SB-505-11W 1

Running Head: SCHOOL-BASED OBESITY INTERVENTIONS

Problem Solving Proposal:

Using School-Based Environmental Policy

To Prevent Childhood Obesity

University of California, San Francisco

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Childhood obesity has become more prevalent in the United States over the last 30 years

(Ogden & Carroll, 2010). The prevalence rate across all age groups has increased two- to three-

fold since the 1970s. For instance, the obesity prevalence rate in young children, ages two to five

years old, increased from 5% between 1976 and 1980 to 10.4% between 2007 and 2008 (Ogden

& Carroll, 2010). Obesity prevalence rates have more than tripled in grade school children and

adolescents during the same time period. For example, the rate increased from 6.5% to 19.6% in

children ages 6 to 11 years old and from 5% to 18.1% in adolescents ages 12 to 19 years old

(Ogden & Carroll, 2010). Between 2005 and 2006, the childhood obesity prevalence rate for

children and adolescents, ages two to 19 years old, was 16.3% (Ogden, Carroll, & Flegal, 2008).

Without effective intervention, the prevalence rate is expected to increase to almost 23% by 2015

(Wang & Beydoun, 2007).

Childhood obesity is defined as a condition that affects children and adolescents who

have excess body fat. One way it is measured is by using the body mass index (BMI). According

to the Centers for Disease Control and Prevention (CDC), a child or adolescent whose BMI is

greater than the 95th percentile is obese. Childhood obesity is seen as a problem in various ways,

from an individual health problem to a social problem. Since the U.S. Surgeon General issued a

warning about the national obesity “epidemic” (Office of the Surgeon General, 2001), the

problem is now defined as a major public health concern. Solutions have been proposed by

clinicians, public health advocates, policy makers, and politicians in various settings such as

homes, schools, clinics, and community centers all over the country. Different groups of people

are working to achieve the same desired outcome of decreased childhood obesity prevalence

rates. Obesity prevention efforts are typically targeted at normal- and over-weight children,

regardless of age, sex/gender, race/ethnicity, and socioeconomic status (SES).

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Why Childhood Obesity is a Policy Problem

Childhood obesity is problematic at the individual level primarily due to negative health

outcomes across the lifespan. These include adulthood mortality and morbidity related to

diabetes, hypertension, ischemic heart disease, and stroke (Reilly & Kelly, 2010). Other obesity-

related health consequences are decreased cardiorespiratory fitness (CRF) (Gidding et al., 2004)

and increased risk for Type 2 diabetes and metabolic syndrome (Biro & Wien, 2010). Aside from

negative health-related outcomes, childhood obesity may also contribute to increased school

absenteeism (Geier et al., 2007) and decreased academic performance (Hollar et al., 2010).

Children may also experience emotional distress due to weight-based teasing and social stigma.

Unlike normal-weight children, they are more likely to be victims and perpetrators of bullying

(Janssen, Craig, Boyce, & Pickett, 2004).

At the population level, the issue is problematic due to increased rates of mortality and

morbidity (Bjorge, Engeland, Tverdal, & Smith, 2008; Reilly & Kelly, 2010). Examples include

increased death and disease rates due to stroke (Reilly & Kelly, 2010) and some forms of cancer

(Fuemmeler, Pendzich, & Tercyak, 2009). The social costs are high due to increased rates of

disability, absenteeism, and lost work productivity (Finkelstein, DiBonaventura, Burgess, &

Hale, 2010; Gates, Succop, Brehm, Gillespie, & Sommers, 2008), which may result in a smaller

workforce and possibly a smaller tax revenue base. The economic implications are significant as

childhood obesity costs the American public about $14.1 billion annually (Transande &

Chatterjee, 2009). These high costs are associated with medications, emergency room visits, and

outpatient care services. According to Brownell and Frieden (2009), half of the annual costs of

childhood obesity are paid for by the government through public assistance programs like

Medicare and Medicaid.

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Childhood obesity is problematic at the global level because of health disparities.

According to the World Health Organization (WHO, 2006) more than 20 million children less

than five years old were obese in 2005. Recent changes in socio-political and economic trends

have promoted the spread of the childhood obesity epidemic from developed countries to

developing countries like Vietnam, Thailand, and Algeria (Dieu, Dibley, Sibbritt, & Hanh, 2009;

Likitmaskul et al., 2003; Oulamara, Agli, & Frelut, 2009). This is problematic because these

countries have neither the health care infrastructure nor do they have the financial resources to

effectively address major public health concerns like childhood obesity. Some would argue that

this is an issue of human rights and social injustice because childhood obesity disproportionately

affects people of low SES (Coogan et al., 2010; O’Dea & Dibley, 2010; Voorhees et al., 2009).

Another cause for concern is that developing world markets are being flooded with less

nutritious “junk foods” produced by multinational corporations (i.e. Kraft, Pepsi-Co) based in

developed countries like the U.S. (Leatherman & Goodman, 2005; Taylor, Satija, Khurana,

Singh, & Ebrahim, 2011). As a result, the WHO has recently recognized obesity as a global

health problem.

Childhood obesity has been studied extensively by individuals from various disciplines

like the health, social, and political sciences. Research activity on this topic has generated

numerous systematic reviews and meta-analyses. As a result, the body of knowledge on

childhood obesity is wide and ever-expanding. Nevertheless, uncertainty remains regarding how

to best intervene in order to provide the greatest amount of health benefits for the greatest

number of people. One option attracting more interest is school-based obesity interventions

(SBOIs). Although results from intervention studies have been mixed, SBOIs have numerous

advantages: they provide an opportunity to affect many students at one time; they influence

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students’ behaviors before diseases develop; they use a comprehensive approach that combines

multiple components like healthy nutrition, physical activity, and education. The purpose of this

paper is to apply research evidence, literature analysis, and agenda-setting theory in order to

propose a policy solution to the childhood obesity problem. The next sections of the paper

include an overview of the problem’s contextual factors, a critical review of the literature, and an

application of Kingdon’s multiple streams theory. The paper will conclude with a school-based

policy proposal, including plans for implementation and evaluation.

Environmental Context

The environmental context includes the physical, socioeconomic, cultural, and political

factors that contribute to the childhood obesity problem. Physical factors include those in the

human body like fat distribution, metabolism, muscle mass, genetics (Veiga et al., 2011), and

food addiction (Liu, von Deneen, Kobeissy, & Gold, 2010). Socio-economic factors include

those in the environment like health care infrastructure, access to resources, and neighborhood

safety. Studies have shown that childhood obesity disproportionately affects minorities of low

SES (Singh, Kogan, Van Dyck, & Siahpush, 2008). For example, while the childhood obesity

prevalence rate between 2007 and 2008 for non-Hispanic white (NHW) boys was 16.7%, the rate

for African American (AA) boys was 19.8% and the rate for Mexican-American boys was 26.8%

(Ogden & Carroll, 2010). Another important factor is “residential segregation,” which refers to

the distribution of housing, schools, and retail outlets based on the race/ethnicity and SES of

inhabitants (Kwate, 2008). For example, an AA girl living in the inner city may have more

access to liquor stores and fast food restaurants than grocery stores, parks, or playgrounds. In

contrast, a NHW girl who lives in an affluent suburb may have easy access to grocery stores,

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farmer’s markets, and hiking trails. As a result, the AA girl is more likely to eat an unhealthy diet

and lead a sedentary life, thus increasing her risk for obesity, compared to the NHW girl.

Cultural factors related to childhood obesity are infant feeding practices (breastfeeding

vs. formula feeding), parenting practices, and body image issues. Another factor is whether

obesity is framed as a matter of personal responsibility or environment (Kersh, 2009). While

supporters of the personal responsibility frame argue that obesity is caused by one’s failure to

make the correct lifestyle choices, supporters of the environmental frame argue that obesity is

caused by external forces. Kersh (2009) describes the “obesogenic food environment” as a place

where people are surrounded by increased portion sizes, increased access to junk food outlets

and vending machines, and increased advertising from fast food restaurants. Political factors

include policy development, constituency building, and coalition building. Another factor is

deciding between conservative and liberal ideals. Conservative policies, which promote

decreased government involvement in favor of business interests, appeal to proponents of the

personal responsibility argument who value choice, freedom, and consumerism. One example

was the Personal Responsibility in Food Consumption Act of 2005 which proposed to prohibit

individuals from suing members of the food industry (Kersh, 2009). Liberal policies, on the other

hand, promote increased government regulation, at the expense of some personal freedoms, in

order to protect a greater majority of the citizenry. Such policies, like the subsidization of healthy

foods and the ban on children’s advertising, appeal to those who share the environmental

argument (Kersh, 2009). Finally, corporate influence on childhood obesity is another factor that

will be discussed later in the paper.

Stakeholders

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Stakeholders who are highly interested in solving the problem are people who are

personally invested, like obese children and their parents. Stakeholders who are not directly

affected by childhood obesity are teachers, school administrators, clinicians, researchers,

lobbyists, and consultants. The most powerful stakeholders are those with financial resources and

political clout. These include elected officials, school board members, policy makers, and

members of the food industry. Stakeholders interact in many settings like schools, city halls, and

clinics. The reasons for the interactions include sharing personal experiences, expertise, and

feedback. Productive interactions result in plans for action, policy development, or program

implementation and evaluation. Unproductive interactions result in an ambiguous course of

action and policies that lack specificity, objective measures, and evaluation criteria. More details

about stakeholder interaction will be discussed in the theoretical application section of this paper.

Nurses play a central role in the fight against childhood obesity. First, at the frontlines

nurses are providing direct patient care, surveying the environment, and collecting data. Second,

in local and state jurisdictions nurses are collaborating with public health officials, coordinating

advocacy activities, and persuading elected officials. Third, at the national level nurses are

sharing research findings, raising public awareness, and providing expertise for policy makers.

Nurses have the ability to make positive contributions to the cause as a result of their training,

skill set, and unique perspective. Because nurses are among some of the most trusted

professionals in society, they can use their influence to not only attract attention to childhood

obesity but also to inspire change in policy to benefit public health.

Review of Literature

Research on school-based obesity interventions

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Three research studies were reviewed to examine the evidence about the effectiveness of

SBOIs. These studies were obtained by searching the PubMed database. Search terms like

“childhood obesity intervention, “school-based intervention,” and “obesity prevention” were

used. Inclusion criteria for the studies were: the use of experimental or quasi-experimental

design, the use of school setting, the use of BMI, and the use of subjects who were students.

Exclusion criteria for the studies were: the use of non-experimental designs, the use of settings

outside of school, and the use of subjects who were not students.

Purpose. First, the HEALTHY Study Group (2010) used a quasi-experimental design to

measure the effect of a multi-component school-based intervention on diabetes risk factors like

obesity. The SBOI consisted of four parts: school nutrition, physical activity, behavioral

knowledge and skills, and communication and social marketing. Second, Peralta, Jones, and

Okley’s (2009) pilot study used a quasi-experimental design to assess a school-based

intervention’s feasibility, acceptability, and possible efficacy. The SBOI, also known as the

Fitness Improvement Lifestyle Awareness (FILA) program, combined one hour per week of

health education class and 40 minutes per week of physical activity. Third, McMurray et al.

(2002) used an experimental, 2x2 factorial design to examine the effect of a school-based

intervention on blood pressure and body fat. The SBOI involved exercise and education.

Sample. The Healthy Study Group (2010) had the largest study sample with 4,603

students in grades 6 through 8. Cluster sampling was used and schools were randomly assigned

to intervention and control conditions. Inclusion criteria were 6th grade status in Fall 2006 and

availability of baseline height, weight, and sex data. Exclusion criteria were diabetes diagnosis or

inability to participate in physical activity. McMurray et al.’s (2002) study sample included

1,140 students, between 11 and 14 years old, who attended one of five schools in rural North

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Carolina. Students were included in the study based on the following criteria: previous

participation in the Cardiovascular Health in Children and Youth Study (CHIC) II, “good” health

status (defined as being free of chronic disease), and ability to exercise. A participation rate of

38.2% was reported. Students who met the inclusion criteria were then randomly assigned to one

of three intervention groups (IGs)--exercise only [ExO], education only [EdO], or combination

of exercise and education [EE]--or to the control group (CG). Peralta et al. (2009) used the

smallest sample: 33 Australian boys in the 7th grade who were randomly assigned to intervention

and comparison groups.

Method. All three studies utilized a quasi-experimental, longitudinal design. The

HEALTHY Study Group (2010) collected data at baseline and at three years. The independent

variable was the SBOI and the dependent variables were diabetes risk factors. Outcomes

included the combined prevalence of overweight (BMI equal to or greater than the 85th

percentile) and obesity, obesity prevalence, waist circumference (WC), fasting glucose level, and

fasting insulin level. Peralta et al. (2009) collected data at baseline and at six months. The

independent variable was the SBOI and the dependent variables were weight, CRF, and health

behaviors. Outcomes included BMI, WC, percentage body fat (%BF), CRF, physical activity,

television viewing activity (TVA), and consumption of sweetened beverages and fruits. By using

a two-arm parallel design, the researchers were able to assess members of the IG, who

participated in the FILA program over the course of 16 weeks, and members of the comparison

group, who participated in the general fitness program as per the school’s curriculum. McMurray

et al. (2002) collected data at baseline and at eight weeks. The independent variable was the

SBOI. Using a 2x2 factorial design, the researchers compared differences between the CG and

the three IGs. Members of the ExO group were exposed to 30-minute aerobics classes three

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times per week while members of the EdO group were exposed to health and nutrition classes

two times per week. Members of the EE group were exposed to a combination of the two

interventions described previously. The dependent variables were blood pressure (BP), BMI,

skin-fold thickness (SFT), and maximal oxygen uptake (MOU).

Similar measures were used among all three studies. One example was BMI. However,

the studies utilized different procedures to obtain their measurements. Peralta et al. (2009) used

height and weight data that were obtained by blinded research assistants (RAs) who measured

subjects according to standardized protocols. McMurray et al. (2002), on the other hand, used

data obtained by RAs who participated in inter-rater reliability testing and measurement training

prior to beginning the study. To ensure the accuracy of height measurements, RAs used a

Stadiometer and rounded to the nearest 0.5 cm. Weight was obtained via a balance-beam scale

and measurements were rounded to the nearest 0.1 kg. The HEALTHY Study Group (2010),

however, did not provide information about measurement procedures because the article was the

second in a series of articles related to the same intervention. Readers were instead referred to

the supplementary appendix and the authors’ previous reports for more specific information.

Other physiological measures included: WC and fasting glucose and insulin levels (The

HEALTHY Study Group, 2010); BP, SFT, and MOU (McMurray et al., 2002); and WC, %BF,

CRF, and physical activity (Peralta et al., 2009). BP was measured via sphygmomanometer and

SFT was measured with calibrated calipers. MOU was measured by monitoring subjects’ heart

rate while exercising on a cycle ergometer. McMurray et al. (2002) used Mocellin, Lindemann,

Rutenfranz, and Sbresny’s (1971) method for measuring MOU because it was highly correlated

(0.807) with actual measurements of MOU. Although McMurray et al. (2002) used study

protocols based on guidelines from the National Health and Nutrition Examination Survey

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(NHANES) and the American Heart Association (AHA), they did not provide information about

the validity of their other measurement tools. Percentage body fat was measured via a body fat

analyzer, CRF was measured via a 20-meter Multistage Fitness Test, and physical activity was

measured via an Actigraph accelerator (Peralta et al., 2009).

Non-physiological measures were also used: TVA, consumption of sweetened beverages

and fruits, and parental SES via questionnaires (Peralta et al., 2009; McMurray et al., 2002).

Both McMurray et al. (2002) and the HEALTHY Study Group (2010) used process measures

like enjoyment scales, semi-structured interviews, and observations to assess fidelity and

intervention acceptability. However, information about the tools’ reliability or validity was not

provided.

Analysis. Data was analyzed in a similar fashion among the three studies. The

HEALTHY Study Group (2010) used descriptive statistics, general linear mixed models, and

odds ratios while Peralta et al. (2009) used descriptive statistics, analyses of covariance

(ANCOVAs), and Cohen’s d to measure effect sizes. McMurray et al. (2002) used descriptive

statistics, change scores (pre- and post-tests), Chi square tests, ANCOVAs, and analyses of main

and interaction effects. The HEALTHY Study Group (2010) made no adjustments to account for

differences in school site, sex, or race/ethnicity while McMurray et al. (2002) used Bonferroni

corrections to detect differences between the IGs and the CG. Only Peralta et al. (2009) provided

information about which statistical software program (SPSS version 16) was used in data

analysis.

Findings. The HEALTHY Study Group (2010) found no statistically significant

differences in overweight (p = 0.92) and obesity (p = 0.05) prevalence between the intervention

and control groups. However, the IG experienced greater reductions compared to the CG in

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obesity prevalence, BMI, WC, and fasting insulin level. No significant differences in fasting

glucose level or adverse events were reported. A case of suicide, unrelated to the study, was

reported. Findings from Peralta et al.’s (2009) pilot study included differences in effect sizes

between the IG and comparison group: the IG had smaller increases in BMI, greater reductions

in WC, %BF, and TVA, and greater improvements in CRF and total weekday physical activity.

Although the intervention produced only a small effect (0.05) on the primary outcome of

decreasing BMI, it produced larger effects (0.72-0.99) on the secondary outcomes related to

physical activity. Peralta et al. (2009) reported that screening, recruitment, and retention goals

were met and that the intervention was found to be both feasible and acceptable. McMurray et al.

(2002) found no statistically significant differences in BMI between the three IGs and the control

group. However, they reported that the intervention was associated with significantly smaller

increases in BP (p = 0.001). Other findings were as follows: the ExO and EE groups had

significantly smaller increases in SFT (p = 0.0001) compared to the CG and the EE group had

significantly greater increases in MOU (p = 0.0001) compared to the EdO group.

Based on these findings, the authors of the three studies concluded different things about

the effectiveness of SBOIs. Because the intervention did not produce any statistically significant

difference in the desired outcome of decreased obesity prevalence as measured by the BMI, none

of the studies were able to conclude definitively that SBOIs were effective. However, many

improvements in anthropometric measurement and physical fitness were reported. For example,

the HEALTHY Study Group (2010) found that the SBOI was effective in producing greater

reductions in BMI, WC, and fasting insulin level. McMurray et al. (2002) reported that the

intervention was associated with significant improvements in BP, SFT, and MOU. Peralta et al.

(2009) used a study design that lacked sufficient power to detect statistically significant

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differences between the IG and comparison group. Based on effect sizes, they concluded that the

SBOI was minimally effective in decreasing BMI and moderately effective in improving

physical fitness. Peralta et al. (2009) concluded that findings from their pilot study could be used

to inform larger future studies because the intervention was found to be feasible and acceptable.

Limitations. Several threats to reliability and validity existed in the three studies. In the

study about diabetes risk factors (The HEALTHY Study Group, 2010), the following threats

existed: interaction and maturation (threats to internal validity), nonrandom and non-

representative sampling (threats to external validity), and the lack of a true control group.

Another threat was the use of an intervention with a broad scope and multiple components,

which opened the study to multiple confounding variables like SES, English literacy, health

literacy, parental participation, and socio-cultural health behavior. In the study of adolescent

boys (Peralta et al., 2009), the following threats existed: small sample and effect sizes (threats to

statistical validity); interaction, diffusion, and rivalry (threats to internal validity); non-

representative sampling, excluding girls (threats to external validity). As a result, findings may

not be generalizable to other populations. The following limitations were also noted: the lack of a

true control group, the short study duration, and the lack of sustainability. The authors reported

validity information for most of the measurement tools but no information was provided about

reliability via calibration or inter-rater testing. In the study about hypertension and obesity

(McMurray et al., 2002), the following threats existed: small sample and effect sizes (threats to

statistical validity), nonrandom sampling (threat to external validity), and experimenter bias due

to lack of blinding (threat to construct validity). Several limitations--such as short study duration,

use of low intervention dose/intensity, and use of self-reported SES data--and confounding

variables also existed. Some examples of confounders included seasonality, decreased access to

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health care (due to rural location), and socio-cultural norms (different perceptions about body

image).

Strengths. To minimize threats to reliability and validity, the studies utilized several

strategies: the use of specially trained RAs, blinding, randomization, unannounced direct

observations, and strict adherence to study protocols. The HEALTHY Study Group (2010)

reported compliance rates to be between 84% and 97%. McMurray et al. (2002) provided

reliability information for MOU and BP testing and used calibrated calipers for SFT. They

reduced interaction effects by selecting geographically isolated schools. Overall, the three studies

shared the following strengths: use of high quality methodologies such as randomized control

trials (RCTs) that compared differences between groups over time, use of objective data to assess

adiposity, and use of valid obesity measurement (BMI).

Findings from these three intervention studies indicate that the evidence in support of

SBOIs is moderately strong. Using criteria like quality, quantity, and consistency, one can assess

the strength of this body of evidence to guide decision-making. First, the body of evidence was

strengthened by the studies’ use of high quality methodologies. This involved study designs that

were randomized and quasi-experimental. Several other factors contributed to quality: use of

specially trained RAs, blinding, inter-rater testing, adherence to protocol, use of objective data,

used of valid measurement tools, and use of process measures. Second, the strength of the body

of evidence was diminished by the small quantity of studies used. This resulted in a combined

sample of 5,773 subjects from only three studies. In addition, the magnitude of the intervention’s

effect was low as all three research groups reported statistically insignificant changes and small

effect sizes. Third, the strength of the body of evidence was enhanced by the consistent nature of

some of the study findings. Although different samples (African Americans, Hispanics, and

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Australians) and settings were used, the findings were relatively similar. In fact, all three

research groups reported that SBOIs were associated with improved anthropometric

measurements like BMI, SFT, and WC. In spite of differences in specific treatment effects, the

findings from the three studies did not contradict one another.

Background on childhood obesity policy

Federal policies

At the federal level, several policies have been enacted to address the childhood obesity

epidemic. Some examples are the National School Lunch Act (NSLA) of 1946 and the 1975

authorization of the national School Breakfast Program (SBP). In exchange for federal subsidies,

schools provide meals that meet nutritional standards, known as the Dietary Guidelines for

Americans (DGAs), established by the U.S. Department of Agriculture (USDA). Competitive

foods (i.e. foods sold in vending machines or during fund raisers), on the other hand, are not

required to comply with any nutritional standards. The regulation of school meals and the

promotion of healthy nutrition play an important role in the fight against childhood obesity as

more than 30 million students participate in the national school lunch program and 10 million

students participate in the SBP (Story, Nanney, & Schwartz, 2009).

Another federal policy is the 2002 Farm Bill, which provided funds for a pilot healthy

snacks program to 25 schools in six states. The program, implemented by the USDA, gave

schools grant money to purchase fruits and vegetables for students to receive free healthy snacks

in addition to school breakfasts and lunches. Other examples of federal policy are the Child

Nutrition and Women, Infants, and Children (WIC) Reauthorization Act of 2004, which

mandated the creation of school wellness policies, and the 2001 No Child Left Behind (NCLB)

Act. The NCLB Act provided funding for the Carol M. White Physical Education Program

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(PEP), which gave grants to schools for exercise and sports equipment and staff training.

However, some criticized the Act for omitting physical and health education from the list of core

academic subjects (Dietz, Benken, & Hunter, 2009). As a result, some states now offer little to

no physical education (PE) in schools. In fact, in 2007 less than one quarter of all states had any

policy for students’ physical fitness testing (Story et al., 2009).

State and local policies

Increased policy activity has been reported at the state and local levels. According to

Story et al. (2009), 25 states have policies that limit students’ access to competitive foods during

the school day, 27 states have policies regarding the nutritional content of competitive foods that

are stricter than the USDA regulations, and 11 states have policies for more nutritious school

meals. A specific example of a state policy was the 18% “obesity tax” on non-diet sodas

proposed by then-governor, David Paterson (D-NY), in 2008 (Powell, Chriqui, & Chaloupka,

2009). Another policy option to reduce the consumption of sugar sweetened beverages (SSBs) is

an excise tax on the sugar in sodas and sports drinks (Brownell & Frieden, 2009; Sturm, Powell,

Chriqui, & Chaloupka, 2010). Other examples of state and local policies are the 2008 menu-

labeling ordinances introduced in New York and California, the 2008 prohibition of sugar

sweetened beverages (SSBs) in Colorado schools, and the restriction of vending machine sales

on school campuses in Chicago and Philadelphia.

Examples of physical education policies include Mississippi’s Healthy Students Act of

2007, which set minimum standards for PE, and California’s Public Health Law and Policy of

2006, which required cities and counties to adopt a General Plan for creating “healthy and

sustainable” communities (Dietz et al., 2009). Another example is Arkansas’ BMI assessment

program which requires all public school students in even-numbered grades to be weighed and

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measured unless parents submit a refusal in writing. Since the policy was implemented in 2003

obesity rates in Arkansan school children have reportedly stopped increasing (Justus, Ryan,

Rockenbach, Katterapalli, & Card-Higginson, 2007).

Policy analysis

Policies, whether implemented at the federal, state, or local level, are most effective in

providing the greatest amount of health benefits for the greatest number of people when they are

based on an environmental approach rather than a personal responsibility approach. For example,

a policy mandating nutrition education will likely have little impact on students’ health behaviors

and outcomes if the school food environment remains toxic. Characteristics of a toxic food

environment are unregulated competitive food sales, unlimited access to vending machines, and

decreased access to healthier alternatives like fresh fruits and vegetables. In order to establish

healthy school food environments, policies must be in place to limit students’ access to

competitive food sources like vending machines (Fox, Dodd, Wilson, & Gleason, 2009; Wiecha,

Finkelstein, Troped, Fragala, & Peterson, 2006). An analysis of the socio-political and economic

factors related to obesity indicates that several threats to public health exist as a result of undue

corporate influence from the food industry. Economic policies are intended to preserve the

solvency of the dollar and stimulate growth in a free market but they often protect business

interests more than they protect those of the public. For example, one disadvantage of the Farm

Bill was that it subsidized corn production. As a result, there was a surplus of corn-based, high-

fructose syrup, and the market became flooded with products like sugary foods and beverages

(Cawley, 2006). This is problematic because increased access to SSBs has been associated with

increased BMI and obesity (Collison et al, 2010; Denova-Gutierrez et al., 2010).

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Public health advocates using an economic perspective recognize that government

intervention is warranted when a “market failure” occurs, resulting in imbalanced production and

consumption (Brownell & Frieden, 2009; Cawley, 2006). This failure is characterized by three

features: information asymmetry, high-cost externalities, and irrational consumers (Cawley,

2006). First, Brownell and Frieden (2009) and Cawley (2006) argue that the information

provided by the food industry through marketing and direct-to-consumer advertising is

financially motivated and not always factual. Second, the social costs of obesity are incurred not

just by obese individuals but by members of the public who pay taxes. According to Brownell

and Frieden (2009) and Dietz et al. (2009), public insurance programs like Medicare and

Medicaid pay for about half of all obesity-related treatment costs. Finally, government action is

needed to protect children who cannot yet participate in rational decision-making. The food

industry recognizes children as potential consumers and spends billions of dollars annually in

advertisements that appeal to a younger audience. In 2007 forty-four food and beverage

companies disclosed their marketing practices as mandated by the Federal Trade Commission

(FTC, 2007). Findings were as follows: $870 million was spent on marketing to children, $1

billion was spent on marketing to adolescents, and $300 million was spent on marketing to both

age groups (FTC, 2008).

According to Brownell and Warner (2009), the food and beverage industry, also known

as Big Food, bears an uncanny resemblance to Big Tobacco in its use of deception and lobbying

to maximize profits at the expense of public health. One example of an industry tactic is making

promises about self-regulation. In 2006 the American Beverage Association (ABA) issued a joint

statement with the Alliance for a Healthier Generation (AHG) that encouraged limiting the sale

of non-diet sodas in middle schools. However, the contents of the agreement made no mention of

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sports drinks which contain high levels of sugar (Wiecha et al., 2006). Other tactics that Big

Food copied from Big Tobacco’s “playbook” (Brownell & Warner, 2000) were the use of front

groups (Americans Against Food Taxes, Center for Consumer Freedom), the use of corporate

social responsibility (CSR), the use of legislative preemption, and the use of harm reduction

strategies. Like Big Tobacco, Big Food uses its money and influence to hire consultants and

researchers, dispute scientific findings (labeled as “junk science”), and block important

legislation (Brownell & Warner, 2009). Failing to recognize the power, influence, and financial

resources of the food industry may severely damage the movement to end childhood obesity.

In spite of advancements in public policy and health science, more research is needed to

identify the most effective obesity interventions. Future research should examine how socio-

political, economic, and cultural factors affect obesity prevention efforts. An especially

important focus of future research should be social determinants of health considering the fact

that health disparities continue to affect many obese children and adolescents who are low-SES

racial/ethnic minorities (Singh et al., 2008).

Kingdon’s Multiple Streams Theory

Theory overview

Kingdon’s (1995) multiple streams theory describes how policy development is

comprised of two interdependent processes: agenda-setting and alternative specification.

Agenda-setting refers to how issues are pushed up and down the political agenda by

entrepreneurs like elected officials and industry leaders. Alternative specification refers to how

different policy options are identified as possible solutions to a given problem. The theory is

useful in addressing why certain issues are a hot topic of discussion one day, then ignored the

next day.

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Kingdon’s three streams are distinct and independently flowing. First, the problem stream

is where an issue is identified as a dilemma or crisis. Problems differ from conditions in that they

violate values and break social norms (Kingdon, 1995). Participants in this stream, like

clinicians, public health advocates, and media personalities, are known as entrepreneurs who

attract attention to the issue, garner support, and provide feedback to decision-makers. Natural

disasters and public controversies are “focusing events” because they attract attention and push

the problem up the agenda. Second, the policy stream is where an issue is investigated to identify

solutions to the problem. It is known as a “primeval soup” where ideas are exchanged and

hypotheses are developed. Participants in this stream, like academics, researchers, and analysts,

are known as hidden participants who work behind the scenes, identifying and testing possible

solutions. Deciding which solution to adopt occurs during alternative specification, where only

the “fittest” policy option survives selection. Fitness refers to a policy’s “technical feasibility,

congruence with the values of community members, and the anticipation of future constraints”

(Kingdon, 1995, p. 200). Participants also “soften up” the environment by issuing press releases

and conducting public forums so that people are more welcoming of future policy change.

Finally, the political stream is where the issue becomes a decision maker’s pet project

and is actively pushed to the top of the government agenda. Participants in this stream are

politicians, policy aides, and other staff members who build coalitions and use bargaining

techniques to reach a consensus with other decision makers. Other components of the political

stream are the national mood and the liberal or conservative nature of the administration.

Additional concepts of Kingdon’s theory include coupling, recombination, mutation, and

spillover. Kingdon’s theory also discusses problem and policy windows which are opportunities

to push attention or solutions to certain issues.

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Theory application to childhood obesity

Problem stream. Entrepreneurs in this stream include First Lady, Michelle Obama,

professional athletes, Drew Brees and Tony Hawk, and celebrity chef, Rachel Ray. Mrs. Obama

launched the “Let’s Move!” campaign in 2010 to raise public awareness about the importance of

nutrition and exercise in ending the childhood obesity epidemic. Brees and Hawk appeared in

public service announcements (PSAs) for the “Fuel Up to Play 60” physical fitness campaign

sponsored by the National Dairy Council and National Football League (NFL). Ray spoke at a

press conference to support Rep. George Miller’s (D-CA) child nutrition bill. Examples of

indicators are the increasing childhood obesity prevalence rates and the rising social costs of

childhood obesity. According to Cawley (2010), obesity costs the public over $14 billion in

medical expenses and $4.3 billion in job absenteeism every year. Obesity also contributes to

decreased work productivity, which costs society about $506 per obese worker per year (Cawley,

2010). Examples of participant feedback in the policy stream are findings from cost-

effectiveness studies about specific childhood obesity interventions. A study by Wang, Yang,

Lowry, and Wechsler (2003), for instance, found that a SBOI implemented in Boston saved

$15,887 in medical costs (from cases of overweight averted) and $25,104 in labor costs (from

cases of lost productivity averted). Other types of feedback may be obtained from discussions

with advocacy groups and reports from international agencies like the WHO. A comparison

between countries is useful in highlighting the need for change. While the childhood obesity

prevalence rate for boys was 35% between 2003 and 2004 in the U.S., it was only 22.7% in

England in 2007 and 13.1% in France between 2006 and 2007 (International Obesity Taskforce,

2007). Examples of focusing events are news stories featuring obese children and TV shows like

“The Biggest Loser” and “Jamie Oliver’s Food Revolution.” Another example was when (Ret.)

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Major General Paul D. Monroe (2010) appeared at the hearing for H.R. 5504, the Improving

Nutrition for America’s Children Act, and testified that childhood obesity was a threat to

national security.

Policy stream. Entrepreneurs like researchers, Kelly Brownell and Marion Nestle, are

known as specialists because of their expertise in the field. Brownell is the director of the Rudd

Center for Food Policy and Obesity at Yale while Nestle is the chair of the Council on Nutrition

Policy at the National Association for Public Health Policy. Examples of policy solutions that

may be “tested” include family-based obesity interventions, school gardens, and anti-obesity

drugs. Entrepreneurs soften up the environment by commenting on blogs, appearing on talk

shows, and creating press releases. The process of alternative specification helps narrow down

the list of possible solutions to those that are most feasible, affordable, and congruent with the

values of community members (Kingdon, 1995). For example, distributing treadmills to every

school in the country is not affordable and providing every student a personal trainer is not

feasible. Also, while mandating that all obese families enroll in Weight Watchers is not likely to

be congruent with the values of the majority of the community, mandating that school

environments be safe and accessible is more likely to be appealing.

Political stream. One example of an entrepreneur is Sen. Kirsten Gillibrand (D-NY),

who proposed a federal law in 2009 to increase the regulation of all foods (including competitive

foods) provided at schools. Other examples include Rep. Rosa DeLauro (D-CT), who proposed a

national menu labeling policy, and former president, Bill Clinton (D), who helped create an

agreement between the ABA (2006) and the AHG to limit students’ access to SSBs. Perhaps one

of the most active entrepreneurs is Sen. Tom Harkin (D-IA), who proposed a national menu

labeling policy, an update of the list of Foods of Minimal Nutritional Value (FMNV), and a shift

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of authority for defining foods of “minimal nutrition” from the USDA to the Food and Drug

Administration (FDA) (Kersh, 2009). Entrepreneurs face opposition from figures such as former

Rep. Ric Heller (R-FL), who proposed to ban lawsuits against fast food companies in 2004, and

former Secretary of Health and Human Services, Tommy Thompson (R), who urged the Grocery

Manufacturers Association (GMA) to oppose increased government regulation and who

attempted to block the release of a report by the WHO on obesity (Brownell & Warner, 2009).

An example of how the national mood influences agenda-setting is when an expensive childhood

obesity proposal introduced during an economic recession fails to gain the public’s support.

Other concepts. Examples of recombination, which modify existing policy, include

increasing funds to support the NSLP and SBP and updating the list of FMNV. An example of a

novel policy option, also known as a mutation, is a federal policy mandating BMI assessment.

Coupling takes place when streams intersect. An example is when a figure from the problem

stream like celebrity chef, Rachel Ray, collaborates with a figure from the political stream like

congressman, George Miller (D-CA), to speak publically about the importance of healthy

nutrition in preventing childhood obesity. However, an issue is more likely to be pushed up the

agenda if all three streams are involved. One example would be if media personality, Oprah

Winfrey, invited first lady, Michelle Obama (from the problem stream), researcher, Kelly

Brownell (from the policy stream), and senator, Tom Harkin (D-IA) (from the political stream),

on her talk show to discuss childhood obesity. An example of a problem window is a news story

that attracts a lot of public attention like when boxer, Mike Tyson, talked about being bullied as a

child because he was overweight. Another example would be if a proposal mandating menu-

labeling resulted in protests or labor strikes. Examples of policy windows include the transition

from a Republican to a Democratic majority in Congress and the replacement of a key cabinet

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member from a pro-business politician to one with a background in public health. Success in the

childhood obesity movement may spill over into other areas like improved academic

performance and decreased rates of teen pregnancy.

Proposal: Healthy School Environment Policy

The Healthy School Environment Policy (HSEP) is a novel policy proposal that has not

yet been established. It would combine elements of the Pennsylvania School Nutrition Policy

Initiative (SNPI) (Foster et al., 2008) and the Arkansas Act 1220 of 2003 (Justus et al., 2007). It

consists of four components: Environment, Nutrition, Physical Activity, and Social Marketing.

First, Environment refers to maintaining a safe, accessible space with athletic fields, gym

facilities, and playgrounds. Access to and from school will be clearly marked and students will

receive incentives for using walking and biking paths as part of the Safe Routes to School

program. Food and beverage advertisements and corporate sponsorship will not be permitted so

as to protect vulnerable children from targeted marketing. Second, Nutrition refers to providing

students with healthy food choices. This includes adopting evidence-based nutritional guidelines

for school meals and competitive foods. If vending machines are present, then the items for sale

must meet a stricter set of nutritional guidelines and access must be limited to two hours per

school day. Students will receive vouchers for good behavior or volunteer work to purchase fresh

fruit and vegetable snacks. A “healthy eating” learning module will be developed for use in

classrooms.

Third, Physical Activity refers to promoting vigorous exercise and mandatory BMI

assessment. Schools will need to update their PE and athletic programs to meet the standards

established by the National Association for Sport and Physical Education (NASPE) (Story et al.,

2009). Grades in PE will count towards students’ GPAs. Students will participate in physical

SB-505-11W 25

fitness testing annually and BMI assessment biannually. Confidential reports will be mailed

home to parents. If a student earns an “unsatisfactory” grade, then a parent-teacher meeting will

be arranged to create a plan for improvement. Fourth, Social Marketing refers to using

multimedia to engage with the greater community. This includes using social media to send

students and parents health reminders via email and text message, creating a health-themed

website, and hosting public health fairs. School staff will be required to collaborate with others

in the community like faith-based organizations, cultural groups, and health care organizations.

Schools will also host a design competition where students create posters about health promotion

for use on campus and in the community.

Expected outcome. The primary outcome of the HSEP is decreased obesity prevalence

as measured by BMI. For Environment, the outcomes are increased student and parent

satisfaction with campus physical activity facilities, increased student participation in the Safe

Routes to School program, and 100% compliance with the advertisement and corporate

sponsorship ban. For Nutrition, the outcomes are compliance with nutritional standards for

school meals and competitive foods, decreased number of and access to vending machines,

decreased consumption of SSBs, and completion of the learning module. For Physical Activity,

the outcomes are compliance with the NASPE standards, satisfactory performance in PE and

fitness testing, and decreased rates of overweight and obesity. For Social Marketing, the

outcomes are increased student and parent use of social media tools, increased number of health

website views, increased participation in health fair, and increased collaboration with community

partners.

The defensibility of the proposed intervention lies in its potential to make improvements

in the childhood obesity epidemic compared to alternative policy options. First, the HSEP uses a

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comprehensive approach that reflects an appreciation for the complex, multi-factorial nature of

the problem. Others (i.e. Summerbell et al., 2005) have reported on the ineffectiveness of

interventions that focused solely on education. In contrast, the HSEP combines nutrition and

physical activity in order to achieve proper energy balance, which others (Jiang et al., 2007;

Nemet et al., 2005) have identified as a key factor in obesity prevention. This comprehensive,

multi-component approach has already been effective elsewhere (Kriemler et al., 2010; Simon et

al., 2008; Spiegel & Foulk, 2006). Second, the HSEP uses an approach that recognizes the

central role that schools play in health promotion. Evidence from previous studies supports the

use of SBOIs in preventing childhood obesity (The HEALTHY Study Group, 2010; McMurray

et al., 2002). Third, the HSEP uses an approach that promotes capacity building, sustainability,

and inter-organization collaboration. By working with stakeholders to develop culturally

competent program materials, the policy is more likely to be adopted by members of the

community, even those not directly affected by the problem. The realism of the proposal lies in

its feasibility to be implemented within a specified environmental context.

The role of the school food environment in obesity prevention is not yet fully understood.

One common misconception is that school meals cause children to become obese. Gleason and

Dodd (2009) found no such association in a study of 2,228 students in the 1st through 12th

grades. Another misconception is that schools need vending machines for the revenues they

produce. Story et al. (2009) cite findings from a systematic literature review which suggest that

improving the nutritional value of competitive foods does not hurt school revenue (Wharton,

Long, & Schwartz, 2008). The HSEP is feasible for the following reasons: it uses the existing

infrastructure of schools, it relies on in-house instructors and their leadership instead of hired

consultants, and it requires minimal investments in new technology. The HSEP is legal, low-

SB-505-11W 27

cost, and culturally-competent. Nevertheless, the proposal’s feasibility may be limited by

difficult program coordination, long implementation schedule, and backlash from stakeholders.

Implementation

The proposed intervention is intended to be implemented at the county level due to the

overwhelming political, financial, and bureaucratic barriers at the state and federal levels. Santa

Clara County may be the ideal setting because the Board of Supervisors recognizes childhood

obesity prevention as a top priority. In fact, several policies that are consistent with the

proposal’s environmental approach are already in place: the 2005 regulation of vending

machines in county buildings, the 2008 menu-labeling ordinance for chain restaurants, and the

2010 ban on using toys as incentives in kids’ meals. Kingdon’s multiple streams theory can help

to describe how the HSEP could get on the policy agenda at the local level. For example, local

celebrities like former football player, Steve Young, or Facebook founder, Mark Zuckerberg,

could hold a press conference about childhood obesity at San Jose’s City Hall. Then nurses and

community leaders could provide testimony at a meeting of the Board of Supervisors. Finally,

county supervisor, Liz Kniss, a registered nurse and public health advocate, could use her skills

as a political entrepreneur to push the issue up the local government agenda.

After the proposal is accepted, the implementation procedure will consist of two phases,

one involving the greater community and one targeting the specific school environment. Because

of the large number of changes planned, a gradual transition is necessary to facilitate acceptance

and obtain buy-in. The first phase will involve the Environment and Social Marketing

components. The steps of implementation are as follows: (1) launch multimedia campaign (hang

posters, create PSAs, launch website) to inform the community about the HSEP; (2) introduce

the Safe Routes to School program and provide incentives for students who walk or bike to

SB-505-11W 28

campus; (3) host design competition for students to design posters about health promotion; (4)

host school clean-up day where volunteers remove food and beverage advertisements from

campus; (5) host public health fair and invite members of different community organizations to

participate in open forum. The second phase of implementation will involve the Nutrition and

Physical Activity components. The steps are as follows: (1) transform school food environment

by adopting new set of stricter nutritional guidelines for school meals and competitive foods and

by eliminating or limiting access to vending machines; (2) provide students with vouchers to

purchase fresh fruit and vegetable snacks on campus; (3) revise curriculum to include mandatory

nutrition and PE classes; (4) conduct biannual BMI and annual physical fitness testing and send

confidential reports to parents; (5) provide parents with the option of removing their children

from BMI testing by submitting paper refusal form.

The following material resources will be required: incentives for the Safe Routes to

School program and poster design competition; fresh fruit and vegetable snacks; sports

equipment; textbooks for nutrition and PE classes. The following human resources will be

required: volunteer staff to patrol along Safe Route to School; artists to create posters and

produce PSAs; staff to develop and maintain website; training for school staff members.

Financial resources will be needed to cover the program costs related to the media campaign,

healthy snacks program, student incentives, and staff training. The following constraints will be

anticipated: serious opposition from the food and beverage industries (Brownell & Warner,

2009), opposition from pro-business politicians, lack of buy-in from school staff, and decreased

parental participation. Another possible constraint is the inability to effectively coordinate all of

the components in an efficient and timely manner. Designated coordinators and program

“champions” will be needed for successful program delivery. Other constraints include the lack

SB-505-11W 29

of political will, inadequate financial resources, and insufficient evidence about the

intervention’s efficacy. It is also uncertain whether or not the policy will produce adverse effects

on students (i.e. disordered eating, negative body image, social stigma).

Evaluation

The four main evaluation criteria correspond to the four components of the HSEP. First,

the Environment component will be evaluated for compliance with safety, accessibility, and

health promotion standards via an environmental assessment. Second, the Nutrition component

will be evaluated for compliance with nutritional guidelines via random, unannounced

inspections, tracking of food and beverage sales, and food intake surveys. Third, the Physical

Activity component will be evaluated for compliance with BMI reporting requirements and

compliance with standards from the NASPE via fitness testing and student and teacher

questionnaires. Fourth, the Social Marketing component will be evaluated for acceptability,

cultural competence, and sustainability via process measures like surveys, interviews, task force

and stakeholder meetings.

The policy will also be evaluated by cost-effective analyses. According to Brown et al.

(2007), interventions with a cost-effectiveness ratio (CER) less than $30,000 per quality of life

years (QALYs) saved and a net benefit (NB) greater than $0 are considered to be cost-effective.

This proposal uses a school-based model that has been assessed for its cost-effectiveness in a

variety of settings. A review of three such studies (McAuley et al., 2009; Wang et al., 2003;

Wang et al., 2008) found that SBOIs are moderately cost-effective, with CERs between $900 and

$4,305 and NBs between $7,313 and $68,125. The evaluation criteria for costs will include:

educational and promotional materials, incentives, website development and maintenance, sports

equipment, healthy snacks, and staff training costs. The evaluation criteria for efficacy will

SB-505-11W 30

include: decreased prevalence of overweight, decreased prevalence of obesity, decreased

consumption of SSBs, increased consumption of fresh fruits and vegetables, improved academic

performance, and improved fitness scores. Overweight and obesity prevalence data will be

collected by the school nurse or advance practice nurse at the public health department. Food

intake data will be collected via questionnaires and academic performance and fitness testing

data will be collected by school staff.

Pros and cons. The proposed HSEP has the following advantages: use of comprehensive

approach that addresses the complexity of the problem; use of evidence-based guidelines for

nutrition and physical activity; use of low-cost incentive programs and social media to promote

student participation; use of objective measurement tool for obesity; use of collaborative

approach that facilitates communication between schools and communities; use of process

measures to ensure fidelity, promote acceptability, and maintain sustainability. Collaborating

with stakeholders will help to obtain buy-in from important groups like student councils and

parent-teacher associations (PTAs). Furthermore, the proposal is based on a SBOI model that has

been used successfully (i.e. The HEALTHY Study Group, 2010) and cost-effectively in other

settings (i.e. Wang et al., 2003). However, there are disadvantages to the HSEP: the use of a

broad scope with multiple components may complicate program delivery; the use of a policy to

decrease students’ access to competitive foods will likely incite opposition from the food

industry or inspire backlash from consumer rights/personal responsibility proponents; the use of

a policy that mandates fitness testing and BMI assessment may result in adverse effects.

Discussion

Childhood obesity is a serious public health concern that threatens the well-being of

individuals, communities, and entire societies. Its negative impact on health is as severe as its

SB-505-11W 31

high social costs and significant economic implications. The issue is too complex to solve with a

one-size-fits-all approach. Too many physiological, socio-cultural, and political factors are

involved in the development and perpetuation of the obesity epidemic to be ignored. Instead, a

policy approach that is as comprehensive as the multi-component HSEP should be considered as

a possible solution. It is based on a SBOI that has already been reported as effective in other

settings (The HEALTHY Study Group, 2010; McMurray et al., 2002) and similar policy

proposals are currently being adopted in states like Pennsylvania (Foster et al., 2008).

Government intervention is warranted when populations are left vulnerable against the

threat of death and disease. Clearly, the market has failed and promises made by members of the

food industry to improve public health have been left unfulfilled. The escalating prevalence rate

of childhood obesity is a call to action for clinicians and politicians alike. It is especially

important for health professionals like nurses to respond to the call by drawing attention to the

problem and persuading policy makers to act in the best interest of the general public. Regardless

of what perspective one uses to analyze the situation, it cannot be denied that the argument in

support of personal responsibility has its limits. Thus far, policies based on such an argument

have failed to adequately protect people from the harmful, deceptive, and exploitative practices

of an industry that is more concerned about profits than public health. Therefore, a different

approach is needed, one that uses an environmental perspective in solving the problem. Although

personal freedoms may be restricted, greater benefits will be provided for a greater number of

people. As a social problem, addressing childhood obesity should be no different than promoting

immunization or smoking cessation. Failing to recognize the parallels between these public

health issues will not only push childhood obesity off the political agenda, it will also delay

action, interfere with progress, and cause harm to current and future generations of Americans.

SB-505-11W 32

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