Tuesday, December 12, 2006

A Criticism of a Public Health Intervention Aimed at Reducing Obesity Among Adolescents in Boston Public Schools: Meghan Keskar

According to the Massachusetts Youth Risk Behavior Survey conducted in 2003 (1), it was reported that nearly 25% of all teens are either overweight or at risk for becoming overweight as compared to an estimated 16% of adolescents nationally. This alarming difference prompted the Boston School Committee to develop a method to reduce obesity by targeting children attending Boston public schools. In 2003 (1), a new nutrition policy banned the sale of high-fat and high-sugar snacks and drinks in vending machines in all Boston public schools. The intent of this policy is to reduce obesity among children and adolescents; however, it fails to consider obesity as a multi-factorial dilemma. This paper aims to criticize the narrow approach this policy employs and to highlight factors that must be taken into consideration to effectively combat childhood obesity; such as physical activity and neighborhood safety, access to healthy foods, and the social and behavioral sciences theory of empowerment. These factors address social factors that influence obesity at the individual level.

A key factor contributing to the increased risk of obesity among children is the lack of physical activity (2). Data from 2003 showed that students in the Boston Public School system are not receiving the level of physical education Massachusetts state law requires, and that 47 of Boston’s 84 public elementary schools do not even offer physical education programs (3). Countless children lack physical activity once they are at home as well, thus promoting a sedentary lifestyle to increase obesity risk. Simply removing unhealthy snacks from vending machines does not address this issue. Children should be provided with stronger physical fitness programs (3).

Children’s environment impacts their ability to engage in physical activity. Children from low-income communities are more likely to be less physically active, and live in areas with limited access to safe play areas (4). In a survey conducted in New York City, it was found that a higher level of parental anxiety toward neighborhood safety and lower level of physical activity among children existed in poor inner-city communities compared to a suburban middle-class community (4). It is possible that parents who have a high level of anxiety toward neighborhood safety may restrict their children’s outdoor activities (4). Given these findings, and similar results from other studies, it is clear that in order to understand childhood obesity, one must also understand the neighborhood or community in which the child lives. These underlying community level factors such as violence, crime, and open drinking and drug use must be addressed to improve the safety of neighborhoods (5).

Research has demonstrated that the greatest predictor of dietary choices is the cost of food (6). In a study conducted in Mississippi, North Carolina, Maryland, and Minnesota, researchers reported that supermarkets were more prevalent in wealthy and white neighborhoods, compared to predominantly black and poor neighborhoods; in these communities small corner grocery stores were more prevalent (6). Thus, those living in poor neighborhoods are restricted to foods available in small grocery stores where healthy options are likely limited (7). In addition to the limited availability of healthy foods, other studies have reported that there are more fast food restaurants per square mile in low-income neighborhoods compared to high income neighborhoods (8). In many neighborhoods the issue of availability of healthy food options must be addressed before declines in childhood obesity are seen.

A study done in Pomona, CA analyzed the proximity of individual addresses to stores selling a variety of fresh produce (9). The addresses of individuals who use local food pantries were used as a marker for low-income households. This study used distance as a measure of access and based on the individual data was able to identify at-risk areas where fresh produce is not available. Based on this information, providing low cost supplies of fresh produce to inner-city and low-income neighborhoods via a mobile delivery van can be a viable option (9).

The social and behavioral sciences theory of empowerment is important to consider when discussing childhood obesity. Empowerment is the social action process that individuals or communities can use to take control over their lives (10). Thus, empowerment can take place on the individual level or community level. The goal of empowerment is to support individuals in making their own decisions so that they may decide what is right for them, rather than simply inducing the desired behavior(11).

Nutrition education in the schools can be used to empower children to make healthy choices in their lives. The idea of educational empowerment is widely advocated by Brazilian educator Paulo Freire (10,11). However, for nutritional education to be empowering, the teacher must facilitate in the children reaching an understanding of healthy eating habits, as opposed to lecturing children on what should be eaten and what should be avoided (11). The idea should be for children to develop their own understanding of healthy eating habits.

The policy adopted by the Boston School Committee does not consider the role of educational empowerment in the issue of childhood obesity. Removing all high-fat and high-sugar snacks from vending machines, effectively removes the ability of children to learn to make decisions on their own. Children are no longer given a choice and cannot take an active role in their own health. However, if nutritional education was added to the curriculum of schools, children could be empowered to make healthful decisions.

The nutrition policy adopted by the Boston School Committee in 2003 is an extremely narrow approach to combating childhood obesity. Obesity cannot be viewed as simply an individual problem. It has been shown that communities play a large role in the process of a child becoming overweight or obese. By supporting public health policies similar to the one currently in place, behavior change in relation to nutritional habits is not likely. The longterm goal of such a policy should be to empower individuals as well as communities. Children must be empowered to make healthy choices on their own and to feel invested in their own health and well being. Within communities, individuals should be empowered to lobby for larger supermarkets carrying a greater variety of foods and for improving neighborhood safety. Combining these factors produces a much more comprehensive approach to combating childhood obesity. By expanding the policy to incorporate each of these factors, the policy would likely be effective.

1. Tobin, John (December 6, 2005). Banning junk food sales in MA public schools. Retrieved November 16, 2006 from http://www.votejohntobin.com/blog/_archives/2005/12/6/1437748.html

2. Overweight and Obesity: Contributing Factors. Retrieved November 11, 2006 from http://www.cdc.gov/nccdphp/dnpa/obesity/contributing_factors.htm

3. Tobin, John (March 3, 2004).Councillor Tobin unveils anti-obesity agenda for city’s public schools. Retrieved October 19, 2006 from http://www.votejohntobin.com/blog/_archives/2004/3/3/282301.html

4. Weir, L. Etelson, D., and Brand, D. (2006). Parents’ perception of neighborhood safety and children’s physical activity. Preventive Medicine, volume 43, pp.212-217

5. Lumeng, J., Appugliese, D., Cabral, H., Bradley, R., Zuckerman, B. (2006). Neighborhood safety and overweight status in children. Archives of Pediatric and Adolescent Medicine, volume 160, pp25-31

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

7. Lee, M. (2006). The neglected link between food marketing and childhood obesity in poor neighborhoods. Retrieved November 11, 2006 from http://www.prb.org/Template.cfm?Section=PRB&template=/ContentManagement/ContentDisplay.cfm&ContentID=13932

8. Block, J. (2004). Fast food, race/ethnicity, and income: a geographic analysis. American Journal of Preventive Medicine, volume 27, number 3, pp. 211-217

9. Algert, S., Agrawal, A., Lewis, D. (2006). Disparities in access to fresh produce in low-income neighborhoods in Los Angeles. American Journal of Preventive Medicine, volume 30, number 5, pp. 365-370

10. Minkler, M. and Wallerstein, N. (1997). Improving health through community organization and community building. Glanz, K., Lewis, F.M., and Rimer, B.K. (Eds.) Health behavior and health education: theory, research, and practice (237-269). San Francisco: Jossey-Bass

11. Kent, G. (1988). Nutrition education as an instrument of empowerment. Journal of Nutrition Education, volume 20 number 4, pp. 193-195


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