Tuesday, May 13, 2014

Failing to Resolve the Childhood Obesity Crisis: A Critique of the Play 60 Movement- Dan Carlow

            Childhood obesity is a severe problem that continues to grow throughout the United States.  Rates of childhood obesity have nearly tripled since 1980 (1).  Recent studies show that nearly one in every three children is now considered obese (1).  Obesity can often last a lifetime, as obese teenagers are 70% more likely to become obese adults (2). This translates to an increased likelihood of negative health outcomes. Obesity severely raises the risk for heart disease, stroke, hypertension, type two diabetes and various cancers (3–6).  These healthcare outcomes result in significant costs, with one study estimating that nearly 9.4% of national healthcare expenditures are related to obesity and inactivity (7).  The childhood obesity epidemic plaguing America is very evident, and while the Country has attempted to alleviate this issue, interventions have been fairly unsuccessful. 
One such failed intervention is the Play 60 movement sponsored by the NFL.  This movement involves engaging children in healthy activity within their school programs.  It is focused on empowering children to take control of their own health. The goal of this movement is to help children live an active lifestyle year round to combat childhood obesity.  The campaign provides outlines to nutritional knowledge and exercising activities. While this campaign certainly has the right intentions, it suffers some serious flaws.  First, the movement fails to recognize the role parents of parents in creating subjective norms which influence a child’s behavior.  Secondly, the movement’s failure to consider the stages of behavioral change has prevented adoption of the movement by children who don’t perceive the value of healthy behavior.  Finally, the overemphasizing on winning awards has the potential to negatively impact the self-esteem of many children in the program, preventing long-term success.  It is these three flaws which will prevent Play 60 from achieving peak success.
Play 60 Fails to Account for Subject Norms in the Household
A major shortfall behind the Play 60 campaign is its assumption that healthy behavior can be emphasized without encompassing the entirety of a child’s social circle.  In particular, the initiative fails to adequately incorporate parents.  One can argue parents are the greatest influence on a child’s behavior.  Parents provide them shelter, love and affection, and thus are greatly influential. Of all the people in a child’s life, a parent is likely to have the most highly weighted opinion in the child’s mind. Play 60’s inability to fully integrate parents within the program reflects their lack of understanding the theory of reasoned action
According to the theory of reasoned action, an individual constructs subjective norms based on the opinions of those in their social environment (8).  The particular weight an individual places on each person’s opinion of a given subject establishes the prevailing norm, which then influences the individual’s behavior (8). One study has found that consumption of unhealthy food was heavily correlated to held beliefs and ideas about the food rather than nutritional knowledge (9).  Another study has found that healthy behavior is best achieved if an individual is provided a health-promoting environment (10).  Both these studies show the influence that subject norms, established within a child’s environment, have on their behavioral decisions.  Surely these subjective norms are heavily determined by parents.  In fact, research has shown that a child is more likely to engage in risky behavior, such as eating unhealthy and being inactive, if parents condone the behavior through a lack of awareness of the potential negative outcomes (11).    Clearly children’s behavior is influenced by their views of what is normal behavior, which is impacted by their parents.
As the program now stands, a child may play for sixty minutes after school, but go home to an environment that tends towards unhealthy eating and a sedentary lifestyle, and thus all their achievement from the program will be negated.  Play 60 fails to transform the attitudes of both parents and children, which will allow the unhealthy subjective norms established in households to remain and negatively impact the child’s fight against obesity.
Play 60 Does Not Take Into Account the Stages of Behavioral Change
                 The transtheoretical model features five stages to behavioral change.  The three early stages are precontemplation, contemplation and preparation, while the later stages are action and maintenance (12). In the early stages, an individual begins to recognize the importance of a particular behavioral (12).  Once the individual is motivated enough by the necessity of the behavior, he or she will move on to preparation, action and finally maintenance. Unfortunately, the Play 60 campaign caters to individuals at the action and maintenance stages.
Reading through the campaign’s main website, it is well-apparent the program focuses on maintenance, while lacking materials to educate children as to why being healthy and active is important to begin. The homepage indicates that children can win prizes for “good-for-you” behavior.  These prizes are clear form or reinforcement.  Reinforce is one of the processes that leads to maintenance, but according to the transtheoretical model, this will only be successful if the individual has reached this stage of behavior (12)
Although the campaign aims to fight obesity, processes of change provided by Play 60 are likely to attract individuals whom are already healthy, and value an active lifestyle, rather than those children who are struggling to recognize this concept.  Therefore, the early adopters to this program are healthy children, while obese children remain on the sidelines. The one-size-fits-all approach of Play 60 goes against proven research that to maximize effectiveness of an intervention, a tailored approached must be offered which can appeal the given stage of behavior for each individual (13). This requires early stage processes of change to be utilized.  Consciousness-raising and self-reevaluation to understand the importance of a healthy lifestyle are two great ways to help develop healthy behavior for children precontemplation and contemplation stages.  Unfortunately, these early processes of change are not apparent in Play 60.  The Play 60 campaign has thus failed to address the concept of behavioral change stages.
Play 60’s Overemphasis on Winning May be a Deterrent to Establishing Self-esteem
Self-esteem is key to successfully achieving behavioral change. Play 60 does not exactly address this issue. The concept of self-esteem is concretely described in Maslow’s Hierarchy of Needs.  According to Maslow, self-actualization, or the reaching of one’s full potential, can only be achieved if four levels of specific needs are met (14).  One such level of needs is self-esteem, which can be produced via achievement, recognition and respect from others (14).  Attainment of self-esteem is critical, because it is the fourth and final level before reaching self-actualization. One particular study has found that a decrease in self-esteem can result in increased sadness and loneliness in children, leading to an increase in risky, unhealthy behaviors (15).  
Play 60 offers very limited opportunities for achievement and recognition within its program, inhibiting growth of self-esteem.  The program offers tips and guidelines to succeed, but only infrequently offers praise and recognition for achievement. A small number of children will be recognized by winning awards and contests, thus boosting their self-esteem, but the achievement of most children will go unannounced, potentially leading to riskier behavior
Additionally, the messages conveyed by the program’s initiatives may actually be a deterrent altogether for self-esteem building.  For example, the program offers chances for children to win super bowl tickets, meet NFL players and attend cool conferences.  The more healthy activities a child performs, the greater their odds to win these prizes.  However, the prizes are very limitedly, and ultimately the majority of children will engage in activities but not win.  Even though a child may have made achievements with the physically activity, he or she may assume that since they lost the contest, they were unsuccessful, thus leading to a loss of self-esteem.  This is all perpetuated by the inability of Play 60 to identify the critical need of self-esteem.
Implementing A Family-based Intervention
                As a new intervention to fight childhood obesity, I suggest an approach which I will call the Holistic Family-centered Activity Movement (H-FAM).  The concept behind this intervention is to use a holistic approach the overcome obesity.  The approach will target both the mind and the body, emphasizing healthy eating, physical activity and relaxation.  The goal of this program will be for families to work together to establish a healthy, active household.  The underlying premise of this program is that obesity is best overcome if a family acts as one cohesive unit.  Children are not independent and are heavily reliant on their parents care.  Parents shape their children, and if children are to be successful at achieving a particular behavior, parents must be committed to the achievement as well. 
There will be two components to the program.  The first will be to employ a strong advertising campaign. There will be two phases of commercials in the advertising campaign.  One phase will portray the struggles of children with obesity, while the other type will profile the success of families who work together to live a healthy, active lifestyle. 
The second component will be titled “For me, For the Family”, and will focus on homemade meals and outdoor activities that resonate with the whole family.  Families will be asked to sign-up online, and each family member will be asked to answer a questionnaire.  The survey results of all family members will be applied in an algorithm to develop a list of suggested recipes and activities that are a fit for the entire family. In addition, the individual results of each member will also produce a list of suggested recipes and activities. The “For the Family” ideas will be suggest dinner recipes to eat in the evening, and suggested family activities to do on the weekend.  The “For Me” results will provide nutritious snack ideas and exciting activities for each child individually.  “For Me” personalization is important because while sports are typically emphasized as the mains to be active, not all children enjoy sports.  However, with this questionnaire, children will be offered options such as nature walks or learning to cook.  Further, parents will better understand their children’s desires, not forcing them to participate in sports or activities that the child doesn’t enjoy.  Lastly, parents and children will have the ability to constantly readjust their likes and dislikes, as well as indicate which activities they have performed and meals they have prepared, so that new ideas can constantly be generated based on recent behavioral choices. Overall, I believe the outlined H-FAM approach will be a more successful intervention for childhood obesity than Play 60.
Involving the Family Will Produce Healthy Subjective Norms
            A family-centered intervention will develop active and healthy norms to influence children’s behavior.  Studies have proven that subjective norms drive an individual’s intention to engage in exercise and healthy eating behaviors (16)  Another study has found that parental support can be very influential factor in food and exercise choice (11,17).  In tandem, these studies build the connection between subjective norms and children’s behavior, while also indicating parents are a huge influence a child’s social circle.  Clearly, parents need to get involved with their children to articulate what is the most appropriate normal behavior for one’s wellbeing.  This can drive the child to eat what is necessary, increase activity and reach or remain at a targeted weight level. 
This intervention works to bridge the gap of that missing piece. With this new intervention, parents will be directly involved with their children’s behavior, as the “For the family” activities will allow parents to show their support of active, healthy habits.  The child’s norms will change from the previously accepted unhealthy behavior to these improved norms.  It is my hope that the advertising campaign will continually focus parents’ efforts to ensure the right norms are transparently messaged in the home.  Using a family-centered approach is a step in the right direction to generate these new subjective norms that lead to healthy behavior.
H-FAM Acknowledges All Stages of Behavioral Change
            Not every child, nor every family, will be ready to engage in nutritional changes and increased physical activity.  Recognizing that each individual and each family is at a different stage of behavioral change will be the key to maximizing the number of individuals that will be impacted by a given intervention.  Tailoring a program to emphasize adoption and adherence to exercise and nutrition is critical (18).  There are numerous ways this can be achieved.  For instance, generating self-efficacy will lead to the confidence booster necessary to propel individuals above the contemplation and preparation humps (18). Likewise, fun, new activities and ideas can prolong maintenance.
            A strong advertising campaign will relate to families at the early stages of behavioral change.   As discussed, the H-FAM commercials will document the struggles and successes of children and their families as they attempt to combat obesity.  These commercials will display health facts about obesity. The idea is that they will provide families with the information necessary to recognize obesity is a serious health issue.  Additionally, this will provide a motivational cue.  The commercials will also show people overcoming obesity.  This will show healthy behaviors as an achievable goal, which will hopefully provide a level of self-efficacy.  In all, this combination of motivation and self-efficacy will drive more family to act on behavioral change to live a fit lifestyle.
            The online website will have the ability to track children’s interest and enjoyment of various activities and produce new activity lists that mesh with the individual’s preferences.  This will be essential to influence children at the action and maintenance stage. Similarly, new family activity lists can be generated.  The concept behind this aspect of the intervention is the idea boredom may lead to a decline in healthy behavior. Boredom has been show to increase eating amongst both obese and normal weight individuals (19).  Therefore avoiding boredom is important to reduce the likelihood of increased food consumption.  This intervention will constantly provide new ideas of activities to avoid boredom.  A second way to drive maintenance is to provide new challenges that raise the bar.  The online website will track children’s activity statistics, and suggest new target goals, which will at as stimulus controls to drive adherence to healthy behavior.  The main components of this intervention definitely target all stages of behavioral change.
H-FAM’s Involvement of Family Members Will Improve Self-Esteem
            Self-esteem is important for kids to exhibit healthy behaviors.  It is particularly important for obese children, whom may be embarrassed or insecure to begin physical exercise. For children to develop and maintain self-esteem, they must constantly be praised and recognized.  By bringing parents and families into the equation, self-esteem is much more likely to be boosted for every child (20,21). Play 60 utilizes teachers to implement its programs.  These teachers have to overlook a number of children, and likely don’t praise every single child for his achievement, nor even notice every child’s achievements.  In other words, there is little opportunity for one on one relationships within this program, where an older influential individual can provide a child with reassurance and self-esteem boosts when he or she achieves.  With H-FAM, parents will be selecting activities, participating activities and will be witness to much more of their child’s success than any third-party could possibly.  Therefore, this will increase the opportunity for parents to congratulation their son for doing his push-ups or praising their daughter for eating a healthy dinner.  Once the self-esteem begins to be raised, it will be a positive feedback system.  The child will see be more apt to eat well and exercise thorough, which will allow them to develop more self-esteem.  Undoubtedly, H-FAM’s incorporation of parents provides a great opportunity for children be praised and recognized, leading to high levels of self-esteem which will aid in the children’s pursuit of healthy behavior.
            To conclude, while the Play 60 program is a valiant attempt to fight obesity, its failure to address a few social behavioral theory principles has led to major flaws which compromise its success.  The Play 60 program fails to acknowledge the subject norms children derive from their parents, inadequately addresses the entire spectrum of behavior change stages and lacks the ability to generate sufficient self-esteem.  On the other hand, the Holistic Family-centered Activity Movement is designed to overcome these flaws by engaging the entire family through an individualized intervention.  With the H-FAM intervention the fight against childhood obesity finally begins.

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