Addressing Atlanta, Georgia’s Childhood Obesity: An Ineffective Public Health Intervention – Emma Lodato

  Childhood obesity is a growing public health concern, especially within the United States.  The Centers for Disease Control and Prevention (CDC) uses the body mass index (BMI) as a unit of measurement for classification of body weight.   Children and adolescents, who are of the same age and sex, are defined as being overweight if the BMI is at or above the 85th percentile and lower than the 95th percentile.  The CDC categorizes obese children and adolescents, who are of the same age and sex, who have a BMI at or above the 95^th percentile.  The National Health and Nutrition Examination Survey (NHANES) estimates that 17% of all US children and adolescents (aged 2-19 years old) are obese as of April 2011 (1).  Since the inception of NHANES in 1971, the prevalence of overweight and obese children and adolescents within the United States has more than tripled (2).  Children and adolescents who are overweight or obese present a major public health concern since they are at an increased risk of experiencing immediate deleterious health problems as well as increased risks for health hazards later in life (3).  Childhood obesity has been positively correlated to increased risk factors for cardiovascular disease as well as type-2 diabetes (4).  Moreover, children and adolescents who are overweight or obese have increased risks of exacerbating obesity related health problems and remaining overweight or obese into adulthood (5-7).  Problems associated with obesity place a financial strain on the US healthcare system costing the US approximately $150 billion each year (8).  The adverse health effects coupled with the high financial costs has urged public health officials to prioritize and address the issue of obesity.

A Multifactorial Explanation for the Childhood Obesity Epidemic

A single explanation accounting for the childhood obesity and overweight epidemic cannot be ascertained since it is considered to be multifactorial (9).  Genetic, environmental, social and behavioral factors have been found to be related in determining an individual’s body weight (10-11).  Many individuals attribute the rising rates of childhood obesity to the obesogenic environment (12).  This environment has an overabundance of unhealthy foods that are laden with fat and sugar coupled with a lifestyle that has decreased amounts of physical activity (13).  Research has revealed that American children are consuming more unhealthy food and engaging in less physical activity compared to previous decades (1).  Individuals living in poverty have more pronounced negative changes in diet and physical activity.  Biro and Wein have stated that children from low-income households are at an increased risk of being overweight or obese due to the unhealthy lifestyles that are common amongst these households (7).

Addressing the Childhood Obesity and Overweight Epidemic

The Southern region of the US reports the highest prevalence rates of childhood obesity.  Currently, nine of the ten states with the highest prevalence rates of childhood obesity are located within the South (8). Mississippi reports the highest prevalence rate of obese and overweight children while Georgia ranks second.  Over 21% of children aged 10-17 years old have a body mass index (BMI) that can be categorized as obese (8).  Due to the rising prevalence rates of obese and overweight children coupled with the adverse health and financial consequences, public health officials have implemented several interventions. 

            The Children’s Healthcare of Atlanta Pediatric Hospital (CHOA), one of the nation’s top pediatric hospitals within the US, has recently designed and implemented a childhood anti-obesity campaign in Atlanta, Georgia (14).  By utilizing several forms of media, such as television and billboard advertisements, CHOA hopes to raise awareness about the problems of childhood obesity and to thereby help control the epidemic.  An example of a television advertisement has a young obese girl speak about how she is frightened that her doctor has diagnosed her with hypertension.  At the end of the clip, a message displays, “Stop sugar-coating it Georgia” (Appendix Television Advertisement #1).  Billboard advertisements were placed around Atlanta, Georgia with a young obese girl and a slogan that reads: “WARNING:  It’s hard to be a little girl if you’re not” (Appendix Billboard Advertisement #1; figure 1).  Previous studies suggest that CHOA’s childhood anti-obesity campaign will most likely do more harm than good since the current campaign has serious flaws and fails to address other important issues such as a child’s self-esteem (13).  This media campaign will probably be ineffective in meeting its goal of reducing the prevalence rates of childhood obesity in Atlanta, Georgia.

Criticisms

            While every public health intervention can be improved, CHAO’s public health intervention to combat childhood obesity is seriously flawed.  Three criticisms discussing this public health campaign are presented below.  These criticisms will discuss how CHOA’s campaign reinforces stigmas and labels, places an emphasis on the individual’s characteristics and does not consider multiple factors that may contribute to the childhood obesity epidemic, and fails to recognize the external locus of control.

Criticism 1:  Reinforcing Stigmas and Labels

            Most stigmas and labels are perceived as negative by and to others often resulting in a diminished sense of self-worth that may further perpetuate the problem (55).  CHOA states that their advertisements were necessary as a public health intervention in order to raise awareness about the adverse health effects that overweight and obese children may face.  By using catch phrases such as “stop sugarcoating it” and “thick like her momma”, CHOA was hoping to relate the problems of childhood obesity to parents since many parents fail to recognize their children as being overweight or obese (14).  The encouragement of labeling and stigmatizing overweight and obese children is ineffective as a public health initiative to improve the health of children who are overweight or obese (14-17).  CHOA failed to recognize the unintended negative consequences of their advertisements such as labeling children who are overweight or obese.  Furthermore, the advertisements used during this campaign stigmatize children who suffer from weight related issues.

Labels

By labeling children as ‘fat’ through messages such as “My fat may be funny to you but it’s killing me” (Appendix Billboard Ad #2; figure 2), one may negatively alter a child’s self-image.  By clearly and harshly labeling people as fat, especially children who are overweight or obese, they may begin to struggle with their self-esteem and self-image.  According to the labeling theory, labels may change how a person behaves since individuals often change his/her behavior in order to meet the standards of the label that has been given to him/her by society (15).  According to current American culture, overweight and obese individuals are commonly viewed as indolent and undisciplined.  Children who are labeled as such may begin to engage in behaviors and activities that promote weight gain through self-fulfilling prophecies.  Examples of such behavior may include increased caloric intake coupled with decreased physical activity.  While CHOA believes that terms such as “fat” and “obese” act as motivators in helping to encourage a child to lose weight, current and previous research does not support CHOA’s assumption.  Regardless of age, people who are overweight or obese do not prefer or like being called “fat” and often view this label as being discouraging rather than motivating (16). With this finding, CHOA’s childhood anti-obesity campaign’s goal and message is counterproductive and thereby will probably be ineffective.

Stigmatizing

            These advertisements pertaining to CHOA’s childhood anti-obesity campaign may further stigmatize overweight and obese children. In current American culture, harsh and realistic social stigmas are applied to individuals who are overweight or obese.  When comparing children and adolescents who are overweight or obese to normal weight children and adolescents, those who suffer from obesity or being overweight report being more likely to be teased than their healthy counterparts.  Children who are overweight or obese are often victims of harassment and bullying.  Individuals who are victimized, in this case children who are obese or overweight, are at an increased risk of developing associated problems such decreased self-esteem, dissatisfaction with body image, depression, and poor social skills (17). 

Literature suggests CHOA’s childhood anti-obesity campaign advertisements will only exacerbate the problems that overweight and obese children encounter on a regular basis (55).  By making these advertisements public and readily visible, children and adolescents who are of normal weight may perceive the message that it is acceptable and actually beneficial to label, stigmatize and berate their overweight or obese peers.  Parents of overweight or obese children may also become insensitive to weight management issues and thereby neglect their child’s weight issue thereby exacerbating the epidemic.  By promoting and permitting the victimization of overweight and obese children, studies suggest that there will be an overall prevalence rate increase of decreased self-esteem, dissatisfaction with one’s body, depression, and decreased social skills (16, 55).  Children who are obese or overweight may experience an increase in teasing, bullying, and become a more likely target for general harassment.  This increase of harassment may promote overweight or obese adolescents and children to engage in solitary behaviors.  Examples of solitary behaviors may include avoiding physical activity and coping mechanisms that induce comfort such as an increase in unhealthier eating habits.  The physical and mental health of overweight and obese children will further wane as a result of CHOA’s childhood anti-obesity campaign.

Critique 2:  Too Much Emphasis on the Individual Characteristics and Not Enough on the Social Factors

Health Belief Model

            CHOA utilized the health belief model in their childhood anti-obesity campaign.  The health belief model is based upon three assumptions:  1) the understanding that an individual will engage in a positive health behavior if the individual feels that a health hazard can be avoided, 2) believes that the positive health behavior will deter the health hazard and 3) that the individual can successfully perform the positive health behavior (18). An example of usage of the health belief model can be found in one of CHOA’s television advertisements in which the mother states, “When the doctor said she [the daughter] had type-2 diabetes, I never thought what we eat made her sick.  I always thought she was thick like her momma” (Appendix TV Advertisement #2).  Another example includes a billboard advertisement that warns that “Chubby kids may not outlive their parents” which implies that overweight and obese children are at a higher risk for premature death (Appendix Billboard Advertisement #3; figure 3). 

Considering the environmental model of health, this model focuses on multiple factors that affect an individual’s health that are typically external and that the health belief model is inadequate for this specific public health intervention.  Such factors may include access to nutritious food, socio-economic conditions, and living conditions which may contribute to the individual’s inability to control his/her weight.  An example of this may be that a family of 2 depends on $367.00, the current maximum benefit allowance for the Supplemental Nutritional Assistance Program (food stamps).  This family may not have access to a personal vehicle to transport them to the supermarket which may be miles away.  The family is then dependent upon small convenience stores for their grocery needs. These convenience stores often lack an assortment of nutritious food at affordable prices, thereby exacerbating the family’s inability to even consider nutritious food.    

The designers of this advertisement campaign thought that if the child and caretaker understood the adverse health effects associated with obesity, then the child and caretaker would take the appropriate measures to help the child reach a healthy weight.  While the health belief model has been proven to be effective and useful for several public health interventions, it probably should not have been applied to this campaign.  While the campaign’s message that caretakers and children should know the facts and health hazards associated with childhood obesity should not be undermined,  the campaign’s belief that by simply informing caretakers and children that the child or adolescent is obese and is therefore at an increased risk for an adverse health effect will be ineffective in decreasing the obesity prevalence rates in Atlanta, Georgia.

Fundamental Attribution Error

            CHOA’s childhood anti-obesity campaign places the fault entirely on the child and the caretaker.  One billboard advertisement states, “Warning:  Big bones didn’t make me this way.  Big meals did” while another states, “Fat prevention begins at home.  And the buffet line” (Appendix Billboard Advertisement #4; figure 4 and Appendix Billboard Advertisement #5; figure 5).  These particular billboard advertisements endorse the current American culture’s perspective of overweight and obese individuals and makes the fundamental attribution error.  The fundamental attribution error is when a party uses personality-based explanations for the observed behaviors of others while under-valuing situational explanations (18).  By simply implying that obese and overweight children are gluttons as the fundamental attribution error does, it completely dismisses the consideration of the environmental model which suggests an array of other factors that may be a reason as to why the child is consuming “big meals” (12, 16, 19).  There could be a variety of external factors that offer valid explanations.  Such examples may be:  1) both parents work several jobs and only have time to cook one meal a day or 2) there may not be a supermarket within the area, only fast food restaurants and bodegas or 3) both aforementioned scenarios.  In order to help tackle the epidemic of childhood obesity, the real reasons behind the epidemic must be addressed rather than placing the blame on the child and or the caretaker.

CHOA committed the fundamental attribution error in their childhood anti-obesity campaign as they dismissed the social, environmental, economic, and biological factors that are contributors to the epidemic.  As mentioned previously, obesity disproportionately affects individuals who are of lower socioeconomic status.  Due to the financial constraints that the caretakers may experience, they probably do not make healthy food choices a top priority, especially for their children (19).  The advertisements that CHOA implemented were based within the metropolitan area of Atlanta, Georgia.  Coincidently, Atlanta, Georgia ranks as the top city with the highest number of poor children and adolescents within the US (20).  Unless the poverty issue is addressed within Atlanta, CHOA’s childhood anti-obesity campaign will do little to help to resolve Atlanta’s epidemic of childhood obesity. 

Critique 3:  Failure to Address the Locus of Control

CHOA and its collaborators of the childhood anti-obesity campaign in Atlanta, Georgia failed to address the theory of the locus of control.   This theory refers to the extent that an individual believes that he/she has control within his/her life.  Those individuals who have an internal locus of control have an increased perception of control within his/her life. Those with an external locus of control reveal a decreased perception of control within his/her life (18).   Populations of lower socioeconomic status often have external locus of controls as well as increased mortality rates (20, 21).  Populations of higher socioeconomic status are more likely to have an internal locus of control.  Previous studies have shown that populations of a comfortable or high socioeconomic status more frequently engage in healthy behaviors and also have a decreased risk of disease and mortality (21).

            In the advertisements issued during this campaign, caretakers are simply warned about the potential health risks that an overweight or obese child may encounter.  This was done because CHOA believed that the caretakers would take measures to encourage healthy weight loss once these risks were understood.  CHOA’s mass media campaign failed to address the issue that some caretakers do not feel in control of their lives, let alone the child’s weight issue.  To further support this idea, previous attempts to lose weight for both the child and caretaker may have been unsuccessful in the past which only further promotes this sense of lack of control. 

            As stated previously, the external locus of control may be a hallmark characteristic of families from a low socioeconomic status (21).  Considering several facts, such as Atlanta’s ranking regarding impoverished children and that socioeconomic status and BMI are inversely proportional, one may conclude that the affected populations in Atlanta are impoverished and therefore have an external locus of control (1, 19, 20, 21,).  With an external locus of control, these individuals are conditioned to believe that they will not be able to avoid adverse health events.  This thereby acts as a discouragement for them from attempting to achieve better health (22).  Since CHAO’s campaign failed to address the issue of the external locus of control, the prevalence rates for childhood obesity probably will not decrease.  This prevalence rate will probably continue to rise because the caretakers are not provided the resources, skills, and tools to develop their internal locus of control. 

Interventions

            As discussed, these issues are critical components of CHAO’s campaign that will most likely lead to an ineffective public health intervention.  A proposal of three different interventions are presented below that may be able to remedy CHAO’s public health campaign against childhood and adolescent obesity.  To formulate a more effective public health campaign against childhood obesity for CHAO, these interventions discuss the elimination of stigmas and labels, consideration of environmental models, and fostering an internal locus of control.

Intervention 1:  Eliminating the Encouragement of Stigmas and Labels

The combination of the social network theory and offering positive messages would eliminate the use of stigmas and labels from CHOA’s campaign.  The social network theory perceives social relationships in terms of nodes and ties. The nodes are the individual characters within the networks and the ties are the relationships between the individual characters. In this theory, the attributes of individuals are not as important as the relationships between the nodes and the ties (18).  First, the campaign must understand the origin of stigmas that are associated with children who are obese or overweight and to avoid incorporating aspects of these stigmas within the campaign.  An effective way to do so would be to offer a social support network for obese or overweight children in collaboration with their peers.  Previous studies have found that early social interactions decrease various forms of discrimination and prejudice (23).  By encouraging a social support network, the behavior of obese and overweight children may change so that they want to become healthy.  Additionally, the harassing behaviors from their peers may evolve to become more accepting.  In a supportive social network, all parties should ideally benefit.

CHOA’s childhood anti-obesity campaign can make immediate modifications by eliminating the advertisements that feature a solitary child and dismal background.  CHOA can incorporate advertisements of children from various ethnic backgrounds and weights engaging in healthy activities thereby dismantling the reinforcement of stigmas and labels.  These advertisements would boast a positive and colorful message, such as an encouragement of fun physical activity with their peers.  The slogans on these advertisements would avoid labels such as “chubby”, “fat”, and “big boned” and utilize phrases that include positive words such as “fun”, “healthy”, and “cool”.  By discouraging the use of social stigmas, obese and overweight children may want to engage in healthy habits with their peers and may find enjoyment in doing so.

The social network theory can also be applied in reducing stigmas by fostering a positive environment and support network that is culturally sensitive.  Weight stigmas, like ethnic stigmas, vary across the US (24).  It is imperative to be culturally understanding and sensitive when developing these positive environments and support networks.  By understanding the origin of weight stigmas in that particular culture, public health officials can begin to reduce them and further avoid situations that may be related to the stigma’s origin.  Moreover, studies have shown that repeated social interactions reduce discrimination and prejudice.  As individuals are repeatedly exposed to something that is ‘negative’, tolerance increases while prejudice decreases.  Different positive environments would help to foster this development of tolerance.  Additionally, networks including individuals with similar weight problems could prove to be more efficacious than targeting the individuals alone (25).

Studies suggest eliminating the warning labels from the advertisements (56).  An alternative could include a group of children of different weights engaging in positive and healthy behaviors.  By showing children interacting together (regardless of any social factor such as weight, age, height, race, ethnicity, socioeconomic status, etc.), a more positive message will be delivered that does not encourage the use of overweight and obese stigmas.  In doing so, the elimination of stigmas from the campaign and possibly society may be feasible.

Intervention 2:  Stop Attributing the Problem to the Individual and Start Addressing the Social Factors

By eliminating the obesogenic environment, it would encourage and facilitate healthy weight-loss as well as the maintenance of a healthy weight.  It is highly improbable that there will be a decrease in obesity rates by simply encouraging personal responsibility and behavioral change on an individual level (26, 27, 28).  Therefore, policy changes that would gradually eliminate the obesogenic environment are necessary.  By utilizing the agenda setting theory, the childhood obesity epidemic would be a primary concern on the health agenda and therefore be addressed by policy makers (18, 28).  This can be done through a variety of creative ways in order to make the childhood obesity epidemic relevant, relatable, and legitimate.  Such ways could frame the childhood obesity epidemic by emphasizing its potential impacts on national security and safety.  This could be accomplished by publicizing shocking statistics relevant to national security and safety.  An example of such statistics are that approximately 30% of all eligible military personnel aged 17-24 years old do not meet the weight requirements (29).  Local security and safety is also affected because many police personnel fail the fitness tests that are required for the continuation of their profession (8, 30, 31).  Once government personnel realize the future negative impacts of the childhood obesity epidemic in relation to security and safety, policy changes may be able to occur (32). 

            Initiatives such as banning unhealthy food items from schools and replacing them with economic healthier alternatives may be also promoted (34).  Rather than recommending a physical education requirement and recess, they would be federally enforced for both public and private institutions (35, 36).  Other policy changes, such as making healthier food available for lower income communities, such as encouraging the acceptance of WIC checks and food stamps at farmers markets, may also be implemented (37, 38).  Furthermore, the recent decision of Congress to end the subsidies on corn ethanol may help to reduce the price healthy foods (39, 40).  Ideally, this decrease in cost should make healthier food alternatives more affordable and available to those of a lower socioeconomic status.

Intervention 3:  Encouraging an Internal Locus of Control

Parental self-efficacy can also be improved upon via the use of advertisements.  As previously discussed in the section “Failure to Address the Locus of Control”, many caretakers feel as if they do not have control over their health let alone their child’s health (8).  The caretakers need to be provided the tools, skills, and ideas to improve their health as well as their child’s health, such as how to deter themselves and their families from unhealthy food choices (22, 41).  Caretakers and children should also be informed of the early signs of negative health effects such as feeling out of breath while going up stairs, sweating while eating or consuming sugary food items, and frequent urination.  By incorporating these tools within an efficacious public health intervention, the caretakers will feel as if they have more control over their health as well as their child’s; thereby improving the self-efficacy of the caretaker (41, 42). 

Previous studies have demonstrated that social support systems, either functional or structural, are often effective in helping an individual adhere to a regime (53).  Furthermore, studies have demonstrated that personal narratives can often foster a sense of empowerment (54).  Similar to the CDC’s VERB campaign, advertisements showing personal stories and social interaction amongst a support group could be implemented ( TV Advertisements 4 – 10).  This can be accomplished by having advertisements convey a personal story about how both the caretaker and child worked together in reaching and maintaining a healthy weight.  Within these advertisements, the families would be shown eating healthy foods and engaging in fun physical activities together (Figures 6 & 7).  These activities would be accessible and feasible amongst the targeted population.  In this scenario, the population that is most affected by the childhood overweight and obesity epidemic in Atlanta, Georgia are those who are of a lower socioeconomic status. Such activities for the affected population in this scenario may include double-dutch skipping rope, engaging in free programs such as Cardio Kids, utilizing playgrounds, line dancing organizations, creating community athletic teams that charge no fee, and urban gardening (43, 44, 45, 46).   Caretakers who view these advertisements may be able to relate to the characters within the advertisement.  They may also feel as if they have gained the optimism to improve their personal health as well as their child’s.  These advertisements would not place the blame on the caretaker or the child but rather offer an optimistic message that is also encouraging.

Conclusion:  A Positive and Encouraging Message

In one of the childhood anti-obesity television advertisements created by CHOA, a child asks his mother, “Why am I fat?” (Appendix Television Advertisement #3).  A more appropriate and effective question would have been “What can I do about my weight to improve my health?”   The television or billboard advertisements only raise awareness about the potential health hazards of a child being obese or overweight and do not offer any solutions.  Raising awareness is great and necessary for some public health issues, but not for a childhood anti-obesity campaign.  Many of the affected individuals are aware that they are overweight or obese, that there are negative health consequences associated with being obese or overweight, and that there is an obesity epidemic plaguing the US.  As public health officials, CHOA could have done a more effective and wholesome job raising awareness that offers encouragement while proposing feasible solutions.  When effective, realistic, and valuable solutions are presented, an overall improvement of our nation’s health may be achieved.

Mass media campaigns and promotions have been shown to be effective in modifying the public’s behavior.  In order to implement an effective mass media campaign addressing the childhood obesity epidemic, it would be best if it were employed simultaneously during the execution of public health policies that also address the same epidemic.  There have been several successful mass public health interventions that have addressed the childhood obesity and overweight epidemic.  An example is the CDC’s national VERB It’s What You Do Campaign.  It has been shown to be highly efficacious in increasing physical activity levels amongst adolescents by using simple marketing principles such as branding.  Huhman and colleagues have also revealed that adolescents perceived the CDC’s VERB marketing campaign as being trendy and popular which thereby encouraged the adolescents to become more physically active (47).  I think that a similar mass media campaign could be implemented by Georgia’s public health officials and would be just as efficacious as the CDC’s VERB campaign.  Currently, Georgia and CHOA are utilizing fear tactics in hopes of modifying unhealthy behaviors that lead to childhood and adolescent obesity.  While fear tactics with strong efficacy messages have been shown to be somewhat effective, CHOA’s used of strong fear tactics and low-efficacy messages will probably prove to be ineffective (48,49). I believe that campaigns with positive messages will offer hope and knowledge to the affected childhood and adolescent populations as well as encouragement (23).

By understanding that the current obesity epidemic cannot and will not be resolved through individual action alone, be it in adults or children, progress can be made in decreasing the prevalence rates of obesity (18, 19, 26, 27, 28).  Moreover, a change in the current obesogenic environment must be made because it is adversely affecting individuals, especially children, who live in it (50, 51).  In doing so, the feelings of helplessness may be addressed (52).  The new campaign would empower the caretakers and children to make a collaborative effort within their familial unit, as well as community, to make better and healthier choices for their health.

REFERENCES

1.      Centers for Disease Control and Prevention.  Overweight and Obesity:  Obesity Rates Among All Children in the US.  Atlanta, GA:  Centers for Disease Control and Prevention, 2011.  http://www.cdc.gov/obesity/childhood/data.html

2.      Centers for Disease Control and Prevention:  Odgen C, Carroll, M.  Prevalence of Obesity Among Children and Adolescents: United States, Trends 1963-1955 and 2007-2008.  Atlanta, GA:  National Center for Health Statistics, 2010.

3.      Centers for Disease Control and Prevention. Overweight and Obesity: Basics About Childhood Obesity. Atlanta, GA: Centers for Disease Control and Prevention, 2011.   http://www.cdc.gov/obesity/childhood/basics.html.

4.      Freedman DS, Dietz WH, Srinivasan SR, Berenson GS. The Relation of Overweight to Cardiovascular Risk Factors Among Children and Adolescents: The Bogalusa Heart Study. Pediatrics 1999;103:1175-1182.

5.      Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting Obesity in Young Adulthood from Childhood and Parental Obesity. New England Journal of Medicine 1997;37:869-873.

6.      Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do Obese Children Become Obese Adults? A Review of the Literature. Preventive Medicine 1993;22:167-177.

7.      Biro FM, Wien M. Childhood Obesity and Adult Morbidities.  American Journal of Clinical Nutrition 2010; 91: 1499S—1505S.

8.      Levi J.  Segal LM,  Laurent B, Kohn D.  F as in Fat: How Obesity Threatens America’s Future.  Issue Report from the Trust for America’s Health and the Robert Wood Johnson Foundation, 2011. http://healthyamericans.org/assets/files/TFAH2011FasInFat10.pdf.

9.      Bray GA, Macdiarmid J.  The Epidemic of Obesity.  The Western Journal of Medicine 2000;172:78-79.

10.   Farooqi S I, O’Rahilly SO.  Recent Advances in the Genetics of Severe Childhood Obesity.  The Archives of Disease in Childhood 2000;83:31-34.

11.  Viner RM, Cole TJ.  Adult Socioeconomic, Educational, Social and Psychological Outcomes of Childhood Obesity:  A National Birth Cohort Study.  The British Journal of Medicine 2005;330:1354-1359.

12.  Ard JA.  Unique Perspectives on the Obesogenic Environment.  The Journal of Internal Medicine 2007;7:1058-1060.

13.  Simon M.   Appetite for Profit: How the Food Industry Undermines Our Health and How to Fight Back. NYC, NY:  Nation Books, 2006.

14.    Children’s Healthcare of Atlanta-CHOA.  Faced with an Epidemic, Children’s Leads Campaign to Stop Childhood Obesity, 2011. http://www.choa.org/Child-Wellness

15.  Link BG, Cullen FT, Struening E, Shrout PE, Dohrenwend BP.  A Modified Labeling Theory Approach to Mental Disorders:  An Empirical Assessment.  American Sociological Review 1989;54:400-423.

16.  Puhl R.  Bias, Discrimination, and Obesity:  A Social Injustice and Public Health Priority, 2011.  http://www.yaleruddcenter.org/resources/upload/docs/what/bias/WeightBias_PhiladelphiaDPH_3.11.pdf.

17.  Robinson S.  Victimization of Obese Adolescents. The Journal of School Nursing 2006;22:201-206.

18.    Aronson E, Wilson TD, Akert RM.  Social Psychology (6^th edition).  Upper Saddle River, NJ:  Pearson Education, 2007.

19.  Link BG, Phelan J.  Social Conditions as Fundamental Causes of Diseases.  The Journal of Health and Social Behavior 1995; 35 (extra issue):80-94.

20. Metro- Atlanta Task Force for the Homeless Statistics and Myth-busters. 2007.  http://www.homelesstaskforce.org/thefacts.html

21.  Wallston BS,  Wallston KA. Locus of control and health: a review of

the literature. Health Education Monographs 1978;6:107-117.

22.   Clarke JH, MacPherson BW, Homes DR.  Cigarette Smoking and External Locus of Control Among Young Adolescence.  The Journal of Health and Social Behavior 1982;23: 253-259. 

23.   Martin JK, Lang A, Olafsdottir S.  Rethinking Theoretical Approches to Stigma :  A Framework Integrating Normative Influences on Stigma (FINIS).  Social Science and Medicine 2008;67 :431-440. 

24.   Puhl RM, Heuer CA.  The Stigma of Obesity:  A Review and Update.  Obesity 2009;17:941-964.

25.   Brown I, Thompson J, Tod A, Jones G.  Primary Care Support for Tackling Obesity:  A Qualitative Study of the Perceptions of Obese Patients.  The British Journal of General Practice 2006;56:666-672.

26.   McGinnis JM, Foege WH. Actual Causes of Death in the United States. JAMA 1993; 270:2207-2212.

27.  Schwartz MB, Puhl R.  Childhood Obesity:  A Societal Problem to Solve.  Obesity Reviews 2003;4:57-71.

28. Sarafino EP. Health Psychology: Biopsychosocial Interactions. Hoboken, NJ: John Wiley & Sons, 2008.

29.   Bacon, LM.  Study:  Soldiers Use Extreme Methods  to Meet Military Weight Rules.  USA Today, 2010.  http://www.usatoday.com/news/military/2010-12-06-military-weight_N.htm

30.   Sorensen L, Smolander J, Louhevaara V, Korhonen O, Oja P.  Physical Activity, Fitness and Body Composition of Finnish Police Officers:  A 15 Year Follow-Up Study.  Oxford Journal of Occupational Medicine 1999;50:3-10.

31.    Joyner C.  More Police, Fire Recruits Flunk Fitness Test.  USA Today 2010.   http://www.usatoday.com/news/health/2010-05-09-obese-recruits_N.htm

32.   Christeson W, Dawson – Taggart A, Messner - Zidell, S. Too Fat to Fight:  Retired Military Leaders Want Junk Food Out of America’s Schools.  Mission:  Readiness 2010.  http://cdn.missionreadiness.org/MR_Too_Fat_to_Fight-1.pdf

33.   Emery SL, Szczypka G, Powell LM, Chaloupka FJ.   Public Health Obesity-Related TV Advertising:  Lessons Learned From Tobacco.   American Journal of Preventative Medicine 2007;33: 257-263.

34. Egan T.  In Bid To Improve Nutrition, Schools Expel Soda and Chips.  New York Times 2002.  http://www.nytimes.com/2002/05/20/us/in-bid-to-improve-nutrition-schools-expel-soda-and-chips.html?pagewanted=all&src=pm

35.  Slater SJ, Nicholson L, Chriqui J, Turner L, Chaloupka F.  The Impact of State Laws and District Policies on Physical Education and Recess Practices in a Nationally Representative Sample of US Public Elementary Schools.  Archives of Pediatrics and Adolescent Medicine 2011;0:201111331-6.

36.   Madsen K.  Promoting the Health of Our Youth:  Why Physical Activity Policies Are Critical.  Archives of Pediatrics and Adolescent Medicine 2011;0:2011112451-2.

37.    Fisher A.  Hot Peppers and Parking Lot Peaches:  Evaluating Farmers’ Markets in Low Income Communities.  Community Food Security Coalition 1999; 1-58.  http://thrive.preventioninstitute.org/sa/enact/neighborhood/documents/community.farmersmarkets.tools.hotpepperspeaches.pdf

38.   Kantor LA.  Community Food Security Program Improves Food Access.  Food Review 2001;24:20-26.

39. Babcock BA, Fabiosa JF.  The Impace of Ethanol and Ethanol Subsidies on Corn Prices:  Revisiting History.  Center for Agricultural and Rural Development Policy Brief 2011;11-PB 5;1-12.

40. Watson B.  How the (Finally Ended) Corn Ethanol Subside Made Us Fatter.  Daily Finance 2011.  http://www.dailyfinance.com/2012/01/04/how-the-finally-ended-corn-ethanol-subsidy-made-us-fatter/

41.   Martin PD, Dutton GR, Brantley PJ.  Self-Efficacy As a Predictor of Weight Change in African-American Women.  Obesity Research 2004;12:646-651.

42.   Kinard BR, Webster C.  The Effects of Advertising, Social Influences, and Self-Efficacy on Adolescent Tobacco Use and Alcohol Consumption.  The Journal of Consumer Affairs 2010;44:24-43.

43.   Queen of Hearts Foundation.  Cardio Kids.  http://www.qohf.org/cardio_kids.html

44.   Centers for Disease Control and Prevention.  BAM!  Body and Mind.  http://www.bam.gov/sub_physicalactivity/activitycards_jumprope.html

45. Hayes M.  Family Dances to Fight Childhood Obesity.  Fox Atlanta 2011.  http://www.myfoxatlanta.com/dpp/good_day_atl/Family-Dances-to-Fight-Child-Obesity-20110315-gda-sd

46.   Libman K.  Growing Youth Growing Food:  How Vegetable Gardening Influences Young People’s Food Consciousness and Eating Habits.  Applied Environmental Education and Communication 2007;6:87-95.

47.    Huhman PM, Wong FL, Banspach SW, Duke JC, Heitzler, CD.  Effects of a Mass Media Campaign to Increase Physical Activity Among Children:  Year -1 Results of the VERB Campaign.  Pediatrics 2005;116:277-284.

48.   Thomas SL, Lewis S, Hyde J, Castle D, Komesaroff P.  “The Solution Needs to be Complex.”  Obese Adults’ Attitudes About the Effectiveness of Individual and Population Based Interventions for Obesity.  Bio Med Central Public Health 2010;10:420-429.

49.   Witte K, Allen M.  A Meta-Analysis of Fear Appeals:  Implications for Effective Public Health Campaigns.  Health Education and Behavior 2000;27:591-615.

50.   Swinburn B, Egger G, Raza F.  Dissecting Obesogenic Environments:  The Development and Application of a Framework for Identifying and Prioritizing Environmental Interventions for Obesity.  Preventive Medicine 1999;29:563-570.

51.   Lobstein T, Dibb S.  Evidence of a Possible Link Between Obesogenic Food Advertising and Child Overweight.  Obesity Reviews 2005;6:203-208.

52.   Burns D, Haggart M, Longshaw K, Thornton R.  The Public Health Challenge of Obesity:  Is it the New Smoking?  The Journal of Community Nursing 2009;23:4-9.

53.  DiMatteo MR.  Social Support and Patient Adherence to Medical Treatment:  A  

Meta-Analysis.  Health Psychology 2004;23(2): 207-218.

54.  Rappaport J.  Empowerment Meets Narrative:  Listening to Stories and Creating Setings.  American Journal of Community Psychology  1995;23(5):795-807.

55.  Lubkin PL.  Chronic Illness:  Impact and Intervention.  Jones and Bartlett Learning 2013: New York, NY.

56. MacLean L, Edwards N, Garrard M, Sims-Jones N, Clinton K, Ashley A.  Obesity, Stigma, and Public Health Planning.  Health Promotional International 2009;24(1):88-93.

APPENDIX

Television Advertisements
1.      YouTube.  August 21, 2011.  http://www.youtube.com/watch?feature=player_embedded&v=CUuu5CODEmg.  Retrieved January 15, 2012.

2.      YouTube.  August 23, 2011.  https://www.youtube.com/watch?feature=player_embedded&v=aaFhB1fu31k.  Retrieved January 17, 2012.

3.      YouTube.  August 21, 2011.  https://www.youtube.com/watch?v=ysIzX_iDUKs.  Retrieved January 17, 2012.  Retrieved January 17, 2012.

4.      CDC.http://streaming.cdc.gov/vod.php?id=609d4e92b6066451e3c913830d5e345020100518165739159.  Retrieved April 10, 2012.

5.      CDC.http://streaming.cdc.gov/vod.php?id=6d8cf5ca1c85553680600beee99b9a5d20100517150602872. Retrieved April 10, 2012.

6.      CDC.http://streaming.cdc.gov/vod.php?id=df0c251502b04d90d56e40fec6807a8420100518170533747. Retrieved April 10, 2012.

7.      CDC.http://streaming.cdc.gov/vod.php?id=8b5938e3e57ec88cefd47fab16787b5220100518144550778. Retrieved April 10, 2012.

8.      CDC.http://streaming.cdc.gov/vod.php?id=76c9cf7be89792811fae03474e19982d20100519142238825. Retrieved April 10, 2012.

9.      CDC.http://streaming.cdc.gov/vod.php?id=eb6c6cbc887b724df3da60733c2cdd8720100519150147959. Retrieved April 10, 2012.

10. CDC.http://streaming.cdc.gov/vod.php?id=b489e9f16dd56813c6229d2083c2009c20100406111842484. Retrieved April 10, 2012.

Billboard Advertisements/Figures
1.      Stampler L.  This Shocking Anti-Childhood Obesity Campaign is Stirring National Controversy.  Business Insider.  January 3, 2012.   http://www.businessinsider.com/this-shocking-anti-childhood-obesity-campaign-is-stirring-national-controversy-2012-1?op=1.  Retrieved January 10, 2012.

2.      Goldgier D.  Childhood Obesity Ads Serve Up Truth With A Side of Guilt.  AdPulp.  January 1, 2012.  .http://www.adpulp.com/childhood-obesity-ads-serve-up-truth-with-a-side-of-guilt/.  Retrieved January 9, 2012.

3.      Van Ness N.  Billboards Target ‘Chubby Kids’.  North West Ohio.  May 6, 2011.  http://www.northwestohio.com/news/photos.aspx?id=614804.  Retrieved January 12, 2012.

4.      Crary D.  Amid ‘War on Obesity’ Skeptics Warn of Stigma.  ABC News.  May 1, 2011.  http://abcnews.go.com/US/wireStory?id=13502691.  Retrieved January 13, 2012.

5.      Stampler L.  This Shocking Anti-Childhood Obesity Campaign is Stirring National Controversy.  Business Insider.  January 3, 2012.   http://www.businessinsider.com/this-shocking-anti-childhood-obesity-campaign-is-stirring-national-controversy-2012-1?op=1.  Retrieved January 10, 2012.

6.      Colplon B.  Weight Management if a Family Affair.  States Man Journal.  March 24, 2012. http://www.statesmanjournal.com/article/20120325/HEALTH/303250010/Weight-management-family-affair.  Retrieved March 28, 2012.

7.      Behen M.  Your Health Family Makeover.  Ladies Home Journal.http://www.lhj.com/health/family/a-healthy-family-makeover/?page=3.  Retrieved April 20, 2012.