Challenging Dogma - Fall 2009

Thursday, December 17, 2009

A Critique of Recent Obesity and Diabetes Interventions of NYC - Aiswarya Menon

Obesity is a growing epidemic in the Unites States with more than 31 percent of adults in America currently categorized as obese and on the cusp of developing, or having developed, subsequent diseases as diabetes and cardiovascular disease (23). Although many factors play into this rise in obesity levels, poor diet is a key cause of obesity. With rising health care costs and burden of supporting people suffering from the consequences of obesity, many cities and states across US are starting to implement programs that directly target daily nutritional intake of individuals. New York City (NYC) has rolled out two high profile, widespread interventions to fight the obesity and diabetes epidemics. Calorie labeling on menus and, more recently, the Pouring on the Pounds campaigns have targeted decreasing the overall caloric intake of NYC inhabitants (14, 17). Although both campaigns have substantial shock value, they lack the impetus to drive any real, long lasting behavioral change because of three fundamental errors they committed in designing these campaigns: the use of education alone to drive behavior change, the complete disregard of social and environmental context of consumers and the attempt to change such an irrational behavior as food consumption at an individual level.
On July 19, 2008, the mandate to post calories on menus of any restaurants that have a certain number of chains went into effect in NYC (18). The rationale behind the calorie labeling legislation was that research showed that people grossly underestimated the amount of calories in meals that they bought at restaurants and with the average American consuming one-third of their calories in restaurants, this was quickly becoming a public health concern (1, 14, 22). In light of the positive response to the Nutritional Education and Labeling Act of 1990 (which mandated nutrition labels on all food products sold in stores), the Department of Health and Mental Hygiene (DOHMH) designed the calorie labeling initiative to provide similar service for individuals at the point of purchase at fast food and other chain restaurants (14, 22). The hope was that seeing the calorie information prominently displayed next to each menu item, the consumer will consistently opt for the lower calorie options (14).
In addition to the calorie labeling initiative, NYC launched the Pouring on the Pounds campaign in September 2009 to fight the drinks industry (17, 19). The ad campaign, that was designed to run for three months, quite graphically showed globs of fats pouring out of soda and high energy drink bottles. The ad asks the consumers if they are pouring on the pounds and advises them to choose water, milk or seltzer as healthy alternatives to such high caloric drinks (20, 21, 2). The ads are supported by a blog where consumers can post questions about beverages and access other important information about nutrition (19). These ads are meant to serve as a reminder of how these beverages can lead to obesity and other subsequent illnesses and are specifically targeted towards adolescents (17, 2).
Education Alone Does Not Drive Behavior Change
As countless public health interventions have demonstrated, education alone that showers individuals with numbers and statistics does not motivate an individual to give up a beloved behavior. Yet, both of these campaigns heavily relies on education and the shock value of the advertised numbers to change such a fundamental human behavior as patterns of food consumption. Although for a certain subset of individuals, these initiatives can cause a momentary pause while ordering food or choosing their drink, there is no immediate incentive for individuals to adopt these behaviors into their daily lives.
The theory of loss aversion dictates that once an individual owns a behavior, they attach unreasonably high value to that behavior and is averse to giving that up (10). Therefore, showing individuals a rather gross image of fat and asking them to opt for seltzer when they are feeling their daily need for caffeine is hardly going to work. It might work the one or two times that the image from the ad is prominent in the minds of individuals but the ad has little force to cause them to give up this highly valued behavior completely. The gain of future well-being is not salient enough for most individuals to trade in the addictive behavior of drinking soda or eating what they crave while at a fast food restaurant (10).
Even for those individuals who already feel the need to change their dietary habits, these interventions provide little context to drive the change. An average American is not aware of what the recommended daily caloric intake is nor do they keep track of all the calories that they consume each day. Therefore, just showing calories of items on a menu does not ensure that consumers are aware that they are grossly overeating and need to change their eating habits. DOHMH did recently roll out an ad campaign in subways that announced that 2000 calories are the recommended caloric intake per day (16). But without offering calorie information at every restaurant that New Yorkers visit or devising a system for them to keep track of their calories throughout the day, this information provides little drive to choose that lower calorie, but more expensive item, on the menu. Especially when they are asked to consider the calories they consume from beverages in addition to their daily meals, it will likely feel as a losing battle.
These Blanket Messages Do Not Consider Social Context
Both of these campaigns are blanket campaigns that target all NYC inhabitants with little regard to the social and environmental contexts that exist while they make these decisions. In essence, these campaigns commit fundamental attribution error where they assume that people are going to make the right decision solely because they are rationally equipped to do so. But DOHMH fails to understand that much of human behavior is driven by the context in which they make the decision, including what and how much they eat or drink (10, 11).
A recent study that evaluated whether the calorie postings made an impact on food selections in a low-income, racial and ethnically diverse population of NYC found that although more people were aware of calories in their meal of choice, most did not choose the lower calorie items on the menu (5, 9). By specifically mandating that only restaurants with more than 15 chains have to post the calories on menus, this law has mainly affected fast food restaurants that are frequented by low-income and an ethnically diverse population. In this group, nutrition does not rank as high as having a cheap, filling meal (5, 9). With African-Americans, Hispanics and people of lower socioeconomic status affected most by the obesity and diabetes epidemic, more needs to be done to make this intervention accessible to them. Although they might notice the high caloric content of their meal of choice, they simply cannot afford the lower calorie, more expensive meal choice on a regular basis (5, 8, 9, 11).
Furthermore, the campaigns did not consider the differential responses based on gender norms (13). Society has created norms that dictate that women should be skinnier and more aware of their looks. Therefore, research has shown that more women notice and try to change their behavior based on the calorie postings in order to lose weight. Meanwhile men are expected to be bulky and muscular. Therefore, research has also shown that men use the calorie postings to order those meals that are high in calories in order to bulk up (13). Individuals play into societal stereotypes that counteract the intended goals of these programs.
The Pouring on the Pounds campaign is geared towards adolescents who consume high amounts of soda and high energy drinks that are detrimental to their health (17). But the campaign is designed in a way that is not easily accessible to children. Adolescents might notice the ad more because of the gory nature of the ads but they are not going to opt for the alternatives when their peer groups (their social environment) are continuing to indulge in sodas and high energy drinks (3). The ad campaign along with the blog does not have enough impetus to create a social change amongst these peer groups and without a social change in this behavior, adolescents are unlikely to give up this behavior for a healthier alternative (3).
In the end, both of these campaigns sell health to their target audience when health is not a tangible need for most individuals (12). For the adolescents, health probably does not even rank as a reason when making a food or drink choice. They are generally full of health and energy and therefore will opt for the food item or drink that they want at that moment (3). For the low socioeconomic population, survival likely ranks higher than health. Therefore, they will make the decisions that will meet their needs in a cheap and efficient manner (11).
Campaigns Assume Food Consumption Decisions are Rational
The primary downfall of these campaigns is that they assume that individuals think through their food and drink choices at every meal. The ads present information that consumers can think through rationally before making the informed decision to choose the lower calorie meal and opt for water instead of soda (14). It completely disregards the irrational and quick ways in which most individuals make such basic decision as what to eat or drink (10). New Yorkers are known to be fast-paced and multitasking individuals who are unlikely to think rationally through every meal decision in a vacuum.
There are many factors that play into the food decisions that individuals make every day. One of the more important things to consider are visceral factors. Both of these campaigns ignore visceral factors that play into making food decisions. If the consumers go to fast food restaurants when they are truly hungry or thirsty, they are unlikely to carefully consider the calorie information displayed on the menu or consider if they are pouring on the pounds, and more likely to just order what will satisfy their needs or cravings. These campaigns will only have an effect if consumers are always going into restaurants or choosing drinks in a completely neutral state (10).
Another factor that plays in daily food decisions is the optimistic bias. People are generally unrealistically optimistic about their future health (24). Therefore, they rationalize that if they have one soda a day or one high calorie meal a day, it is not going to adversely affect their own health. They rationalize that bad health only happens to people who are worse off than they are, those who are already overweight or obese or have genetics that promote cardiovascular diseases or diabetes. People do not apply the same health risks that they apply to other people to themselves because of this optimistic bias (1, 10, 24).
Both of these ad campaigns also assume the people have self-control when in reality, most people lack self-control. People are subject to the needs and cravings that are going to give them immediate gratification. With healthy food and beverage choices, individuals are not going to see the benefits of making the right choices until much later on in life. Therefore, they are going to choose the things that give them gratification right away (10). When trying to lower the caloric intake of individuals through a behavior change, there needs to something more substantial than facts to motivate individuals to gain self-control and persistently order healthier meals (10).
Finally, these ad campaigns defy the fundamentals of social marketing theory which dictates that ads should not sell the product but should rather sell something the audience wants - this commonly includes core values such as freedom, youth, love, happiness (12). Both of these campaigns explicitly sell health by showing gory images of fat and educating the consumers on calorie content of regular meals. As research has shown, individuals do not consider their health needs until they are already at risk of losing it (24). By telling people to choose healthy alternatives to soda and high calorie foods, these ads are actually threatening their freedom. In fact, competing ads have started to show up in subways that attack NYC government for taking away the consumer’s right to choose (2). In the end, as much as these ads have the shock value of showing New Yorkers how many calories and fat they are putting into their bodies every day, it has little sell to motivate them to change their eating behavior. For these campaigns to be effective, they need to sell something that the consumers want to invest in and not feel that their basic rights are being threatened (12).
Obesity is a growing epidemic in New York City and the rest of United States. As individuals start to develop the consequences of obesity, the expenses of supporting this population is also going to increase (23). Therefore obesity is a cause that is at the forefront of public health issues. The calorie postings initiative has already been approved by other cities across United States and is part of the national health reform (22). If the Pouring on the Pounds campaign makes a substantial impact, it also has the potential to be rolled out throughout the country (21). But if these campaigns are to make a true, long-lasting impact, it needs to address such basic things as social and environmental context of consumers and irrational human behavior. Before millions of dollars are poured in these campaigns, the public health departments across the country should consider if these campaigns will truly be effective for their public.
A Proposal for Changes to the NYC Obesity and Diabetes Campaigns
Obesity is a raging epidemic in the United States. A recent study found that if obesity trends continue as is, an estimated 103 million people in the United States will be diagnosed as obese by 2018 (23). The New York City (NYC) Department of Health and Mental Hygiene recently rolled out two initiatives to change the daily caloric intake of New Yorkers: calorie posting on menus and Pouring on the Pounds campaign (14, 17). Although both campaigns try to guide New Yorkers to make informed decisions, DOHMH fails to realize that individuals do not always think rationally through food choices. In order to make a better campaign, DOHMH needs to make obesity a highly ranked issue on the public agenda, create an interactive club that New Yorkers can join to part of the social movement towards beating obesity and restructure the current campaigns to not sell explicitly health.
Use Mass Media to Put Obesity onto the Public Agenda
Obesity and subsequent diseases such as diabetes and cardiovascular disease have been on the public health agenda for quite some time but it really has not caught the attention of the general public. With the obesity epidemic on the rise, people are surrounded by overweight and obese people so much so that an unhealthy weight is quickly becoming the norm. Although people might be aware that obesity is becoming an epidemic, they are not compelled to do anything about it themselves because society makes it alright to be of a certain weight and accept those who are overweight and/or obese. Society as a whole needs to change attitudes and norms about obesity and needs to consider obesity as an issue about which to be passionate.
In order to bring obesity to the forefront of issues for the public and to make their existing campaigns more powerful, DOHMH can use the basic tenets of Agenda Setting Theory. The Agenda Setting Theory deems that there is a correlation between how much the media covers certain stories to how high the public ranks the issue on their own agenda (25). DOHMH should use the media to make the issue of obesity and the two nutrition campaigns more salient to the public. Media can play a key role in shifting the public’s focus onto the obesity epidemic as an epidemic that everyone can help to fight.
Recent research has shown that one of the reasons that the calorie posting is not as effective as intended is because people who are already obese feel like they have already lost the battle to obesity and now it does not matter what they eat (4, 5, 9). DOHMH can use public figures and media to show that everyone can gain from making smart choices while eating at a fast food restaurant. Additionally, DOHMH can use media as part of the education to provide necessary context for their campaigns instead of web sites, blogs and booklets that consumers have to seek out for themselves. Essentially, DOHMH should use media to re-frame the obesity issue as a fight that everyone should be involved in and arm the public with information that they will need to join the fight. They need to make it a cause for the public not just the public health officials of the city.
Create a Low Calorie Club (LoCal Club)
One of the reasons why these campaigns are not having a widespread and persistent effect is because it aims to change individual behavior without considering social context, effects of peer groups and the heterogeneity of the NYC consumers. Consumers who frequent fast food restaurants do so because they are looking for a cheap and quick meal and lower calorie items are generally the more expensive items on the menu (9). The targeted adolescents of the beverage campaigns are going to be less influenced by adults telling them not to drink soda than by what their peers are doing (3). DOHMH needs to create a program that will make a healthy diet easy and accessible to everyone.
Research has shown that people tend to behave according to their self-attributed label. People who are already overweight or obese will continue to eat the high calorie food and drink sodas because they behave as they think someone who is fat, their label, should act. Just as adolescents who consider themselves to be teenagers who are going through the “teenage phase” are going to act like the label dictates that they act. To support the two nutrient campaigns, DOHMH needs to create a positive label for people to attribute to themselves. One way to do this would be for DOHMH to create a Low Calorie Club (LoCal Club) that people can join. DOHMH can brand the club as a distinct identity that strives to fight the growing obesity epidemic. The blogs and web sites that DOHMH currently has to promote their campaigns can be consolidated into a web site for this club. People who join the club will have the opportunity to talk to each other online and share stories about their journey to change diet. Members should also be able to track their daily caloric intake on this web site and those who sustain the 2000 calories per day diet for a certain amount of time should be awarded for it. These awards should be LoCal Club merchandise so that it further promotes this brand. Essentially, the LoCal Club will make this less about any one individual fighting their own battle against obesity and more about the group fighting a citywide fight against obesity.
With the LoCal club, DOHMH can address some of the other factors that influence food choices. First of all, people of lower socioeconomic status and minorities tend to have higher rates of obesity because they cannot afford nor do they have access to fresh, healthy food (10). With a free LoCal club membership, the city should provide people of a certain socioeconomic status lower calorie food and drinks at fast food restaurants at subsidized prices with a membership card. If the choice between higher or lower calorie food depends on price, the city should make it easier for individuals to choose the healthier option.
Finally, since New Yorkers are constantly on the move, the LoCal Club will sponsor fast food restaurants to offer a default low calorie meal of the day which would be comparable in price to higher calorie (but cheaper) food items on the menu. Research has shown that when people who are generally thinking about other things or multitasking while ordering food at a restaurant tend to make the easiest choice, the default one. This is so that they don’t have to think through their various options and figure out what they want (10). Therefore by creating a default lower calorie meal option, the consumers can easily choose that option without weighing the calories of all their different food options.
Stop Selling Health
The DOHMH should consider the fundamentals of Social Marketing Theory to restructure their ad campaigns. Unless people are at a risk of losing their health, they are not always thinking about health or driven to buy or do things such that they can have better health in the future. That is, health is not an enticing product (12). DOHMH would fare much better with these campaigns if they spend time to figure out what different groups of New Yorkers want and then sell that in their ads instead (12). The current ad posters should be less about the numbers, facts and shocking images and more about an uplifting product that New Yorkers will want to buy. There is so much more to sell about a life without obesity and diabetes than just health.
For the Pouring on the Pounds and the 2000 calories poster campaigns, the ads should feature the youth and the energy individuals can get from making healthier choices. Youth and fitness are both core values that tempt everyone. Making these food and drink choices less about health and more about sustained youthfulness and energy can make these campaigns more appealing to the general public. Currently, the ads are giving the wrong message - that the government is telling the public what they should or should not eat. They need to change this message to show that healthy lifestyle is choice that the public can make to regain youth, happiness and to live a long life.
Finally, to create a strong brand of the LoCal Club, the DOHMH should air ads that accompany the poster ads that are already in circulation. These ads should not sell health but rather products that appeal to potential members after they join the LoCal Club. The DOHMH should hire an actual advertising company and do research on what specific groups are looking for and market their product to specific audiences. It should not be a blanket commercial but rather different ones that target different groups of audiences (12, 11).
With the use of social and advertising theories, DOHMH can create a stronger campaign to promote better nutrition. By making obesity a battle that everyone can fight in and make a difference, it becomes less of an individual struggle and more of a social movement. Additionally, creating a brand such as the LoCal Club gives members an identity and a label that they can proud of and which will motivate them to change their eating habits. Finally, these campaigns need to promise the consumers core values that they desire such as youth, happiness and longevity. By making these key changes, DOHMH can help curb the rising obesity and diabetes epidemic and make for stronger and healthier America.
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