behavior is based on the interaction between one’s environment, the behaviors one witnesses, and the individual themselves. Ads like these posted by CCHG construct a negative outcome expectation and in so doing dismantle whatever self-efficacy they could otherwise have fostered. It simply isn’t enough to provide a website and helpline when the ad itself effectively destroys self-efficacy.

Labeling and Normalizing Obesity

Not only do these ads beget powerlessness as shown in the last paragraph, but they concurrently label and normalize childhood obesity. The relationship between labeling and normalizing obesity presents a double-edged sword for potential public health interventions aimed at preventing childhood obesity. The normalizing of obesity comes with a hefty price tag including rising economic costs. According to the Brookings Institution, “the total costs of obesity in the U.S. alone may exceed $215 billion annually” (5). The direct medical costs resulting from obesity in the U.S. have been estimated to account for over 9% of the national medical bill (6). Societal costs are also extensive. Obese children are less likely to be sent to college by their parents (6). Obese adults are less likely to be given jobs, and miss more work, overall costing employers something on the order of $4 billion. Obese children are at much higher risk of becoming obese adults than their thinner peers (7 - 8). In sum, normalizing obesity, particularly in children, presents a great hazard to personal health and has a major negative impact on costs at the society level.

On the flip side of normalizing, labeling obese children forces them to contend with the heavy stigma associated with obesity, decreasing the likelihood that they will overcome the many hurdles to health and wellness placed on them by society. Obesity is the fourth most common type of discrimination people report experiencing in the U.S. (9). Simply labeling children as obese has the potential to greatly influence their behavior. While the ads don’t literally use the word “obese”, they make it visually quite clear that they’re targeting obese children, and point a finger at poor eating habits. Labeling Theory (which is also known as Social Reactance Theory) posits that labeling an individual influences their behavior and more often than not causes them to conform to the stereotypes of the label in a self-fulfilling prophecy (10 - 11). Obese children must endure negative stigma not only from their peers, but also by their teachers and themselves (9). They are often ascribed negative characteristics including mean, stupid, loud, sloppy, ugly, lazy, sad, and lacking in friends (12 - 14). Obese children can become trapped within this self-fulfilling prophecy and may thus accept these traits as part of their role in society as an “obese child”. Studies have shown that the stigma associated with obesity causes an increase in coping methods like binge eating instead of being a contributing factor to motivation to lose weight and stay healthy (9, 15).

Not only are the children taught how to act by the characteristics attached to their label, but they learn through cognition in conjunction with observing behaviors within their environment. These elements operate reciprocally. For example, the environment in which one is raised affects one’s cognition and perceptions of behaviors that one witnesses. In state where approximately 30% of people are obese and where television stations air shows like “More to Love” or “Ruby” (in which the star, Ruby, spends three seasons trying lose weight only to end the third season having gained over 50 pounds) obesity is not likely to be perceived as abnormal (1). It is likely seen simply as the status quo. Posting health billboards featuring obese children eating is wading into dangerous territory. It risks adding more obesity normalizing media to the local environment and simultaneously reinforces the stereotypes and stigma associated with obesity, particularly qualities like lack of self-control.

Proponents of the campaign cite the fact that 93% of parents of obese children didn’t perceive their kids as being an abnormal weight (16). Research backs up this frightening assertion and shows that parents of overweight children consistently underestimated their children's weight (17 - 18). CCHG’s Childhood Obesity Awareness Campaign aims to inform parents that their children are at risk for serious health outcomes and the organization has deemed that shocking parents is necessary to do so. This scaremongering tactic assumes that by informing parents that their children are at risk of very serious health outcomes like death, they will be moved to act. This assumption takes for granted that people are rational decision makers. Rational decision-making generally entails defining the problem, identifying criteria relevant to the problem, considering all possible solutions, calculating the potential consequences of each solution, and choosing the best option. Many public health interventions are based on this same assumption. It is in fact the very basis of the Health Belief Model, which is commonly used in public health interventions. This model postulates that a behavioral change at the individual level depends on a person’s attitudes toward expected outcomes, the strength of those attitudes and the resulting outcome expectancies, as well as the individual’s perceptions of how others see them, and what the societal norms are (4). All of these factors meld to produce intention, which is followed by behavior. When applied to a parent’s role in preventing childhood obesity, as CCHG has done, the model suggests that if parents become aware of the potential hazardous heath outcomes of obesity and their attitudes toward obesity change, they will intend to prevent or reverse obesity in their children and that intention will lead to a change in behavior. This progression assumes rationalism prevails. Unfortunately assuming rationality fails to account for an individual’s subconscious thought process, irrational decision-making, group behavior and societal and environmental factors, all of which are crucial variables guiding behavior (4, 19, 20).
Irrational decision-making often relies upon the way that a particular issue is introduced or framed. Framing is a method of presenting a fact, topic or idea in a specific light so as to change how it is received among the audience to whom it is being presented. The concept of framing is central to Prospect Theory. Put simply, Prospect Theory states that people value gains and losses differently and that individuals make decisions based on perceived gains rather than perceived losses (21). Given two options with equal outcomes, an individual would choose the outcome expressed in terms of possible gains instead of the one expressed in possible losses. CCHG’s billboard frames childhood obesity in terms of the expected health outcome as a loss. Presenting the issue of childhood obesity by framing it within the context of not only a negative outcome but its most terrifying potential outcome, premature death from obesity related health problems, sets the campaign up for failure.

DO RIGHT! SUCCESSES: A SPRINGBOARD

While CCHGs program’s billboard and ad campaign are majorly flawed, there are a number of things the Do Right! campaign as a whole has gotten right. The organization was correct to take multi-faceted and all-encompassing approach to targeting childhood obesity prevention. Research suggests that families, schools and communities should all be included in programs aimed at preventing and reducing childhood obesity (22). Targeting parents exclusively has also been shown to be effective in reducing the BMI of overweight and obese children. A recent study from the United Kingdom showed that the BMI percentile of children whose parents were provided with eight sessions of cognitive-behavioral therapy for weight loss decreased significantly by 2.4% in the treatment group (23). Community involvement or not, targeting parents is crucial childhood obesity prevention programs. Children of obese parents are more likely to be obese themselves. Children aged 15 to 17 years old with at least one obese parent are over twice as likely as children with no obese parents to be obese adults. Children aged 1 to 2 years old were three times as likely to be obese as their peers who didn’t have an obese parent (24). Beyond the nuclear family, recent research has shown that obesity also spreads through social networks. A study conducted using data from Framingham, MA found that the chances of someone becoming obese increase 57% if they had a long-term friend who was obese (25). However, succeeding in utilizing parent and community involvement in childhood obesity prevention programs is challenging. As anyone who has ever tried to lose even a few pounds knows, attempting to lose weight can be daunting. For an obese person the barriers to weight loss, potentially including difficulty engaging in physical activity, addiction and lack of social support, can often seem indomitable. At any rate, with at minimum an adequate level of support within the environment and from family and community members, childhood obesity can be overcome. Methods to resolve each of the previously outlined failings within the billboard and ad campaign are presented in the following three sections.

As addressed in a previous section of this paper, the Health Belief Model as a champion of rational decision-making, and as it was implemented, was not an effective archetype from which to create the childhood obesity prevention billboard and ad campaign. On the other hand, framing, as delineated within Prospect Theory, can be an incredibly useful tool with which to begin to reconstruct this intervention. Bearing in mind that the original intent of the ad was to create awareness of childhood obesity as a serious problem among parents of obese children, the following proposed ad is aimed at both parents and children who will inevitably see the ads as well. This approach utilizes an entirely novel angle that frames health, with regard to weight, as a desirable and attainable outcome.

The proposed billboards will feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This sends the following messages physical activity is fun obese children are also entitled to fun obese children can do sports. In this way fighting childhood obesity through physical activity is framed in a positive light, as a fun and attainable goal. Making weight-loss and health attainable completely reverses the billboards, taking them from negative to positive and fomenting self-efficacy in children.

ENGENDERING SELF-EFFICACY BY NORMALIZING HEALTH

Labeling and normalizing obesity both have serious negative consequences at the individual and thus also societal level. They contribute to lower levels of self-esteem among obese children, and contribute to extensive monetary costs at the national level. A good public health campaign will succeed in achieving improved health and preventing obesity without further contributing to the extensive and damaging effects of labeling. While the billboard proposed in the prior section may be argued as normalizing obesity, it should be seen as normalizing activity among children of all shapes and sizes. Obese children are usually stereotyped as stupid, sloppy, ugly and lazy. In personal stories shared on blogs obese adults recount experiences that, in line with research published in peer reviewed journals, illustrate the cyclical nature of the self-fulfilling prophecy. In a blog published on Newsweek, Leslie Kinzel wrote,

“Prior to being told I was fat by my well-intentioned pediatrician … I'd spent my life as an active and athletic child, my fatness no obstacle in keeping up with my peers (and frequently besting them). As I got older I came to understand what being fat meant: fat kids were lousy at sports, and those who tried to play were to be mocked for it. Fat kids were always picked last, and though I was never picked last, I came to fear that it would inevitably happen. So I stopped playing. I backed away from sports and games altogether.” (26)

Her account is unfortunately not uncommon and characterizes the major negative impacts that labeling has on obese children. Obesity carries such stigma that for many children it becomes the single characteristic by which they feel most defined. At the end of her post Kinzel pleads,
“Call it a campaign against childhood couch-sitting. Call it a drive to get kids to go outside and play. Call it a movement to educate children on basic nutrition and how their amazing growing bodies work for them. But don't single out the fat kids. If I am any indication, doing this will only ensure that this generation will be fatter than ever, dragging behind them some heavy baggage around food issues and low self-esteem.” (26)

Kinzel’s well-put conclusion holds true given what has been learned from the failures of the Health Belief Model and the potential outcomes associated with Label Theory and Social Reactance Theory. It is absolutely necessary to change the personal characteristics associated with the obesity label. Getting obese children re-involved in sports and other physical activities will help to get rid of the stereotype that obese children can’t play sports. This will serve a dual purpose. It will encourage other obese children to take up arms so to speak and join the revolt against stereotypes. At the same time becoming involved in sports once again or perhaps for the first time will have positive health effects. While these effects certainly can’t be expected to be immediate they will have a positive effect on the local environment that should grow exponentially.

ENGENDERING SELF-EFFICACY BY REVOLTING AGAINST THE LABEL

Inciting obese children in Cincinnati to rise up against the fat label takes advantage of the mechanisms described in Psychological Reactance Theory. This theory asserts that perceived limitations to freedom or autonomy provoke an aversive affective reaction in people (27). In other words, if an individual perceives that their freedom has somehow been limited they will become provoked to regain it. A wonderful example of psychological reactance at work is the Truth campaign, which aims to curb youth use of tobacco by inciting a rebellion of sorts among young people. The campaign’s theme is “truth, a generation united against tobacco” (28). The Truth campaign successfully framed the tobacco industry as a liar that was hiding the truth from teens. In doing so they provoked teens to rebel against big tobacco and its lies, successfully decreasing youth smoking initiation rates.

The proposed alternative billboards showing obese children standing up to the labels and stereotypes associated with childhood obesity will do the same. This reaction is particularly common when individuals feel obliged to adopt a particular opinion or engage in a specific behavior (27). The billboards will bring to light these expectations and the violation of freedom that they cause for obese children, inspiring rebellion. In inciting this silent, healthy insurrection the campaign will be rekindling self-efficacy in obese children, which has a powerful effect on an individual’s level of motivation. “Boredom and apathy occur when a challenge is too small anxiety and withdrawal occur when a challenge is too great curiosity and engagement occur when the challenge is optimal” (29). If children don’t feel like they will succeed in losing weight or getting healthy they are much less likely to try to do so. Engendering self-efficacy through these billboards is an indispensible component of a successful childhood obesity prevention public health campaign. Recent work has found that “exercise’s association with weight loss was better explained through psychological, rather than physiological (ie, caloric expenditure), pathways” proving even further the importance of self-efficacy in weight loss (30). Giving obese children a common cause and an enemy to take down will help to create this self-efficacy, aiding in reducing and preventing childhood obesity over time.

Childhood obesity is a serious public health threat that requires sincere and practical interventions. The potential health consequences that are associated with childhood obesity are grave. They are harmful both to the individual and at the national level. Obese children are at increased risk for type II diabetes, cardiovascular disease, respiratory problems and future reproductive problems. They have added to increased medical costs at the national level, and as childhood obesity prevalence rates are higher among lower income quintiles the increased prevalence of childhood obesity has contributed to growing government expenditures on health (1). Practical, effective solutions are crucial in the fight to prevent and decrease childhood obesity.

In order to create a billboard campaign that effectively reduces and prevents childhood obesity while carefully avoiding potential adverse affects that such a billboard could so easily have, as evidenced by the one used by CCHG, social and behavioral sciences theories should be employed. Social Cognitive Theory, Labeling Theory (which is also known as Social Reactance Theory), the Health Belief Model, Framing Theory (as well as Prospect Theory) and Psychological Reactance Theory were used to analyze and critique CCHG’s billboard and ad intervention. CCHG’s billboard intervention was found to be inappropriate on the grounds that it contributed to defeating self-efficacy among obese children, added to labeling and normalizing childhood obesity and resorted to terrorizing parents in an effort to create awareness and incite a behavior change among parents and children. These same theories were then employed to suggest an appropriate intervention to replace CCHG’s billboard ads. The proposed replacement intervention consists of billboards that feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This intervention is based on engendering self-efficacy by reframing the childhood obesity issue in a positive light, normalizing healthy choices among obese children and using Psychological Reactance Theory to empower children to fight against the labels associated with childhood obesity. Casting a glow of optimism on the problem will help to bring back to life self-efficacy that has been squashed by labeling and stigma. Social and behavioral sciences theories were instrumental tools in understanding the effects that the Cincinnati CHG’s billboards could be expected to have on the target population, as well as any projected externalities, and in creating a better alternative.

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12. Holub SC. Individual differences in the anti-fat attitudes of preschool-children: The importance of perceived body size. Body Image. 20085(3):317-321.
13. Musher-Eizenman DR, Holub SC, Miller AB, Goldstein SE, Edwards-Leeper L. Body Size Stigmatization in Preschool Children: The Role of Control Attributions. Journal of Pediatric Psychology. 200429(8):613 -620.
14. Iobst EA. The Relationship Among Gender, Age, Blame, and Children’s Attributions about an Overweight Peer. 2007. Available at: http://etd.ohiolink.edu/view.cgi?acc_num=ucin1242390002. Accessed May 4, 2011.
15. Bensley K. Obesity and Perceptions of the Body in Teenage American Girls. UCL Centre for Applied Global Citizenship [online]. December 17, 2010. London, U.K.: . http://www.ucl.ac.uk/network-for-student-activism/w/Obesity_and_Perceptions_of_the_Body_in_Teenage_American_Girls.
16. Orr K. Provacative local campaign to target childhood obesity. WVXU Radio [online]. July 31, 2008. http://www.wvxu.org/news/wvxunews_article.asp?ID=5421.
17. Etelson D, Brand DA, Patrick PA, Shirali A. Childhood Obesity: Do Parents Recognize This Health Risk? Obesity. 200311(11):1362-1368.
18. Health & Parenting. Many Parents Don’t See Child Obesity. Web MD. http://www.webmd.com/parenting/news/20071211/many-parents-dont-see-child-obesity.
19. Janz NK, Becker MH. The Health Belief Model: A Decade Later. Health Education & Behavior. 198411(1):1 -47.
20. Rosenstock IM, Strecher VJ, Becker MH. Social Learning Theory and the Health Belief Model. Health Education & Behavior. 198815(2):175-183.
21. Kahneman D, Tversky A. Prospect Theory: An Analysis of Decision under Risk. Econometrica. 197947(2):263-291.
22. Lindsay AC, Sussner KM, Kim J, Gortmaker S. The role of parents in preventing childhood obesity. Future Child. 200616(1):169-186.
23. Jansen E, Mulkens S, Jansen A. Tackling childhood overweight: treating parents exclusively is effective. Int J Obes (Lond). 201135(4):501-509.
24. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N. Engl. J. Med. 1997337(13):869-873.
25. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N. Engl. J. Med. 2007357(4):370-379.
26. Kinzel L. Why the first lady's fight to end childhood obesity does damage to the children it's trying to help. Newsweek [online]. April 20, 2010. http://www.newsweek.com/2010/04/19/fat-kids-cruel-world.html.
27. Burke WW, Lake DG, Paine JW. Organization Change: A Comprehensive Reader. John Wiley and Sons 2008.
28. Truth. http://www.thetruth.com/.
29. Snyder CR, Lopez SJ. Oxford handbook of positive psychology. Oxford University Press US 2009 (P573).
30. Annesi JJ. Behaviorally supported exercise predicts weight loss in obese adults through improvements in mood, self-efficacy, and self-regulation, rather than by caloric expenditure. Perm J. 201115(1):23-27.