A Preliminary Study of the Meanings Children Attach to Healthy and Unhealthy Lifestyles

Over the past 30 years, the incidence of childhood obesity in the United States has tripled. Current estimates suggest that 15% of American children aged 6 to 19 are overweight, which places them at a higher risk for becoming overweight adults and thus for developing health problems in later years (e.g., cardiovascular disease and diabetes) (Ogden, Flegal, Carroll, & Johnson, 2002). This upward trend in childhood overweight and obesity has roused concern among health professionals, moving them to make calls for government, industry, and families to work toward the prevention of childhood obesity and the promotion of healthy lifestyles among children (International Food Information Council [IFIC], 2004; National Academies' Institute of Medicine [IOM], 2006).

As researchers in health and family and consumer sciences, we appreciate the importance of preventing childhood obesity and of teaching children to make healthful choices about diet and physical activity. At the same time, we are concerned about consumer culture messages that constitute an interpretive context for obesity prevention campaigns targeting children. In particular, we are troubled by consumer culture's idealization of extreme thinness and its equation of thinness and healthfulness (Shilling, 2003). In this context, appearance and healthfulness may become obscured, and bodies that do not meet demanding cultural norms of thinness may be assumed to be unhealthful (Edgley & Brissett, 1990).

With the present work, we build a foundation for responding to calls to promote healthful lifestyles among children and to prevent childhood obesity. This article describes results from four focus groups exploring the meanings that children attach to concepts such as health, healthy lifestyles, and healthy bodies. The focus groups were conducted as a preliminary study in support of a larger research agenda proposing to develop and test educational curricula aimed at concurrently promoting healthful eating, regular exercising, and an emphasis upon the physical functioning of the body rather than its size or appearance, a focus that is sometimes associated with the "health at any size" paradigm (Campos, Saguy, Ernsberger, Oliver, & Gaesser, 2006).

The need for the preliminary study arose as our interdisciplinary research team recognized that any efforts undertaken to develop educational programming and instruments to measure children's attitudes and knowledge about health must be informed by an "insider understanding" of the meanings that children attach to the ideas of "health" and "healthfulness."

However, a literature search revealed that much of the work exploring children's health-related beliefs has incorporated (a) forced-choice response formats, which do not allow participant perspectives to emerge, (b) questions worded such that the "right" answers were obvious, and (c) "yes/no" questions, which are problematic, given the tendency of children to acquiesce to adults (see Macaux, 2001; Proponnett, 1997; Young, 2003). The study reported here, which used an open-ended response format, was designed to overcome these methodological flaws in prior work.

Method

Four focus groups were conducted with children aged 5 to 12 years (n = 64). Focus groups are an effective way to access the meanings systems of young children, who may find one-on-one interviews intimidating (Madriz, 2000). Participants were divided into four groups by age and gender. Table 1 includes mean ages and body mass indices for each group.

Table 1.
Focus Group Participants

	Means	Means
	Younger Girls 5 - 8 years (n = 23)	Older Girls 9 - 12 years (n = 16)
Age	6.81	10.18
Body Mass Index	15.91	20.08
	Younger Boys 5 - 8 years (n = 14)	Older Boys 9 - 12 years (n = 11)
Age	7.17	9.89
Body Mass Index	17.01	21.82
Note: Body mass index is an estimate of body fatness that is adjusted for height. The range for a normal BMI changes with a child's age, decreasing after 12 months of age and reaching a minimum at four to six years of age. Thus, BMIs for children must be interpreted using a BMI-for-age chart (see http://cdc.gov/growthcharts/). If BMI-for-age is ≥ 95th percentile, the child is considered overweight. At 4, 9, and 13 years of age the BMI-for-age scores at the 95% percentile are 17.8, 21.0, and 25.1 (Center for Disease Control, 2002).

Participants were children who had voluntarily enrolled in a "Fun LIFE" summer camp offered at a large U.S. university. Fun LIFE camp is designed for elementary school-aged children and focuses upon Learning to Improve Fitness and Eating (thus, the acronym "LIFE"). Campers participate in physical and creative classroom activities examining nutrition, fitness, and healthy lifestyles. Fun LIFE participants register for the camp on a first-come, first-served basis and represent diverse ethnic and socioeconomic backgrounds. Because the camp is administered by a university, permission to include the children in relevant research studies is sought from the campers and their parents.

Focus groups were conducted at the beginning of the camp session, before participants were exposed to the camp curriculum. Focus group questions explored definitions of a healthy body and what it means to lead a healthy lifestyle. Following are some sample focus group questions:

• When you hear the words, "healthy lifestyle," what does it mean to you?


• What things make you healthy?


• What is a healthy body?


• What can a healthy body do?


• Is it important to have a healthy body? Why/why not?

Data were audio-recorded and transcribed. All authors participated in the analysis process, which focused upon the identification of key themes. The authors' backgrounds represented diverse areas--including Cooperative Extension, family and consumer sciences education, nutrition education, youth development, health and exercise science, and body image--and thus afforded multiple perspectives on the data.

Emergent Themes: A Model of Children's Logic About Healthfulness and Unhealthfulness

Findings are visually represented in Figure 1, A Model of Children's Logic About Healthfulness and Unhealthfulness. The model includes two separate components: one that reflects the participants' logic about healthfulness and one that addresses participants' understanding of unhealthfulness. These two components were included because participants frequently defined healthfulness in terms of what it was not, contrasting what they perceived to be healthy and unhealthy behaviors. Additionally, the model illustrates the way in which participants conceptualized healthfulness and unhealthfulness in terms of "inputs" and "outputs." Here, behavioral antecedents related to food intake, exercise participation, and hygiene habits were seen as directly linked to specific well-being and appearance outcomes.

Figure 1.
A Model of Children's Logic About Healthfulness and Unhealthfulness

In this section, we discuss the components and relationships that are included in Figure 1. Where appropriate, we make observations about the possible influence of age and gender upon participant responses. The following abbreviations are used to identify remarks made by participants in the younger girls', younger boys', older girls', and older boys' groups: YG, YB, OG, and OB, respectively.

Antecedents of Healthfulness and Unhealthfulness

Good Versus Bad Foods

Participants viewed eating behavior as a key component of a healthy or unhealthy lifestyle, readily identifying foods that would contribute to or undermine healthfulness. Two ideologies about the healthfulness of various foods emerged. The first ideology was marked by a dualistic logic in which foods were categorically classified as either "good" or "bad." Foods frequently identified as good or healthy included fruits, fish, low-fat items, meats, salads, vegetables, milk, orange juice, and water. Junk foods, hamburgers, hotdogs, and foods high in salt and sugar were identified as potentially unhealthy. Younger children were more inclined to invoke this type of simplistic, binary logic in conceptualizing the relative healthfulness of foods: "[My] brother isn't healthy because he eats lots of sugar, doesn't eat carrots, and eats lots of junk food like hot dogs" (YG).

The second ideology used to conceptualize the healthfulness of various foods involved a more complex understanding of nutritional value in the context of one's overall diet. Here, participants acknowledged the importance of a balanced diet and conceded that a limited amount of fat and sugar could be part of a healthy lifestyle. Although such observations were more common among older children, even younger participants occasionally made comments to this effect: "We need a little fat in our diet, and we need carrots and vegetables. If we don't have fat, we won't be healthy. We need a little fat" (YG).

Additionally, some participants viewed the building of a healthy diet as a tricky task that required careful monitoring of foods consumed. Here, slight deviations from the "right proportions" of foods eaten were seen as threatening to health: "If you eat too much meat, you'll get too fat. If you only eat vegetables, you could get too skinny, and you might starve. And, you have to eat the right amount of things, you have to get the well-balanced diet" (OB).

Finally, participants--particularly girls--occasionally conceptualized healthful eating in terms of unpleasantness and denial. Older girls' remarks were sometimes reflective of behaviors associated with weight loss diets. These girls defined healthful eating as "not eating too much," and in some cases, they identified low-fat or low calorie foods (e.g., baked chips) as healthy.

Active versus Sedentary Lifestyles

Participants identified physical activity as part of a healthful lifestyle. Although both girls and boys identified exercise as essential to healthfulness, boys were much more likely than were girls to identify specific physical activities that they participated in. Boys named a wide variety of sport and game activities as contributing to a healthy way of living, including baseball, basketball, biking, cricket, golf, gymnastics, fencing, hockey, jogging, river rafting, rugby, taekwondo, and walking.

Participants identified a sedentary lifestyle as unhealthy, here again using a dualistic or categorical logic system to structure their thinking about healthy and unhealthy lifestyles (active = healthy, inactive = unhealthy). The older boys frequently mentioned prolonged or frequent participation in video or computer games as an unhealthy: "It's not activity to play video games! If you only play it once in awhile is okay. I only play them on vacation" (OB).

Similarly, older girls conceptualized "indoor activities" as more likely to be inactive and as less health promoting than outdoor activities.

Finally, although they acknowledged the value of physical activity, a few of the older boys indicated that their desire to exercise or play outside was impeded by safety concerns (e.g., living in a dangerous neighborhood) and difficulty in identifying nearby playmates.

Good Versus Bad Hygiene Habits

Participants in all groups except for that comprising younger boys identified good and poor hygiene habits as contributing to healthfulness and unhealthfulness, respectively. The following behaviors were viewed as central to good hygiene and thus good health: hand and face washing, showering, teeth brushing, getting an appropriate amount of sleep, and avoiding sunburns. These behaviors were conceptualized as part of "taking care of yourself" (OG). Conversely, not engaging in these behaviors on a regular basis was perceived as a threat to good hygiene, and consequently, to being healthy. Additionally, being too stressed was perceived as unhealthy.

Outcomes of Healthfulness and Unhealthfulness

Growth and Physical Effectiveness

Participants of all ages and genders indicated that eating a healthy diet and exercising frequently could bolster one's strength and the efficiency of one's bodily systems: "[with exercise and a healthy diet] your body will be able to build stronger immune systems, stronger blood systems, stronger muscles, tendons…and you can keep going" (OB).

Among younger participants, consuming a healthy diet was viewed as an essential antecedent to growing or to getting bigger. At this age, growing bigger and gaining weight were viewed in a positive light: "You should eat lots of fruits and vegetables because they give you weight and strong bones" (YG).

Additionally, being healthy was viewed as enhancing one's physical effectiveness, or his/her capacity for doing things and for enjoying life. This view was shared among participants of all ages and genders: "[Eating healthy] makes you grow bigger…if you are like that big, you can do anything" (YB). "If you're healthy you can go to camps, play sports, have fun" (OG).

Sickness/Disease

Leading a healthy life--including eating the right foods or a balanced diet, exercising regularly, and maintaining good hygiene--was viewed by participants as imperative to warding off sickness and disease: "My doctor [taught me] that eating healthy keeps you from getting sick" (YG).

Two primary themes emerged in relation to disease prevention. First, with one exception, a well body was conceptualized as an unequivocally thin and fit one: [A healthy body]: "looks like a pencil" (YB); "has muscles and not too much fat" (YG); "is skinny" (YG); and "is fit, strong, and lightweight" (OB). In some instances, participants even attributed an increased life expectancy to weight reduction: "[My dad] lost twenty-five pounds, and he added ten years to his life" (OB).

Second, participants envisioned specific hygiene practices--such as hand washing, teeth brushing, and getting an adequate amount of sleep--as integral to both physical and emotional wellness.

Conversely, unhealthy eating habits and an inactive lifestyle were seen as promoting sickness and disease. Across gender and age groups, poor eating and exercise habits were presumed to increase one's risk for diseases such as cancer and diabetes as well as for premature death: "[Living healthy] increases the time you live, because if you're healthier your body can last longer and work. It's stronger"(OB). "Don't get overweight and get diabetes. You have to be in the hospital for a long time" (OG).

As the second quote above illustrates, being overweight was framed as a grave threat to health. Although one younger girl participant indicated that she thought it was most healthy to be "middle size," none of the participants conceded that an overweight body also could be a healthy one. Thus, it is perhaps not surprising that participants frequently mentioned weight loss as a conduit to improved health. Implicit here were the assumptions that body size (a) can readily be altered through changes in diet and exercise and (b) is a matter of personal responsibility that warrants monitoring and attention. Here, individuals who did not keep their weight in check were perceived as needing to attend to their bodies by changing their lifestyles: "If you have too many carbs in your body, you have to burn those calories off" (OB).

Finally, a few participants also acknowledged that being too thin could pose a risk to one's health. Although none of the participants used the phrase "eating disorder" in their conversations, it was clear that they were aware of the potentially negative consequences of pervasive cultural pressures to be thin.

Attractiveness

Like the popular culture discourses surrounding them, participants frequently conflated issues of appearance and health. Thus, an attractive appearance was interpreted as a signal of good health and an unattractive one was thought to indicate unhealthiness. Among girls, especially, being attractive--or having good teeth, skin, and hair--was viewed as the product of fastidious hygiene habits. Conversely, having discolored teeth or unclear and oily skin was associated with being unhealthy or failing to take proper care of oneself.

Implicit here was the assumption that one can control such characteristics as the oiliness of one's skin through adherence to certain behaviors (e.g., face washing). Participants also suggested that thin and toned bodies were not only the healthiest, but also the most attractive. Both the social value accorded to the appearance of a healthy or thin body as well as the stigma attached to a body that does not appear to be healthy are reflected in the following comments, which suggest a concern among participants about appearance-related teasing: "And um the other thing about having a healthy lifestyle is um that people won't pick on you, and say, 'You're a freak and stuff.'" (OB). [Why is it important to have a healthy or thin body?] "So you won't be teased" (OG).

Discussion and Implications

Findings point to a number of concerns relevant to health-related Extension programming for elementary school-aged children. First, that the majority of participants readily identified foods widely understood among nutrition professionals to be healthy or unhealthy as "good" and "bad" foods, respectively, may reflect the effectiveness of on-going Extension efforts to prevent childhood obesity by communicating to children a better understanding of the relative healthfulness of various foods and the link between diet and well-being. At the same time, however, the participants' identification of "good" and "bad" foods may suggest a relatively simplistic and rigid understanding of what it means to be healthy.

The danger in this conceptualization is that it fuels an "all or nothing" approach to healthfulness in which some foods are treated as wholly "bad" and "off-limits." Such an ideology may lead to unhealthy eating behaviors and conflicts with the position of the American Dietetic Association (ADA), which suggests that all foods can fit into a healthful eating style, so long as they are consumed in moderation and combined with regular exercise (Freeland-Graves & Nitzke, 2002).

Although this view was expressed by a minority of participants in the present study, it was not widely held within this sample. As such, we believe that educational materials addressing health and obesity prevention should be designed to help educators move children--in developmentally appropriate ways--beyond the dualistic "good food/bad food" model. Such programming should aim to engender within children an understanding of healthfulness that emphasizes the overall diet or pattern of food consumed rather than focusing upon the relative healthfulness a few specific foods in isolation.

Second, that participants viewed being overweight as a potential health risk may suggest the efficacy of existing obesity prevention programming. However, this finding also suggests that participants did not recognize that healthy bodies can come in diverse shapes and sizes, a position that is gaining some support among health professionals (Campos et al., 2006; Miller & Jacob, 2001). Further, participants' comments suggest a stigmatization of people whose bodies do not meet cultural demands of thinness and an assumption that, with the "right" lifestyle, any body can be thin.

This observation, along with some female participants' equation of healthful eating with denial, points to a need for programming promoting healthful eating and exercise among children (as described by the ADA) while at the same time encouraging them (a) to question strong cultural messages promoting the value of a singular body ideal (i.e., thinness), (b) to consider factors beyond appearance (e.g., physical functioning) in assessing healthfulness, and (c) to adopt sensitive attitudes toward persons of diverse body shapes and sizes. Because research suggests that regular exercise improves health for people of any size (Blair & Church, 2004), this curriculum should focus on the health and social benefits of exercise and underscore the potentially negative outcomes of weight-related teasing (e.g., low self-esteem) (Klaczynski, Goold, & Mudry, 2004).

Third, that participants conceptualized hygiene as part of a healthful lifestyle was an unexpected finding and may point to the value of including a hygiene component in health curricula. To respect the ways in which appearance management practices may vary across individual families and cultural groups, we recommend that educational content related to hygiene emphasize health rather than appearance outcomes, underscoring the efficacy of given hygiene practices--such as regular hand washing and teeth brushing--in preventing disease (Carvalho, Van Nieuwenhuysen, & D'Hoore, 2001; Uhari & Mottonen, 1999).

Fourth, the finding that all participants viewed physical activity as part of a healthy lifestyle is encouraging. That girls did not discuss their participation in physical activities to the same extent as did boys, however, may highlight a potential need for programming designed to promote physical activity among girls. Before pursuing the development of such programming, further research should be undertaken to assess need; participants in this study were not directly asked to report the frequency of participated in physical activity.

Finally, that participants identified safety and social concerns as obstacles to participating in regular exercise points to the need for organized, adult-supervised physical activity events designed for youth residing in high risk neighborhoods. To afford all children safe and convenient access, these activities should be held on public school grounds or in close proximity to children's residences.

Conclusions

This preliminary study yields insights about the ways in which elementary school-aged children think about and understand healthy and unhealthy lifestyles. Figure 1 provides a valuable representation of the logic children may use in conceptualizing what behaviors are healthy or unhealthy and how those behaviors may contribute to health- and appearance-related outcomes. Findings provide valuable insights about the need to develop a health curriculum that encourages sensible food choices within the context of one's overall diet, regular exercise, and more flexible ideas about what a healthy body looks like. Beyond informing the development of curricula, the present findings also underscore the value of:

• Invoking qualitative approaches to identify meaning systems relevant to a research sample or the audience of an educational program;


• Being open to unexpected findings, which may shape the direction of subsequent research or curriculum development efforts; and


• Working with a multidisciplinary team whose diverse perspectives afford a multifaceted interpretation of the data.

Last, findings suggest fruitful directions for future research. Results provide a foundation for the development of quantitative instruments that tap children's health beliefs in a holistic manner and that incorporate ideas and language salient to young respondents. Additionally, because the present sample was both small and potentially biased (e.g., by virtue of their enrollment in a healthy lifestyle camp, it is likely that participants were growing up in families who were predisposed to value healthfulness), it will be important for future researchers to explore the health-related beliefs of children using larger, generalizable samples free of this bias.

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