Amy Jordan: Striking Down Childhood Obesity

Amy Jordan: The problem of childhood obesity has been described as an epidemic and I think accurately; although it’s not a condition that you can catch from someone else, which is usually how we think about epidemics. That it’s a contagious sort of thing. It is a problem that cuts across geographic regions, socioeconomic groups, ages. Also when we think about the issue or the problem of childhood obesity, we really need to think beyond just what children look like, what their size is or how they might be stigmatized by being overweight. We really need to be thinking about the health problems they’ll be facing. We see that children who are overweight are at greater risk for developing endocrine problems, skeletal muscular problems. And we also see that children who are overweight are very likely to be overweight as adults. So upwards of 70% of children who are overweight become adults who are overweight. And those kinds of problems that last through a lifetime do shorten life spans, do cause heart disease, and adult diabetes and even increased risk for cancer. So we need to be thinking, short term and long term, about the costs of childhood overweight.

SM: In The Annals about childhood obesity, which you edited, the articles there lay out how multi-dimensional the problem of childhood obesity is. If you could talk about that.

AJ: There are a lot of ways to think about how obesity emerges in children. We need to think about the built environment, the context that children live and grow in. Their playgrounds. The way their homes are laid out. Whether they have opportunities to walk to school or other kinds of places. We need to think about how they’re spending their leisure time. Are they more sedentary than they used to be? And the answer is yes. They’re using a lot more electronic media than they did 20 or 30 years ago. The average home has four television sets. Children’s bedrooms are replete with screen media. We also need to think about genetics because we are understanding better that some children are more at risk for overweight. We see that the best predictor of childhood obesity is parental obesity. And it could be that’s how they’re genetically programmed. It’s also likely that they’re learning eating patterns and physical activity patterns that make them more at risk. So it’s a multi-factoral kind of problem and as we’re thinking about ways to solve it, we need to come at it from lots of different directions.

SM: What we also learned in The Annals is that a third of the nation’s kids are overweight. That’s about 9 million kids. That number has tripled since 1980. We have the possibility of a generation of children who might have shorter life spans than their parents. Can you talk a bit about which children in this country are more likely to be overweight? To what extent is this is a minority and income class problem?

AJ: We have seen over the last couple of decades a doubling and then a tripling of the number of children who are classified as overweight or obese. And the good news is that with the last data that we collected in 2008 that trend appears to be leveling off. We hope to bend the curve a little bit and start to bring the numbers down. But at least it’s leveled off. But there are children in this country who are more at risk. We find that the children who are most at risk are ethnic minorities, specifically Hispanic and African American. And again, we need to think about the confluence of factors that put them more at risk. It probably is genetic but also behavioral in terms of opportunities; and economic, what kinds of foods are affordable. In this country, what we find, because of government subsidies and changes in marketing practices, the foods that are cheaper and more accessible for low-income families are foods that aren’t as healthy. And we need to start to change that or at least think about how we provide or deliver fresh foods, and make them available in low-income communities so that they have the same opportunity to eat as healthfully as their higher-income counterparts.

SM: And certainly this brings up elements of the Obama administration’s Let’s Move initiative an anti-childhood obesity campaign that the White House released earlier this year. And these are elements of how to get healthy food to families and children who might not ordinarily have that ability. As we think about this initiative, it’s sort of unprecedented at the White House level to be doing this. Can you talk a bit about this program and what you see some of the strengths of this initiative to be so far?

AJ: It’s so exciting that Michelle Obama took this on as her topic. It’s something that’s clearly been on the minds of parents for some time. We look at poll data over the last five or so years and when we ask Americans what is the number one problem facing children today, they say childhood obesity. So there’s a recognition that this is something that as a nation we need to address. But it really hadn’t been addressed at a presidential level until Michelle Obama took it on as an issue that she was personally to be involved in. And I think the way she’s approaching it is really smart. Because she’s not just pointing a finger at one problem, let’s say food marketing or the lack of physical activity in schools—the elimination of recess. She’s looking at all of the factors that affect it: communities that don’t have grocery stores that have fresh food available, for example, and ways to bring those kinds of stores into what she calls food deserts. She’s also thinking about ways of encouraging kids to be more physically active and has specifically talked about limiting her own children’s media time, screen time, to come in line with the American Academy of Pediatrics recommendation for two hours a day or less. She’s also been leading by example. Talking about her own experiences as a mother. Talking to a pediatrician about what’s happening with her children’s weight. And although she never has and no one ever would call her children overweight or fat, she also recognizes that there’s a trajectory that children get on. And if we don’t pay attention to it, we see that behaviors that are established when children are five, or six or seven, might continue on unless something is changed. So as a working mother, she’s talked about the difficulty of getting healthy food on the table for her children after a long day of work. And the kinds of things we need to do to empower parents, not just point fingers at the problem.

SM: You mentioned screen media and this is something that the Let’s Move campaign in its literature, its mission, doesn’t tackle outright. It doesn’t target food marketing, children’s media consumption. And yet this is something that you and other scholars, especially in The Annals, see a link between the rise of childhood obesity and the rise of children’s media consumption in this country. And we know from the Kaiser Family Foundation, earlier this year, that children’s media consumption is way up. Seven hours thirty-eight minutes on average, four of those hours—a good chunk devoted to TV. Can you talk a bit about what some of these links are that you see between media consumption and childhood obesity?

AJ: Yes. The Kaiser Family Foundation report that was released in January [2010] showed that the average child between eight and 18 is spending 7.5 hours a day with screen media. We know from large survey data sets that children who spend a lot of time with media are more likely to be overweight. We know also that spending a lot of time with media precedes overweight. We have a good sense of what’s causing what, although ultimately it’s probably cyclical. You watch more television, you’re exposed to more ads for junk food. You’re more sedentary. You become more overweight, less likely to participate in physically active kinds of things like sports as you spend more time watching television. It’s a vicious cycle. And it’s really important for parents to think about how much time their children are spending in front of a screen. In our studies at the Annenberg Public Policy Center, when we’ve asked parents how much time does your child spend with media, they’ll think about it and say about two hours a day. But then when we ask them to walk us through their child’s day and indicate how much time they’re spending with various media between the time they get up and go to school, get home from school and dinner and bedtime— they suddenly recognize it’s many more hours than they originally thought because so much of it is going on behind closed doors or off the radar of parents. So I think that one of the first things we need to do is to get parents to be more aware of how children are spending their time and how much of that time is spent looking at a screen. With respect to the Let’s Move campaign and Michelle Obama’s perspective on bringing together many different stakeholders to solve this problem, I think she’s wise not to go after television per se or food marketers per se because we really don’t want to alienate them. We want to make them part of the solution. For example, Nickelodeon has a campaign where they encourage children to be more active. And at one point, they actually cut transmission. So the screen goes black for a couple of hours. In the run-up to it, they try to encourage children to be physically active. So I think if we can recognize that if we’re going to deliver a campaign, then it’s probably going to be through television or other media. And we need to have them on board in order to bring these kinds of messages to children. That’s important. It’s also important for food marketers to think about what kinds of foods they can be marketing that maybe aren’t so detrimental to children’s health. And we really haven’t seen that change much, although the food marketers have pledged to do a better job of promoting healthy foods. Not everyone has signed up for this initiative. And not everyone has the same goals or priorities. So we need to do a better job of encouraging the food marketers to change their products or select more healthful products for kids to consume. About a third of products that are advertised on children’s television are for food. And the vast majority of those food and beverage products—about 70%–are what we would call junk food—are high in sugar, salt, fat; and low in nutritional value, high in caloric content. And we really need to start to see changes in that. It’s something that I hope Michelle Obama, the First Lady, will start to tackle with them.

SM: One thing she [First Lady Michelle Obama] did say when launching the initiative, “Our kids didn’t choose to make food products with tons of fat and sugar and supersized portions, and then to have those foods marketed to them wherever they turn.” So she acknowledges that this is a problem. But like you said, they’re not outright going after the food industry because perhaps there’s an advantage to bring them in as part of the solution. And one of the things that we see with this initiative is that public service announcements are a big part of it. Some media companies are doing pro bono work for it. There are celebrities, cartoon characters, athletes promoting a healthy lifestyle.

As Susan Linn’s article in The Annals, “Calories for Sale,” they [Susan Linn and Courtney Novosat] make the point that: is it such a good idea for the food industry to even advertise healthy foods? Is this influencing how kids eat? So I wonder what you thought about this. Is it a Catch-22? You sort of need the food industry but then where’s that balance?

AJ: It’s a tricky problem. The food industry, when they first had eyebrows raised at what it was doing—this was maybe even seven or ten years ago—did start thinking about what they were advertising and how they were advertising. And of course they always want to ward off regulation wherever they can. If there is to be regulation, they want it to be self-regulation. They want to be able to dictate the terms of what the quote, unquote voluntary guidelines will be. So they said to the Federal Trade Commission, the Federal Communications Commission and many advocacy groups, here’s what we’re going to do: we’ll keep marketing these foods to children but we’ll encourage a more healthy lifestyle. And that’s great. But confusing, I think, for children. In the sense that if the advertisement for McDonalds is one that shows Ronald McDonald and kids riding their bikes to McDonalds, it’s a mixed message. And it points to the need for research, for all of these kinds of public service advertisements or exercise campaigns or nutrition campaigns to understand how the messages are getting received. We still don’t know what it means to children and the choices they make in terms of food. To see unhealthy food products being advertised in the context of physical activity, we don’t know how they’re receiving that message. And the same thing with celebrities becoming involved and encouraging children to get fit or the NFL crafting messages to encourage children to get outside and play. We believe that it’s probably good but it’s possible that it could have a kind of boomerang effect where it has the opposite. But that’s where research is important and it’s really necessary to build in very thoughtful analysis of how the messages are crafted and how they’re received and whether they affect behavior.

SM: In terms of children’s media consumption and food marketing, if the Obama administration came to you and said, ‘Amy Jordan, what would you recommend we do if we want to address food marketing, children’s media consumption.’ What sort of outreach would you recommend?

AJ: It may seem as though I’m contradicting my concern about the effect of unhealthy food product marketing to children by saying that I don’t think it should be regulated or banned. One concern that I have with outright banning of junk food is what we’ve seen in England. You cast a net and say here are the kinds of products that can’t be advertised to children and then you end up catching products that most people think would be just fine like cheese or raisins, because it doesn’t meet the criteria set by a government agency. Also, we know that food marketing is important in terms of the economic structure of children’s television. If you take away an important base for the media companies and they have to look elsewhere for funding, then we may see less quality children’s programming or we might just see less programming. And it’s been pretty good lately. So better, I think, is the idea of presenting healthy foods to children within the context of the programs they love—so encouraging the marketing of low-fat dairy and vegetables and water and alternative kinds of foods. And also we should think about counter-marketing. We did this when we first started tackling the problem of tobacco. Where for every four cigarette ads there had to be an anti-smoking public service announcement. And so the ads can still be there. But we can also see that here are the kinds of problems that might result from overeating the kinds of products that are so heavily marketed to children. There’s a reason why these products are so successful: why Kraft Foods or General Mills puts all of their marketing dollars into these kinds of products. Children like them. They taste good and there’s immediate gratification in them. But children aren’t thinking long term about their health and their bodies and parents often don’t have control over what children are eating. So I think going right to children and helping them to understand what the consequences of eating too many Ho Hos or too much sugared cereal or drinking too many cans of soda will do for their health and their energy and their ability to do well in school, I think will be really important. So promoting healthier foods and providing counter-marketing to the unhealthy foods, I think are two strategies we could take up.

SM: Overall, when you look at this Let’s Move initiative, does it address the multi-dimensional aspects of childhood obesity that you and other scholars see, as laid out in The Annals?

AJ: In theory, yes. It addresses the major issues that we know influence children’s weight status: physical activity and nutrition. But it’s not clear to me yet what the campaign as a whole will emphasize. And it’s not clear to me, yet, whether the campaign will be focused on parents or youth or communities or states or the nation. So all of that needs to become real before we really have a good sense of whether and how it’s affecting weight status.

SM: In The Annals, you do talk about what parents and caregivers and physicians could do as far as informing families about TV consumption. Could you lay out some of those recommendations?

AJ: Sure. The authors who contributed to The Annals volume on childhood obesity had really good ideas about ways that pediatricians and parents and educators could start to approach it. One really good idea that was put forth by my colleagueTo m Robinson at Stanford [“What Can We Do to Control Childhood Obesity”] was that pediatricians talk to parents about how much time their child is spending watching a television or using a computer or playing video games. And in his view—he’s a pediatrician—it gives the issue more gravitas. It helps parents see that this is something they need to think about in terms of their child’s overall health. Pediatricians will talk to parents about the importance of wearing a bike helmet. The importance of getting enough physical activity. But they haven’t spent as much time talking about sedentary activity or sedentary behaviors. And you and I might think about this as two sides of the same coin. You know if you just decrease television viewing, which is sedentary behavior, that will increase physical activity. But studies have shown that that’s not the case. That turning off the television doesn’t make kids suddenly become more active. But it does, in and of itself, predict overweight status. Even if you can’t get children to become more physically active, if you can get them to be less sedentary—just moving from watching TV to reading a book—you can somehow change behaviors. So that’s one suggestion. Another suggestion that was made in The Annals volume was that parents disconnect television viewing from eating. There have been several experiments that have shown that when children are given the opportunity to eat with the television on or off, they eat more when the TV is on. And there’s a few different hypotheses for why that would be the case. And by the way, we found this to be true of college-age students. But we found it especially to be true of kids who are overweight. So children who are overweight who take their snack, with the television on, just consume far more calories than when the television is off. Why? It’s possible that they just don’t pay attention to feelings of fullness. They’re distracted by what they’re seeing on the screen. They’re making their way through a tube of Pringles. They get to the bottom of it by the time the show is over and everybody is surprised. They don’t quite realize how much they’ve eaten. So having the television off allows individuals, adults and children to pay more attention to how full they are and whether they’ve eaten enough.

SM: In The Annals, the research showed that a high number of families have TVs in their dining areas.

AJ: Yes. One of the really surprising findings from a study we did here at Annenberg was, we asked parents to map out where media are in their homes. So we gave them what we called a home media inventory to see where the TVs were and how many different kinds of media were in children’s bedrooms. And we found that about half of the families had a TV in a room where they ate, the dining room or the kitchen. So a very simple strategy to disconnect eating and viewing would be just to take the TV out of those places where people eat. Or to say to children you know when you watch TV, you can’t snack or when you snack, you can’t watch TV. So just having a rule that you can’t bring your snack into the living room where the best TV is would likely decrease the number of calories that children consume.

SM: As far as what parents can do in helping stem the problem of childhood obesity, what role can they play? To what extent do they need to be role models for their children in terms of their lifestyle?

AJ: Parents need to be role models in every extent. The best predictor of childhood obesity is parental obesity. The best predictor of children’s heavy media use is parents’ heavy media use. One of the best predictors of children’s physical activity levels is parents’ physical activity levels. So in every way parents are living, walking, breathing examples of what children can and should be doing with their time and with their food. At the Annenberg Public Policy Center, one of the things that we explored was the challenges that parents face in bringing children’s screen time to the recommended levels of two hours a day or less. And with television viewing and computer use and video game playing, we see that it’s part of the fabric of family life. For many families, it punctuates the day. Children watch television in the hour before bedtime and when that TV show is over, now it’s time for bed. So say, okay now change without providing a lot of alternatives, I think will be hard for parents. One of the scenarios that we presented to parents and children is what would you do with your time if there was an ice storm and the power went out and you couldn’t watch TV. Many children would say ‘I would play my Game Boy.’ Or parents would say ‘I would tell them to go listen to the radio.’ So there isn’t a lot of thinking about what kinds of things kids can do in the home that don’t involve media. We also said to parents, outside of the ice storm scenario, what would you suggest your child do instead of watch TV? And we found many parents saying ‘I’d have him clean his room. Or maybe he could do his homework.’ So presenting attractive alternatives to kids will also be an important step. I think providing parents with ideas about things they can be doing with their children that don’t involve the media will be important. Because we have a generation of parents now who grew up themselves with media, and the concept of getting down on the floor and stacking up blocks or coloring with their child, is kind of foreign to them. And I think it’s a generation of parents who forgot how to play, or maybe never learned how to play and aren’t passing that onto their children. So the more we can do of that, I think the more successful we’ll be at getting children away from screens and into activities that are enriching and more physically healthy.

SM: In The Annals, we read about what school administrators can do and some suggestions for fighting childhood obesity. So what would be your advice to school administrators who are concerned about childhood obesity, and some strategies they could implement?

AJ: Children are spending almost as much of their waking time in schools as they are in other kinds of environments, including the home. So what they’re doing in school is really affecting a lot of the way they think about how they should be spending their time and what kinds of foods they’re eating. And I think we’ve come a long way in considering what cafeterias offer to children over the last two decades. But there’s still a serious problem of what we call competitive foods. So the foods that come in from the outside, like Pizza Hut or McDonalds, children are very aware of because they’re heavily marketed and branded and don’t have as much nutritional value as the kind of thing the lunch lady might put on a plate. Many schools have banned sugary drinks from their campuses. So we don’t have in elementary and middle schools, soda or Gatorade or those kinds of drinks available to kids. They’re choosing low-fat milk and getting used to drinking water. So those are positive steps. But many schools are trying to get back to the place where they feel that they have control over providing children with recess. In many districts, because of the heavy focus on tests and squeezing a lot of academic material into a day and making sure that the schools are reaching academic benchmarks, children no longer have a chance to run around the way they used to; even though studies show that it’s important for their physical well-being but also their emotional and academic well-being. Children who have a chance to run around and blow off steam are more prepared to learn when they get back into the classroom. So I think we’re seeing that come full circle again and the recognition of the need for a recess period or physical activity period. I think schools can also be at the cutting edge of teaching children how to be critical consumers of the marketing that’s around them, to not take at face value an advertisement that says if you drink this sugary beverage, you’re going to be a better soccer player. Or if you eat these chips, you’re going to be a more popular student.

We can use these kinds of ubiquitous marketing strategies that all kids know about as teachable moments and help them understand that this is what they’re trying to do. They’re trying to get you to buy products and this is what the consequence might be. So yes, I think schools on many levels can be an important part of the puzzle to raising children’s awareness and changing children’s practices.