Sunday, December 12, 2010

The Healthy, Hunger-Free Kids Act of 2010: The Flaw of Eliminating Unhealthy Foods in Schools to Combat Childhood Obesity – Jermie Gandhi

INTRODUCTION

Childhood Obesity in the U.S.

The current increasing rates of individuals who are considered overweight or obese in the United States has often been described as reaching epidemic proportions. Although these obesity rates are tremendous in the adult population, the greater issue in public health involves the growing waists of our nation’s school-age children. In fact, between 1976-1980 and 2007-2008, the prevalence of obesity in pre-school children aged 2 to 5 years doubled from 5% to 10.4%, tripled from 6.5% to 19.6% among those aged 6 to 11, and significantly increased from 5% to 18.1% in adolescents aged 12 to 19. (1) With a strong association between being overweight as a child and the risk of obesity as an adult, these weight issues during childhood can lead to more critical conditions later in life, such as increased risk for cardiovascular diseases (i.e. hypertension, high cholesterol, stoke, type II diabetes), several cancers, and osteoarthritis. (2,3) In addition, overweight youth confront short-term concerns, such as bone and joint difficulties, sleep apnea, and psychological problems involving stigmatization and reduced self-esteem, all of which can become exacerbated with age. (3) Therefore, it comes at no surprise that public health officials have been fairly successful, in recent years, of raising awareness of this issue via numerous public health initiatives.

As a disorder based on an individual’s caloric imbalance, obesity has been tackled by public health interventions by focusing, rightfully, on three major behavioral factors: energy intake, physical activity, and sedentary behavior. (4) Although physical activity and developing a more active lifestyle among U.S. youth play a major role in reducing childhood obesity, controlling adequate energy intake has been a more difficult task due to the great abundance of high-calorie foods available to youths. In addition, since children and adolescents predominantly spend most of their time in schools during the ages 5-18, school administrators have been pressured to avoid large portion sizes for food and beverages, reduce frequent snacking of energy-dense foods available in vending machines, and eliminate sugar-sweetened drinks and high-sugar foods, all of which have been associated with weight gain in children. (4) However, even with this knowledge and need for innovation, the diffusion of healthy foods in schools across the country has been slow, prompting many health organizations and obesity awareness groups to push for federal legislation to combat the growing number of obese children.

In fact, the urgency to reduce childhood obesity has become the cornerstone of First Lady Michelle Obama’s campaign, Let’s Move!. In addition to the establishing the “four pillars of the First Lady’s Let’s Move! campaign of empowering parents and caregivers, providing healthy food in schools, improving access to healthy, affordable foods, and increasing physical activity,” (5) President Obama created the first-ever presidential Task Force on Childhood Obesity to review programs and policies affiliated with childhood obesity. While this newly-established campaign might prove successful in accomplishing its vision of becoming “America’s Move to Raise a Healthier Generation of Kids,” its support for portions of the recently passed The Healthy, Hunger-Free Kids Act of 2010, may prove detrimental to their stated goals.

The Healthy, Hunger-Free Kids Act of 2010

The Healthy, Hunger-Free Kids Act (HHFKA) of 2010, passed and signed into law in early December 2010, addresses the food received by millions of American children in school and child-care, which is often the only healthy meal available to them all day. (6) However, with these institutions increasingly relying on high-calorie foods and sweetened beverages to supply the growing number of children eating at school, the prevalence of childhood obesity has continued to rise. Therefore, HHFKA was passed to “dramatically improve children’s access to nutritious meals, enhance the quality of meals children eat both in and out of school and in child-care settings, implement new school food safety guidelines, and…establish nutrition standards for all foods sold in schools.” (6,7) While provisions within the bill, such as increased access and support to schools for providing more nutritious foods will have a positive impact in giving school-aged children a choice of consuming healthier foods, the bill contains language that assigns authority to the Secretary of Agriculture to reduce junk food sold at schools by applying nutritional standards to all food available at schools, as well as limiting the number of fundraisers and bake sales (where sales of cookies and brownies are the norm) conducted annually. (7) While, superficially, this influence may seemingly have a positive impact reducing obesity by eliminating high-fat, high-sugar items, a more comprehensive analysis will reveal flaws within its implementation. Thus, by first predicting imperfections that may arise, an improved intervention can be proposed to combat childhood obesity.

FLAWS OF ELIMINATING UNHEATLHY FOODS FROM SCHOOLS

Whereas anti-childhood obesity organizations, such as Let’s Move!, and lawmakers in Washington, D.C. have good intentions in removing access to non-nutritious foods from school cafeterias, their neglect of the functions of social behavior and reactions to these flawed policies may result in undesired implications. In particular, the removal of “junk” food from school cafeterias and limiting the number of bake sales, may lead to a revolt by both students and institutions if not supported by additional legislation that also considers the basics of social behavior.

Critique 1: Limitations of the Trans-theoretical Model

One major flaws of this particular provision is its’ use of the trans-theoretical model (also known as the Stages of Change Model) as its foundational basis. This model, developed by James Prochaska and his colleagues in 1977, attempts to describe an individual’s ability to modify his behavior by progressing gradually through a series of five stages, which permits individual intervention to be targeted at a particular stage, and is comprised of:

1. Pre-contemplation – no intention for action in near future,

2. Contemplation – intention to change in the near future,

3. Preparation – setting the stage for behavior change in the immediate future,

4. Action – behavioral modification has been attempted,

5. Maintenance – behavioral change is continued and relapse is avoided. (8.9)

While this method may be effective in modeling an intervention based on an individual’s needs, it fails to recognize that not everyone may progress sequentially through each step gradually, and more importantly, disregards social factors required to alter group, rather than individual, behavior. (10) In this case, administrators are attempting to combat childhood obesity by assuming every child in the U.S. is currently in the contemplation phase, with the intention to eat healthier but lacking the resources to prepare for this behavioral change. Thus, with the removal of junk food, the legislation hopes to assist students to gradually proceed into the preparation stage, and ultimately to the action stage. However, as witnessed with interventions affecting other public health issues, the presence of social factors play an enormous role in soliciting behavioral change. (10) In fact, this law ignores that many students will continue to consume unhealthy foods outside of school, where unhealthy options are abundantly and readily available. In addition, the fact that the source of this “ban” on junk food and bake sales will be coming from legislators in Washington, D.C., (or perceived as an outrageous act by school administrators) may lead to psychological reactance among the students, resulting in the opposite effect of the regulation’s intention.

Critique 2: Psychological Reactance

Perhaps the greatest flaw in battling childhood obesity by setting stricter guidelines for the foods served in schools is the intense possibility of psychological reactance to the novel law by the students. The theory of psychological reactance states that when confronted with a risk to one’s control or freedom, an individual will attempt to resolve this threat by behaving oppositely from what is demanded. (11) As a core belief, the need to control the food one consumes is discounted by the makers of this policy. In fact, the three chief factors (explicitness, authoritativeness, and reason) determining the extent of psychological reactance experienced to a message are ignored in the implementation the law, paving the way for a strong reactance to a reduction of junk food and bake sales. (11) Explicitness, or the degree of openness of message, is lowered since many school districts will gradually substitute popular food items with healthier ones (while still offering the unhealthy items), sending an unclear message that the school is fighting childhood obesity. In addition, the perception that lawmakers and administrators are removing control of food selection by reducing preferred, unhealthy foods will increase the students’ desire for junk food due to the high authoritativeness of the message. Finally, as healthier foods are substituted, it is doubtful many school districts will explain the reason to eat healthier, further intensifying psychological reactance.

Furthermore, based on the importance of these unhealthy foods on other aspect of the students’ lives, the psychological reactance experienced will only deepen. Acknowledging the utilization of bake sales (which often involve selling cookies or brownies) in most schools, especially in low-income communities, as a effortless tool to fund a significant number of activates, limiting the number of bake sales may be perceived as a further attack on the students’ freedom to partake in social activities during and after school hours. In addition to fostering greater psychological reactance, the healthy foods may become identified as a symbol for, or branded as, destroying one’s ability to partake in these activities, and thus the students may completely overlook the message that this legislation was passed to reduce childhood obesity.

However, while psychological reactance will be minimized in school cafeterias that serve only healthy options, it will be increasingly witnessed at home (i.e. after school and weekends), where parents are more lenient on the amounts of high-calorie and sweetened foods consumed. Therefore, as students attempt to resolve the attack on their control on food selection at school by eating these unhealthy foods at home, the problem of childhood obesity will persist, and may even become more severe.

Critique 3: Institutional Racism

Finally, in addition to sparking a reaction by students, the adoption of this law represents a form of institutional racism, where the requirement to sell foods that meet a strict standard will be more difficult to abide by for financially struggling school districts, which are often the ones with a high proportion of minorities. (12) Although the bill allocates funds to schools to offer healthier options, the limitations on bake sales may adversely alter the activities of its students, where high-minority districts often rely disproportionately higher on bake sales to finance after-school programs and sporting events. As described with the increased psychological reactance by students, the bill may ultimately not only affect childhood obesity rates negatively, but also increase trouble in other public health issues, such as drug and alcohol use, which are often mediated by after-school programs. (13) Since these students are already at higher risk, due to their socio-economic background, the HHK Act unintentionally practices institutional racism by excessively punishing schools that must rely on bake sales the most.

A NEW PROPOSAL TO FIGHT CHILDHOOD OBESITY: PEER EDUCATION

In order to establish a more productive intervention in paving the way to eliminating childhood obesity, social factors and responses by those involved (i.e. students, schools, etc.) must be considered and manipulated to successfully achieve the goal in a comprehensive approach. One such initiative, rather than regulation of foods offered in schools, would be the organization of peer-led education programs within schools to transition students to healthier lifestyles. Selected based on leadership skills and ability to promote diffusion of innovation (i.e. sociable and able to control opinions) (14), these peer leaders would be responsible for not only disseminating information on living healthy lifestyles through physical activity and substituting junk foods with healthier options, but also serve as change agents to be followed by living healthy lifestyles themselves. As a peer-led movement, the flaws witnessed in the techniques employed by the Healthy, Hunger-Free Kids Act can be eliminated, and thus create an environment in which children not only choose the healthier option when given a choice, but also retain this behavior outside school hours. Thus, this group-level program, as an alternate to limiting junk foods and bake sales, would be more effective in eradicating childhood obesity.

Defense 1: Social Network Theory/Social Learning Theory

Based upon a group-level model, the peer-led education program would take advantage of the fact that individuals, rather than act independently, interact with others, and this often effects one’s decisions and behaviors. In particular, the plan utilizes Social Network Theory, which “emphasizes the interdependence between individuals and the relational ties that exist between individuals within a social system, where a social system refers to a targeted population that can be identified by specific boundaries,” (14) and the related Social Learning Theory, which stresses “the mechanism of social influence, and states that behaviors are learned through the observation of others engaged in a behavior and subsequent modeling of that behavior.” (15) Therefore, the students elected to lead these programs within each school must have key ties to many other students and be seen as role models whose actions should be modeled. In particular, since the spread of obesity has been demonstrated in large social networks in previous studies, (16) it is not unreasonable to manipulate social ties to create a network where physical activity and healthy eating habits proliferates to all those within the network (i.e. all the students in the school).

Additionally, as a multi-faceted program, peer directed education would utilize modeling behavior, which is often observed innately, to tackle the problem of childhood obesity at the social level. As demonstrated through one major aspect of Social Learning Theory, observing behaviors of perceived role models, leads to imitation, or modeling, of these behaviors. (17) In the case for creating healthy dietary norms, this can be a powerful tool in diffusing healthy behaviors via imitation of peer leaders by other students. Perhaps, most significant, and one that sets it apart from the approach suggested by the Healthy, Hunger-Free Act of 2010, is this use of similarity to minimize the effects of psychological reactance.

Defense 2: Minimization of Psychological Reactance

In fact, one of the most noteworthy characteristics of utilizing an intervention based on social network theory is its achievement of minimizing psychological reactance to the uptake of healthy foods. As a perceived attack on control, psychological reactance results in the opposite of the wanted action. However, psychological reactance is considerably reduced under some key distinguishing factors, which among them include high explicitness, low authoritativeness, and high supportive reason given for the message. Whereas the limitation on unhealthy foods and bake sales in schools has been demonstrated to result in a high psychological reactance, this program takes advantage of utilizing similarity among peers to promote healthy behaviors, which as been shown to markedly reduce reactance. (18)

In having opinion leaders within a particular school directing the program, its goals will be explicit to students, who will become aware of the need for healthy eating habits as they witness and engage in educational material. In addition, with the message seemingly originating from their peers, the program will reduce the authoritativeness of the message perceived by the students, which will add to the lowering of the reactance. Finally, the reasons for the transition to healthier foods will be unambiguously stated via educational instruction and modeling behavior. However, rather than using statistics, such as the reality of developing cardiovascular disease later in life, the program will attempt to demonstrate the need to reduce childhood obesity as a method to gain control of one’s life. Thus, students will observe the leaders, and others who live a healthy lifestyle, having greater control over the foods that they eat, activities in which they participate, and, in general, live more sociable existences with both their family and friends.

Defense 3: Race Neutrality

In addition to a great reduction in psychological reactance, this program would be race neutral, where both affluent and underprivileged communities will receive adequate funds to establish a comprehensive plan. As the peer leaders are selected and the promotion of healthy behaviors becomes engraved in the social norms of the school, the need to use baked, sugar-heavy treats will become diminished. Therefore, as the sale of healthier items becomes a viable option, even institutions (such as those located in underserved neighborhoods) that heavily rely on fundraisers to support after-school programs and sports will be able to foster an environment discouraging unhealthy foods and childhood obesity.

CONCLUSION

As childhood obesity in the United States, along with its increased risk of deadlier conditions through adulthood, has continued to sharply rise, the need for public health initiatives to combat this condition has become more significant. Where these interventions have failed, the government has attempted to facilitate changes in children’s behaviors by authorizing guidelines affecting the amount of physical activity and calorie consumptions by students, especially in schools. One solution, the Healthy, Hunger-Free Kids Act of 2010, championed by President Barack Obama and First Lady Michelle Obama, contains many aspects that are capable of having a constructive effect on ameliorating the issue of childhood obesity. Nevertheless, like many policies, the imperfections that exist can completely derail the goals of the law. In this case, the basic social behavioral model on which the bill is based upon can lead to psychological reactance and ultimately negatively impact students and school districts that most need the assistance to reduce childhood obesity. Rather than eliminating unhealthy foods and limiting bake sales from school cafeterias, the use of peers in establishing social norms of healthy lifestyles can achieve a reduction in childhood obesity by manipulating how people perceive requests to alter current behavior. Specifically, an immense psychological reactance, where one’s control is threatened, is replaced by behaviors, such as changes in social values and modeling, which have proved to be vastly superior in promoting long-standing behavioral change. If the U.S. is to dramatically reduce the increasing rate of childhood obesity, legislators must recognize more effective policies that rely less on imposing structural changes and places greater emphasis on a healthy diet by giving students the ability to control their own decision-making. In this way, we may finally be able to begin “America’s Move to Raise a Healthier Generation of Kids.”

REFERENCES

(1) Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM. Prevalence of high body mass index in US children and adolescents, 2007–2008. JAMA 2010; 303(3):242–9.

(2) Freedman DS, Zuguo M, Srinivasan SR, Berenson GS, Dietz WH. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study. Journal of Pediatrics 2007;150(1):12–17.

(3) Daniels SR, Arnett DK, Eckel RH, et al. Overweight in children and adolescents: pathophysiology, consequences, prevention, and treatment. Circulation. 2005;111;1999–2002.

(4) Centers for Disease Control and Prevention. Overweight and Obesity: Contributing Factors. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/obesity/childhood/causes.html

(5) Let’s Move. Washington, D.C.: Let’s Move. http://www.letsmove.gov/

(6) Hon. Goerge Miller, Chairman. Healthy, Hunger-Free Kids Act of 2010. Washington, D.C.: United States House of Representatives Committee on Education and Labor. http://edlabor.house.gov/blog/2010/11/healthy-hunger-free-kids-act-o.shtml

(7) Sen. Blanche Lincoln, Chairman. Current Legislation: Healthy, Hunger-Free Kids Act of 2010. Washington, D.C.: Unites States Senate Committee on Agriculture, Nutrition, and Forestry. http://ag.senate.gov/site/legislation.html

(8) Prochaska JO, DiClemente CC. The transtheoretical approach. In: Norcross JC, Goldfried MR, eds. Handbook of psychotherapy integration. 2nd ed. New York: Oxford University Press; 2005. p.147-171.

(9) Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot 1997 Sep-Oct;12(1):38-48.

(10) Wilson GT, Schlam TR. The transtheoretical model and motivational interviewing in the treatment of eating and weight disorders. Clinical Psychology Review. 2004, 24(3):361-78.

(11) Brehm, JW. (1966). "A Theory of Psychological Reactance." In: Burke WW, Lake DG, Paine JW, eds. Organization Change: A Comprehensive Reader. New York: Academic Press.

(12) Morland K, Wing S, Roux AD, Poole C. Neighborhood characteristics associated with the location of food stores and food service places. American Journal of Preventive Medicine 2002, 22(1): 23-29

(13) Gottfredson DC, Gerstenblith SA, Soulé DA, Womer SC, Lu S. Do After School Programs Reduce Delinquency?. Journal of Prevention Science. 2004: 5(4): 253-66.

(14) Wasserman S, Faust K. Social Network Analysis: Methods and Applications. New York: Cambridge University Press; 1994.

(15) Bandura A. Social Learning Theory. Englewood Cliffs, NJ: Prentice Hall; 1977.

(16) Plotnikoff RC, Bercovitz K, Rhodes RE, Loucaides CA, Karunamuni N. Testing a conceptual model related to weight perceptions, physical activity and smoking in adolescents. Health Educ. Res. (2007) 22 (2): 192-202.

(17) DeFluer ML and Ball-Rokeach SJ. Socialization ad Theories of Indirect Influence (pp213-219) In: Theories of mass communication. New York, NY: Longman Inc., 1989.

(18) Silvia, P. (2005). Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology, 27 (3): 277-284.

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