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Reversing the Obesogenic Environment
by Rebecca E. Lee, Kristen McAlexander and Jorge A. Banda
Series: Physical Activity Intervention
248 Pages
Obesity has become a global crisis. Although most would agree that eating better and being more physically active are the answer to the problem, researchers have recently become aware that the problem goes beyond just changing individual behaviors. We can convince people of the benefits of healthful eating and regular physical activity, but what happens when they go home to a neighborhood where fresh vegetables are not available and opportunities for physical activity are hard to find? If the environment doesn’t help support healthy lifestyles, the change will be next to impossible to sustain. In Reversing the Obesogenic Environment, leading researchers Lee, McAlexander, and Banda introduce the concept of the obesogenic environment—an environment that leads people to become obese—and explore ways that changing our environment can encourage healthier choices.
Although most of the current literature focuses on the food supply and dietary habits, Reversing the ObesogenicEnvironment takes a broader view of the current obesity problem. It looks at all of the elements that combine to create the obesogenic environment:
•The ways that the built environment, access to resources, and active transportation systems can either foster or discourage regular physical activity
•The multiple factors that encourage consumption of calorie-laden, nutritionally inadequate foods that can lead to obesity
•The positive and negative impact of public policy
•The influence of family, culture, socioeconomic status, and other social factors on an individual’s health behaviors as well as access to physical activity opportunities and healthier food options
•The role that media and marketing play in food purchasing decisions
With Reversing the Obesogenic Environment, readers will get a cutting-edge view of this emerging body of research with applications that can be realistically implemented in their communities. The book goes beyond defining the issues that contribute to the obesity epidemic—it offers tools that will help practitioners start to reverse it. Throughout the book, the authors incorporate practical recommendations based on the latest research. Sample programs and policies, checklists, and potential solutions offer readers a starting point for changes in their own communities.
The obesity epidemic is a multifaceted issue influenced by factors ranging from international trade and national policy to individual behaviors. Reversing the problem will take coordinated multilevel efforts. These efforts may take years to come to fruition, but it isn’t too late to take action. Reversing the Obesogenic Environment is the ideal guide to taking the first steps toward change.
Reversing the Obesogenic Environment is part of the Physical Activity Intervention Series (PAIS). This timely series provides educational resources for professionals interested in promoting and implementing physical activity and health promotion programs to a diverse and often-resistant population.
Part I: Public Health and Obesity
Chapter 1: Emergence of the Obesogenic Environment
Historical Emergence of Obesity as a Public Health Concern
The Case for an Obesogenic Environment
Ecologic Models of Health and the Importance of Supportive Environments
Summary
Chapter 2: Scope of Obesity
Obesity Defined
Causes of Obesity
Vulnerable Populations
Health Risks Associated With Overweight and Obesity
Social and Psychological Costs of Obesity
Summary
Chapter 3: Body Composition Measurements
Field Methods
Laboratory Methods
Summary
Part II: Physical Activity and Obesity
Chapter 4: The Built Environment
Components of the Built Environment
Measuring the Built Environment
Limitations of Research on the Built Environment
Neighborhood Walkability and Physical Activity
Emerging Research and Recommendations
Summary
Chapter 5: Physical Activity Resources
Parks and Open Spaces
Walking Trails and Bikeways
Home Environment
Factors Influencing the Use of Physical Activity Resources
Measuring Physical Activity Resources
Emerging Research and Implications for the Future
Summary
Chapter 6: Active Transportation
Personal Automobile and Obesity
Walkability
Public Transportation
Active Transport to School
Stair Use
Summary
Part III: Food Accessibility
Chapter 7: Food Supply and Security
Nutrition Transition
Food Production
Imports and Exports
Food Storage
Nutritional Disparities, Obesity, and Undernutrition
Food Security
Government intervention
Supplemental Nutrition Assistance Program
Summary
Chapter 8: Food Technology
Genetic Engineering
Trans-Fatty Acids
Factory Farming
Summary
Part IV: Public Policy, Sociocultural Influences, and Obesity
Chapter 9: Policy and Individual Health Choices
Levels of Preventions
Guidelines
Educating Individuals
Regulations at the Point of Purchase
Incentives for Good Behavior
Other Approaches
Summary
Chapter 10: Policy and the Obesogenic Environment
Agriculture
International Trade
Food Industry and Food Environments
Built Environment
Transportation
Schools
Worksites
Summary
Chapter 11: Cultural and Familial Influences
Family Culture Within the Ecologic Model of Obesity
Cultural Influences
Familial Influences
Summary
Chapter 12: Social Justice, Health Disparities, and Obesity
Socioeconomic Status
SES, Social Injustices, Health Behaviors, and Obesity
Weight Discrimination
Resiliency to Social Injustices
Solutions
Summary
Part V: Media and Marketing
Chapter 13: Point of Purchase
Marketing, Advertising, Branding
The Four Ps
Summary
Chapter 14: Influence of Media and Technology
Biological Responses to Food Images
Television Advertising and Children
Internet Advertising
Billboard Advertising
Sports Sponsorships
Media Interventions Strategies
Summary
Rebecca E. Lee, PhD, is the founding director of the Texas Obesity Research Center at the University of Houston. Lee is also an associate professor in the department of health and human performance at the University of Houston and holds a courtesy appointment at the University of Texas School of Public Health. She is a community health psychologist who has been principal investigator for numerous federally and privately funded research grants. Her studies have focused on interventions for populations of color, specifically interventions that incorporate social cohesion, ameliorate social injustices, and improve the quality of the neighborhood environment.
Lee serves on the editorial boards of the International Journal of Women’s Health, the American Journal of Health Promotion, and Health Psychology. She has served as a charter member of the community-level health promotion study section of the Center for Scientific Review at the National Institutes of Health and a member and former chair of the Mayor’s Wellness Council Public Policy Committee, which works to improve the health of Houstonians.
Dr. Lee is a fellow of the Society of Behavioral Medicine. She is a member of the Obesity Society and the International Society for Behavioral Nutrition and Physical Activity. She received the University of Houston College of Education Research Excellence Award in 2005 and 2008, and she has been recognized by the National Institutes of Health as a National Health Disparities Scholar. In 2009, her Saving Lives, Staying Active (SALSA) program was given the Outstanding Achievement for a Community Program Award by the Texas Council on Cardiovascular Disease and Stroke
Kristen M. McAlexander, PhD, is a lecturer in the department of applied physiology and wellness at Southern Methodist University in Dallas, Texas. Dr. McAlexander’s research interests include environmental and sociocultural influences of wellness behaviors and obesity, particularly among vulnerable populations such as women and low socioeconomic populations. McAlexander is also president and founder of Reflections Wellness, a local nonprofit organization designed to promote wellness while fighting local poverty and eliminating health disparities. Her research and nonprofit organization focus on understanding and reducing health disparities and improving wellness opportunities among underserved neighborhoods.
McAlexander received a graduate research award and two graduate fellowships from the University of Houston department of health and human performance. McAlexander is an American Council on Exercise (ACE) certified personal trainer and a member of the Society for Behavioral Medicine, the American College of Sports Medicine, and the Urban Affairs Association.
Jorge A. Banda, MS, is a PhD candidate in the department of exercise science at the University of South Carolina in Columbia and a research assistant at the university’s Prevention Research Center. Banda holds a master’s degree in exercise science from the University of Houston. His research has focused primarily on underserved populations, including low-income-housing residents, African-American and Latina women, and low-income rural communities.
Banda received a Prevention Research Center Minority Health fellowship from the Association of Schools of Public Health and the Centers for Disease Control and Prevention, aand the Charles Coker Fellowship from the University of South Carolina. He was twice awarded a Norman Arnold School of Public Health fellowship. Banda also attended the Built Environment Assessment Training Institute sponsored by the U.S. Department of Agriculture, San Diego State University, and the University of Pennsylvania. He is a member of the American College of Sports Medicine and the American Public Health Association.
Decisions to take part in physical activity influenced by multiple environmental factors
Many factors influence whether people use physical activity resources. In this chapter we discuss the more common factors examined in the research literature, including those we think are the strongest predictors of physical activity resource use: accessibility, proximity, safety, and the presence and quality of features and amenities, aesthetics, and incivilities.
Accessibility
Accessibility is composed of many factors that influence the use of physical activity resources and is often used interchangeably with the term usability. One important accessibility factor is ease of travel to and from the resources as well as the ease of using the resources and equipment. An accessible resource is one that is easy to approach and use; one with little or no traffic en route; one that has adequate, convenient parking; and one that is accessible via inexpensive, convenient, and pleasant public transportation. In contrast, an inaccessible resource may have no readily available public transportation, inconvenient or no parking, equipment that is difficult to understand and use, or long lines for entry and equipment use. Cost is another important accessibility factor that can influence physical activity resource use, particularly among populations of lower socioeconomic status and children and adolescents.
Accessibility is a factor in determining whether people use physical activity resources and ultimately in whether they do physical activity. Research has indicated that children and adolescents with access to physical activity resources and physical activity programs are more physically active than those without access (Allison et al., 2005; Dwyer et al., 2006; Mota, Almeida, Santos, & Ribeiro, 2005). In addition, it's important to note that populations of lower socioeconomic status typically have more limited access to physical activity resources. This is important because reduced access to physical activity resources is associated with increased body fat and BMI in low-income, minority populations (Heinrich et al., 2008). As a result, it's important to consider this additional barrier when working with populations of lower socioeconomic status.
Proximity
Proximity influences whether people use physical activity resources. Proximity can be measured subjectively using self-report questionnaires or objectively using street network or straight line distances. Briefly, network distance is the distance one would travel on streets to get to a resource, while straight line distance is the direct distance between two points; it represents the absolute distance one would travel if there were no buildings or obstacles. The more proximal a resource is to someone, the more accessible it is as well.
There is a strong relationship between proximity of physical activity resources and physical activity. In a study among low-income, midlife women, those who reported greater proximity to physical activity resources also did more physical activity (Jilcott, Evenson, Laraia, & Ammerman, 2007). There is also evidence that suggests there is a direct relationship between proximity to physical activity resources and meeting physical activity guidelines (Sallis, Patterson, Buono, & Nader, 1988). In addition, proximity to physical activity resources may be particularly important for children and adolescents, since most youth are limited to the immediate resources to which they can walk or bicycle.
Within the context of proximity, the density of physical activity resources is another factor to consider. For example, a study found that adolescent girls who lived near more parks did more physical activity than those who lived near fewer parks (Cohen et al., 2006). Similar results were found in women: Women who lived near more physical activity resources and parks were more physically active than those who lived near fewer physical activity resources and parks (Jilcott et al., 2007; Norman et al., 2006; Lee et al., 2007).
The findings from these studies stress the importance of proximity to physical activity resources. Furthermore, these studies suggest that the built environment plays a vital role in resident health and that careful community planning can affect the health of residents. Research has shown that having a nearby park or gym may help to buffer the relationship between lower socioeconomic status and engaging in less physical activity (Lee et al., 2007). As a result, creating a variety of opportunities for recreation and physical activity that are easily accessible can provide a means to increase the amount of energy expended by Americans, a crucial part of solving the obesity epidemic (figure 5.1).
Safety
Safety is freedom from danger, risk, and injury, and it plays a crucial role in determining whether physical activity resources are used. Safety can act as a motivator or a barrier to being physically active. For example, trails and walking paths may offer a feeling of personal safety because they are traditionally placed far away from cars and traffic and because they typically offer more privacy than other types of physical activity resources (Gobster & Dickhut, 1995). On the other hand, safety is most often cited as a deterrent to using physical activity resources (King et al., 2000). For example, crime and traffic are common safety concerns that prevent people from being physically active in outdoor recreation facilities (Molnar, Gortmaker, Bull, & Buka, 2004).
Playgrounds are an important setting in which children can be physically active. However, the safety of playground equipment, which has typically been overlooked in research, plays a pivotal role in determining whether children use physical activity resources. Parks and playgrounds must meet regulatory safety guidelines set forth by local, state, and federal agencies before they are deemed safe for use. Unfortunately, these safety guidelines are not always strictly enforced—older parks and playgrounds often do not meet current guidelines. This lack of enforcement has public health implications: Almost 190,000 children required emergency room treatment after being injured on public playground equipment in 2001. As a result, the condition of park and playground equipment is likely an important factor in parents' decisions about whether to let their children play in parks and playgrounds (Bedimo-Rung et al., 2005).
Some population groups are disproportionately burdened with unsafe areas that discourage physical activity. For example, children living in low socioeconomic status neighborhoods dominated by ethnic minorities typically have fewer safe playgrounds, do less physical activity, and have higher rates of overweight and obesity when compared to children in their counterpart neighborhoods (Cradock et al., 2005; Lee, Booth, Reese-Smith, Regan, & Howard, 2005).
Features, Amenities, Aesthetics, and Incivilities
The mere presence of physical activity resources is not the only determinant of their use; the availability and quality of features are important as well. Features are specific elements of resources that encourage physical activity. As an example, a baseball field is a feature that encourages users to play baseball or engage in some other types of physical activity. Features can be extremely influential in terms of the types of users they attract and in the amount of maintenance required for the physical activity resource. For example, parks with basketball courts may draw more young users, while parks with swimming pools may draw more families and adult users. However, features such as baseball fields and swimming pools require more maintenance and upkeep than features with fewer, less sophisticated features.
Features that encourage the use of physical activity resources, but are not specifically related to physical activity, are called amenities. Amenities add comfort or convenience that may influence people to visit the resource. For example, restrooms, lighting, drinking fountains, and benches are amenities that may be found in a park or along walking trails and that may influence whether people visit the park or trail. Research has shown that people are more likely to use physical activity resources with amenities than those without them (Shores & West, 2008). In addition, research has indicated that the quantity and quality of amenities at physical activity resources may be associated with the prevalence of obesity (Heinrich et al., 2008). As a result, it's important that health-conscious community planners include amenities when building or renovating physical activity resources.
Aesthetics refers to the quality, condition, and appeal of the physical activity resource and its features and can strongly influence whether a physical activity resource is used. For example, park users are more likely to visit a park with pleasant landscaping, appealing amenities, and well-maintained features. Research has shown that well-maintained amenities and features are associated with physical activity (Owen, Humpel, Leslie, Bauman, & Sallis, 2004). As a result, physical activity resources that are poorly maintained, worn down, or in disrepair will dissuade users and contribute to the obesogenic environment.
Incivilities are elements of physical activity resources that reduce the pleasure associated with their use. Examples of incivilities are auditory annoyances, broken glass, dog refuse, graffiti, litter, evidence of alcohol use, and other unpleasantries that could deter the use of a physical activity resource. It should be noted that incivilities are not created as part of the physical activity resource; they are created by users who do not consider the impact on others of the incivilities they create. In addition, incivilities may be considered a source of social disorder that can contribute to feelings of unhappiness and a lack of safety (Sampson & Raudenbush, 2004); incivilities are also associated with many poor health outcomes (Lee et al., 2005). There is no question that incivilities can deter people from using physical activity resources.
Having physical activity resources nearby, accessible, and available are good first steps toward a neighborhood that promotes physical activity among its residents. However, for most physical activity resources, the determination of whether and how they are used is much more complicated. Factors related to the accessibility of physical activity resources, along with physical activity resource features, amenities, incivilities, and aesthetics are also important to consider.
Excessive TV viewing and TV ads contribute to serious health problems among youth
Most Americans watch several hours of television each night and are bombarded by commercials (Holmes, 2008). But Americans are not alone in their television habits, despite the health detriments associated with excessive viewing.
Television advertisements are now a multimillion-dollar method of promoting the latest food product or beverage. The accessibility of a television and time to watch is also an issue for many children. Recent research suggests that children are now watching more television than ever with black and Latino children watching more television than white children (Dennison, Erb, & Jenkins, 2002; Viner & Cole, 2005). This is a public health concern because watching television typically decreases physical activity and increases the likelihood of poor dietary habits and child overweight and obesity (Gable, Chang, & Krull, 2007). For example, each additional hour of television that 5-year-olds watch on weekends increases their risk of adult obesity by 7% (Viner & Cole, 2005). Furthermore, a recent study from the American Academy of Pediatrics found that children who spend the most time watching television have higher blood pressure, regardless of body composition, compared to those who watch very little or no television (Martinez-Gomez, Tucker, Heelan, Welk, & Eisenmann, 2009). Watching television as a child can also predict future dietary habits. One recent study looked at two groups of adolescents (middle school and high school) and found that heavy television viewers reported lower fruit and vegetable intakes five years later.
Televisions are often a substitute family member for a busy household, regardless of people's awareness of the increased health risks associated with excessive exposure. Low socioeconomic status (SES) and income levels have been linked to increased television viewing and decreased physical activity (Bennett et al., 2006; Multimedia Audiences Summary, 2003). Recent research has shown that children who watch more television are more likely to be overweight or obese and children from low-income families who have a television in their room have an even higher risk of being overweight (Burdette & Whitaker, 2005; Dennison et al., 2002). Another alarming finding suggested that children from families who watch television during meals eat more meat, pizza, salty snacks, and soda than children who do not watch television during family meals (Coon, Goldberg, Rogers, & Tucker, 2001).
Although not every family owns a computer or has Internet access at home, televisions are prevalent in American households. As more families become two-working-parent households, more children come home to empty houses, resulting in television watching that is unsupervised and excessive. Parents who are absent or are busy when at home often rely on the television to provide stimulation, comfort, and entertainment (Dennison et al., 2002). As children view more television, they are also exposed to more commercials. Food advertising accounts for nearly half of these commercials, the vast majority of which are for energy dense foods of poor nutritional content (Powell, Szczypka, Chaloupka, & Braunschweig, 2007; Stitt & Kunkel, 2008). Not surprisingly, one study found that watching food commercials cued a significantly higher commercial recall in an after-movie questionnaire for young children. The children were also allowed to freely snack while watching the commercials. Boys ate more snack foods when watching the food commercials than neutral commercials (although girls ate slightly less). Further, since the snack food was a non-advertised food brand, the increased caloric consumption was not a function of brand recognition (Anschutz, Engels, & Van Strien, 2009). The net result is an increased risk for many lifelong adverse health consequences.
Television commercials are the most prominent form of marketing in the home, with food advertisements heavily represented. These food advertisements use publicly recognizable figures, branding, and popular cartoon, television, and movie characters in order to attract a child's attention (Coon et al., 2001). These tactics create an exciting, pleasurable experience for the viewer. Most food television commercials equate food with fun and pleasure, creating an even stronger ploy to persuade viewers to purchase and consume the product (Connor, 2006).
Public figures, ranging from athletes to musicians, are often a frequent component of television advertisements. Fast-food and beverage companies often use music and dance personalities to display their latest creation. Jessica and Ashlee Simpson, two pop music artists, have collaborated to sell Pizza Hut products, while other singers, like Britney Spears and Beyoncé, have advertised for Pepsi. Celebrity influence is a high priority for food producers, and many large corporations choose to have celebrities represent their products. The image of a popular personality can increase sales and marketability tremendously. In contrast, public figures are rarely involved with alcohol and drug-related advertisements, shying away from potentially controversial advertisements. Instead music, television, movie, and athletic personalities choose to attach their characters to safer products like fast food or soft drinks even though overconsumption of processed and fattening foods can lead to life-threatening conditions.
Food corporations have a variety of methods to target children and adolescents based on their preferences and the current culture. Branding can begin as early as preschool (Connor, 2006). Branding is an advertising tactic designed to establish product familiarity and to form positive associations with a product or company name. The goal of branding for young children is to produce recognition of company names and products, increasing the likelihood of future use as an adult. Branding can be created through a memorable musical theme or sequence of events. Often children can remember a commercial's song or tune which can later trigger recollection of the product. The Kaiser Family Foundation surveyed parents of children six years old and younger and found that, on an average day, over half of the children under age two watch television even though the American Academy of Pediatrics does not recommend television viewing for children two years of age and younger (Connor, 2006; Rideout, Hamel, & Kaiser Family Foundation, 2006). To capture the attention of these young children, food producers often use cartoon, movie, and TV characters. Ronald McDonald, representing McDonald's, and the Trix Rabbit are licensed characters that can assist in the branding process. Often these characters are cross-referenced and used in other food marketing corporation strategies. Examples of these are Teletubby Happy Meals and popular Disney characters that are used to promote fast food.
As described previously, the stimulation of gustatory processes from food pictures and the frequency of commercials and images are important among food promoters of children's programming. Children's television is regularly bombarded with food and beverage advertisements, with some programs being openly supported by these companies. Nickelodeon's Nick Jr. block draws up to one million viewers ages two to five each weekday and is supported openly by advertisements (Connor, 2006). Other channels like the Disney Channel and Public Broadcasting Service (PBS) are commercial free, but they still rely on corporate sponsors who supply underwriting credits. The high frequency of food-related commercials cannot be denied. A recent study found that in 96 half-hour blocks of preschool programming, Nickelodeon, the Disney Channel, and PBS had a total of 130 food-related advertisements. The majority of the advertisements aimed at children were for fast food and sweetened cereals (Connor, 2006).
Regardless of whether children have access to television at home, many view televised advertisements at school. Channel One, a popular educational program in American middle and high schools, airs 2 minutes of commercials with every 10 minutes of current-events programming (Strasburger, 2006). Even if children are not exposed to food advertisements within the home, they will more than likely see hundreds of commercials in school.
A typical child or adolescent sees about 40,000 television advertisements a year despite the Children's Television Act of 1990. This law limits advertising on children's programming to 10.5 minutes per hour on weekends and 12 minutes per hour on weekdays (Strasburger, 2006). Along with the high amount of food and beverage promotion, nutritional misinformation can often result (American Dietetic Association, 2006). Studies have shown that high-fat and high-sugar foods like candy, soft drinks, convenience and fast foods are most frequently advertised (Harrison & Marske, 2005; Powell et al., 2007). Furthermore, children who view junk food ads report a lower liking of healthful foods (Dixon, Scully, Wakefield, White, & Crawford, 2007).
Researchers continue to report that television food advertising increases children's preferences for the advertised foods and their requests for those foods (Harris, Brownell, & Bargh, 2009). One study estimated the effects of television fast-food restaurant advertising on the childhood obesity epidemic and found that banning fast-food restaurant advertising would reduce the number of overweight children ages 3 to 11 in a fixed population by 18% and would reduce the number of overweight adolescents ages 12 to 18 by 14%. The effects of television advertising on childhood obesity cannot be denied (Chou, Rashad, & Grossman, 2008).
With the known negative effects of television viewing and advertisements on children, researchers have begun extensive studies of new approaches for a better understanding of how food marketing affects young people. For example, the newly developed food marketing defense model presents four necessary conditions to effectively counter harmful food marketing practices: awareness, understanding, ability, and motivation to resist (Harris et al., 2009). Food marketing defense models like these are often used to create media literacy education materials. Media literacy education and methods used to dispute unsound nutrition information are discussed later in the chapter.
The implications of children's excessive television exposure are apparent during adolescence. Adolescents are increasingly more overweight and sedentary, leading to health problems in their youth and later adulthood (Ogden, Carroll, & Flegal, 2008). Overweight adolescents have more weight struggles, willpower issues, and family problems compared to those of normal weight (Glessner, Hoover, & Halzlett, 2006). In particular, adolescent girls may experience body image pressures perpetuated by media-generated images because both television commercials and programs often present young, thin, attractive people. The heavy reliance on television as entertainment may contribute to serious health problems such as obesity for today's youth.
Modern lifestyles, environments play large role in obesity epidemic
If the obesogenic genetic risk profile has remained the same in humans since the obesity epidemic began, what has changed? The simple answer is that our environment has changed.
Because obesity rates have been escalating at annually measurable rates, much research money has been devoted to determining the underlying causes. Despite the world's brightest and best scientific efforts, no single gene or direct pathway explaining obesity has been identified. Numerous genetic factors may contribute to an obesogenic genetic risk profile, but this profile is only an indicator of the potential for someone to gain excess weight under obesogenic conditions. It also happens that most humans share this genetic profile favoring weight gain. There has been no significant genetic shift, mutation, or other biological change in humans in thousands of years. Thus, if the obesogenic genetic risk profile has remained the same in humans since the obesity epidemic began, what has changed?
The answer to this conundrum is both simple and complex. The simple answer is that our environment has changed; the complexity lies in determining the aspects of our environment that have changed to make it obesogenic and how we can reverse the obesogenic environment.
The spectrum of causes of death when we compare today to a century ago is remarkably different in industrialized countries. A century ago, most people died from infectious diseases such as pneumonia or tuberculosis (table 1.1), and most people died young and often relatively quickly. Even if one was overweight or obese, it was less of a concern because the typical health-compromising conditions associated with obesity tend to happen later in life, a period in the life cycle that most people did not live long enough to see. In the past century, tremendous scientific advances in microbiology, improved understanding of contagions, and the technological innovation of vaccination have eliminated nearly all deadly infectious diseases from a century ago. Now people live longer lives free from many infectious diseases, and they tend to die much later in the life span from chronic health-compromising conditions that slowly reduce the capacity of one or more organ systems. The top causes of death in industrialized countries are all chronic diseases such as heart disease, cancers, and stroke, for which obesity, lack of physical activity, and dietary habits are strong contributors (Centers for Disease Control and Prevention [CDC] & National Center for Injury Prevention and Control [NCIPC], 2008).
The dramatic shift in causes of death in industrialized society reflects the changes in our environments and resulting lifestyles. Everything has changed. Technological innovation has changed the way our food is grown, prepared, and presented in the retail marketplace. Policies promoting economic growth while yielding to political pressures have changed the food supply. Economic growth and the globalization of the marketplace have increased communication and travel, influencing lifestyle habits and changing available jobs. School policies have changed the types of physical activities taught, if they are taught at all, and the kinds of foods youths learn to love at an early age. Our individual lives have changed. We buy our food already partially or wholly prepared rather than hunt or gather it ourselves. We travel to our jobs and schools by car rather than by foot. Many of us may rely on televisions and computers that bring the world directly to the comfort of our own homes. There are many more examples.
Decisions to take part in physical activity influenced by multiple environmental factors
Many factors influence whether people use physical activity resources. In this chapter we discuss the more common factors examined in the research literature, including those we think are the strongest predictors of physical activity resource use: accessibility, proximity, safety, and the presence and quality of features and amenities, aesthetics, and incivilities.
Accessibility
Accessibility is composed of many factors that influence the use of physical activity resources and is often used interchangeably with the term usability. One important accessibility factor is ease of travel to and from the resources as well as the ease of using the resources and equipment. An accessible resource is one that is easy to approach and use; one with little or no traffic en route; one that has adequate, convenient parking; and one that is accessible via inexpensive, convenient, and pleasant public transportation. In contrast, an inaccessible resource may have no readily available public transportation, inconvenient or no parking, equipment that is difficult to understand and use, or long lines for entry and equipment use. Cost is another important accessibility factor that can influence physical activity resource use, particularly among populations of lower socioeconomic status and children and adolescents.
Accessibility is a factor in determining whether people use physical activity resources and ultimately in whether they do physical activity. Research has indicated that children and adolescents with access to physical activity resources and physical activity programs are more physically active than those without access (Allison et al., 2005; Dwyer et al., 2006; Mota, Almeida, Santos, & Ribeiro, 2005). In addition, it's important to note that populations of lower socioeconomic status typically have more limited access to physical activity resources. This is important because reduced access to physical activity resources is associated with increased body fat and BMI in low-income, minority populations (Heinrich et al., 2008). As a result, it's important to consider this additional barrier when working with populations of lower socioeconomic status.
Proximity
Proximity influences whether people use physical activity resources. Proximity can be measured subjectively using self-report questionnaires or objectively using street network or straight line distances. Briefly, network distance is the distance one would travel on streets to get to a resource, while straight line distance is the direct distance between two points; it represents the absolute distance one would travel if there were no buildings or obstacles. The more proximal a resource is to someone, the more accessible it is as well.
There is a strong relationship between proximity of physical activity resources and physical activity. In a study among low-income, midlife women, those who reported greater proximity to physical activity resources also did more physical activity (Jilcott, Evenson, Laraia, & Ammerman, 2007). There is also evidence that suggests there is a direct relationship between proximity to physical activity resources and meeting physical activity guidelines (Sallis, Patterson, Buono, & Nader, 1988). In addition, proximity to physical activity resources may be particularly important for children and adolescents, since most youth are limited to the immediate resources to which they can walk or bicycle.
Within the context of proximity, the density of physical activity resources is another factor to consider. For example, a study found that adolescent girls who lived near more parks did more physical activity than those who lived near fewer parks (Cohen et al., 2006). Similar results were found in women: Women who lived near more physical activity resources and parks were more physically active than those who lived near fewer physical activity resources and parks (Jilcott et al., 2007; Norman et al., 2006; Lee et al., 2007).
The findings from these studies stress the importance of proximity to physical activity resources. Furthermore, these studies suggest that the built environment plays a vital role in resident health and that careful community planning can affect the health of residents. Research has shown that having a nearby park or gym may help to buffer the relationship between lower socioeconomic status and engaging in less physical activity (Lee et al., 2007). As a result, creating a variety of opportunities for recreation and physical activity that are easily accessible can provide a means to increase the amount of energy expended by Americans, a crucial part of solving the obesity epidemic (figure 5.1).
Safety
Safety is freedom from danger, risk, and injury, and it plays a crucial role in determining whether physical activity resources are used. Safety can act as a motivator or a barrier to being physically active. For example, trails and walking paths may offer a feeling of personal safety because they are traditionally placed far away from cars and traffic and because they typically offer more privacy than other types of physical activity resources (Gobster & Dickhut, 1995). On the other hand, safety is most often cited as a deterrent to using physical activity resources (King et al., 2000). For example, crime and traffic are common safety concerns that prevent people from being physically active in outdoor recreation facilities (Molnar, Gortmaker, Bull, & Buka, 2004).
Playgrounds are an important setting in which children can be physically active. However, the safety of playground equipment, which has typically been overlooked in research, plays a pivotal role in determining whether children use physical activity resources. Parks and playgrounds must meet regulatory safety guidelines set forth by local, state, and federal agencies before they are deemed safe for use. Unfortunately, these safety guidelines are not always strictly enforced—older parks and playgrounds often do not meet current guidelines. This lack of enforcement has public health implications: Almost 190,000 children required emergency room treatment after being injured on public playground equipment in 2001. As a result, the condition of park and playground equipment is likely an important factor in parents' decisions about whether to let their children play in parks and playgrounds (Bedimo-Rung et al., 2005).
Some population groups are disproportionately burdened with unsafe areas that discourage physical activity. For example, children living in low socioeconomic status neighborhoods dominated by ethnic minorities typically have fewer safe playgrounds, do less physical activity, and have higher rates of overweight and obesity when compared to children in their counterpart neighborhoods (Cradock et al., 2005; Lee, Booth, Reese-Smith, Regan, & Howard, 2005).
Features, Amenities, Aesthetics, and Incivilities
The mere presence of physical activity resources is not the only determinant of their use; the availability and quality of features are important as well. Features are specific elements of resources that encourage physical activity. As an example, a baseball field is a feature that encourages users to play baseball or engage in some other types of physical activity. Features can be extremely influential in terms of the types of users they attract and in the amount of maintenance required for the physical activity resource. For example, parks with basketball courts may draw more young users, while parks with swimming pools may draw more families and adult users. However, features such as baseball fields and swimming pools require more maintenance and upkeep than features with fewer, less sophisticated features.
Features that encourage the use of physical activity resources, but are not specifically related to physical activity, are called amenities. Amenities add comfort or convenience that may influence people to visit the resource. For example, restrooms, lighting, drinking fountains, and benches are amenities that may be found in a park or along walking trails and that may influence whether people visit the park or trail. Research has shown that people are more likely to use physical activity resources with amenities than those without them (Shores & West, 2008). In addition, research has indicated that the quantity and quality of amenities at physical activity resources may be associated with the prevalence of obesity (Heinrich et al., 2008). As a result, it's important that health-conscious community planners include amenities when building or renovating physical activity resources.
Aesthetics refers to the quality, condition, and appeal of the physical activity resource and its features and can strongly influence whether a physical activity resource is used. For example, park users are more likely to visit a park with pleasant landscaping, appealing amenities, and well-maintained features. Research has shown that well-maintained amenities and features are associated with physical activity (Owen, Humpel, Leslie, Bauman, & Sallis, 2004). As a result, physical activity resources that are poorly maintained, worn down, or in disrepair will dissuade users and contribute to the obesogenic environment.
Incivilities are elements of physical activity resources that reduce the pleasure associated with their use. Examples of incivilities are auditory annoyances, broken glass, dog refuse, graffiti, litter, evidence of alcohol use, and other unpleasantries that could deter the use of a physical activity resource. It should be noted that incivilities are not created as part of the physical activity resource; they are created by users who do not consider the impact on others of the incivilities they create. In addition, incivilities may be considered a source of social disorder that can contribute to feelings of unhappiness and a lack of safety (Sampson & Raudenbush, 2004); incivilities are also associated with many poor health outcomes (Lee et al., 2005). There is no question that incivilities can deter people from using physical activity resources.
Having physical activity resources nearby, accessible, and available are good first steps toward a neighborhood that promotes physical activity among its residents. However, for most physical activity resources, the determination of whether and how they are used is much more complicated. Factors related to the accessibility of physical activity resources, along with physical activity resource features, amenities, incivilities, and aesthetics are also important to consider.
Excessive TV viewing and TV ads contribute to serious health problems among youth
Most Americans watch several hours of television each night and are bombarded by commercials (Holmes, 2008). But Americans are not alone in their television habits, despite the health detriments associated with excessive viewing.
Television advertisements are now a multimillion-dollar method of promoting the latest food product or beverage. The accessibility of a television and time to watch is also an issue for many children. Recent research suggests that children are now watching more television than ever with black and Latino children watching more television than white children (Dennison, Erb, & Jenkins, 2002; Viner & Cole, 2005). This is a public health concern because watching television typically decreases physical activity and increases the likelihood of poor dietary habits and child overweight and obesity (Gable, Chang, & Krull, 2007). For example, each additional hour of television that 5-year-olds watch on weekends increases their risk of adult obesity by 7% (Viner & Cole, 2005). Furthermore, a recent study from the American Academy of Pediatrics found that children who spend the most time watching television have higher blood pressure, regardless of body composition, compared to those who watch very little or no television (Martinez-Gomez, Tucker, Heelan, Welk, & Eisenmann, 2009). Watching television as a child can also predict future dietary habits. One recent study looked at two groups of adolescents (middle school and high school) and found that heavy television viewers reported lower fruit and vegetable intakes five years later.
Televisions are often a substitute family member for a busy household, regardless of people's awareness of the increased health risks associated with excessive exposure. Low socioeconomic status (SES) and income levels have been linked to increased television viewing and decreased physical activity (Bennett et al., 2006; Multimedia Audiences Summary, 2003). Recent research has shown that children who watch more television are more likely to be overweight or obese and children from low-income families who have a television in their room have an even higher risk of being overweight (Burdette & Whitaker, 2005; Dennison et al., 2002). Another alarming finding suggested that children from families who watch television during meals eat more meat, pizza, salty snacks, and soda than children who do not watch television during family meals (Coon, Goldberg, Rogers, & Tucker, 2001).
Although not every family owns a computer or has Internet access at home, televisions are prevalent in American households. As more families become two-working-parent households, more children come home to empty houses, resulting in television watching that is unsupervised and excessive. Parents who are absent or are busy when at home often rely on the television to provide stimulation, comfort, and entertainment (Dennison et al., 2002). As children view more television, they are also exposed to more commercials. Food advertising accounts for nearly half of these commercials, the vast majority of which are for energy dense foods of poor nutritional content (Powell, Szczypka, Chaloupka, & Braunschweig, 2007; Stitt & Kunkel, 2008). Not surprisingly, one study found that watching food commercials cued a significantly higher commercial recall in an after-movie questionnaire for young children. The children were also allowed to freely snack while watching the commercials. Boys ate more snack foods when watching the food commercials than neutral commercials (although girls ate slightly less). Further, since the snack food was a non-advertised food brand, the increased caloric consumption was not a function of brand recognition (Anschutz, Engels, & Van Strien, 2009). The net result is an increased risk for many lifelong adverse health consequences.
Television commercials are the most prominent form of marketing in the home, with food advertisements heavily represented. These food advertisements use publicly recognizable figures, branding, and popular cartoon, television, and movie characters in order to attract a child's attention (Coon et al., 2001). These tactics create an exciting, pleasurable experience for the viewer. Most food television commercials equate food with fun and pleasure, creating an even stronger ploy to persuade viewers to purchase and consume the product (Connor, 2006).
Public figures, ranging from athletes to musicians, are often a frequent component of television advertisements. Fast-food and beverage companies often use music and dance personalities to display their latest creation. Jessica and Ashlee Simpson, two pop music artists, have collaborated to sell Pizza Hut products, while other singers, like Britney Spears and Beyoncé, have advertised for Pepsi. Celebrity influence is a high priority for food producers, and many large corporations choose to have celebrities represent their products. The image of a popular personality can increase sales and marketability tremendously. In contrast, public figures are rarely involved with alcohol and drug-related advertisements, shying away from potentially controversial advertisements. Instead music, television, movie, and athletic personalities choose to attach their characters to safer products like fast food or soft drinks even though overconsumption of processed and fattening foods can lead to life-threatening conditions.
Food corporations have a variety of methods to target children and adolescents based on their preferences and the current culture. Branding can begin as early as preschool (Connor, 2006). Branding is an advertising tactic designed to establish product familiarity and to form positive associations with a product or company name. The goal of branding for young children is to produce recognition of company names and products, increasing the likelihood of future use as an adult. Branding can be created through a memorable musical theme or sequence of events. Often children can remember a commercial's song or tune which can later trigger recollection of the product. The Kaiser Family Foundation surveyed parents of children six years old and younger and found that, on an average day, over half of the children under age two watch television even though the American Academy of Pediatrics does not recommend television viewing for children two years of age and younger (Connor, 2006; Rideout, Hamel, & Kaiser Family Foundation, 2006). To capture the attention of these young children, food producers often use cartoon, movie, and TV characters. Ronald McDonald, representing McDonald's, and the Trix Rabbit are licensed characters that can assist in the branding process. Often these characters are cross-referenced and used in other food marketing corporation strategies. Examples of these are Teletubby Happy Meals and popular Disney characters that are used to promote fast food.
As described previously, the stimulation of gustatory processes from food pictures and the frequency of commercials and images are important among food promoters of children's programming. Children's television is regularly bombarded with food and beverage advertisements, with some programs being openly supported by these companies. Nickelodeon's Nick Jr. block draws up to one million viewers ages two to five each weekday and is supported openly by advertisements (Connor, 2006). Other channels like the Disney Channel and Public Broadcasting Service (PBS) are commercial free, but they still rely on corporate sponsors who supply underwriting credits. The high frequency of food-related commercials cannot be denied. A recent study found that in 96 half-hour blocks of preschool programming, Nickelodeon, the Disney Channel, and PBS had a total of 130 food-related advertisements. The majority of the advertisements aimed at children were for fast food and sweetened cereals (Connor, 2006).
Regardless of whether children have access to television at home, many view televised advertisements at school. Channel One, a popular educational program in American middle and high schools, airs 2 minutes of commercials with every 10 minutes of current-events programming (Strasburger, 2006). Even if children are not exposed to food advertisements within the home, they will more than likely see hundreds of commercials in school.
A typical child or adolescent sees about 40,000 television advertisements a year despite the Children's Television Act of 1990. This law limits advertising on children's programming to 10.5 minutes per hour on weekends and 12 minutes per hour on weekdays (Strasburger, 2006). Along with the high amount of food and beverage promotion, nutritional misinformation can often result (American Dietetic Association, 2006). Studies have shown that high-fat and high-sugar foods like candy, soft drinks, convenience and fast foods are most frequently advertised (Harrison & Marske, 2005; Powell et al., 2007). Furthermore, children who view junk food ads report a lower liking of healthful foods (Dixon, Scully, Wakefield, White, & Crawford, 2007).
Researchers continue to report that television food advertising increases children's preferences for the advertised foods and their requests for those foods (Harris, Brownell, & Bargh, 2009). One study estimated the effects of television fast-food restaurant advertising on the childhood obesity epidemic and found that banning fast-food restaurant advertising would reduce the number of overweight children ages 3 to 11 in a fixed population by 18% and would reduce the number of overweight adolescents ages 12 to 18 by 14%. The effects of television advertising on childhood obesity cannot be denied (Chou, Rashad, & Grossman, 2008).
With the known negative effects of television viewing and advertisements on children, researchers have begun extensive studies of new approaches for a better understanding of how food marketing affects young people. For example, the newly developed food marketing defense model presents four necessary conditions to effectively counter harmful food marketing practices: awareness, understanding, ability, and motivation to resist (Harris et al., 2009). Food marketing defense models like these are often used to create media literacy education materials. Media literacy education and methods used to dispute unsound nutrition information are discussed later in the chapter.
The implications of children's excessive television exposure are apparent during adolescence. Adolescents are increasingly more overweight and sedentary, leading to health problems in their youth and later adulthood (Ogden, Carroll, & Flegal, 2008). Overweight adolescents have more weight struggles, willpower issues, and family problems compared to those of normal weight (Glessner, Hoover, & Halzlett, 2006). In particular, adolescent girls may experience body image pressures perpetuated by media-generated images because both television commercials and programs often present young, thin, attractive people. The heavy reliance on television as entertainment may contribute to serious health problems such as obesity for today's youth.
Modern lifestyles, environments play large role in obesity epidemic
If the obesogenic genetic risk profile has remained the same in humans since the obesity epidemic began, what has changed? The simple answer is that our environment has changed.
Because obesity rates have been escalating at annually measurable rates, much research money has been devoted to determining the underlying causes. Despite the world's brightest and best scientific efforts, no single gene or direct pathway explaining obesity has been identified. Numerous genetic factors may contribute to an obesogenic genetic risk profile, but this profile is only an indicator of the potential for someone to gain excess weight under obesogenic conditions. It also happens that most humans share this genetic profile favoring weight gain. There has been no significant genetic shift, mutation, or other biological change in humans in thousands of years. Thus, if the obesogenic genetic risk profile has remained the same in humans since the obesity epidemic began, what has changed?
The answer to this conundrum is both simple and complex. The simple answer is that our environment has changed; the complexity lies in determining the aspects of our environment that have changed to make it obesogenic and how we can reverse the obesogenic environment.
The spectrum of causes of death when we compare today to a century ago is remarkably different in industrialized countries. A century ago, most people died from infectious diseases such as pneumonia or tuberculosis (table 1.1), and most people died young and often relatively quickly. Even if one was overweight or obese, it was less of a concern because the typical health-compromising conditions associated with obesity tend to happen later in life, a period in the life cycle that most people did not live long enough to see. In the past century, tremendous scientific advances in microbiology, improved understanding of contagions, and the technological innovation of vaccination have eliminated nearly all deadly infectious diseases from a century ago. Now people live longer lives free from many infectious diseases, and they tend to die much later in the life span from chronic health-compromising conditions that slowly reduce the capacity of one or more organ systems. The top causes of death in industrialized countries are all chronic diseases such as heart disease, cancers, and stroke, for which obesity, lack of physical activity, and dietary habits are strong contributors (Centers for Disease Control and Prevention [CDC] & National Center for Injury Prevention and Control [NCIPC], 2008).
The dramatic shift in causes of death in industrialized society reflects the changes in our environments and resulting lifestyles. Everything has changed. Technological innovation has changed the way our food is grown, prepared, and presented in the retail marketplace. Policies promoting economic growth while yielding to political pressures have changed the food supply. Economic growth and the globalization of the marketplace have increased communication and travel, influencing lifestyle habits and changing available jobs. School policies have changed the types of physical activities taught, if they are taught at all, and the kinds of foods youths learn to love at an early age. Our individual lives have changed. We buy our food already partially or wholly prepared rather than hunt or gather it ourselves. We travel to our jobs and schools by car rather than by foot. Many of us may rely on televisions and computers that bring the world directly to the comfort of our own homes. There are many more examples.
Decisions to take part in physical activity influenced by multiple environmental factors
Many factors influence whether people use physical activity resources. In this chapter we discuss the more common factors examined in the research literature, including those we think are the strongest predictors of physical activity resource use: accessibility, proximity, safety, and the presence and quality of features and amenities, aesthetics, and incivilities.
Accessibility
Accessibility is composed of many factors that influence the use of physical activity resources and is often used interchangeably with the term usability. One important accessibility factor is ease of travel to and from the resources as well as the ease of using the resources and equipment. An accessible resource is one that is easy to approach and use; one with little or no traffic en route; one that has adequate, convenient parking; and one that is accessible via inexpensive, convenient, and pleasant public transportation. In contrast, an inaccessible resource may have no readily available public transportation, inconvenient or no parking, equipment that is difficult to understand and use, or long lines for entry and equipment use. Cost is another important accessibility factor that can influence physical activity resource use, particularly among populations of lower socioeconomic status and children and adolescents.
Accessibility is a factor in determining whether people use physical activity resources and ultimately in whether they do physical activity. Research has indicated that children and adolescents with access to physical activity resources and physical activity programs are more physically active than those without access (Allison et al., 2005; Dwyer et al., 2006; Mota, Almeida, Santos, & Ribeiro, 2005). In addition, it's important to note that populations of lower socioeconomic status typically have more limited access to physical activity resources. This is important because reduced access to physical activity resources is associated with increased body fat and BMI in low-income, minority populations (Heinrich et al., 2008). As a result, it's important to consider this additional barrier when working with populations of lower socioeconomic status.
Proximity
Proximity influences whether people use physical activity resources. Proximity can be measured subjectively using self-report questionnaires or objectively using street network or straight line distances. Briefly, network distance is the distance one would travel on streets to get to a resource, while straight line distance is the direct distance between two points; it represents the absolute distance one would travel if there were no buildings or obstacles. The more proximal a resource is to someone, the more accessible it is as well.
There is a strong relationship between proximity of physical activity resources and physical activity. In a study among low-income, midlife women, those who reported greater proximity to physical activity resources also did more physical activity (Jilcott, Evenson, Laraia, & Ammerman, 2007). There is also evidence that suggests there is a direct relationship between proximity to physical activity resources and meeting physical activity guidelines (Sallis, Patterson, Buono, & Nader, 1988). In addition, proximity to physical activity resources may be particularly important for children and adolescents, since most youth are limited to the immediate resources to which they can walk or bicycle.
Within the context of proximity, the density of physical activity resources is another factor to consider. For example, a study found that adolescent girls who lived near more parks did more physical activity than those who lived near fewer parks (Cohen et al., 2006). Similar results were found in women: Women who lived near more physical activity resources and parks were more physically active than those who lived near fewer physical activity resources and parks (Jilcott et al., 2007; Norman et al., 2006; Lee et al., 2007).
The findings from these studies stress the importance of proximity to physical activity resources. Furthermore, these studies suggest that the built environment plays a vital role in resident health and that careful community planning can affect the health of residents. Research has shown that having a nearby park or gym may help to buffer the relationship between lower socioeconomic status and engaging in less physical activity (Lee et al., 2007). As a result, creating a variety of opportunities for recreation and physical activity that are easily accessible can provide a means to increase the amount of energy expended by Americans, a crucial part of solving the obesity epidemic (figure 5.1).
Safety
Safety is freedom from danger, risk, and injury, and it plays a crucial role in determining whether physical activity resources are used. Safety can act as a motivator or a barrier to being physically active. For example, trails and walking paths may offer a feeling of personal safety because they are traditionally placed far away from cars and traffic and because they typically offer more privacy than other types of physical activity resources (Gobster & Dickhut, 1995). On the other hand, safety is most often cited as a deterrent to using physical activity resources (King et al., 2000). For example, crime and traffic are common safety concerns that prevent people from being physically active in outdoor recreation facilities (Molnar, Gortmaker, Bull, & Buka, 2004).
Playgrounds are an important setting in which children can be physically active. However, the safety of playground equipment, which has typically been overlooked in research, plays a pivotal role in determining whether children use physical activity resources. Parks and playgrounds must meet regulatory safety guidelines set forth by local, state, and federal agencies before they are deemed safe for use. Unfortunately, these safety guidelines are not always strictly enforced—older parks and playgrounds often do not meet current guidelines. This lack of enforcement has public health implications: Almost 190,000 children required emergency room treatment after being injured on public playground equipment in 2001. As a result, the condition of park and playground equipment is likely an important factor in parents' decisions about whether to let their children play in parks and playgrounds (Bedimo-Rung et al., 2005).
Some population groups are disproportionately burdened with unsafe areas that discourage physical activity. For example, children living in low socioeconomic status neighborhoods dominated by ethnic minorities typically have fewer safe playgrounds, do less physical activity, and have higher rates of overweight and obesity when compared to children in their counterpart neighborhoods (Cradock et al., 2005; Lee, Booth, Reese-Smith, Regan, & Howard, 2005).
Features, Amenities, Aesthetics, and Incivilities
The mere presence of physical activity resources is not the only determinant of their use; the availability and quality of features are important as well. Features are specific elements of resources that encourage physical activity. As an example, a baseball field is a feature that encourages users to play baseball or engage in some other types of physical activity. Features can be extremely influential in terms of the types of users they attract and in the amount of maintenance required for the physical activity resource. For example, parks with basketball courts may draw more young users, while parks with swimming pools may draw more families and adult users. However, features such as baseball fields and swimming pools require more maintenance and upkeep than features with fewer, less sophisticated features.
Features that encourage the use of physical activity resources, but are not specifically related to physical activity, are called amenities. Amenities add comfort or convenience that may influence people to visit the resource. For example, restrooms, lighting, drinking fountains, and benches are amenities that may be found in a park or along walking trails and that may influence whether people visit the park or trail. Research has shown that people are more likely to use physical activity resources with amenities than those without them (Shores & West, 2008). In addition, research has indicated that the quantity and quality of amenities at physical activity resources may be associated with the prevalence of obesity (Heinrich et al., 2008). As a result, it's important that health-conscious community planners include amenities when building or renovating physical activity resources.
Aesthetics refers to the quality, condition, and appeal of the physical activity resource and its features and can strongly influence whether a physical activity resource is used. For example, park users are more likely to visit a park with pleasant landscaping, appealing amenities, and well-maintained features. Research has shown that well-maintained amenities and features are associated with physical activity (Owen, Humpel, Leslie, Bauman, & Sallis, 2004). As a result, physical activity resources that are poorly maintained, worn down, or in disrepair will dissuade users and contribute to the obesogenic environment.
Incivilities are elements of physical activity resources that reduce the pleasure associated with their use. Examples of incivilities are auditory annoyances, broken glass, dog refuse, graffiti, litter, evidence of alcohol use, and other unpleasantries that could deter the use of a physical activity resource. It should be noted that incivilities are not created as part of the physical activity resource; they are created by users who do not consider the impact on others of the incivilities they create. In addition, incivilities may be considered a source of social disorder that can contribute to feelings of unhappiness and a lack of safety (Sampson & Raudenbush, 2004); incivilities are also associated with many poor health outcomes (Lee et al., 2005). There is no question that incivilities can deter people from using physical activity resources.
Having physical activity resources nearby, accessible, and available are good first steps toward a neighborhood that promotes physical activity among its residents. However, for most physical activity resources, the determination of whether and how they are used is much more complicated. Factors related to the accessibility of physical activity resources, along with physical activity resource features, amenities, incivilities, and aesthetics are also important to consider.
Excessive TV viewing and TV ads contribute to serious health problems among youth
Most Americans watch several hours of television each night and are bombarded by commercials (Holmes, 2008). But Americans are not alone in their television habits, despite the health detriments associated with excessive viewing.
Television advertisements are now a multimillion-dollar method of promoting the latest food product or beverage. The accessibility of a television and time to watch is also an issue for many children. Recent research suggests that children are now watching more television than ever with black and Latino children watching more television than white children (Dennison, Erb, & Jenkins, 2002; Viner & Cole, 2005). This is a public health concern because watching television typically decreases physical activity and increases the likelihood of poor dietary habits and child overweight and obesity (Gable, Chang, & Krull, 2007). For example, each additional hour of television that 5-year-olds watch on weekends increases their risk of adult obesity by 7% (Viner & Cole, 2005). Furthermore, a recent study from the American Academy of Pediatrics found that children who spend the most time watching television have higher blood pressure, regardless of body composition, compared to those who watch very little or no television (Martinez-Gomez, Tucker, Heelan, Welk, & Eisenmann, 2009). Watching television as a child can also predict future dietary habits. One recent study looked at two groups of adolescents (middle school and high school) and found that heavy television viewers reported lower fruit and vegetable intakes five years later.
Televisions are often a substitute family member for a busy household, regardless of people's awareness of the increased health risks associated with excessive exposure. Low socioeconomic status (SES) and income levels have been linked to increased television viewing and decreased physical activity (Bennett et al., 2006; Multimedia Audiences Summary, 2003). Recent research has shown that children who watch more television are more likely to be overweight or obese and children from low-income families who have a television in their room have an even higher risk of being overweight (Burdette & Whitaker, 2005; Dennison et al., 2002). Another alarming finding suggested that children from families who watch television during meals eat more meat, pizza, salty snacks, and soda than children who do not watch television during family meals (Coon, Goldberg, Rogers, & Tucker, 2001).
Although not every family owns a computer or has Internet access at home, televisions are prevalent in American households. As more families become two-working-parent households, more children come home to empty houses, resulting in television watching that is unsupervised and excessive. Parents who are absent or are busy when at home often rely on the television to provide stimulation, comfort, and entertainment (Dennison et al., 2002). As children view more television, they are also exposed to more commercials. Food advertising accounts for nearly half of these commercials, the vast majority of which are for energy dense foods of poor nutritional content (Powell, Szczypka, Chaloupka, & Braunschweig, 2007; Stitt & Kunkel, 2008). Not surprisingly, one study found that watching food commercials cued a significantly higher commercial recall in an after-movie questionnaire for young children. The children were also allowed to freely snack while watching the commercials. Boys ate more snack foods when watching the food commercials than neutral commercials (although girls ate slightly less). Further, since the snack food was a non-advertised food brand, the increased caloric consumption was not a function of brand recognition (Anschutz, Engels, & Van Strien, 2009). The net result is an increased risk for many lifelong adverse health consequences.
Television commercials are the most prominent form of marketing in the home, with food advertisements heavily represented. These food advertisements use publicly recognizable figures, branding, and popular cartoon, television, and movie characters in order to attract a child's attention (Coon et al., 2001). These tactics create an exciting, pleasurable experience for the viewer. Most food television commercials equate food with fun and pleasure, creating an even stronger ploy to persuade viewers to purchase and consume the product (Connor, 2006).
Public figures, ranging from athletes to musicians, are often a frequent component of television advertisements. Fast-food and beverage companies often use music and dance personalities to display their latest creation. Jessica and Ashlee Simpson, two pop music artists, have collaborated to sell Pizza Hut products, while other singers, like Britney Spears and Beyoncé, have advertised for Pepsi. Celebrity influence is a high priority for food producers, and many large corporations choose to have celebrities represent their products. The image of a popular personality can increase sales and marketability tremendously. In contrast, public figures are rarely involved with alcohol and drug-related advertisements, shying away from potentially controversial advertisements. Instead music, television, movie, and athletic personalities choose to attach their characters to safer products like fast food or soft drinks even though overconsumption of processed and fattening foods can lead to life-threatening conditions.
Food corporations have a variety of methods to target children and adolescents based on their preferences and the current culture. Branding can begin as early as preschool (Connor, 2006). Branding is an advertising tactic designed to establish product familiarity and to form positive associations with a product or company name. The goal of branding for young children is to produce recognition of company names and products, increasing the likelihood of future use as an adult. Branding can be created through a memorable musical theme or sequence of events. Often children can remember a commercial's song or tune which can later trigger recollection of the product. The Kaiser Family Foundation surveyed parents of children six years old and younger and found that, on an average day, over half of the children under age two watch television even though the American Academy of Pediatrics does not recommend television viewing for children two years of age and younger (Connor, 2006; Rideout, Hamel, & Kaiser Family Foundation, 2006). To capture the attention of these young children, food producers often use cartoon, movie, and TV characters. Ronald McDonald, representing McDonald's, and the Trix Rabbit are licensed characters that can assist in the branding process. Often these characters are cross-referenced and used in other food marketing corporation strategies. Examples of these are Teletubby Happy Meals and popular Disney characters that are used to promote fast food.
As described previously, the stimulation of gustatory processes from food pictures and the frequency of commercials and images are important among food promoters of children's programming. Children's television is regularly bombarded with food and beverage advertisements, with some programs being openly supported by these companies. Nickelodeon's Nick Jr. block draws up to one million viewers ages two to five each weekday and is supported openly by advertisements (Connor, 2006). Other channels like the Disney Channel and Public Broadcasting Service (PBS) are commercial free, but they still rely on corporate sponsors who supply underwriting credits. The high frequency of food-related commercials cannot be denied. A recent study found that in 96 half-hour blocks of preschool programming, Nickelodeon, the Disney Channel, and PBS had a total of 130 food-related advertisements. The majority of the advertisements aimed at children were for fast food and sweetened cereals (Connor, 2006).
Regardless of whether children have access to television at home, many view televised advertisements at school. Channel One, a popular educational program in American middle and high schools, airs 2 minutes of commercials with every 10 minutes of current-events programming (Strasburger, 2006). Even if children are not exposed to food advertisements within the home, they will more than likely see hundreds of commercials in school.
A typical child or adolescent sees about 40,000 television advertisements a year despite the Children's Television Act of 1990. This law limits advertising on children's programming to 10.5 minutes per hour on weekends and 12 minutes per hour on weekdays (Strasburger, 2006). Along with the high amount of food and beverage promotion, nutritional misinformation can often result (American Dietetic Association, 2006). Studies have shown that high-fat and high-sugar foods like candy, soft drinks, convenience and fast foods are most frequently advertised (Harrison & Marske, 2005; Powell et al., 2007). Furthermore, children who view junk food ads report a lower liking of healthful foods (Dixon, Scully, Wakefield, White, & Crawford, 2007).
Researchers continue to report that television food advertising increases children's preferences for the advertised foods and their requests for those foods (Harris, Brownell, & Bargh, 2009). One study estimated the effects of television fast-food restaurant advertising on the childhood obesity epidemic and found that banning fast-food restaurant advertising would reduce the number of overweight children ages 3 to 11 in a fixed population by 18% and would reduce the number of overweight adolescents ages 12 to 18 by 14%. The effects of television advertising on childhood obesity cannot be denied (Chou, Rashad, & Grossman, 2008).
With the known negative effects of television viewing and advertisements on children, researchers have begun extensive studies of new approaches for a better understanding of how food marketing affects young people. For example, the newly developed food marketing defense model presents four necessary conditions to effectively counter harmful food marketing practices: awareness, understanding, ability, and motivation to resist (Harris et al., 2009). Food marketing defense models like these are often used to create media literacy education materials. Media literacy education and methods used to dispute unsound nutrition information are discussed later in the chapter.
The implications of children's excessive television exposure are apparent during adolescence. Adolescents are increasingly more overweight and sedentary, leading to health problems in their youth and later adulthood (Ogden, Carroll, & Flegal, 2008). Overweight adolescents have more weight struggles, willpower issues, and family problems compared to those of normal weight (Glessner, Hoover, & Halzlett, 2006). In particular, adolescent girls may experience body image pressures perpetuated by media-generated images because both television commercials and programs often present young, thin, attractive people. The heavy reliance on television as entertainment may contribute to serious health problems such as obesity for today's youth.
Modern lifestyles, environments play large role in obesity epidemic
If the obesogenic genetic risk profile has remained the same in humans since the obesity epidemic began, what has changed? The simple answer is that our environment has changed.
Because obesity rates have been escalating at annually measurable rates, much research money has been devoted to determining the underlying causes. Despite the world's brightest and best scientific efforts, no single gene or direct pathway explaining obesity has been identified. Numerous genetic factors may contribute to an obesogenic genetic risk profile, but this profile is only an indicator of the potential for someone to gain excess weight under obesogenic conditions. It also happens that most humans share this genetic profile favoring weight gain. There has been no significant genetic shift, mutation, or other biological change in humans in thousands of years. Thus, if the obesogenic genetic risk profile has remained the same in humans since the obesity epidemic began, what has changed?
The answer to this conundrum is both simple and complex. The simple answer is that our environment has changed; the complexity lies in determining the aspects of our environment that have changed to make it obesogenic and how we can reverse the obesogenic environment.
The spectrum of causes of death when we compare today to a century ago is remarkably different in industrialized countries. A century ago, most people died from infectious diseases such as pneumonia or tuberculosis (table 1.1), and most people died young and often relatively quickly. Even if one was overweight or obese, it was less of a concern because the typical health-compromising conditions associated with obesity tend to happen later in life, a period in the life cycle that most people did not live long enough to see. In the past century, tremendous scientific advances in microbiology, improved understanding of contagions, and the technological innovation of vaccination have eliminated nearly all deadly infectious diseases from a century ago. Now people live longer lives free from many infectious diseases, and they tend to die much later in the life span from chronic health-compromising conditions that slowly reduce the capacity of one or more organ systems. The top causes of death in industrialized countries are all chronic diseases such as heart disease, cancers, and stroke, for which obesity, lack of physical activity, and dietary habits are strong contributors (Centers for Disease Control and Prevention [CDC] & National Center for Injury Prevention and Control [NCIPC], 2008).
The dramatic shift in causes of death in industrialized society reflects the changes in our environments and resulting lifestyles. Everything has changed. Technological innovation has changed the way our food is grown, prepared, and presented in the retail marketplace. Policies promoting economic growth while yielding to political pressures have changed the food supply. Economic growth and the globalization of the marketplace have increased communication and travel, influencing lifestyle habits and changing available jobs. School policies have changed the types of physical activities taught, if they are taught at all, and the kinds of foods youths learn to love at an early age. Our individual lives have changed. We buy our food already partially or wholly prepared rather than hunt or gather it ourselves. We travel to our jobs and schools by car rather than by foot. Many of us may rely on televisions and computers that bring the world directly to the comfort of our own homes. There are many more examples.
Decisions to take part in physical activity influenced by multiple environmental factors
Many factors influence whether people use physical activity resources. In this chapter we discuss the more common factors examined in the research literature, including those we think are the strongest predictors of physical activity resource use: accessibility, proximity, safety, and the presence and quality of features and amenities, aesthetics, and incivilities.
Accessibility
Accessibility is composed of many factors that influence the use of physical activity resources and is often used interchangeably with the term usability. One important accessibility factor is ease of travel to and from the resources as well as the ease of using the resources and equipment. An accessible resource is one that is easy to approach and use; one with little or no traffic en route; one that has adequate, convenient parking; and one that is accessible via inexpensive, convenient, and pleasant public transportation. In contrast, an inaccessible resource may have no readily available public transportation, inconvenient or no parking, equipment that is difficult to understand and use, or long lines for entry and equipment use. Cost is another important accessibility factor that can influence physical activity resource use, particularly among populations of lower socioeconomic status and children and adolescents.
Accessibility is a factor in determining whether people use physical activity resources and ultimately in whether they do physical activity. Research has indicated that children and adolescents with access to physical activity resources and physical activity programs are more physically active than those without access (Allison et al., 2005; Dwyer et al., 2006; Mota, Almeida, Santos, & Ribeiro, 2005). In addition, it's important to note that populations of lower socioeconomic status typically have more limited access to physical activity resources. This is important because reduced access to physical activity resources is associated with increased body fat and BMI in low-income, minority populations (Heinrich et al., 2008). As a result, it's important to consider this additional barrier when working with populations of lower socioeconomic status.
Proximity
Proximity influences whether people use physical activity resources. Proximity can be measured subjectively using self-report questionnaires or objectively using street network or straight line distances. Briefly, network distance is the distance one would travel on streets to get to a resource, while straight line distance is the direct distance between two points; it represents the absolute distance one would travel if there were no buildings or obstacles. The more proximal a resource is to someone, the more accessible it is as well.
There is a strong relationship between proximity of physical activity resources and physical activity. In a study among low-income, midlife women, those who reported greater proximity to physical activity resources also did more physical activity (Jilcott, Evenson, Laraia, & Ammerman, 2007). There is also evidence that suggests there is a direct relationship between proximity to physical activity resources and meeting physical activity guidelines (Sallis, Patterson, Buono, & Nader, 1988). In addition, proximity to physical activity resources may be particularly important for children and adolescents, since most youth are limited to the immediate resources to which they can walk or bicycle.
Within the context of proximity, the density of physical activity resources is another factor to consider. For example, a study found that adolescent girls who lived near more parks did more physical activity than those who lived near fewer parks (Cohen et al., 2006). Similar results were found in women: Women who lived near more physical activity resources and parks were more physically active than those who lived near fewer physical activity resources and parks (Jilcott et al., 2007; Norman et al., 2006; Lee et al., 2007).
The findings from these studies stress the importance of proximity to physical activity resources. Furthermore, these studies suggest that the built environment plays a vital role in resident health and that careful community planning can affect the health of residents. Research has shown that having a nearby park or gym may help to buffer the relationship between lower socioeconomic status and engaging in less physical activity (Lee et al., 2007). As a result, creating a variety of opportunities for recreation and physical activity that are easily accessible can provide a means to increase the amount of energy expended by Americans, a crucial part of solving the obesity epidemic (figure 5.1).
Safety
Safety is freedom from danger, risk, and injury, and it plays a crucial role in determining whether physical activity resources are used. Safety can act as a motivator or a barrier to being physically active. For example, trails and walking paths may offer a feeling of personal safety because they are traditionally placed far away from cars and traffic and because they typically offer more privacy than other types of physical activity resources (Gobster & Dickhut, 1995). On the other hand, safety is most often cited as a deterrent to using physical activity resources (King et al., 2000). For example, crime and traffic are common safety concerns that prevent people from being physically active in outdoor recreation facilities (Molnar, Gortmaker, Bull, & Buka, 2004).
Playgrounds are an important setting in which children can be physically active. However, the safety of playground equipment, which has typically been overlooked in research, plays a pivotal role in determining whether children use physical activity resources. Parks and playgrounds must meet regulatory safety guidelines set forth by local, state, and federal agencies before they are deemed safe for use. Unfortunately, these safety guidelines are not always strictly enforced—older parks and playgrounds often do not meet current guidelines. This lack of enforcement has public health implications: Almost 190,000 children required emergency room treatment after being injured on public playground equipment in 2001. As a result, the condition of park and playground equipment is likely an important factor in parents' decisions about whether to let their children play in parks and playgrounds (Bedimo-Rung et al., 2005).
Some population groups are disproportionately burdened with unsafe areas that discourage physical activity. For example, children living in low socioeconomic status neighborhoods dominated by ethnic minorities typically have fewer safe playgrounds, do less physical activity, and have higher rates of overweight and obesity when compared to children in their counterpart neighborhoods (Cradock et al., 2005; Lee, Booth, Reese-Smith, Regan, & Howard, 2005).
Features, Amenities, Aesthetics, and Incivilities
The mere presence of physical activity resources is not the only determinant of their use; the availability and quality of features are important as well. Features are specific elements of resources that encourage physical activity. As an example, a baseball field is a feature that encourages users to play baseball or engage in some other types of physical activity. Features can be extremely influential in terms of the types of users they attract and in the amount of maintenance required for the physical activity resource. For example, parks with basketball courts may draw more young users, while parks with swimming pools may draw more families and adult users. However, features such as baseball fields and swimming pools require more maintenance and upkeep than features with fewer, less sophisticated features.
Features that encourage the use of physical activity resources, but are not specifically related to physical activity, are called amenities. Amenities add comfort or convenience that may influence people to visit the resource. For example, restrooms, lighting, drinking fountains, and benches are amenities that may be found in a park or along walking trails and that may influence whether people visit the park or trail. Research has shown that people are more likely to use physical activity resources with amenities than those without them (Shores & West, 2008). In addition, research has indicated that the quantity and quality of amenities at physical activity resources may be associated with the prevalence of obesity (Heinrich et al., 2008). As a result, it's important that health-conscious community planners include amenities when building or renovating physical activity resources.
Aesthetics refers to the quality, condition, and appeal of the physical activity resource and its features and can strongly influence whether a physical activity resource is used. For example, park users are more likely to visit a park with pleasant landscaping, appealing amenities, and well-maintained features. Research has shown that well-maintained amenities and features are associated with physical activity (Owen, Humpel, Leslie, Bauman, & Sallis, 2004). As a result, physical activity resources that are poorly maintained, worn down, or in disrepair will dissuade users and contribute to the obesogenic environment.
Incivilities are elements of physical activity resources that reduce the pleasure associated with their use. Examples of incivilities are auditory annoyances, broken glass, dog refuse, graffiti, litter, evidence of alcohol use, and other unpleasantries that could deter the use of a physical activity resource. It should be noted that incivilities are not created as part of the physical activity resource; they are created by users who do not consider the impact on others of the incivilities they create. In addition, incivilities may be considered a source of social disorder that can contribute to feelings of unhappiness and a lack of safety (Sampson & Raudenbush, 2004); incivilities are also associated with many poor health outcomes (Lee et al., 2005). There is no question that incivilities can deter people from using physical activity resources.
Having physical activity resources nearby, accessible, and available are good first steps toward a neighborhood that promotes physical activity among its residents. However, for most physical activity resources, the determination of whether and how they are used is much more complicated. Factors related to the accessibility of physical activity resources, along with physical activity resource features, amenities, incivilities, and aesthetics are also important to consider.
Excessive TV viewing and TV ads contribute to serious health problems among youth
Most Americans watch several hours of television each night and are bombarded by commercials (Holmes, 2008). But Americans are not alone in their television habits, despite the health detriments associated with excessive viewing.
Television advertisements are now a multimillion-dollar method of promoting the latest food product or beverage. The accessibility of a television and time to watch is also an issue for many children. Recent research suggests that children are now watching more television than ever with black and Latino children watching more television than white children (Dennison, Erb, & Jenkins, 2002; Viner & Cole, 2005). This is a public health concern because watching television typically decreases physical activity and increases the likelihood of poor dietary habits and child overweight and obesity (Gable, Chang, & Krull, 2007). For example, each additional hour of television that 5-year-olds watch on weekends increases their risk of adult obesity by 7% (Viner & Cole, 2005). Furthermore, a recent study from the American Academy of Pediatrics found that children who spend the most time watching television have higher blood pressure, regardless of body composition, compared to those who watch very little or no television (Martinez-Gomez, Tucker, Heelan, Welk, & Eisenmann, 2009). Watching television as a child can also predict future dietary habits. One recent study looked at two groups of adolescents (middle school and high school) and found that heavy television viewers reported lower fruit and vegetable intakes five years later.
Televisions are often a substitute family member for a busy household, regardless of people's awareness of the increased health risks associated with excessive exposure. Low socioeconomic status (SES) and income levels have been linked to increased television viewing and decreased physical activity (Bennett et al., 2006; Multimedia Audiences Summary, 2003). Recent research has shown that children who watch more television are more likely to be overweight or obese and children from low-income families who have a television in their room have an even higher risk of being overweight (Burdette & Whitaker, 2005; Dennison et al., 2002). Another alarming finding suggested that children from families who watch television during meals eat more meat, pizza, salty snacks, and soda than children who do not watch television during family meals (Coon, Goldberg, Rogers, & Tucker, 2001).
Although not every family owns a computer or has Internet access at home, televisions are prevalent in American households. As more families become two-working-parent households, more children come home to empty houses, resulting in television watching that is unsupervised and excessive. Parents who are absent or are busy when at home often rely on the television to provide stimulation, comfort, and entertainment (Dennison et al., 2002). As children view more television, they are also exposed to more commercials. Food advertising accounts for nearly half of these commercials, the vast majority of which are for energy dense foods of poor nutritional content (Powell, Szczypka, Chaloupka, & Braunschweig, 2007; Stitt & Kunkel, 2008). Not surprisingly, one study found that watching food commercials cued a significantly higher commercial recall in an after-movie questionnaire for young children. The children were also allowed to freely snack while watching the commercials. Boys ate more snack foods when watching the food commercials than neutral commercials (although girls ate slightly less). Further, since the snack food was a non-advertised food brand, the increased caloric consumption was not a function of brand recognition (Anschutz, Engels, & Van Strien, 2009). The net result is an increased risk for many lifelong adverse health consequences.
Television commercials are the most prominent form of marketing in the home, with food advertisements heavily represented. These food advertisements use publicly recognizable figures, branding, and popular cartoon, television, and movie characters in order to attract a child's attention (Coon et al., 2001). These tactics create an exciting, pleasurable experience for the viewer. Most food television commercials equate food with fun and pleasure, creating an even stronger ploy to persuade viewers to purchase and consume the product (Connor, 2006).
Public figures, ranging from athletes to musicians, are often a frequent component of television advertisements. Fast-food and beverage companies often use music and dance personalities to display their latest creation. Jessica and Ashlee Simpson, two pop music artists, have collaborated to sell Pizza Hut products, while other singers, like Britney Spears and Beyoncé, have advertised for Pepsi. Celebrity influence is a high priority for food producers, and many large corporations choose to have celebrities represent their products. The image of a popular personality can increase sales and marketability tremendously. In contrast, public figures are rarely involved with alcohol and drug-related advertisements, shying away from potentially controversial advertisements. Instead music, television, movie, and athletic personalities choose to attach their characters to safer products like fast food or soft drinks even though overconsumption of processed and fattening foods can lead to life-threatening conditions.
Food corporations have a variety of methods to target children and adolescents based on their preferences and the current culture. Branding can begin as early as preschool (Connor, 2006). Branding is an advertising tactic designed to establish product familiarity and to form positive associations with a product or company name. The goal of branding for young children is to produce recognition of company names and products, increasing the likelihood of future use as an adult. Branding can be created through a memorable musical theme or sequence of events. Often children can remember a commercial's song or tune which can later trigger recollection of the product. The Kaiser Family Foundation surveyed parents of children six years old and younger and found that, on an average day, over half of the children under age two watch television even though the American Academy of Pediatrics does not recommend television viewing for children two years of age and younger (Connor, 2006; Rideout, Hamel, & Kaiser Family Foundation, 2006). To capture the attention of these young children, food producers often use cartoon, movie, and TV characters. Ronald McDonald, representing McDonald's, and the Trix Rabbit are licensed characters that can assist in the branding process. Often these characters are cross-referenced and used in other food marketing corporation strategies. Examples of these are Teletubby Happy Meals and popular Disney characters that are used to promote fast food.
As described previously, the stimulation of gustatory processes from food pictures and the frequency of commercials and images are important among food promoters of children's programming. Children's television is regularly bombarded with food and beverage advertisements, with some programs being openly supported by these companies. Nickelodeon's Nick Jr. block draws up to one million viewers ages two to five each weekday and is supported openly by advertisements (Connor, 2006). Other channels like the Disney Channel and Public Broadcasting Service (PBS) are commercial free, but they still rely on corporate sponsors who supply underwriting credits. The high frequency of food-related commercials cannot be denied. A recent study found that in 96 half-hour blocks of preschool programming, Nickelodeon, the Disney Channel, and PBS had a total of 130 food-related advertisements. The majority of the advertisements aimed at children were for fast food and sweetened cereals (Connor, 2006).
Regardless of whether children have access to television at home, many view televised advertisements at school. Channel One, a popular educational program in American middle and high schools, airs 2 minutes of commercials with every 10 minutes of current-events programming (Strasburger, 2006). Even if children are not exposed to food advertisements within the home, they will more than likely see hundreds of commercials in school.
A typical child or adolescent sees about 40,000 television advertisements a year despite the Children's Television Act of 1990. This law limits advertising on children's programming to 10.5 minutes per hour on weekends and 12 minutes per hour on weekdays (Strasburger, 2006). Along with the high amount of food and beverage promotion, nutritional misinformation can often result (American Dietetic Association, 2006). Studies have shown that high-fat and high-sugar foods like candy, soft drinks, convenience and fast foods are most frequently advertised (Harrison & Marske, 2005; Powell et al., 2007). Furthermore, children who view junk food ads report a lower liking of healthful foods (Dixon, Scully, Wakefield, White, & Crawford, 2007).
Researchers continue to report that television food advertising increases children's preferences for the advertised foods and their requests for those foods (Harris, Brownell, & Bargh, 2009). One study estimated the effects of television fast-food restaurant advertising on the childhood obesity epidemic and found that banning fast-food restaurant advertising would reduce the number of overweight children ages 3 to 11 in a fixed population by 18% and would reduce the number of overweight adolescents ages 12 to 18 by 14%. The effects of television advertising on childhood obesity cannot be denied (Chou, Rashad, & Grossman, 2008).
With the known negative effects of television viewing and advertisements on children, researchers have begun extensive studies of new approaches for a better understanding of how food marketing affects young people. For example, the newly developed food marketing defense model presents four necessary conditions to effectively counter harmful food marketing practices: awareness, understanding, ability, and motivation to resist (Harris et al., 2009). Food marketing defense models like these are often used to create media literacy education materials. Media literacy education and methods used to dispute unsound nutrition information are discussed later in the chapter.
The implications of children's excessive television exposure are apparent during adolescence. Adolescents are increasingly more overweight and sedentary, leading to health problems in their youth and later adulthood (Ogden, Carroll, & Flegal, 2008). Overweight adolescents have more weight struggles, willpower issues, and family problems compared to those of normal weight (Glessner, Hoover, & Halzlett, 2006). In particular, adolescent girls may experience body image pressures perpetuated by media-generated images because both television commercials and programs often present young, thin, attractive people. The heavy reliance on television as entertainment may contribute to serious health problems such as obesity for today's youth.
Modern lifestyles, environments play large role in obesity epidemic
If the obesogenic genetic risk profile has remained the same in humans since the obesity epidemic began, what has changed? The simple answer is that our environment has changed.
Because obesity rates have been escalating at annually measurable rates, much research money has been devoted to determining the underlying causes. Despite the world's brightest and best scientific efforts, no single gene or direct pathway explaining obesity has been identified. Numerous genetic factors may contribute to an obesogenic genetic risk profile, but this profile is only an indicator of the potential for someone to gain excess weight under obesogenic conditions. It also happens that most humans share this genetic profile favoring weight gain. There has been no significant genetic shift, mutation, or other biological change in humans in thousands of years. Thus, if the obesogenic genetic risk profile has remained the same in humans since the obesity epidemic began, what has changed?
The answer to this conundrum is both simple and complex. The simple answer is that our environment has changed; the complexity lies in determining the aspects of our environment that have changed to make it obesogenic and how we can reverse the obesogenic environment.
The spectrum of causes of death when we compare today to a century ago is remarkably different in industrialized countries. A century ago, most people died from infectious diseases such as pneumonia or tuberculosis (table 1.1), and most people died young and often relatively quickly. Even if one was overweight or obese, it was less of a concern because the typical health-compromising conditions associated with obesity tend to happen later in life, a period in the life cycle that most people did not live long enough to see. In the past century, tremendous scientific advances in microbiology, improved understanding of contagions, and the technological innovation of vaccination have eliminated nearly all deadly infectious diseases from a century ago. Now people live longer lives free from many infectious diseases, and they tend to die much later in the life span from chronic health-compromising conditions that slowly reduce the capacity of one or more organ systems. The top causes of death in industrialized countries are all chronic diseases such as heart disease, cancers, and stroke, for which obesity, lack of physical activity, and dietary habits are strong contributors (Centers for Disease Control and Prevention [CDC] & National Center for Injury Prevention and Control [NCIPC], 2008).
The dramatic shift in causes of death in industrialized society reflects the changes in our environments and resulting lifestyles. Everything has changed. Technological innovation has changed the way our food is grown, prepared, and presented in the retail marketplace. Policies promoting economic growth while yielding to political pressures have changed the food supply. Economic growth and the globalization of the marketplace have increased communication and travel, influencing lifestyle habits and changing available jobs. School policies have changed the types of physical activities taught, if they are taught at all, and the kinds of foods youths learn to love at an early age. Our individual lives have changed. We buy our food already partially or wholly prepared rather than hunt or gather it ourselves. We travel to our jobs and schools by car rather than by foot. Many of us may rely on televisions and computers that bring the world directly to the comfort of our own homes. There are many more examples.
Decisions to take part in physical activity influenced by multiple environmental factors
Many factors influence whether people use physical activity resources. In this chapter we discuss the more common factors examined in the research literature, including those we think are the strongest predictors of physical activity resource use: accessibility, proximity, safety, and the presence and quality of features and amenities, aesthetics, and incivilities.
Accessibility
Accessibility is composed of many factors that influence the use of physical activity resources and is often used interchangeably with the term usability. One important accessibility factor is ease of travel to and from the resources as well as the ease of using the resources and equipment. An accessible resource is one that is easy to approach and use; one with little or no traffic en route; one that has adequate, convenient parking; and one that is accessible via inexpensive, convenient, and pleasant public transportation. In contrast, an inaccessible resource may have no readily available public transportation, inconvenient or no parking, equipment that is difficult to understand and use, or long lines for entry and equipment use. Cost is another important accessibility factor that can influence physical activity resource use, particularly among populations of lower socioeconomic status and children and adolescents.
Accessibility is a factor in determining whether people use physical activity resources and ultimately in whether they do physical activity. Research has indicated that children and adolescents with access to physical activity resources and physical activity programs are more physically active than those without access (Allison et al., 2005; Dwyer et al., 2006; Mota, Almeida, Santos, & Ribeiro, 2005). In addition, it's important to note that populations of lower socioeconomic status typically have more limited access to physical activity resources. This is important because reduced access to physical activity resources is associated with increased body fat and BMI in low-income, minority populations (Heinrich et al., 2008). As a result, it's important to consider this additional barrier when working with populations of lower socioeconomic status.
Proximity
Proximity influences whether people use physical activity resources. Proximity can be measured subjectively using self-report questionnaires or objectively using street network or straight line distances. Briefly, network distance is the distance one would travel on streets to get to a resource, while straight line distance is the direct distance between two points; it represents the absolute distance one would travel if there were no buildings or obstacles. The more proximal a resource is to someone, the more accessible it is as well.
There is a strong relationship between proximity of physical activity resources and physical activity. In a study among low-income, midlife women, those who reported greater proximity to physical activity resources also did more physical activity (Jilcott, Evenson, Laraia, & Ammerman, 2007). There is also evidence that suggests there is a direct relationship between proximity to physical activity resources and meeting physical activity guidelines (Sallis, Patterson, Buono, & Nader, 1988). In addition, proximity to physical activity resources may be particularly important for children and adolescents, since most youth are limited to the immediate resources to which they can walk or bicycle.
Within the context of proximity, the density of physical activity resources is another factor to consider. For example, a study found that adolescent girls who lived near more parks did more physical activity than those who lived near fewer parks (Cohen et al., 2006). Similar results were found in women: Women who lived near more physical activity resources and parks were more physically active than those who lived near fewer physical activity resources and parks (Jilcott et al., 2007; Norman et al., 2006; Lee et al., 2007).
The findings from these studies stress the importance of proximity to physical activity resources. Furthermore, these studies suggest that the built environment plays a vital role in resident health and that careful community planning can affect the health of residents. Research has shown that having a nearby park or gym may help to buffer the relationship between lower socioeconomic status and engaging in less physical activity (Lee et al., 2007). As a result, creating a variety of opportunities for recreation and physical activity that are easily accessible can provide a means to increase the amount of energy expended by Americans, a crucial part of solving the obesity epidemic (figure 5.1).
Safety
Safety is freedom from danger, risk, and injury, and it plays a crucial role in determining whether physical activity resources are used. Safety can act as a motivator or a barrier to being physically active. For example, trails and walking paths may offer a feeling of personal safety because they are traditionally placed far away from cars and traffic and because they typically offer more privacy than other types of physical activity resources (Gobster & Dickhut, 1995). On the other hand, safety is most often cited as a deterrent to using physical activity resources (King et al., 2000). For example, crime and traffic are common safety concerns that prevent people from being physically active in outdoor recreation facilities (Molnar, Gortmaker, Bull, & Buka, 2004).
Playgrounds are an important setting in which children can be physically active. However, the safety of playground equipment, which has typically been overlooked in research, plays a pivotal role in determining whether children use physical activity resources. Parks and playgrounds must meet regulatory safety guidelines set forth by local, state, and federal agencies before they are deemed safe for use. Unfortunately, these safety guidelines are not always strictly enforced—older parks and playgrounds often do not meet current guidelines. This lack of enforcement has public health implications: Almost 190,000 children required emergency room treatment after being injured on public playground equipment in 2001. As a result, the condition of park and playground equipment is likely an important factor in parents' decisions about whether to let their children play in parks and playgrounds (Bedimo-Rung et al., 2005).
Some population groups are disproportionately burdened with unsafe areas that discourage physical activity. For example, children living in low socioeconomic status neighborhoods dominated by ethnic minorities typically have fewer safe playgrounds, do less physical activity, and have higher rates of overweight and obesity when compared to children in their counterpart neighborhoods (Cradock et al., 2005; Lee, Booth, Reese-Smith, Regan, & Howard, 2005).
Features, Amenities, Aesthetics, and Incivilities
The mere presence of physical activity resources is not the only determinant of their use; the availability and quality of features are important as well. Features are specific elements of resources that encourage physical activity. As an example, a baseball field is a feature that encourages users to play baseball or engage in some other types of physical activity. Features can be extremely influential in terms of the types of users they attract and in the amount of maintenance required for the physical activity resource. For example, parks with basketball courts may draw more young users, while parks with swimming pools may draw more families and adult users. However, features such as baseball fields and swimming pools require more maintenance and upkeep than features with fewer, less sophisticated features.
Features that encourage the use of physical activity resources, but are not specifically related to physical activity, are called amenities. Amenities add comfort or convenience that may influence people to visit the resource. For example, restrooms, lighting, drinking fountains, and benches are amenities that may be found in a park or along walking trails and that may influence whether people visit the park or trail. Research has shown that people are more likely to use physical activity resources with amenities than those without them (Shores & West, 2008). In addition, research has indicated that the quantity and quality of amenities at physical activity resources may be associated with the prevalence of obesity (Heinrich et al., 2008). As a result, it's important that health-conscious community planners include amenities when building or renovating physical activity resources.
Aesthetics refers to the quality, condition, and appeal of the physical activity resource and its features and can strongly influence whether a physical activity resource is used. For example, park users are more likely to visit a park with pleasant landscaping, appealing amenities, and well-maintained features. Research has shown that well-maintained amenities and features are associated with physical activity (Owen, Humpel, Leslie, Bauman, & Sallis, 2004). As a result, physical activity resources that are poorly maintained, worn down, or in disrepair will dissuade users and contribute to the obesogenic environment.
Incivilities are elements of physical activity resources that reduce the pleasure associated with their use. Examples of incivilities are auditory annoyances, broken glass, dog refuse, graffiti, litter, evidence of alcohol use, and other unpleasantries that could deter the use of a physical activity resource. It should be noted that incivilities are not created as part of the physical activity resource; they are created by users who do not consider the impact on others of the incivilities they create. In addition, incivilities may be considered a source of social disorder that can contribute to feelings of unhappiness and a lack of safety (Sampson & Raudenbush, 2004); incivilities are also associated with many poor health outcomes (Lee et al., 2005). There is no question that incivilities can deter people from using physical activity resources.
Having physical activity resources nearby, accessible, and available are good first steps toward a neighborhood that promotes physical activity among its residents. However, for most physical activity resources, the determination of whether and how they are used is much more complicated. Factors related to the accessibility of physical activity resources, along with physical activity resource features, amenities, incivilities, and aesthetics are also important to consider.
Excessive TV viewing and TV ads contribute to serious health problems among youth
Most Americans watch several hours of television each night and are bombarded by commercials (Holmes, 2008). But Americans are not alone in their television habits, despite the health detriments associated with excessive viewing.
Television advertisements are now a multimillion-dollar method of promoting the latest food product or beverage. The accessibility of a television and time to watch is also an issue for many children. Recent research suggests that children are now watching more television than ever with black and Latino children watching more television than white children (Dennison, Erb, & Jenkins, 2002; Viner & Cole, 2005). This is a public health concern because watching television typically decreases physical activity and increases the likelihood of poor dietary habits and child overweight and obesity (Gable, Chang, & Krull, 2007). For example, each additional hour of television that 5-year-olds watch on weekends increases their risk of adult obesity by 7% (Viner & Cole, 2005). Furthermore, a recent study from the American Academy of Pediatrics found that children who spend the most time watching television have higher blood pressure, regardless of body composition, compared to those who watch very little or no television (Martinez-Gomez, Tucker, Heelan, Welk, & Eisenmann, 2009). Watching television as a child can also predict future dietary habits. One recent study looked at two groups of adolescents (middle school and high school) and found that heavy television viewers reported lower fruit and vegetable intakes five years later.
Televisions are often a substitute family member for a busy household, regardless of people's awareness of the increased health risks associated with excessive exposure. Low socioeconomic status (SES) and income levels have been linked to increased television viewing and decreased physical activity (Bennett et al., 2006; Multimedia Audiences Summary, 2003). Recent research has shown that children who watch more television are more likely to be overweight or obese and children from low-income families who have a television in their room have an even higher risk of being overweight (Burdette & Whitaker, 2005; Dennison et al., 2002). Another alarming finding suggested that children from families who watch television during meals eat more meat, pizza, salty snacks, and soda than children who do not watch television during family meals (Coon, Goldberg, Rogers, & Tucker, 2001).
Although not every family owns a computer or has Internet access at home, televisions are prevalent in American households. As more families become two-working-parent households, more children come home to empty houses, resulting in television watching that is unsupervised and excessive. Parents who are absent or are busy when at home often rely on the television to provide stimulation, comfort, and entertainment (Dennison et al., 2002). As children view more television, they are also exposed to more commercials. Food advertising accounts for nearly half of these commercials, the vast majority of which are for energy dense foods of poor nutritional content (Powell, Szczypka, Chaloupka, & Braunschweig, 2007; Stitt & Kunkel, 2008). Not surprisingly, one study found that watching food commercials cued a significantly higher commercial recall in an after-movie questionnaire for young children. The children were also allowed to freely snack while watching the commercials. Boys ate more snack foods when watching the food commercials than neutral commercials (although girls ate slightly less). Further, since the snack food was a non-advertised food brand, the increased caloric consumption was not a function of brand recognition (Anschutz, Engels, & Van Strien, 2009). The net result is an increased risk for many lifelong adverse health consequences.
Television commercials are the most prominent form of marketing in the home, with food advertisements heavily represented. These food advertisements use publicly recognizable figures, branding, and popular cartoon, television, and movie characters in order to attract a child's attention (Coon et al., 2001). These tactics create an exciting, pleasurable experience for the viewer. Most food television commercials equate food with fun and pleasure, creating an even stronger ploy to persuade viewers to purchase and consume the product (Connor, 2006).
Public figures, ranging from athletes to musicians, are often a frequent component of television advertisements. Fast-food and beverage companies often use music and dance personalities to display their latest creation. Jessica and Ashlee Simpson, two pop music artists, have collaborated to sell Pizza Hut products, while other singers, like Britney Spears and Beyoncé, have advertised for Pepsi. Celebrity influence is a high priority for food producers, and many large corporations choose to have celebrities represent their products. The image of a popular personality can increase sales and marketability tremendously. In contrast, public figures are rarely involved with alcohol and drug-related advertisements, shying away from potentially controversial advertisements. Instead music, television, movie, and athletic personalities choose to attach their characters to safer products like fast food or soft drinks even though overconsumption of processed and fattening foods can lead to life-threatening conditions.
Food corporations have a variety of methods to target children and adolescents based on their preferences and the current culture. Branding can begin as early as preschool (Connor, 2006). Branding is an advertising tactic designed to establish product familiarity and to form positive associations with a product or company name. The goal of branding for young children is to produce recognition of company names and products, increasing the likelihood of future use as an adult. Branding can be created through a memorable musical theme or sequence of events. Often children can remember a commercial's song or tune which can later trigger recollection of the product. The Kaiser Family Foundation surveyed parents of children six years old and younger and found that, on an average day, over half of the children under age two watch television even though the American Academy of Pediatrics does not recommend television viewing for children two years of age and younger (Connor, 2006; Rideout, Hamel, & Kaiser Family Foundation, 2006). To capture the attention of these young children, food producers often use cartoon, movie, and TV characters. Ronald McDonald, representing McDonald's, and the Trix Rabbit are licensed characters that can assist in the branding process. Often these characters are cross-referenced and used in other food marketing corporation strategies. Examples of these are Teletubby Happy Meals and popular Disney characters that are used to promote fast food.
As described previously, the stimulation of gustatory processes from food pictures and the frequency of commercials and images are important among food promoters of children's programming. Children's television is regularly bombarded with food and beverage advertisements, with some programs being openly supported by these companies. Nickelodeon's Nick Jr. block draws up to one million viewers ages two to five each weekday and is supported openly by advertisements (Connor, 2006). Other channels like the Disney Channel and Public Broadcasting Service (PBS) are commercial free, but they still rely on corporate sponsors who supply underwriting credits. The high frequency of food-related commercials cannot be denied. A recent study found that in 96 half-hour blocks of preschool programming, Nickelodeon, the Disney Channel, and PBS had a total of 130 food-related advertisements. The majority of the advertisements aimed at children were for fast food and sweetened cereals (Connor, 2006).
Regardless of whether children have access to television at home, many view televised advertisements at school. Channel One, a popular educational program in American middle and high schools, airs 2 minutes of commercials with every 10 minutes of current-events programming (Strasburger, 2006). Even if children are not exposed to food advertisements within the home, they will more than likely see hundreds of commercials in school.
A typical child or adolescent sees about 40,000 television advertisements a year despite the Children's Television Act of 1990. This law limits advertising on children's programming to 10.5 minutes per hour on weekends and 12 minutes per hour on weekdays (Strasburger, 2006). Along with the high amount of food and beverage promotion, nutritional misinformation can often result (American Dietetic Association, 2006). Studies have shown that high-fat and high-sugar foods like candy, soft drinks, convenience and fast foods are most frequently advertised (Harrison & Marske, 2005; Powell et al., 2007). Furthermore, children who view junk food ads report a lower liking of healthful foods (Dixon, Scully, Wakefield, White, & Crawford, 2007).
Researchers continue to report that television food advertising increases children's preferences for the advertised foods and their requests for those foods (Harris, Brownell, & Bargh, 2009). One study estimated the effects of television fast-food restaurant advertising on the childhood obesity epidemic and found that banning fast-food restaurant advertising would reduce the number of overweight children ages 3 to 11 in a fixed population by 18% and would reduce the number of overweight adolescents ages 12 to 18 by 14%. The effects of television advertising on childhood obesity cannot be denied (Chou, Rashad, & Grossman, 2008).
With the known negative effects of television viewing and advertisements on children, researchers have begun extensive studies of new approaches for a better understanding of how food marketing affects young people. For example, the newly developed food marketing defense model presents four necessary conditions to effectively counter harmful food marketing practices: awareness, understanding, ability, and motivation to resist (Harris et al., 2009). Food marketing defense models like these are often used to create media literacy education materials. Media literacy education and methods used to dispute unsound nutrition information are discussed later in the chapter.
The implications of children's excessive television exposure are apparent during adolescence. Adolescents are increasingly more overweight and sedentary, leading to health problems in their youth and later adulthood (Ogden, Carroll, & Flegal, 2008). Overweight adolescents have more weight struggles, willpower issues, and family problems compared to those of normal weight (Glessner, Hoover, & Halzlett, 2006). In particular, adolescent girls may experience body image pressures perpetuated by media-generated images because both television commercials and programs often present young, thin, attractive people. The heavy reliance on television as entertainment may contribute to serious health problems such as obesity for today's youth.
Modern lifestyles, environments play large role in obesity epidemic
If the obesogenic genetic risk profile has remained the same in humans since the obesity epidemic began, what has changed? The simple answer is that our environment has changed.
Because obesity rates have been escalating at annually measurable rates, much research money has been devoted to determining the underlying causes. Despite the world's brightest and best scientific efforts, no single gene or direct pathway explaining obesity has been identified. Numerous genetic factors may contribute to an obesogenic genetic risk profile, but this profile is only an indicator of the potential for someone to gain excess weight under obesogenic conditions. It also happens that most humans share this genetic profile favoring weight gain. There has been no significant genetic shift, mutation, or other biological change in humans in thousands of years. Thus, if the obesogenic genetic risk profile has remained the same in humans since the obesity epidemic began, what has changed?
The answer to this conundrum is both simple and complex. The simple answer is that our environment has changed; the complexity lies in determining the aspects of our environment that have changed to make it obesogenic and how we can reverse the obesogenic environment.
The spectrum of causes of death when we compare today to a century ago is remarkably different in industrialized countries. A century ago, most people died from infectious diseases such as pneumonia or tuberculosis (table 1.1), and most people died young and often relatively quickly. Even if one was overweight or obese, it was less of a concern because the typical health-compromising conditions associated with obesity tend to happen later in life, a period in the life cycle that most people did not live long enough to see. In the past century, tremendous scientific advances in microbiology, improved understanding of contagions, and the technological innovation of vaccination have eliminated nearly all deadly infectious diseases from a century ago. Now people live longer lives free from many infectious diseases, and they tend to die much later in the life span from chronic health-compromising conditions that slowly reduce the capacity of one or more organ systems. The top causes of death in industrialized countries are all chronic diseases such as heart disease, cancers, and stroke, for which obesity, lack of physical activity, and dietary habits are strong contributors (Centers for Disease Control and Prevention [CDC] & National Center for Injury Prevention and Control [NCIPC], 2008).
The dramatic shift in causes of death in industrialized society reflects the changes in our environments and resulting lifestyles. Everything has changed. Technological innovation has changed the way our food is grown, prepared, and presented in the retail marketplace. Policies promoting economic growth while yielding to political pressures have changed the food supply. Economic growth and the globalization of the marketplace have increased communication and travel, influencing lifestyle habits and changing available jobs. School policies have changed the types of physical activities taught, if they are taught at all, and the kinds of foods youths learn to love at an early age. Our individual lives have changed. We buy our food already partially or wholly prepared rather than hunt or gather it ourselves. We travel to our jobs and schools by car rather than by foot. Many of us may rely on televisions and computers that bring the world directly to the comfort of our own homes. There are many more examples.
Decisions to take part in physical activity influenced by multiple environmental factors
Many factors influence whether people use physical activity resources. In this chapter we discuss the more common factors examined in the research literature, including those we think are the strongest predictors of physical activity resource use: accessibility, proximity, safety, and the presence and quality of features and amenities, aesthetics, and incivilities.
Accessibility
Accessibility is composed of many factors that influence the use of physical activity resources and is often used interchangeably with the term usability. One important accessibility factor is ease of travel to and from the resources as well as the ease of using the resources and equipment. An accessible resource is one that is easy to approach and use; one with little or no traffic en route; one that has adequate, convenient parking; and one that is accessible via inexpensive, convenient, and pleasant public transportation. In contrast, an inaccessible resource may have no readily available public transportation, inconvenient or no parking, equipment that is difficult to understand and use, or long lines for entry and equipment use. Cost is another important accessibility factor that can influence physical activity resource use, particularly among populations of lower socioeconomic status and children and adolescents.
Accessibility is a factor in determining whether people use physical activity resources and ultimately in whether they do physical activity. Research has indicated that children and adolescents with access to physical activity resources and physical activity programs are more physically active than those without access (Allison et al., 2005; Dwyer et al., 2006; Mota, Almeida, Santos, & Ribeiro, 2005). In addition, it's important to note that populations of lower socioeconomic status typically have more limited access to physical activity resources. This is important because reduced access to physical activity resources is associated with increased body fat and BMI in low-income, minority populations (Heinrich et al., 2008). As a result, it's important to consider this additional barrier when working with populations of lower socioeconomic status.
Proximity
Proximity influences whether people use physical activity resources. Proximity can be measured subjectively using self-report questionnaires or objectively using street network or straight line distances. Briefly, network distance is the distance one would travel on streets to get to a resource, while straight line distance is the direct distance between two points; it represents the absolute distance one would travel if there were no buildings or obstacles. The more proximal a resource is to someone, the more accessible it is as well.
There is a strong relationship between proximity of physical activity resources and physical activity. In a study among low-income, midlife women, those who reported greater proximity to physical activity resources also did more physical activity (Jilcott, Evenson, Laraia, & Ammerman, 2007). There is also evidence that suggests there is a direct relationship between proximity to physical activity resources and meeting physical activity guidelines (Sallis, Patterson, Buono, & Nader, 1988). In addition, proximity to physical activity resources may be particularly important for children and adolescents, since most youth are limited to the immediate resources to which they can walk or bicycle.
Within the context of proximity, the density of physical activity resources is another factor to consider. For example, a study found that adolescent girls who lived near more parks did more physical activity than those who lived near fewer parks (Cohen et al., 2006). Similar results were found in women: Women who lived near more physical activity resources and parks were more physically active than those who lived near fewer physical activity resources and parks (Jilcott et al., 2007; Norman et al., 2006; Lee et al., 2007).
The findings from these studies stress the importance of proximity to physical activity resources. Furthermore, these studies suggest that the built environment plays a vital role in resident health and that careful community planning can affect the health of residents. Research has shown that having a nearby park or gym may help to buffer the relationship between lower socioeconomic status and engaging in less physical activity (Lee et al., 2007). As a result, creating a variety of opportunities for recreation and physical activity that are easily accessible can provide a means to increase the amount of energy expended by Americans, a crucial part of solving the obesity epidemic (figure 5.1).
Safety
Safety is freedom from danger, risk, and injury, and it plays a crucial role in determining whether physical activity resources are used. Safety can act as a motivator or a barrier to being physically active. For example, trails and walking paths may offer a feeling of personal safety because they are traditionally placed far away from cars and traffic and because they typically offer more privacy than other types of physical activity resources (Gobster & Dickhut, 1995). On the other hand, safety is most often cited as a deterrent to using physical activity resources (King et al., 2000). For example, crime and traffic are common safety concerns that prevent people from being physically active in outdoor recreation facilities (Molnar, Gortmaker, Bull, & Buka, 2004).
Playgrounds are an important setting in which children can be physically active. However, the safety of playground equipment, which has typically been overlooked in research, plays a pivotal role in determining whether children use physical activity resources. Parks and playgrounds must meet regulatory safety guidelines set forth by local, state, and federal agencies before they are deemed safe for use. Unfortunately, these safety guidelines are not always strictly enforced—older parks and playgrounds often do not meet current guidelines. This lack of enforcement has public health implications: Almost 190,000 children required emergency room treatment after being injured on public playground equipment in 2001. As a result, the condition of park and playground equipment is likely an important factor in parents' decisions about whether to let their children play in parks and playgrounds (Bedimo-Rung et al., 2005).
Some population groups are disproportionately burdened with unsafe areas that discourage physical activity. For example, children living in low socioeconomic status neighborhoods dominated by ethnic minorities typically have fewer safe playgrounds, do less physical activity, and have higher rates of overweight and obesity when compared to children in their counterpart neighborhoods (Cradock et al., 2005; Lee, Booth, Reese-Smith, Regan, & Howard, 2005).
Features, Amenities, Aesthetics, and Incivilities
The mere presence of physical activity resources is not the only determinant of their use; the availability and quality of features are important as well. Features are specific elements of resources that encourage physical activity. As an example, a baseball field is a feature that encourages users to play baseball or engage in some other types of physical activity. Features can be extremely influential in terms of the types of users they attract and in the amount of maintenance required for the physical activity resource. For example, parks with basketball courts may draw more young users, while parks with swimming pools may draw more families and adult users. However, features such as baseball fields and swimming pools require more maintenance and upkeep than features with fewer, less sophisticated features.
Features that encourage the use of physical activity resources, but are not specifically related to physical activity, are called amenities. Amenities add comfort or convenience that may influence people to visit the resource. For example, restrooms, lighting, drinking fountains, and benches are amenities that may be found in a park or along walking trails and that may influence whether people visit the park or trail. Research has shown that people are more likely to use physical activity resources with amenities than those without them (Shores & West, 2008). In addition, research has indicated that the quantity and quality of amenities at physical activity resources may be associated with the prevalence of obesity (Heinrich et al., 2008). As a result, it's important that health-conscious community planners include amenities when building or renovating physical activity resources.
Aesthetics refers to the quality, condition, and appeal of the physical activity resource and its features and can strongly influence whether a physical activity resource is used. For example, park users are more likely to visit a park with pleasant landscaping, appealing amenities, and well-maintained features. Research has shown that well-maintained amenities and features are associated with physical activity (Owen, Humpel, Leslie, Bauman, & Sallis, 2004). As a result, physical activity resources that are poorly maintained, worn down, or in disrepair will dissuade users and contribute to the obesogenic environment.
Incivilities are elements of physical activity resources that reduce the pleasure associated with their use. Examples of incivilities are auditory annoyances, broken glass, dog refuse, graffiti, litter, evidence of alcohol use, and other unpleasantries that could deter the use of a physical activity resource. It should be noted that incivilities are not created as part of the physical activity resource; they are created by users who do not consider the impact on others of the incivilities they create. In addition, incivilities may be considered a source of social disorder that can contribute to feelings of unhappiness and a lack of safety (Sampson & Raudenbush, 2004); incivilities are also associated with many poor health outcomes (Lee et al., 2005). There is no question that incivilities can deter people from using physical activity resources.
Having physical activity resources nearby, accessible, and available are good first steps toward a neighborhood that promotes physical activity among its residents. However, for most physical activity resources, the determination of whether and how they are used is much more complicated. Factors related to the accessibility of physical activity resources, along with physical activity resource features, amenities, incivilities, and aesthetics are also important to consider.
Excessive TV viewing and TV ads contribute to serious health problems among youth
Most Americans watch several hours of television each night and are bombarded by commercials (Holmes, 2008). But Americans are not alone in their television habits, despite the health detriments associated with excessive viewing.
Television advertisements are now a multimillion-dollar method of promoting the latest food product or beverage. The accessibility of a television and time to watch is also an issue for many children. Recent research suggests that children are now watching more television than ever with black and Latino children watching more television than white children (Dennison, Erb, & Jenkins, 2002; Viner & Cole, 2005). This is a public health concern because watching television typically decreases physical activity and increases the likelihood of poor dietary habits and child overweight and obesity (Gable, Chang, & Krull, 2007). For example, each additional hour of television that 5-year-olds watch on weekends increases their risk of adult obesity by 7% (Viner & Cole, 2005). Furthermore, a recent study from the American Academy of Pediatrics found that children who spend the most time watching television have higher blood pressure, regardless of body composition, compared to those who watch very little or no television (Martinez-Gomez, Tucker, Heelan, Welk, & Eisenmann, 2009). Watching television as a child can also predict future dietary habits. One recent study looked at two groups of adolescents (middle school and high school) and found that heavy television viewers reported lower fruit and vegetable intakes five years later.
Televisions are often a substitute family member for a busy household, regardless of people's awareness of the increased health risks associated with excessive exposure. Low socioeconomic status (SES) and income levels have been linked to increased television viewing and decreased physical activity (Bennett et al., 2006; Multimedia Audiences Summary, 2003). Recent research has shown that children who watch more television are more likely to be overweight or obese and children from low-income families who have a television in their room have an even higher risk of being overweight (Burdette & Whitaker, 2005; Dennison et al., 2002). Another alarming finding suggested that children from families who watch television during meals eat more meat, pizza, salty snacks, and soda than children who do not watch television during family meals (Coon, Goldberg, Rogers, & Tucker, 2001).
Although not every family owns a computer or has Internet access at home, televisions are prevalent in American households. As more families become two-working-parent households, more children come home to empty houses, resulting in television watching that is unsupervised and excessive. Parents who are absent or are busy when at home often rely on the television to provide stimulation, comfort, and entertainment (Dennison et al., 2002). As children view more television, they are also exposed to more commercials. Food advertising accounts for nearly half of these commercials, the vast majority of which are for energy dense foods of poor nutritional content (Powell, Szczypka, Chaloupka, & Braunschweig, 2007; Stitt & Kunkel, 2008). Not surprisingly, one study found that watching food commercials cued a significantly higher commercial recall in an after-movie questionnaire for young children. The children were also allowed to freely snack while watching the commercials. Boys ate more snack foods when watching the food commercials than neutral commercials (although girls ate slightly less). Further, since the snack food was a non-advertised food brand, the increased caloric consumption was not a function of brand recognition (Anschutz, Engels, & Van Strien, 2009). The net result is an increased risk for many lifelong adverse health consequences.
Television commercials are the most prominent form of marketing in the home, with food advertisements heavily represented. These food advertisements use publicly recognizable figures, branding, and popular cartoon, television, and movie characters in order to attract a child's attention (Coon et al., 2001). These tactics create an exciting, pleasurable experience for the viewer. Most food television commercials equate food with fun and pleasure, creating an even stronger ploy to persuade viewers to purchase and consume the product (Connor, 2006).
Public figures, ranging from athletes to musicians, are often a frequent component of television advertisements. Fast-food and beverage companies often use music and dance personalities to display their latest creation. Jessica and Ashlee Simpson, two pop music artists, have collaborated to sell Pizza Hut products, while other singers, like Britney Spears and Beyoncé, have advertised for Pepsi. Celebrity influence is a high priority for food producers, and many large corporations choose to have celebrities represent their products. The image of a popular personality can increase sales and marketability tremendously. In contrast, public figures are rarely involved with alcohol and drug-related advertisements, shying away from potentially controversial advertisements. Instead music, television, movie, and athletic personalities choose to attach their characters to safer products like fast food or soft drinks even though overconsumption of processed and fattening foods can lead to life-threatening conditions.
Food corporations have a variety of methods to target children and adolescents based on their preferences and the current culture. Branding can begin as early as preschool (Connor, 2006). Branding is an advertising tactic designed to establish product familiarity and to form positive associations with a product or company name. The goal of branding for young children is to produce recognition of company names and products, increasing the likelihood of future use as an adult. Branding can be created through a memorable musical theme or sequence of events. Often children can remember a commercial's song or tune which can later trigger recollection of the product. The Kaiser Family Foundation surveyed parents of children six years old and younger and found that, on an average day, over half of the children under age two watch television even though the American Academy of Pediatrics does not recommend television viewing for children two years of age and younger (Connor, 2006; Rideout, Hamel, & Kaiser Family Foundation, 2006). To capture the attention of these young children, food producers often use cartoon, movie, and TV characters. Ronald McDonald, representing McDonald's, and the Trix Rabbit are licensed characters that can assist in the branding process. Often these characters are cross-referenced and used in other food marketing corporation strategies. Examples of these are Teletubby Happy Meals and popular Disney characters that are used to promote fast food.
As described previously, the stimulation of gustatory processes from food pictures and the frequency of commercials and images are important among food promoters of children's programming. Children's television is regularly bombarded with food and beverage advertisements, with some programs being openly supported by these companies. Nickelodeon's Nick Jr. block draws up to one million viewers ages two to five each weekday and is supported openly by advertisements (Connor, 2006). Other channels like the Disney Channel and Public Broadcasting Service (PBS) are commercial free, but they still rely on corporate sponsors who supply underwriting credits. The high frequency of food-related commercials cannot be denied. A recent study found that in 96 half-hour blocks of preschool programming, Nickelodeon, the Disney Channel, and PBS had a total of 130 food-related advertisements. The majority of the advertisements aimed at children were for fast food and sweetened cereals (Connor, 2006).
Regardless of whether children have access to television at home, many view televised advertisements at school. Channel One, a popular educational program in American middle and high schools, airs 2 minutes of commercials with every 10 minutes of current-events programming (Strasburger, 2006). Even if children are not exposed to food advertisements within the home, they will more than likely see hundreds of commercials in school.
A typical child or adolescent sees about 40,000 television advertisements a year despite the Children's Television Act of 1990. This law limits advertising on children's programming to 10.5 minutes per hour on weekends and 12 minutes per hour on weekdays (Strasburger, 2006). Along with the high amount of food and beverage promotion, nutritional misinformation can often result (American Dietetic Association, 2006). Studies have shown that high-fat and high-sugar foods like candy, soft drinks, convenience and fast foods are most frequently advertised (Harrison & Marske, 2005; Powell et al., 2007). Furthermore, children who view junk food ads report a lower liking of healthful foods (Dixon, Scully, Wakefield, White, & Crawford, 2007).
Researchers continue to report that television food advertising increases children's preferences for the advertised foods and their requests for those foods (Harris, Brownell, & Bargh, 2009). One study estimated the effects of television fast-food restaurant advertising on the childhood obesity epidemic and found that banning fast-food restaurant advertising would reduce the number of overweight children ages 3 to 11 in a fixed population by 18% and would reduce the number of overweight adolescents ages 12 to 18 by 14%. The effects of television advertising on childhood obesity cannot be denied (Chou, Rashad, & Grossman, 2008).
With the known negative effects of television viewing and advertisements on children, researchers have begun extensive studies of new approaches for a better understanding of how food marketing affects young people. For example, the newly developed food marketing defense model presents four necessary conditions to effectively counter harmful food marketing practices: awareness, understanding, ability, and motivation to resist (Harris et al., 2009). Food marketing defense models like these are often used to create media literacy education materials. Media literacy education and methods used to dispute unsound nutrition information are discussed later in the chapter.
The implications of children's excessive television exposure are apparent during adolescence. Adolescents are increasingly more overweight and sedentary, leading to health problems in their youth and later adulthood (Ogden, Carroll, & Flegal, 2008). Overweight adolescents have more weight struggles, willpower issues, and family problems compared to those of normal weight (Glessner, Hoover, & Halzlett, 2006). In particular, adolescent girls may experience body image pressures perpetuated by media-generated images because both television commercials and programs often present young, thin, attractive people. The heavy reliance on television as entertainment may contribute to serious health problems such as obesity for today's youth.
Modern lifestyles, environments play large role in obesity epidemic
If the obesogenic genetic risk profile has remained the same in humans since the obesity epidemic began, what has changed? The simple answer is that our environment has changed.
Because obesity rates have been escalating at annually measurable rates, much research money has been devoted to determining the underlying causes. Despite the world's brightest and best scientific efforts, no single gene or direct pathway explaining obesity has been identified. Numerous genetic factors may contribute to an obesogenic genetic risk profile, but this profile is only an indicator of the potential for someone to gain excess weight under obesogenic conditions. It also happens that most humans share this genetic profile favoring weight gain. There has been no significant genetic shift, mutation, or other biological change in humans in thousands of years. Thus, if the obesogenic genetic risk profile has remained the same in humans since the obesity epidemic began, what has changed?
The answer to this conundrum is both simple and complex. The simple answer is that our environment has changed; the complexity lies in determining the aspects of our environment that have changed to make it obesogenic and how we can reverse the obesogenic environment.
The spectrum of causes of death when we compare today to a century ago is remarkably different in industrialized countries. A century ago, most people died from infectious diseases such as pneumonia or tuberculosis (table 1.1), and most people died young and often relatively quickly. Even if one was overweight or obese, it was less of a concern because the typical health-compromising conditions associated with obesity tend to happen later in life, a period in the life cycle that most people did not live long enough to see. In the past century, tremendous scientific advances in microbiology, improved understanding of contagions, and the technological innovation of vaccination have eliminated nearly all deadly infectious diseases from a century ago. Now people live longer lives free from many infectious diseases, and they tend to die much later in the life span from chronic health-compromising conditions that slowly reduce the capacity of one or more organ systems. The top causes of death in industrialized countries are all chronic diseases such as heart disease, cancers, and stroke, for which obesity, lack of physical activity, and dietary habits are strong contributors (Centers for Disease Control and Prevention [CDC] & National Center for Injury Prevention and Control [NCIPC], 2008).
The dramatic shift in causes of death in industrialized society reflects the changes in our environments and resulting lifestyles. Everything has changed. Technological innovation has changed the way our food is grown, prepared, and presented in the retail marketplace. Policies promoting economic growth while yielding to political pressures have changed the food supply. Economic growth and the globalization of the marketplace have increased communication and travel, influencing lifestyle habits and changing available jobs. School policies have changed the types of physical activities taught, if they are taught at all, and the kinds of foods youths learn to love at an early age. Our individual lives have changed. We buy our food already partially or wholly prepared rather than hunt or gather it ourselves. We travel to our jobs and schools by car rather than by foot. Many of us may rely on televisions and computers that bring the world directly to the comfort of our own homes. There are many more examples.
Decisions to take part in physical activity influenced by multiple environmental factors
Many factors influence whether people use physical activity resources. In this chapter we discuss the more common factors examined in the research literature, including those we think are the strongest predictors of physical activity resource use: accessibility, proximity, safety, and the presence and quality of features and amenities, aesthetics, and incivilities.
Accessibility
Accessibility is composed of many factors that influence the use of physical activity resources and is often used interchangeably with the term usability. One important accessibility factor is ease of travel to and from the resources as well as the ease of using the resources and equipment. An accessible resource is one that is easy to approach and use; one with little or no traffic en route; one that has adequate, convenient parking; and one that is accessible via inexpensive, convenient, and pleasant public transportation. In contrast, an inaccessible resource may have no readily available public transportation, inconvenient or no parking, equipment that is difficult to understand and use, or long lines for entry and equipment use. Cost is another important accessibility factor that can influence physical activity resource use, particularly among populations of lower socioeconomic status and children and adolescents.
Accessibility is a factor in determining whether people use physical activity resources and ultimately in whether they do physical activity. Research has indicated that children and adolescents with access to physical activity resources and physical activity programs are more physically active than those without access (Allison et al., 2005; Dwyer et al., 2006; Mota, Almeida, Santos, & Ribeiro, 2005). In addition, it's important to note that populations of lower socioeconomic status typically have more limited access to physical activity resources. This is important because reduced access to physical activity resources is associated with increased body fat and BMI in low-income, minority populations (Heinrich et al., 2008). As a result, it's important to consider this additional barrier when working with populations of lower socioeconomic status.
Proximity
Proximity influences whether people use physical activity resources. Proximity can be measured subjectively using self-report questionnaires or objectively using street network or straight line distances. Briefly, network distance is the distance one would travel on streets to get to a resource, while straight line distance is the direct distance between two points; it represents the absolute distance one would travel if there were no buildings or obstacles. The more proximal a resource is to someone, the more accessible it is as well.
There is a strong relationship between proximity of physical activity resources and physical activity. In a study among low-income, midlife women, those who reported greater proximity to physical activity resources also did more physical activity (Jilcott, Evenson, Laraia, & Ammerman, 2007). There is also evidence that suggests there is a direct relationship between proximity to physical activity resources and meeting physical activity guidelines (Sallis, Patterson, Buono, & Nader, 1988). In addition, proximity to physical activity resources may be particularly important for children and adolescents, since most youth are limited to the immediate resources to which they can walk or bicycle.
Within the context of proximity, the density of physical activity resources is another factor to consider. For example, a study found that adolescent girls who lived near more parks did more physical activity than those who lived near fewer parks (Cohen et al., 2006). Similar results were found in women: Women who lived near more physical activity resources and parks were more physically active than those who lived near fewer physical activity resources and parks (Jilcott et al., 2007; Norman et al., 2006; Lee et al., 2007).
The findings from these studies stress the importance of proximity to physical activity resources. Furthermore, these studies suggest that the built environment plays a vital role in resident health and that careful community planning can affect the health of residents. Research has shown that having a nearby park or gym may help to buffer the relationship between lower socioeconomic status and engaging in less physical activity (Lee et al., 2007). As a result, creating a variety of opportunities for recreation and physical activity that are easily accessible can provide a means to increase the amount of energy expended by Americans, a crucial part of solving the obesity epidemic (figure 5.1).
Safety
Safety is freedom from danger, risk, and injury, and it plays a crucial role in determining whether physical activity resources are used. Safety can act as a motivator or a barrier to being physically active. For example, trails and walking paths may offer a feeling of personal safety because they are traditionally placed far away from cars and traffic and because they typically offer more privacy than other types of physical activity resources (Gobster & Dickhut, 1995). On the other hand, safety is most often cited as a deterrent to using physical activity resources (King et al., 2000). For example, crime and traffic are common safety concerns that prevent people from being physically active in outdoor recreation facilities (Molnar, Gortmaker, Bull, & Buka, 2004).
Playgrounds are an important setting in which children can be physically active. However, the safety of playground equipment, which has typically been overlooked in research, plays a pivotal role in determining whether children use physical activity resources. Parks and playgrounds must meet regulatory safety guidelines set forth by local, state, and federal agencies before they are deemed safe for use. Unfortunately, these safety guidelines are not always strictly enforced—older parks and playgrounds often do not meet current guidelines. This lack of enforcement has public health implications: Almost 190,000 children required emergency room treatment after being injured on public playground equipment in 2001. As a result, the condition of park and playground equipment is likely an important factor in parents' decisions about whether to let their children play in parks and playgrounds (Bedimo-Rung et al., 2005).
Some population groups are disproportionately burdened with unsafe areas that discourage physical activity. For example, children living in low socioeconomic status neighborhoods dominated by ethnic minorities typically have fewer safe playgrounds, do less physical activity, and have higher rates of overweight and obesity when compared to children in their counterpart neighborhoods (Cradock et al., 2005; Lee, Booth, Reese-Smith, Regan, & Howard, 2005).
Features, Amenities, Aesthetics, and Incivilities
The mere presence of physical activity resources is not the only determinant of their use; the availability and quality of features are important as well. Features are specific elements of resources that encourage physical activity. As an example, a baseball field is a feature that encourages users to play baseball or engage in some other types of physical activity. Features can be extremely influential in terms of the types of users they attract and in the amount of maintenance required for the physical activity resource. For example, parks with basketball courts may draw more young users, while parks with swimming pools may draw more families and adult users. However, features such as baseball fields and swimming pools require more maintenance and upkeep than features with fewer, less sophisticated features.
Features that encourage the use of physical activity resources, but are not specifically related to physical activity, are called amenities. Amenities add comfort or convenience that may influence people to visit the resource. For example, restrooms, lighting, drinking fountains, and benches are amenities that may be found in a park or along walking trails and that may influence whether people visit the park or trail. Research has shown that people are more likely to use physical activity resources with amenities than those without them (Shores & West, 2008). In addition, research has indicated that the quantity and quality of amenities at physical activity resources may be associated with the prevalence of obesity (Heinrich et al., 2008). As a result, it's important that health-conscious community planners include amenities when building or renovating physical activity resources.
Aesthetics refers to the quality, condition, and appeal of the physical activity resource and its features and can strongly influence whether a physical activity resource is used. For example, park users are more likely to visit a park with pleasant landscaping, appealing amenities, and well-maintained features. Research has shown that well-maintained amenities and features are associated with physical activity (Owen, Humpel, Leslie, Bauman, & Sallis, 2004). As a result, physical activity resources that are poorly maintained, worn down, or in disrepair will dissuade users and contribute to the obesogenic environment.
Incivilities are elements of physical activity resources that reduce the pleasure associated with their use. Examples of incivilities are auditory annoyances, broken glass, dog refuse, graffiti, litter, evidence of alcohol use, and other unpleasantries that could deter the use of a physical activity resource. It should be noted that incivilities are not created as part of the physical activity resource; they are created by users who do not consider the impact on others of the incivilities they create. In addition, incivilities may be considered a source of social disorder that can contribute to feelings of unhappiness and a lack of safety (Sampson & Raudenbush, 2004); incivilities are also associated with many poor health outcomes (Lee et al., 2005). There is no question that incivilities can deter people from using physical activity resources.
Having physical activity resources nearby, accessible, and available are good first steps toward a neighborhood that promotes physical activity among its residents. However, for most physical activity resources, the determination of whether and how they are used is much more complicated. Factors related to the accessibility of physical activity resources, along with physical activity resource features, amenities, incivilities, and aesthetics are also important to consider.
Excessive TV viewing and TV ads contribute to serious health problems among youth
Most Americans watch several hours of television each night and are bombarded by commercials (Holmes, 2008). But Americans are not alone in their television habits, despite the health detriments associated with excessive viewing.
Television advertisements are now a multimillion-dollar method of promoting the latest food product or beverage. The accessibility of a television and time to watch is also an issue for many children. Recent research suggests that children are now watching more television than ever with black and Latino children watching more television than white children (Dennison, Erb, & Jenkins, 2002; Viner & Cole, 2005). This is a public health concern because watching television typically decreases physical activity and increases the likelihood of poor dietary habits and child overweight and obesity (Gable, Chang, & Krull, 2007). For example, each additional hour of television that 5-year-olds watch on weekends increases their risk of adult obesity by 7% (Viner & Cole, 2005). Furthermore, a recent study from the American Academy of Pediatrics found that children who spend the most time watching television have higher blood pressure, regardless of body composition, compared to those who watch very little or no television (Martinez-Gomez, Tucker, Heelan, Welk, & Eisenmann, 2009). Watching television as a child can also predict future dietary habits. One recent study looked at two groups of adolescents (middle school and high school) and found that heavy television viewers reported lower fruit and vegetable intakes five years later.
Televisions are often a substitute family member for a busy household, regardless of people's awareness of the increased health risks associated with excessive exposure. Low socioeconomic status (SES) and income levels have been linked to increased television viewing and decreased physical activity (Bennett et al., 2006; Multimedia Audiences Summary, 2003). Recent research has shown that children who watch more television are more likely to be overweight or obese and children from low-income families who have a television in their room have an even higher risk of being overweight (Burdette & Whitaker, 2005; Dennison et al., 2002). Another alarming finding suggested that children from families who watch television during meals eat more meat, pizza, salty snacks, and soda than children who do not watch television during family meals (Coon, Goldberg, Rogers, & Tucker, 2001).
Although not every family owns a computer or has Internet access at home, televisions are prevalent in American households. As more families become two-working-parent households, more children come home to empty houses, resulting in television watching that is unsupervised and excessive. Parents who are absent or are busy when at home often rely on the television to provide stimulation, comfort, and entertainment (Dennison et al., 2002). As children view more television, they are also exposed to more commercials. Food advertising accounts for nearly half of these commercials, the vast majority of which are for energy dense foods of poor nutritional content (Powell, Szczypka, Chaloupka, & Braunschweig, 2007; Stitt & Kunkel, 2008). Not surprisingly, one study found that watching food commercials cued a significantly higher commercial recall in an after-movie questionnaire for young children. The children were also allowed to freely snack while watching the commercials. Boys ate more snack foods when watching the food commercials than neutral commercials (although girls ate slightly less). Further, since the snack food was a non-advertised food brand, the increased caloric consumption was not a function of brand recognition (Anschutz, Engels, & Van Strien, 2009). The net result is an increased risk for many lifelong adverse health consequences.
Television commercials are the most prominent form of marketing in the home, with food advertisements heavily represented. These food advertisements use publicly recognizable figures, branding, and popular cartoon, television, and movie characters in order to attract a child's attention (Coon et al., 2001). These tactics create an exciting, pleasurable experience for the viewer. Most food television commercials equate food with fun and pleasure, creating an even stronger ploy to persuade viewers to purchase and consume the product (Connor, 2006).
Public figures, ranging from athletes to musicians, are often a frequent component of television advertisements. Fast-food and beverage companies often use music and dance personalities to display their latest creation. Jessica and Ashlee Simpson, two pop music artists, have collaborated to sell Pizza Hut products, while other singers, like Britney Spears and Beyoncé, have advertised for Pepsi. Celebrity influence is a high priority for food producers, and many large corporations choose to have celebrities represent their products. The image of a popular personality can increase sales and marketability tremendously. In contrast, public figures are rarely involved with alcohol and drug-related advertisements, shying away from potentially controversial advertisements. Instead music, television, movie, and athletic personalities choose to attach their characters to safer products like fast food or soft drinks even though overconsumption of processed and fattening foods can lead to life-threatening conditions.
Food corporations have a variety of methods to target children and adolescents based on their preferences and the current culture. Branding can begin as early as preschool (Connor, 2006). Branding is an advertising tactic designed to establish product familiarity and to form positive associations with a product or company name. The goal of branding for young children is to produce recognition of company names and products, increasing the likelihood of future use as an adult. Branding can be created through a memorable musical theme or sequence of events. Often children can remember a commercial's song or tune which can later trigger recollection of the product. The Kaiser Family Foundation surveyed parents of children six years old and younger and found that, on an average day, over half of the children under age two watch television even though the American Academy of Pediatrics does not recommend television viewing for children two years of age and younger (Connor, 2006; Rideout, Hamel, & Kaiser Family Foundation, 2006). To capture the attention of these young children, food producers often use cartoon, movie, and TV characters. Ronald McDonald, representing McDonald's, and the Trix Rabbit are licensed characters that can assist in the branding process. Often these characters are cross-referenced and used in other food marketing corporation strategies. Examples of these are Teletubby Happy Meals and popular Disney characters that are used to promote fast food.
As described previously, the stimulation of gustatory processes from food pictures and the frequency of commercials and images are important among food promoters of children's programming. Children's television is regularly bombarded with food and beverage advertisements, with some programs being openly supported by these companies. Nickelodeon's Nick Jr. block draws up to one million viewers ages two to five each weekday and is supported openly by advertisements (Connor, 2006). Other channels like the Disney Channel and Public Broadcasting Service (PBS) are commercial free, but they still rely on corporate sponsors who supply underwriting credits. The high frequency of food-related commercials cannot be denied. A recent study found that in 96 half-hour blocks of preschool programming, Nickelodeon, the Disney Channel, and PBS had a total of 130 food-related advertisements. The majority of the advertisements aimed at children were for fast food and sweetened cereals (Connor, 2006).
Regardless of whether children have access to television at home, many view televised advertisements at school. Channel One, a popular educational program in American middle and high schools, airs 2 minutes of commercials with every 10 minutes of current-events programming (Strasburger, 2006). Even if children are not exposed to food advertisements within the home, they will more than likely see hundreds of commercials in school.
A typical child or adolescent sees about 40,000 television advertisements a year despite the Children's Television Act of 1990. This law limits advertising on children's programming to 10.5 minutes per hour on weekends and 12 minutes per hour on weekdays (Strasburger, 2006). Along with the high amount of food and beverage promotion, nutritional misinformation can often result (American Dietetic Association, 2006). Studies have shown that high-fat and high-sugar foods like candy, soft drinks, convenience and fast foods are most frequently advertised (Harrison & Marske, 2005; Powell et al., 2007). Furthermore, children who view junk food ads report a lower liking of healthful foods (Dixon, Scully, Wakefield, White, & Crawford, 2007).
Researchers continue to report that television food advertising increases children's preferences for the advertised foods and their requests for those foods (Harris, Brownell, & Bargh, 2009). One study estimated the effects of television fast-food restaurant advertising on the childhood obesity epidemic and found that banning fast-food restaurant advertising would reduce the number of overweight children ages 3 to 11 in a fixed population by 18% and would reduce the number of overweight adolescents ages 12 to 18 by 14%. The effects of television advertising on childhood obesity cannot be denied (Chou, Rashad, & Grossman, 2008).
With the known negative effects of television viewing and advertisements on children, researchers have begun extensive studies of new approaches for a better understanding of how food marketing affects young people. For example, the newly developed food marketing defense model presents four necessary conditions to effectively counter harmful food marketing practices: awareness, understanding, ability, and motivation to resist (Harris et al., 2009). Food marketing defense models like these are often used to create media literacy education materials. Media literacy education and methods used to dispute unsound nutrition information are discussed later in the chapter.
The implications of children's excessive television exposure are apparent during adolescence. Adolescents are increasingly more overweight and sedentary, leading to health problems in their youth and later adulthood (Ogden, Carroll, & Flegal, 2008). Overweight adolescents have more weight struggles, willpower issues, and family problems compared to those of normal weight (Glessner, Hoover, & Halzlett, 2006). In particular, adolescent girls may experience body image pressures perpetuated by media-generated images because both television commercials and programs often present young, thin, attractive people. The heavy reliance on television as entertainment may contribute to serious health problems such as obesity for today's youth.
Modern lifestyles, environments play large role in obesity epidemic
If the obesogenic genetic risk profile has remained the same in humans since the obesity epidemic began, what has changed? The simple answer is that our environment has changed.
Because obesity rates have been escalating at annually measurable rates, much research money has been devoted to determining the underlying causes. Despite the world's brightest and best scientific efforts, no single gene or direct pathway explaining obesity has been identified. Numerous genetic factors may contribute to an obesogenic genetic risk profile, but this profile is only an indicator of the potential for someone to gain excess weight under obesogenic conditions. It also happens that most humans share this genetic profile favoring weight gain. There has been no significant genetic shift, mutation, or other biological change in humans in thousands of years. Thus, if the obesogenic genetic risk profile has remained the same in humans since the obesity epidemic began, what has changed?
The answer to this conundrum is both simple and complex. The simple answer is that our environment has changed; the complexity lies in determining the aspects of our environment that have changed to make it obesogenic and how we can reverse the obesogenic environment.
The spectrum of causes of death when we compare today to a century ago is remarkably different in industrialized countries. A century ago, most people died from infectious diseases such as pneumonia or tuberculosis (table 1.1), and most people died young and often relatively quickly. Even if one was overweight or obese, it was less of a concern because the typical health-compromising conditions associated with obesity tend to happen later in life, a period in the life cycle that most people did not live long enough to see. In the past century, tremendous scientific advances in microbiology, improved understanding of contagions, and the technological innovation of vaccination have eliminated nearly all deadly infectious diseases from a century ago. Now people live longer lives free from many infectious diseases, and they tend to die much later in the life span from chronic health-compromising conditions that slowly reduce the capacity of one or more organ systems. The top causes of death in industrialized countries are all chronic diseases such as heart disease, cancers, and stroke, for which obesity, lack of physical activity, and dietary habits are strong contributors (Centers for Disease Control and Prevention [CDC] & National Center for Injury Prevention and Control [NCIPC], 2008).
The dramatic shift in causes of death in industrialized society reflects the changes in our environments and resulting lifestyles. Everything has changed. Technological innovation has changed the way our food is grown, prepared, and presented in the retail marketplace. Policies promoting economic growth while yielding to political pressures have changed the food supply. Economic growth and the globalization of the marketplace have increased communication and travel, influencing lifestyle habits and changing available jobs. School policies have changed the types of physical activities taught, if they are taught at all, and the kinds of foods youths learn to love at an early age. Our individual lives have changed. We buy our food already partially or wholly prepared rather than hunt or gather it ourselves. We travel to our jobs and schools by car rather than by foot. Many of us may rely on televisions and computers that bring the world directly to the comfort of our own homes. There are many more examples.
Decisions to take part in physical activity influenced by multiple environmental factors
Many factors influence whether people use physical activity resources. In this chapter we discuss the more common factors examined in the research literature, including those we think are the strongest predictors of physical activity resource use: accessibility, proximity, safety, and the presence and quality of features and amenities, aesthetics, and incivilities.
Accessibility
Accessibility is composed of many factors that influence the use of physical activity resources and is often used interchangeably with the term usability. One important accessibility factor is ease of travel to and from the resources as well as the ease of using the resources and equipment. An accessible resource is one that is easy to approach and use; one with little or no traffic en route; one that has adequate, convenient parking; and one that is accessible via inexpensive, convenient, and pleasant public transportation. In contrast, an inaccessible resource may have no readily available public transportation, inconvenient or no parking, equipment that is difficult to understand and use, or long lines for entry and equipment use. Cost is another important accessibility factor that can influence physical activity resource use, particularly among populations of lower socioeconomic status and children and adolescents.
Accessibility is a factor in determining whether people use physical activity resources and ultimately in whether they do physical activity. Research has indicated that children and adolescents with access to physical activity resources and physical activity programs are more physically active than those without access (Allison et al., 2005; Dwyer et al., 2006; Mota, Almeida, Santos, & Ribeiro, 2005). In addition, it's important to note that populations of lower socioeconomic status typically have more limited access to physical activity resources. This is important because reduced access to physical activity resources is associated with increased body fat and BMI in low-income, minority populations (Heinrich et al., 2008). As a result, it's important to consider this additional barrier when working with populations of lower socioeconomic status.
Proximity
Proximity influences whether people use physical activity resources. Proximity can be measured subjectively using self-report questionnaires or objectively using street network or straight line distances. Briefly, network distance is the distance one would travel on streets to get to a resource, while straight line distance is the direct distance between two points; it represents the absolute distance one would travel if there were no buildings or obstacles. The more proximal a resource is to someone, the more accessible it is as well.
There is a strong relationship between proximity of physical activity resources and physical activity. In a study among low-income, midlife women, those who reported greater proximity to physical activity resources also did more physical activity (Jilcott, Evenson, Laraia, & Ammerman, 2007). There is also evidence that suggests there is a direct relationship between proximity to physical activity resources and meeting physical activity guidelines (Sallis, Patterson, Buono, & Nader, 1988). In addition, proximity to physical activity resources may be particularly important for children and adolescents, since most youth are limited to the immediate resources to which they can walk or bicycle.
Within the context of proximity, the density of physical activity resources is another factor to consider. For example, a study found that adolescent girls who lived near more parks did more physical activity than those who lived near fewer parks (Cohen et al., 2006). Similar results were found in women: Women who lived near more physical activity resources and parks were more physically active than those who lived near fewer physical activity resources and parks (Jilcott et al., 2007; Norman et al., 2006; Lee et al., 2007).
The findings from these studies stress the importance of proximity to physical activity resources. Furthermore, these studies suggest that the built environment plays a vital role in resident health and that careful community planning can affect the health of residents. Research has shown that having a nearby park or gym may help to buffer the relationship between lower socioeconomic status and engaging in less physical activity (Lee et al., 2007). As a result, creating a variety of opportunities for recreation and physical activity that are easily accessible can provide a means to increase the amount of energy expended by Americans, a crucial part of solving the obesity epidemic (figure 5.1).
Safety
Safety is freedom from danger, risk, and injury, and it plays a crucial role in determining whether physical activity resources are used. Safety can act as a motivator or a barrier to being physically active. For example, trails and walking paths may offer a feeling of personal safety because they are traditionally placed far away from cars and traffic and because they typically offer more privacy than other types of physical activity resources (Gobster & Dickhut, 1995). On the other hand, safety is most often cited as a deterrent to using physical activity resources (King et al., 2000). For example, crime and traffic are common safety concerns that prevent people from being physically active in outdoor recreation facilities (Molnar, Gortmaker, Bull, & Buka, 2004).
Playgrounds are an important setting in which children can be physically active. However, the safety of playground equipment, which has typically been overlooked in research, plays a pivotal role in determining whether children use physical activity resources. Parks and playgrounds must meet regulatory safety guidelines set forth by local, state, and federal agencies before they are deemed safe for use. Unfortunately, these safety guidelines are not always strictly enforced—older parks and playgrounds often do not meet current guidelines. This lack of enforcement has public health implications: Almost 190,000 children required emergency room treatment after being injured on public playground equipment in 2001. As a result, the condition of park and playground equipment is likely an important factor in parents' decisions about whether to let their children play in parks and playgrounds (Bedimo-Rung et al., 2005).
Some population groups are disproportionately burdened with unsafe areas that discourage physical activity. For example, children living in low socioeconomic status neighborhoods dominated by ethnic minorities typically have fewer safe playgrounds, do less physical activity, and have higher rates of overweight and obesity when compared to children in their counterpart neighborhoods (Cradock et al., 2005; Lee, Booth, Reese-Smith, Regan, & Howard, 2005).
Features, Amenities, Aesthetics, and Incivilities
The mere presence of physical activity resources is not the only determinant of their use; the availability and quality of features are important as well. Features are specific elements of resources that encourage physical activity. As an example, a baseball field is a feature that encourages users to play baseball or engage in some other types of physical activity. Features can be extremely influential in terms of the types of users they attract and in the amount of maintenance required for the physical activity resource. For example, parks with basketball courts may draw more young users, while parks with swimming pools may draw more families and adult users. However, features such as baseball fields and swimming pools require more maintenance and upkeep than features with fewer, less sophisticated features.
Features that encourage the use of physical activity resources, but are not specifically related to physical activity, are called amenities. Amenities add comfort or convenience that may influence people to visit the resource. For example, restrooms, lighting, drinking fountains, and benches are amenities that may be found in a park or along walking trails and that may influence whether people visit the park or trail. Research has shown that people are more likely to use physical activity resources with amenities than those without them (Shores & West, 2008). In addition, research has indicated that the quantity and quality of amenities at physical activity resources may be associated with the prevalence of obesity (Heinrich et al., 2008). As a result, it's important that health-conscious community planners include amenities when building or renovating physical activity resources.
Aesthetics refers to the quality, condition, and appeal of the physical activity resource and its features and can strongly influence whether a physical activity resource is used. For example, park users are more likely to visit a park with pleasant landscaping, appealing amenities, and well-maintained features. Research has shown that well-maintained amenities and features are associated with physical activity (Owen, Humpel, Leslie, Bauman, & Sallis, 2004). As a result, physical activity resources that are poorly maintained, worn down, or in disrepair will dissuade users and contribute to the obesogenic environment.
Incivilities are elements of physical activity resources that reduce the pleasure associated with their use. Examples of incivilities are auditory annoyances, broken glass, dog refuse, graffiti, litter, evidence of alcohol use, and other unpleasantries that could deter the use of a physical activity resource. It should be noted that incivilities are not created as part of the physical activity resource; they are created by users who do not consider the impact on others of the incivilities they create. In addition, incivilities may be considered a source of social disorder that can contribute to feelings of unhappiness and a lack of safety (Sampson & Raudenbush, 2004); incivilities are also associated with many poor health outcomes (Lee et al., 2005). There is no question that incivilities can deter people from using physical activity resources.
Having physical activity resources nearby, accessible, and available are good first steps toward a neighborhood that promotes physical activity among its residents. However, for most physical activity resources, the determination of whether and how they are used is much more complicated. Factors related to the accessibility of physical activity resources, along with physical activity resource features, amenities, incivilities, and aesthetics are also important to consider.
Excessive TV viewing and TV ads contribute to serious health problems among youth
Most Americans watch several hours of television each night and are bombarded by commercials (Holmes, 2008). But Americans are not alone in their television habits, despite the health detriments associated with excessive viewing.
Television advertisements are now a multimillion-dollar method of promoting the latest food product or beverage. The accessibility of a television and time to watch is also an issue for many children. Recent research suggests that children are now watching more television than ever with black and Latino children watching more television than white children (Dennison, Erb, & Jenkins, 2002; Viner & Cole, 2005). This is a public health concern because watching television typically decreases physical activity and increases the likelihood of poor dietary habits and child overweight and obesity (Gable, Chang, & Krull, 2007). For example, each additional hour of television that 5-year-olds watch on weekends increases their risk of adult obesity by 7% (Viner & Cole, 2005). Furthermore, a recent study from the American Academy of Pediatrics found that children who spend the most time watching television have higher blood pressure, regardless of body composition, compared to those who watch very little or no television (Martinez-Gomez, Tucker, Heelan, Welk, & Eisenmann, 2009). Watching television as a child can also predict future dietary habits. One recent study looked at two groups of adolescents (middle school and high school) and found that heavy television viewers reported lower fruit and vegetable intakes five years later.
Televisions are often a substitute family member for a busy household, regardless of people's awareness of the increased health risks associated with excessive exposure. Low socioeconomic status (SES) and income levels have been linked to increased television viewing and decreased physical activity (Bennett et al., 2006; Multimedia Audiences Summary, 2003). Recent research has shown that children who watch more television are more likely to be overweight or obese and children from low-income families who have a television in their room have an even higher risk of being overweight (Burdette & Whitaker, 2005; Dennison et al., 2002). Another alarming finding suggested that children from families who watch television during meals eat more meat, pizza, salty snacks, and soda than children who do not watch television during family meals (Coon, Goldberg, Rogers, & Tucker, 2001).
Although not every family owns a computer or has Internet access at home, televisions are prevalent in American households. As more families become two-working-parent households, more children come home to empty houses, resulting in television watching that is unsupervised and excessive. Parents who are absent or are busy when at home often rely on the television to provide stimulation, comfort, and entertainment (Dennison et al., 2002). As children view more television, they are also exposed to more commercials. Food advertising accounts for nearly half of these commercials, the vast majority of which are for energy dense foods of poor nutritional content (Powell, Szczypka, Chaloupka, & Braunschweig, 2007; Stitt & Kunkel, 2008). Not surprisingly, one study found that watching food commercials cued a significantly higher commercial recall in an after-movie questionnaire for young children. The children were also allowed to freely snack while watching the commercials. Boys ate more snack foods when watching the food commercials than neutral commercials (although girls ate slightly less). Further, since the snack food was a non-advertised food brand, the increased caloric consumption was not a function of brand recognition (Anschutz, Engels, & Van Strien, 2009). The net result is an increased risk for many lifelong adverse health consequences.
Television commercials are the most prominent form of marketing in the home, with food advertisements heavily represented. These food advertisements use publicly recognizable figures, branding, and popular cartoon, television, and movie characters in order to attract a child's attention (Coon et al., 2001). These tactics create an exciting, pleasurable experience for the viewer. Most food television commercials equate food with fun and pleasure, creating an even stronger ploy to persuade viewers to purchase and consume the product (Connor, 2006).
Public figures, ranging from athletes to musicians, are often a frequent component of television advertisements. Fast-food and beverage companies often use music and dance personalities to display their latest creation. Jessica and Ashlee Simpson, two pop music artists, have collaborated to sell Pizza Hut products, while other singers, like Britney Spears and Beyoncé, have advertised for Pepsi. Celebrity influence is a high priority for food producers, and many large corporations choose to have celebrities represent their products. The image of a popular personality can increase sales and marketability tremendously. In contrast, public figures are rarely involved with alcohol and drug-related advertisements, shying away from potentially controversial advertisements. Instead music, television, movie, and athletic personalities choose to attach their characters to safer products like fast food or soft drinks even though overconsumption of processed and fattening foods can lead to life-threatening conditions.
Food corporations have a variety of methods to target children and adolescents based on their preferences and the current culture. Branding can begin as early as preschool (Connor, 2006). Branding is an advertising tactic designed to establish product familiarity and to form positive associations with a product or company name. The goal of branding for young children is to produce recognition of company names and products, increasing the likelihood of future use as an adult. Branding can be created through a memorable musical theme or sequence of events. Often children can remember a commercial's song or tune which can later trigger recollection of the product. The Kaiser Family Foundation surveyed parents of children six years old and younger and found that, on an average day, over half of the children under age two watch television even though the American Academy of Pediatrics does not recommend television viewing for children two years of age and younger (Connor, 2006; Rideout, Hamel, & Kaiser Family Foundation, 2006). To capture the attention of these young children, food producers often use cartoon, movie, and TV characters. Ronald McDonald, representing McDonald's, and the Trix Rabbit are licensed characters that can assist in the branding process. Often these characters are cross-referenced and used in other food marketing corporation strategies. Examples of these are Teletubby Happy Meals and popular Disney characters that are used to promote fast food.
As described previously, the stimulation of gustatory processes from food pictures and the frequency of commercials and images are important among food promoters of children's programming. Children's television is regularly bombarded with food and beverage advertisements, with some programs being openly supported by these companies. Nickelodeon's Nick Jr. block draws up to one million viewers ages two to five each weekday and is supported openly by advertisements (Connor, 2006). Other channels like the Disney Channel and Public Broadcasting Service (PBS) are commercial free, but they still rely on corporate sponsors who supply underwriting credits. The high frequency of food-related commercials cannot be denied. A recent study found that in 96 half-hour blocks of preschool programming, Nickelodeon, the Disney Channel, and PBS had a total of 130 food-related advertisements. The majority of the advertisements aimed at children were for fast food and sweetened cereals (Connor, 2006).
Regardless of whether children have access to television at home, many view televised advertisements at school. Channel One, a popular educational program in American middle and high schools, airs 2 minutes of commercials with every 10 minutes of current-events programming (Strasburger, 2006). Even if children are not exposed to food advertisements within the home, they will more than likely see hundreds of commercials in school.
A typical child or adolescent sees about 40,000 television advertisements a year despite the Children's Television Act of 1990. This law limits advertising on children's programming to 10.5 minutes per hour on weekends and 12 minutes per hour on weekdays (Strasburger, 2006). Along with the high amount of food and beverage promotion, nutritional misinformation can often result (American Dietetic Association, 2006). Studies have shown that high-fat and high-sugar foods like candy, soft drinks, convenience and fast foods are most frequently advertised (Harrison & Marske, 2005; Powell et al., 2007). Furthermore, children who view junk food ads report a lower liking of healthful foods (Dixon, Scully, Wakefield, White, & Crawford, 2007).
Researchers continue to report that television food advertising increases children's preferences for the advertised foods and their requests for those foods (Harris, Brownell, & Bargh, 2009). One study estimated the effects of television fast-food restaurant advertising on the childhood obesity epidemic and found that banning fast-food restaurant advertising would reduce the number of overweight children ages 3 to 11 in a fixed population by 18% and would reduce the number of overweight adolescents ages 12 to 18 by 14%. The effects of television advertising on childhood obesity cannot be denied (Chou, Rashad, & Grossman, 2008).
With the known negative effects of television viewing and advertisements on children, researchers have begun extensive studies of new approaches for a better understanding of how food marketing affects young people. For example, the newly developed food marketing defense model presents four necessary conditions to effectively counter harmful food marketing practices: awareness, understanding, ability, and motivation to resist (Harris et al., 2009). Food marketing defense models like these are often used to create media literacy education materials. Media literacy education and methods used to dispute unsound nutrition information are discussed later in the chapter.
The implications of children's excessive television exposure are apparent during adolescence. Adolescents are increasingly more overweight and sedentary, leading to health problems in their youth and later adulthood (Ogden, Carroll, & Flegal, 2008). Overweight adolescents have more weight struggles, willpower issues, and family problems compared to those of normal weight (Glessner, Hoover, & Halzlett, 2006). In particular, adolescent girls may experience body image pressures perpetuated by media-generated images because both television commercials and programs often present young, thin, attractive people. The heavy reliance on television as entertainment may contribute to serious health problems such as obesity for today's youth.
Modern lifestyles, environments play large role in obesity epidemic
If the obesogenic genetic risk profile has remained the same in humans since the obesity epidemic began, what has changed? The simple answer is that our environment has changed.
Because obesity rates have been escalating at annually measurable rates, much research money has been devoted to determining the underlying causes. Despite the world's brightest and best scientific efforts, no single gene or direct pathway explaining obesity has been identified. Numerous genetic factors may contribute to an obesogenic genetic risk profile, but this profile is only an indicator of the potential for someone to gain excess weight under obesogenic conditions. It also happens that most humans share this genetic profile favoring weight gain. There has been no significant genetic shift, mutation, or other biological change in humans in thousands of years. Thus, if the obesogenic genetic risk profile has remained the same in humans since the obesity epidemic began, what has changed?
The answer to this conundrum is both simple and complex. The simple answer is that our environment has changed; the complexity lies in determining the aspects of our environment that have changed to make it obesogenic and how we can reverse the obesogenic environment.
The spectrum of causes of death when we compare today to a century ago is remarkably different in industrialized countries. A century ago, most people died from infectious diseases such as pneumonia or tuberculosis (table 1.1), and most people died young and often relatively quickly. Even if one was overweight or obese, it was less of a concern because the typical health-compromising conditions associated with obesity tend to happen later in life, a period in the life cycle that most people did not live long enough to see. In the past century, tremendous scientific advances in microbiology, improved understanding of contagions, and the technological innovation of vaccination have eliminated nearly all deadly infectious diseases from a century ago. Now people live longer lives free from many infectious diseases, and they tend to die much later in the life span from chronic health-compromising conditions that slowly reduce the capacity of one or more organ systems. The top causes of death in industrialized countries are all chronic diseases such as heart disease, cancers, and stroke, for which obesity, lack of physical activity, and dietary habits are strong contributors (Centers for Disease Control and Prevention [CDC] & National Center for Injury Prevention and Control [NCIPC], 2008).
The dramatic shift in causes of death in industrialized society reflects the changes in our environments and resulting lifestyles. Everything has changed. Technological innovation has changed the way our food is grown, prepared, and presented in the retail marketplace. Policies promoting economic growth while yielding to political pressures have changed the food supply. Economic growth and the globalization of the marketplace have increased communication and travel, influencing lifestyle habits and changing available jobs. School policies have changed the types of physical activities taught, if they are taught at all, and the kinds of foods youths learn to love at an early age. Our individual lives have changed. We buy our food already partially or wholly prepared rather than hunt or gather it ourselves. We travel to our jobs and schools by car rather than by foot. Many of us may rely on televisions and computers that bring the world directly to the comfort of our own homes. There are many more examples.
Decisions to take part in physical activity influenced by multiple environmental factors
Many factors influence whether people use physical activity resources. In this chapter we discuss the more common factors examined in the research literature, including those we think are the strongest predictors of physical activity resource use: accessibility, proximity, safety, and the presence and quality of features and amenities, aesthetics, and incivilities.
Accessibility
Accessibility is composed of many factors that influence the use of physical activity resources and is often used interchangeably with the term usability. One important accessibility factor is ease of travel to and from the resources as well as the ease of using the resources and equipment. An accessible resource is one that is easy to approach and use; one with little or no traffic en route; one that has adequate, convenient parking; and one that is accessible via inexpensive, convenient, and pleasant public transportation. In contrast, an inaccessible resource may have no readily available public transportation, inconvenient or no parking, equipment that is difficult to understand and use, or long lines for entry and equipment use. Cost is another important accessibility factor that can influence physical activity resource use, particularly among populations of lower socioeconomic status and children and adolescents.
Accessibility is a factor in determining whether people use physical activity resources and ultimately in whether they do physical activity. Research has indicated that children and adolescents with access to physical activity resources and physical activity programs are more physically active than those without access (Allison et al., 2005; Dwyer et al., 2006; Mota, Almeida, Santos, & Ribeiro, 2005). In addition, it's important to note that populations of lower socioeconomic status typically have more limited access to physical activity resources. This is important because reduced access to physical activity resources is associated with increased body fat and BMI in low-income, minority populations (Heinrich et al., 2008). As a result, it's important to consider this additional barrier when working with populations of lower socioeconomic status.
Proximity
Proximity influences whether people use physical activity resources. Proximity can be measured subjectively using self-report questionnaires or objectively using street network or straight line distances. Briefly, network distance is the distance one would travel on streets to get to a resource, while straight line distance is the direct distance between two points; it represents the absolute distance one would travel if there were no buildings or obstacles. The more proximal a resource is to someone, the more accessible it is as well.
There is a strong relationship between proximity of physical activity resources and physical activity. In a study among low-income, midlife women, those who reported greater proximity to physical activity resources also did more physical activity (Jilcott, Evenson, Laraia, & Ammerman, 2007). There is also evidence that suggests there is a direct relationship between proximity to physical activity resources and meeting physical activity guidelines (Sallis, Patterson, Buono, & Nader, 1988). In addition, proximity to physical activity resources may be particularly important for children and adolescents, since most youth are limited to the immediate resources to which they can walk or bicycle.
Within the context of proximity, the density of physical activity resources is another factor to consider. For example, a study found that adolescent girls who lived near more parks did more physical activity than those who lived near fewer parks (Cohen et al., 2006). Similar results were found in women: Women who lived near more physical activity resources and parks were more physically active than those who lived near fewer physical activity resources and parks (Jilcott et al., 2007; Norman et al., 2006; Lee et al., 2007).
The findings from these studies stress the importance of proximity to physical activity resources. Furthermore, these studies suggest that the built environment plays a vital role in resident health and that careful community planning can affect the health of residents. Research has shown that having a nearby park or gym may help to buffer the relationship between lower socioeconomic status and engaging in less physical activity (Lee et al., 2007). As a result, creating a variety of opportunities for recreation and physical activity that are easily accessible can provide a means to increase the amount of energy expended by Americans, a crucial part of solving the obesity epidemic (figure 5.1).
Safety
Safety is freedom from danger, risk, and injury, and it plays a crucial role in determining whether physical activity resources are used. Safety can act as a motivator or a barrier to being physically active. For example, trails and walking paths may offer a feeling of personal safety because they are traditionally placed far away from cars and traffic and because they typically offer more privacy than other types of physical activity resources (Gobster & Dickhut, 1995). On the other hand, safety is most often cited as a deterrent to using physical activity resources (King et al., 2000). For example, crime and traffic are common safety concerns that prevent people from being physically active in outdoor recreation facilities (Molnar, Gortmaker, Bull, & Buka, 2004).
Playgrounds are an important setting in which children can be physically active. However, the safety of playground equipment, which has typically been overlooked in research, plays a pivotal role in determining whether children use physical activity resources. Parks and playgrounds must meet regulatory safety guidelines set forth by local, state, and federal agencies before they are deemed safe for use. Unfortunately, these safety guidelines are not always strictly enforced—older parks and playgrounds often do not meet current guidelines. This lack of enforcement has public health implications: Almost 190,000 children required emergency room treatment after being injured on public playground equipment in 2001. As a result, the condition of park and playground equipment is likely an important factor in parents' decisions about whether to let their children play in parks and playgrounds (Bedimo-Rung et al., 2005).
Some population groups are disproportionately burdened with unsafe areas that discourage physical activity. For example, children living in low socioeconomic status neighborhoods dominated by ethnic minorities typically have fewer safe playgrounds, do less physical activity, and have higher rates of overweight and obesity when compared to children in their counterpart neighborhoods (Cradock et al., 2005; Lee, Booth, Reese-Smith, Regan, & Howard, 2005).
Features, Amenities, Aesthetics, and Incivilities
The mere presence of physical activity resources is not the only determinant of their use; the availability and quality of features are important as well. Features are specific elements of resources that encourage physical activity. As an example, a baseball field is a feature that encourages users to play baseball or engage in some other types of physical activity. Features can be extremely influential in terms of the types of users they attract and in the amount of maintenance required for the physical activity resource. For example, parks with basketball courts may draw more young users, while parks with swimming pools may draw more families and adult users. However, features such as baseball fields and swimming pools require more maintenance and upkeep than features with fewer, less sophisticated features.
Features that encourage the use of physical activity resources, but are not specifically related to physical activity, are called amenities. Amenities add comfort or convenience that may influence people to visit the resource. For example, restrooms, lighting, drinking fountains, and benches are amenities that may be found in a park or along walking trails and that may influence whether people visit the park or trail. Research has shown that people are more likely to use physical activity resources with amenities than those without them (Shores & West, 2008). In addition, research has indicated that the quantity and quality of amenities at physical activity resources may be associated with the prevalence of obesity (Heinrich et al., 2008). As a result, it's important that health-conscious community planners include amenities when building or renovating physical activity resources.
Aesthetics refers to the quality, condition, and appeal of the physical activity resource and its features and can strongly influence whether a physical activity resource is used. For example, park users are more likely to visit a park with pleasant landscaping, appealing amenities, and well-maintained features. Research has shown that well-maintained amenities and features are associated with physical activity (Owen, Humpel, Leslie, Bauman, & Sallis, 2004). As a result, physical activity resources that are poorly maintained, worn down, or in disrepair will dissuade users and contribute to the obesogenic environment.
Incivilities are elements of physical activity resources that reduce the pleasure associated with their use. Examples of incivilities are auditory annoyances, broken glass, dog refuse, graffiti, litter, evidence of alcohol use, and other unpleasantries that could deter the use of a physical activity resource. It should be noted that incivilities are not created as part of the physical activity resource; they are created by users who do not consider the impact on others of the incivilities they create. In addition, incivilities may be considered a source of social disorder that can contribute to feelings of unhappiness and a lack of safety (Sampson & Raudenbush, 2004); incivilities are also associated with many poor health outcomes (Lee et al., 2005). There is no question that incivilities can deter people from using physical activity resources.
Having physical activity resources nearby, accessible, and available are good first steps toward a neighborhood that promotes physical activity among its residents. However, for most physical activity resources, the determination of whether and how they are used is much more complicated. Factors related to the accessibility of physical activity resources, along with physical activity resource features, amenities, incivilities, and aesthetics are also important to consider.
Excessive TV viewing and TV ads contribute to serious health problems among youth
Most Americans watch several hours of television each night and are bombarded by commercials (Holmes, 2008). But Americans are not alone in their television habits, despite the health detriments associated with excessive viewing.
Television advertisements are now a multimillion-dollar method of promoting the latest food product or beverage. The accessibility of a television and time to watch is also an issue for many children. Recent research suggests that children are now watching more television than ever with black and Latino children watching more television than white children (Dennison, Erb, & Jenkins, 2002; Viner & Cole, 2005). This is a public health concern because watching television typically decreases physical activity and increases the likelihood of poor dietary habits and child overweight and obesity (Gable, Chang, & Krull, 2007). For example, each additional hour of television that 5-year-olds watch on weekends increases their risk of adult obesity by 7% (Viner & Cole, 2005). Furthermore, a recent study from the American Academy of Pediatrics found that children who spend the most time watching television have higher blood pressure, regardless of body composition, compared to those who watch very little or no television (Martinez-Gomez, Tucker, Heelan, Welk, & Eisenmann, 2009). Watching television as a child can also predict future dietary habits. One recent study looked at two groups of adolescents (middle school and high school) and found that heavy television viewers reported lower fruit and vegetable intakes five years later.
Televisions are often a substitute family member for a busy household, regardless of people's awareness of the increased health risks associated with excessive exposure. Low socioeconomic status (SES) and income levels have been linked to increased television viewing and decreased physical activity (Bennett et al., 2006; Multimedia Audiences Summary, 2003). Recent research has shown that children who watch more television are more likely to be overweight or obese and children from low-income families who have a television in their room have an even higher risk of being overweight (Burdette & Whitaker, 2005; Dennison et al., 2002). Another alarming finding suggested that children from families who watch television during meals eat more meat, pizza, salty snacks, and soda than children who do not watch television during family meals (Coon, Goldberg, Rogers, & Tucker, 2001).
Although not every family owns a computer or has Internet access at home, televisions are prevalent in American households. As more families become two-working-parent households, more children come home to empty houses, resulting in television watching that is unsupervised and excessive. Parents who are absent or are busy when at home often rely on the television to provide stimulation, comfort, and entertainment (Dennison et al., 2002). As children view more television, they are also exposed to more commercials. Food advertising accounts for nearly half of these commercials, the vast majority of which are for energy dense foods of poor nutritional content (Powell, Szczypka, Chaloupka, & Braunschweig, 2007; Stitt & Kunkel, 2008). Not surprisingly, one study found that watching food commercials cued a significantly higher commercial recall in an after-movie questionnaire for young children. The children were also allowed to freely snack while watching the commercials. Boys ate more snack foods when watching the food commercials than neutral commercials (although girls ate slightly less). Further, since the snack food was a non-advertised food brand, the increased caloric consumption was not a function of brand recognition (Anschutz, Engels, & Van Strien, 2009). The net result is an increased risk for many lifelong adverse health consequences.
Television commercials are the most prominent form of marketing in the home, with food advertisements heavily represented. These food advertisements use publicly recognizable figures, branding, and popular cartoon, television, and movie characters in order to attract a child's attention (Coon et al., 2001). These tactics create an exciting, pleasurable experience for the viewer. Most food television commercials equate food with fun and pleasure, creating an even stronger ploy to persuade viewers to purchase and consume the product (Connor, 2006).
Public figures, ranging from athletes to musicians, are often a frequent component of television advertisements. Fast-food and beverage companies often use music and dance personalities to display their latest creation. Jessica and Ashlee Simpson, two pop music artists, have collaborated to sell Pizza Hut products, while other singers, like Britney Spears and Beyoncé, have advertised for Pepsi. Celebrity influence is a high priority for food producers, and many large corporations choose to have celebrities represent their products. The image of a popular personality can increase sales and marketability tremendously. In contrast, public figures are rarely involved with alcohol and drug-related advertisements, shying away from potentially controversial advertisements. Instead music, television, movie, and athletic personalities choose to attach their characters to safer products like fast food or soft drinks even though overconsumption of processed and fattening foods can lead to life-threatening conditions.
Food corporations have a variety of methods to target children and adolescents based on their preferences and the current culture. Branding can begin as early as preschool (Connor, 2006). Branding is an advertising tactic designed to establish product familiarity and to form positive associations with a product or company name. The goal of branding for young children is to produce recognition of company names and products, increasing the likelihood of future use as an adult. Branding can be created through a memorable musical theme or sequence of events. Often children can remember a commercial's song or tune which can later trigger recollection of the product. The Kaiser Family Foundation surveyed parents of children six years old and younger and found that, on an average day, over half of the children under age two watch television even though the American Academy of Pediatrics does not recommend television viewing for children two years of age and younger (Connor, 2006; Rideout, Hamel, & Kaiser Family Foundation, 2006). To capture the attention of these young children, food producers often use cartoon, movie, and TV characters. Ronald McDonald, representing McDonald's, and the Trix Rabbit are licensed characters that can assist in the branding process. Often these characters are cross-referenced and used in other food marketing corporation strategies. Examples of these are Teletubby Happy Meals and popular Disney characters that are used to promote fast food.
As described previously, the stimulation of gustatory processes from food pictures and the frequency of commercials and images are important among food promoters of children's programming. Children's television is regularly bombarded with food and beverage advertisements, with some programs being openly supported by these companies. Nickelodeon's Nick Jr. block draws up to one million viewers ages two to five each weekday and is supported openly by advertisements (Connor, 2006). Other channels like the Disney Channel and Public Broadcasting Service (PBS) are commercial free, but they still rely on corporate sponsors who supply underwriting credits. The high frequency of food-related commercials cannot be denied. A recent study found that in 96 half-hour blocks of preschool programming, Nickelodeon, the Disney Channel, and PBS had a total of 130 food-related advertisements. The majority of the advertisements aimed at children were for fast food and sweetened cereals (Connor, 2006).
Regardless of whether children have access to television at home, many view televised advertisements at school. Channel One, a popular educational program in American middle and high schools, airs 2 minutes of commercials with every 10 minutes of current-events programming (Strasburger, 2006). Even if children are not exposed to food advertisements within the home, they will more than likely see hundreds of commercials in school.
A typical child or adolescent sees about 40,000 television advertisements a year despite the Children's Television Act of 1990. This law limits advertising on children's programming to 10.5 minutes per hour on weekends and 12 minutes per hour on weekdays (Strasburger, 2006). Along with the high amount of food and beverage promotion, nutritional misinformation can often result (American Dietetic Association, 2006). Studies have shown that high-fat and high-sugar foods like candy, soft drinks, convenience and fast foods are most frequently advertised (Harrison & Marske, 2005; Powell et al., 2007). Furthermore, children who view junk food ads report a lower liking of healthful foods (Dixon, Scully, Wakefield, White, & Crawford, 2007).
Researchers continue to report that television food advertising increases children's preferences for the advertised foods and their requests for those foods (Harris, Brownell, & Bargh, 2009). One study estimated the effects of television fast-food restaurant advertising on the childhood obesity epidemic and found that banning fast-food restaurant advertising would reduce the number of overweight children ages 3 to 11 in a fixed population by 18% and would reduce the number of overweight adolescents ages 12 to 18 by 14%. The effects of television advertising on childhood obesity cannot be denied (Chou, Rashad, & Grossman, 2008).
With the known negative effects of television viewing and advertisements on children, researchers have begun extensive studies of new approaches for a better understanding of how food marketing affects young people. For example, the newly developed food marketing defense model presents four necessary conditions to effectively counter harmful food marketing practices: awareness, understanding, ability, and motivation to resist (Harris et al., 2009). Food marketing defense models like these are often used to create media literacy education materials. Media literacy education and methods used to dispute unsound nutrition information are discussed later in the chapter.
The implications of children's excessive television exposure are apparent during adolescence. Adolescents are increasingly more overweight and sedentary, leading to health problems in their youth and later adulthood (Ogden, Carroll, & Flegal, 2008). Overweight adolescents have more weight struggles, willpower issues, and family problems compared to those of normal weight (Glessner, Hoover, & Halzlett, 2006). In particular, adolescent girls may experience body image pressures perpetuated by media-generated images because both television commercials and programs often present young, thin, attractive people. The heavy reliance on television as entertainment may contribute to serious health problems such as obesity for today's youth.
Modern lifestyles, environments play large role in obesity epidemic
If the obesogenic genetic risk profile has remained the same in humans since the obesity epidemic began, what has changed? The simple answer is that our environment has changed.
Because obesity rates have been escalating at annually measurable rates, much research money has been devoted to determining the underlying causes. Despite the world's brightest and best scientific efforts, no single gene or direct pathway explaining obesity has been identified. Numerous genetic factors may contribute to an obesogenic genetic risk profile, but this profile is only an indicator of the potential for someone to gain excess weight under obesogenic conditions. It also happens that most humans share this genetic profile favoring weight gain. There has been no significant genetic shift, mutation, or other biological change in humans in thousands of years. Thus, if the obesogenic genetic risk profile has remained the same in humans since the obesity epidemic began, what has changed?
The answer to this conundrum is both simple and complex. The simple answer is that our environment has changed; the complexity lies in determining the aspects of our environment that have changed to make it obesogenic and how we can reverse the obesogenic environment.
The spectrum of causes of death when we compare today to a century ago is remarkably different in industrialized countries. A century ago, most people died from infectious diseases such as pneumonia or tuberculosis (table 1.1), and most people died young and often relatively quickly. Even if one was overweight or obese, it was less of a concern because the typical health-compromising conditions associated with obesity tend to happen later in life, a period in the life cycle that most people did not live long enough to see. In the past century, tremendous scientific advances in microbiology, improved understanding of contagions, and the technological innovation of vaccination have eliminated nearly all deadly infectious diseases from a century ago. Now people live longer lives free from many infectious diseases, and they tend to die much later in the life span from chronic health-compromising conditions that slowly reduce the capacity of one or more organ systems. The top causes of death in industrialized countries are all chronic diseases such as heart disease, cancers, and stroke, for which obesity, lack of physical activity, and dietary habits are strong contributors (Centers for Disease Control and Prevention [CDC] & National Center for Injury Prevention and Control [NCIPC], 2008).
The dramatic shift in causes of death in industrialized society reflects the changes in our environments and resulting lifestyles. Everything has changed. Technological innovation has changed the way our food is grown, prepared, and presented in the retail marketplace. Policies promoting economic growth while yielding to political pressures have changed the food supply. Economic growth and the globalization of the marketplace have increased communication and travel, influencing lifestyle habits and changing available jobs. School policies have changed the types of physical activities taught, if they are taught at all, and the kinds of foods youths learn to love at an early age. Our individual lives have changed. We buy our food already partially or wholly prepared rather than hunt or gather it ourselves. We travel to our jobs and schools by car rather than by foot. Many of us may rely on televisions and computers that bring the world directly to the comfort of our own homes. There are many more examples.
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