Proposal for Obesity Management Programme

OBESITY PROGRAMEE: “FITNESS FOR FULFILMENT”

• Kathiravan Pillay Kumar

Abstract

The world has seen a rise in the issue of obesity and its effects on the biological, psychological and social wellbeing of individuals. This proposal reviews literature in relation to the causes as well as effects on obesity specifically targeted at children between the ages of 6 – 18 years old and evaluates current programs in place to curb the rise in obesity. Programs from both the United States as well as Singapore are used to analyse the western and Asian perspectives on tackling the issue of obesity. The proposed program would be aimed at reducing social stigma and increasing self-esteem that past or current programs do not address. The program will be made up of three phases which include implementation, motivation and feedback as well as evaluation of the entire program’s effectiveness. Feasibility and efficacy of instilling the program are also discussed.

Introduction and Review on Obesity

Obesity has been an issue present through various generations and is one faced by many nations worldwide. Recent years has seen a rise in the levels of obesity especially in western nations but is currently seen to be a growing issue even in Asian nations (Ramachandran & Snehalatha, 2010). Based on recent findings by Ogden, Carroll, Kit and Flegal (2014) an estimated two third of the adult population in the United States are overweight or obese with about one third of school going children also falling under this category. A growing trend is also seen in Asia where findings in Singapore indicate that approximately one in nine Singaporean adults between the age ranges of 18 to 69 were considered to be obese in 2010 with obesity rates said to be increasing at an estimated 1 percent per year (“One in nine Singaporean”, 2014).

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Multiple factors have been suggested as causes to obesity, often focusing on mainly physical and psychological factors. General physical causes of obesity are often due to genetic factors that cause abnormalities in fat cell metabolism and metabolic defects or simply having a sedentary lifestyle (Bray, York & DeLany, 1992). There are also various psychological conditions or disorders that have been suggested to lead to obesity however depression is considered to be the main cause of it as evidenced in Blaine’s (2008) study which indicated that individuals who were depressed were proven to be at significantly higher risk of becoming obese. Obesity is also often comorbid with depression and other eating disorders Blaine’s (2008).

The key area of concern especially in recent times would be the effects of obesity on the individual as well as society as a whole. Numerous studies have been done to show the physical and psychological effects that obesity has on an individual. Physical aspects often include the risk of contracting illnesses such as heart disease, hypertension, and diabetes (Sturm, 2002). Psychological effects tend to focus on an individual’s body dissatisfaction and self-image (Wardle & Cooke, 2005) as well as well as psychosocial effects such as negative experiences through weight bias at home, in school, at work, through the media and even health and fitness areas (Amianto, Lavagnino, Abbate-Daga & Fassino, 2011).

Evaluation on Obesity Related Programmes

Over the years there have been many programs put into place by governments and private agencies around the world that have been aimed to curb obesity. One key program introduced in the United States was the HEROES Initiative which targets tackling issues on childhood obesity (King et. al, 2014). The HEROES Initiative is a grant-funded intervention that targets schools to play a vital role in educating youth in obesity related behaviours (King et. al, 2014). The key aims of this this initiative would be to take a comprehensive school health approach that decreases childhood obesity that in turn promotes healthy lifestyle habits among students as well as their families and also the school staff (King et. al, 2014). Key features that make the intervention unique would be that it offers a supportive means for participating schools by providing regular oversight, significant funding and various implementation strategies that are catered to a particular needs for certain schools depending on the district and neighbourhood that they are located in (King et. al, 2014). This initiative also enables schools to have a sense of ownership over assessing the needs of their students and in turn coming out with a plan to implement certain strategies for changes in the school’s health programs (King et. al, 2014). The key feature in maintaining the effectiveness of this program would be the strong emphasis on an annual cycle of evaluation and assessment on opportunities in enhancing the program to cater to the needs of the students which turn increases the intervention’s efficacy (King et. al, 2014).

The evaluation process was broken down into 3 main areas. The process evaluation stage, school level outcome evaluation and student level outcome evaluation (King et. al, 2014). The process evaluation stage is carried out by site visits to schools to view their administrative processes in carrying out health promotion as well as inspection of the school’s general environment and conducting interviews with the staff to determine challenging areas (King et. al, 2014). Feedback on information obtained is given to the staff as a means to address these issues (King et. al, 2014). In the school level outcome evaluation, assessments are made to the systemic changes in promoting healthy behaviour and reducing obesity rates in the students. The school level outcome evaluation is based on domains relating to physical education/activity, nutrition education, food service, staff wellness, as well as family and community involvement (King et. al, 2014). The student level outcome evaluation, focuses on understanding the changes in behaviour and knowledge in relation to obesity and its effects (King et. al, 2014). This done through weight measurements as well as surveys and quizzes to identify student’s knowledge about obesity (King et. al, 2014).

With regard to the effectiveness of this initiative, evaluation between the periods of 2011-2012 showed a significant amount of variability between schools. Based on results obtained from the process and school level evaluation outcomes, it was found that the school’s processes were well implemented however some schools found difficulties in coming up with new or improved health and wellness related policies (King et. al, 2014). Based on the student level outcome evaluation it was found that small but significant changes were made in terms of behaviour and mindset of the students (King et. al, 2014). Students were also more engaged in rigorous physical activities in comparison to the baseline from first 18 months of the intervention (King et. al, 2014). However a set back to the intervention was that changes to behaviour were mostly found in overweight students rather than students who were already obese.

In relation to the Asian context, there have been various health related programs and promotions carried out in Singapore. The Singapore health promotion board has come up with various programs and initiatives to promote healthy lifestyle practices to prevent conditions such as obesity. Programs such as the 1 million kg challenge, aims to encourage individuals to lose weight by allowing them to set a weight loss target then setting a period for them to lose this weight. If individuals are able to lose the amount of weight within the given time frame they are rewarded with certain incentives and prizes (“1 million kg challenge”, 2014).

In relation to health promotion in schools, a key program that was introduced in the early 90s was the National Physical Fitness Award Test (NAPFA) and the TAF (Trim and Fit) scheme which aimed to increase physical activity and reduce the weight of overweight and obese students in both the primary and secondary levels of education (Gupta et. al, 2010). The TAF program basically tasked students with physical activities before and after the school day (Gupta et. al, 2010). The initiative was a success in the 90s with obesity levels dropping between 10-17% in students (Gupta et. al, 2010). Success of the TAF scheme would later bring about a collaboration between the Singapore Health Promotion Board and the World Health Organisation to introduce a HPB-MOE bi-annual award aimed at targeting the healthy development of students and awarding schools for good health practices (Gupta et. al, 2010).

Challenges faced in the TAF program as well as similar programs introduced in Korea as mentioned by Shin and Shin (2008) was that such programs bring about a sort of negative stigma to students involved. Student then tend to become highly self-conscious and develop body dissatisfaction which in turn effects their self-esteem (Shin & Shin, 2008). This is often the result of segregation from their peers due to their weight and appearance and this segregation is further contributed by schools who single out overweight or obese individuals to be part of such programs (Shin & Shin, 2008). This effect could in turn lead to depression which has been established as a cause for obesity and would hence defeat the whole purpose of having such health promotion programs.

Proposed Health Program

Having identified the causes and effects of obesity as well as certain health programs available both on the western and Asian context along with their strengths and weaknesses, an alternative health program could be developed. Through analysing the health programs available in both the United States and Singapore, a program catering specifically to the needs of students between the ages of 6 – 18 year olds could be proposed. The program will be entitled the “Fitness for Fulfilment Programme” (FFFP) catered specifically in the Singaporean context. The program is also given a name that does not infer or refer to obesity so as to prevent any form of social stigma relating to obesity. The main goals of the program would be to reduce the weight of overweight and obese students but to do so in a manner that will not cause stigmatization or embarrassment. The program would also further aim to instil a healthy mindset in these students and encourage them to maintain healthy behaviour well into adulthood.

The FFFP will mainly be broken down into three key phases. The first phase will be the implementation phase which will introduce rigorous exercise specifically catered to losing weight for obese children. These exercises will be done during school hours as part of an enhanced physical education program and these obese students will carry out their activities together with other students so as to limit any sense of being ostracised. The enhanced physical education program will target the specific needs of each student be it normal weight students or overweight or obese students by focusing on their weak physical areas that are limiting them from passing or getting a good grade on their NAPFA test. The fitness program will be one that gradually increases in rigorousness so as to allow the students time to condition themselves to its requirements. Another key feature of the implementation phase would be the enforcement of strict diet practices during the school day. Since schools are already given guidelines by the Health Promotion Board on the type of food to be served, there must be a form of enforcement that ensures that students are getting the appropriate meals. Therefore there should be two to three staff on canteen duty to ensure that proper meals are being served to the students and that obese children are getting sufficient food but maintained at healthy levels.

The second phase of the FFFP would the feedback and motivation phase. This would be a key feature of the program as it caters to the psychological well-being of the students involved. This phase will be implemented during the first and last session of the enhanced physical education program. During these sessions, time will be set aside for instructors to carry out one on one interviews or feedback sessions with the students which will aim to understand the challenges that they face with physical exercise as well as issues they have with motivating themselves to indulge in physical exercise. With knowledge of the challenges that individual students face, instructors can cater their physical education session to better accommodate to both the strengths and the weaknesses of the students. This will facilitate a more positive outlook in carrying out physical exercise and encourage students to put in a greater effort and hence may lead better physical results and lower obesity levels. Another aspect of this phase would be educating other students in the challenges that overweight and obese students. Students will be taught to encourage and motivate rather than stigmatize or humiliate their overweight or obese peers.

The final phase of this program will be the evaluation phase. Ideally a review council should be formed to evaluate the effectiveness of the program at national level. This phase will be similar to the HEROES initiative evaluation process used in the United States, but will comprise of two instead of three key parts of the evaluation process of the effectiveness of the program. The process and school level evaluation will be combined into one. This part of the evaluation process will seek to understand the challenges that the staff have with the FFFP through means of interviews as well as on site assessments of the program in action. Availability of proper equipment and exercise facilities in the school will be key points at this level of evaluation. The next part of the evaluation will be at the student level, the review council will assess data relating to changes in weight as well as NAPFA standards and also find out the level of knowledge that students have with regard to healthy behaviour through surveys and quizzes which can be done through the internet. The evaluation process should be done annually and aim to identify problem areas so that newer and improved implementation could be introduced in the following years.

The feasibility and efficacy of the FFFP would depend on the amount support through funding from private agencies or the government as well as having instructors who are trained in not only physical aspects of exercise and healthy lifestyle but also with the psychological capability to deal and understand the needs and challenges for individual students to overcome obesity.

References

Amianto, F., Lavagnino, L., Abbate-Daga, G., & Fassino, S. (2011). The forgotten psychosocial dimension of the obesity epidemic.The Lancet, 378(9805), e8

Blaine, B. (2008). Does depression cause obesity? A meta-analysis of longitudinal studies of depression and weight control.Journal of health psychology,13(8), 1190-1197.

Bray, G. A., York, B., & DeLany, J. (1992). A survey of the opinions of obesity experts on the causes and treatment of obesity.The American journal of clinical nutrition,55(1 Suppl), 151S-154S.

Gupta, N., Chin, M. K., Yang, J., Balasekaran, G., Chia, M., Girandola, R. N., … & Mok, M. M. C. (2010). Obesity prevention in Singapore: Collaborative efforts among government, health professionals and the community.

King, M. H., Lederer, A. M., Sovinski, D., Knoblock, H. M., Meade, R. K., Seo, D. C., & Kim, N. (2014). Implementation and Evaluation of the HEROES Initiative A Tri-State Coordinated School Health Program to Reduce Childhood Obesity.Health promotion practice,15(3), 395-405.

Ogden C. L., Carroll, M. D., Kit, B.K., & Flegal K. M. (2014). Prevalence of childhood and adult obesity in the United States, 2011-2012.Journal of the American Medical Association,311(8), 806-814.

One in nine Singaporean adults were obese in 2010: Survey (2014, January 17).Today.Retrieved from http://www.todayonline.com/daily-focus/health/one-nine- singaporean-adults-were-obese-2010-survey

One million kg challenge. (2014). Retrieved August 21, 2014, from http://www.hpb.gov.sg/

References

Ramachandran, A., & Snehalatha, C. (2010). Rising burden of obesity in Asia.Journal of obesity,2010.

Shin, N. Y., & Shin, M. S. (2008). Body dissatisfaction, self-esteem, and depression in obese Korean children.The Journal of pediatrics,152(4), 502-506

Sturm, R. (2002). The effects of obesity, smoking, and drinking on medical problems and costs.Health Affairs,21(2), 245-253.

Wardle, J., & Cooke, L. (2005). The impact of obesity on psychological well-being.Best Practice & Research Clinical Endocrinology & Metabolism,19(3), 421-440.