Challenging Dogma - Fall 2009

Wednesday, December 16, 2009

Help Stop Childhood Obesity: A Critique and Reformulation of the “Change4life” Campaign of U.K Government -Yang Wang

Section 1: Introduction

Prevalence of overweight and obesity has been increasing over last several decades. In 2005-2006, 67% of the adults in United States were overweight or obese; out of these 34% were obese (1). 15% of children aged 6 to 11 and 18% of adolescents aged 12 to 19 were overweight, respectively. Similarly, data from Health Survey for England (HSE) shows that in 2007, 60.8% of adults aged 16 or over in England were overweight or obese; of these, 24% were obese. In 2007, 28.6% of children aged 2 to 10 in England were overweight or obese; of these, 15.4% were obese (2).

The increasing prevalence of obesity in children is a result of high-calorie diet, decrease of exercise and increase of sedentary lifestyle (3). Consumption of fast-food has been a preeminent dietary pattern in the United States and United Kingdom today (3, 4) . Several factors of fast-food such as massive portion size, high calorie density, high density of saturated acid and trans fat and low content of fiber have all contributed to obesity of children(3). In addition, low levels of physical activity have also been shown to contribute to children obesity and consequent circulatory problems. Data from the CDC report shows that high students’ participation in physical education has declined by 30% in the past decade (5). Marketing campaigns and pervasive advertisements of fast-fast also drive adults and children to consume fast-food (3). Studies shows that children spend an average of 5.5 hours per day averagely using various media and are exposed to an 40,000 television commercials annually(6). Most of these commercials are for candy, fast-food and high sugar cereal (6, 7). Furthermore, parents report that they prefer that their children watch TV at home rather than play outside unattended because parents then can complete some chores while keeping an eye on their children(8).

On January 3 2009, the UK Government started a “Change4life” campaign. The ambition of this campaign is “to be the first major nation to reverse the rising tide of obesity and overweight in the population by ensuring that everyone is able to achieve and maintain a healthy weight”(9). The initiative of the Change4life campaign targets families with children under 12 years old. Its goal is to reduce the proportion of overweight and obese children to the 2000 level by 2020 (9). Change4life campaign launches television advertisements, billboards to build awareness of what families can do to live healthy lifestyles and prevent childhood obesity (9). The first advertisement, which is available on YouTube, starts with a stone-age family in the shape of cartoon-like dough figures hunting a mammoth and hitting a dinosaur with clubs. The picture moves on to a modern-day family eating pizza and playing electronic games. One day the child finds that there is too much fat in his body, so the modern-day family decides to change their lifestyle. The slogan of the Change4life campaign is “Eat well, move more, live longer” (9). Subsequently, the Change4life campaign focuses on“8 changes of lifestyles” including “sugar swaps, 5 a day, meal time, snack check, Me size meal, cut back fat, 60 active minutes, up and about”(9).

This paper focuses on the UK “Change4life”campain. It presents three critiques of the“Change4life”campain and then proposes and supports an alternative intervention to address the three flaws of the“Change4life” campaign.

Section 2: Critiques of the “Change4life” campaign

This section presents three flaws of the “Change4life” campaign. First, it assumes that food consumption and physical activity behavior is rational. Second, it does not incorporate some important environmental and social factors into the campaign. Third, it does not apply advertising and marketing theory appropriately.

The “Change4life” campaign assumes food consumption and physical activity behavior are rational

The “Change4life” campaign makes a assumption that when parents and children are told that unhealthy diet and lack of exercise can cause obesity and consequent heart disease, type 2 diabetes and cancer, parents and children will weigh the pros and cons of changing unhealthy food consumption and physical inactive behavior and the outcome of weighing will lead people to choose a healthy lifestyle.

This assumption is based on the Health Belief Model (HBM), in which an individual would balance the perceived benefits of taking an action against the perceived barriers of taking that action (10). In the “Change4life” campaign, the benefits refer to helping children avoid obesity and live longer. Perceived benefits result from the perceived susceptibility to the specific health outcomes and perceived severity of the health outcomes (10). The result of balancing benefits and barriers decides the intention of taking an action, and this intention finally dictates behavior changing (10).

However, “Change4life” ignores the fact that some irrational factors may affect the perceived benefits and perceived barriers.

One fact is unrealistic optimism: people tend to think their risk of experiencing negative events is lower than others. This unrealistic optimism may affect their perceived susceptibility and perceived severity of obesity (11). The likelihood of belief that their own chances of a negative event are lower than average increases when the event is more undesirable and when people perceive it is controllable (11). The undesirability of obesity and its consequent health problems and the belief that people can control their own food consumption and physical activity behavior would increase the optimism bias. Parents and children may be unrealistically optimistic that they will not be obese if they choose unhealthy diet or exercise little.

Second, time preference of behavior may affect the perceived benefits. That is, people give less preference to delayed outcomes compared to immediate outcomes (12). The benefits of healthy food and taking physical activities occur so far away in the future that they may seem little value to the individual relative to the immediate costs (12). People give greater weight to current costs of having healthy food or doing physical activities, such as less desirable taste of healthy food, exhausted feeling after exercise than future benefits of improved health (13). This phenomenon of behavior especially affects the perceived benefits among young children. Young children are concerned their realistic day-to-day lives rather than their future health conditions and the benefits of choosing fast-food, such as good tastes, lower prices or opportunity to make friends concern them more than being obese and developing heart disease, type 2 diabetes and cancer.

Also, time preference of behavior affects the perceived barriers because the current costs of having healthy food are tangible and immediate (10,13). Studies showed that children found that taste and the presentation of products such as sweets, chocolate, fizzy drinks and fast food hugely appealing. Many children think the temptation of fast food and drink is “too hard to resist” (14). In addition, for parents, prices, tastes and convenience of food are important when they choose food (15). Therefore, choosing healthy food means higher prices, less appealing taste and less convenience. These tangible and immediate costs of choosing healthy food may place inappropriate weight on perceived barriers, which will affect the intention of changing behaviors.

Another two bias- status quo and default biases which mean that “individuals are highly prone to keeping with customary (status quo) and default options even when superior alternative are available”(13) also contribute to an increase of perceived barriers. According to status quo and default biases, people are likely to adhere to what they have done in the past or what is automatic (13). This helps explain the lack of success of many interventions that attempt to change people’s behavior by simply informing them of the risks of bad behaviors or convincing them of the benefits of good behaviors (13).

Even though people have the intention to change unhealthy behaviors, there are many other environmental factors such as the unavailability of healthy food in dining halls of schools and social factors such as influence of organization structure of school (16), exposure to heavily marketed and branded food products (14) that will influence the conduct of behavior. We will discuss about the influence of environmental and social factors influencing children’s behavior in the next section.

In summary, “Change4life” campaign is flawed because it assumes that people will make a rational decision to change the unhealthy modern lifestyle when they are presented with the perceived benefits of choosing healthy lifestyle by simplistic advertisements. In reality, intervention to reduce children obesity requires consideration of irrational factors that affect behavior.

The “Change4life” campaign fails to consider some important environmental and social influences on behaviors

“Change4life” campaign calls for support and action from health and education professionals, charities, government agencies, the media and stakeholders in the private sector(9) to convey the message of “Eat well, move more, live longer”. However, the “Change4life”fails to incorporate some important environmental and social factors which can influence behaviors of children or parents (17).

First, the “Change4life” campaign fails to incorporate the school environment. Children who are 6-11 years old spend about half of their time every day at schools. The organizational structure in schools affects a child’s food choices and physical activities. A study shows that if there are lengthy queues at the school lunch room, children will opt to buy their lunch at local shops, choosing fast food outlets that have the shortest or fastest moving queues in order to eat quickly and resume other non-food activities (16). Even if children bring healthy lunches which their parents prepare for them, they will also probably neglect their homemade lunches just because their friends choose to go to a fast food restaurant and they do not want to lose the opportunities to be with friends. Also, children in schools spend less time in physical education classes (18). Schools are forced to reduce or eliminate time for recess and physical education classes in an attempt to meet the expectations of state and federal pressure to improve performance on state proficiency tests (18). As a result, only 21% of school children attend weekly physical education classes (18).

Second, the “Change4life” campaign ignores the influence of food marketing. Food advertising campaigns link fast-food, soft drink and candy products with enticing features such as movies, cartoon characters, toys, video games, branded kid clubs and educational materials(19, 20). Such advertising is especially influential among children younger than 8 years (18). In schools, fast-food vendors and other types of food-related advertising in school computer screen savers, yearbook pages, school media channels, and textbook covers are increasing (18). Children are exposed to these food advertisements every day and their food consumption are influenced greatly by these advertisements. US General Accounting Office report shows that soft drink and sport drink consumption has increased by 500% in the past 50 years (21). Ridiculously, the “Change4life” campaign has decided to allow sponsorship by commercial companies including PepsiCo and Kelloggs—the makers of the very products that contribute to obesity (22).
In summary, the “Change4life” campaign fails to incorporate the environment of school and food marketing into the intervention which may influence children’s behavior very largely. It makes a fundamental attribution error (23) that attributes behavior to individual characteristics rather than the context in which the behavior is conducted.

The “Change4life” campaign fails to apply advertising and marketing theory appropriately

The “Change4life” campaign realizes that “to be successful it has to appeal to everyone” (9) and has launched television advertisements, billboards, and posters by using social marketing principles. Unfortunately, the “Change4life” does not apply advertising and marketing theory appropriately. It provides an inappropriate promise to target audience and use poor images to support the promise it makes.

The benefit that the “Change4life” campaign offers to its target audience is health. However, because of unrealistic optimism and time preference, people do not take health but price, taste or convenience as the primary consideration when choosing food. Moreover, health itself is not the thing people value most (24). Rather, the independence, freedom, control and autonomy that comes with being healthy are what people really need and desire (24). The “Change4life” campaign provides a promise that if you eat too much or do not take exercise, you will have fat deposits in your body and become obese. This promise does not fulfill the deep aspirations of the target audience, but instead frustrates people and gives them no hope.

Exchange is one of the important components of social marketing (25). If you ask someone to give up, or modify, an old behavior or accept a new one, you must offer that person something very appealing in return because people have feeling of ownership to the behaviors they are making now (26). In commercial marketing, many fast-food advertisings master this important component to make their products successful. For example, by drinking Pepsi, consumers feel they receive everything that goes with the image of brand which includes control over life, freedom and attractiveness (25). But the “Change4life” campaign does not research the target audience well enough to understand what will motivate them to make changes in their lives.

While the advertisements of the “Change4life” campaign make an attempt to fulfill the principle of social marketing theory by creating a symbolic image to support the promise, the use of cartoon-like dough figures portrays an entirely unrealistic situation. Furthermore, the ads use many exaggerated and preposterous behaviors to support how unhealthy food and sedentary lifestyles affect our health. In one ad, the child opens a slide fastener on his belly to let his parents see how much fat is deposited in his intestinal tract. And in another ad, parents feed the child dishes with a truck: they load sausages and other unhealthy food on a truck and pour them onto their child’s dining plate. These unrealistic images and exaggerated, preposterous behaviors undermine people’s willingness to change behaviors. They also fail to increase parents’ understanding of unhealthy lifestyles because they convey information that only when you feed your child with dishes as large as a truck load does your family experience unhealthy lifestyles and your child become obese.

Failing to apply advertising and marketing theory appropriately undermines the effectiveness of the “Change4life” campaign in changing unhealthy lifestyles of families.

Section 3: A Reformulation of the “Change4life” campaign

This section proposes an intervention which addresses the three flaws of the “Change4life” campaign. The proposed intervention acknowledges that people do not behave rationally and are influenced by many environmental and social factors. It uses two techniques: asymmetrical paternalism (13) and marketing theory (24) to modify the three flaws we mentioned in the previous sections.

Asymmetric paternalism is asymmetric in the sense that it helps individuals who are prone to behaving irrationally without affecting those individuals who are making informed, rational decisions (13). It changes behavior without limiting individuals’ freedom of choice (13). Asymmetric paternalism is paternalistic in the sense that it helps people to achieve their own goals(13).

First, the proposed intervention uses asymmetrical paternalism to address different biases which make behavior irrational.

To address the status quo and default options biases, the proposed intervention would replace the soft drink with a bottle of water as a default, with soda serviced only on request. With soda as a default drink in most chain restaurants currently, people usually choose soda because of status quo and default options. Replacing soda with a bottle of water will preserve the freedom of choice while potentially make a change in beverage consumption behavior(13).

To address time preference, the proposed intervention would position soft drink vending machines in obscure places and serve healthy food in convenient containers that could be obtained and consumed quickly in schools(13, 27). To place soft drink vending machines in obscure places will help to address time preference because people will not constantly have to choose whether or not consume them(13), which requires and depletes the will power of choosing healthier alternatives. Also, to serve healthy food in convenient containers that could be obtained and consumed quickly in schools would allow children to choose healthier food in a more convenient way and leave them free time for other desired activities. It changes short-term incentives rather than requiring them to make decisions based on consideration of a long-term best interest (13).

Second, the proposed intervention uses asymmetric paternalism in several ways to address the flaw of the “Change4life” campaign of failing to incorporate some important environment and social influences into the campaign.

Price is an important factor which can influence people’s food consumption (15). The proposed intervention has recognized the influence of prices on behavior and would increase the prices of unhealthy food while decrease the prices of healthy food. This method uses asymmetric paternalism to increase the opportunities for healthy food to be chosen without depriving people’s freedom of choice.

The proposed intervention also realizes that school environment and food marketing are two important factors which can influence children’s behavior. Children will give up having their lunch at schools if the queues at the school lunch room are too long and will opt to choose fast food in order to have free time to resume other activities (16). Therefore, the proposed intervention would serve healthy food in convenient containers which will shorten the queues at the school lunch rooms and nudge children into making healthier decisions (28). Also, the proposed intervention provides a nudge towards making healthier decisions by limiting advertising of fast-food in children’s programs and decreasing fast-food advertising in school computer screen savers, yearbook pages, school media channels, and textbook covers. Instead, it would play more advertisements of healthy food in children’s programs and advertise more healthy food in the school environment. In addition, the proposed intervention would cooperate with supermarkets to place unhealthy products in obscure or inconvenient places and put healthy products in the middle of shelves which they are easier to see and more convenient to reach. When people go shopping in supermarkets, many people hurry to take what they need and then check out. People do not have enough time to go around the whole supermarket. Most time, people would choose what are arranged in the middle of shelves. Actually, this method takes advantage of default options and time preference biases because people would take the products on middle of shelves as their default options and weigh more on current time-savings.

The proposed intervention would build a walking school bus system (27) to allow children who live within 30 minutes walking distance to schools have opportunities to walk more.This optional project supplies to children who would like to walk an opportunity to make their own decisions and do not harm other children’s freedom of choice.

The asymmetrically paternalistic intervention may meet with resistance from fast-food companies whose revenue will be undermined. Therefore, we need to consider whether legally mandating is necessary to implement this intervention. Given that the “Change4life” is a national public health campaign which incorporates the efforts of government, the government should work out a practical and effective strategy to ensure the implementation of the proposed intervention.

Another component of the proposed intervention is appropriate application of advertising and marketing theory. The proposed intervention recognizes that health is not the most important thing to most people(24), therefore, it would use core values such as control, freedom and physical attractiveness rather than health, as the promises to fulfill people’s deep aspiration and motivate people to make changes in their lifestyles(24,29). In addition, the proposed intervention would abandon cartoon-like dough figures to support the promise and stop playing the set of advertisements using cartoon-like dough figures. Instead, it supports the promises it makes to people through both attractive images and real stories which will make people believe in the promises and finally convince people to change their behavior.

The advertisements of proposed intervention consist of two subthemes: “being yourself” and “joining us”. Two sets of advertisements provide different promises to different target audience. The advertisements of “being yourself” part will use physical attractive, beautiful images to advertise or invite parents who themselves or their children had got the benefits of control, freedom and physical attractiveness by choosing healthy food and doing exercise in their real lives to tell their stories. It promises to parents that by choosing healthier lifestyles, their family will become physical attractive, free and can control their own lives. In addition, the advertisements of “joining us” suggest that fast-food companies are manipulating our lives by duplicity. They cover up the facts about high calories, sodium and fat in their products in their commercial ads and deprive people of control and freedom of their lives. This set of advertisements focuses on young children for whom independence and rebellion are important (30). This set of advertisements conveys the promise that choosing healthy food (joining us) actually is rebelling to the duplicity and manipulation of the fast-food companies and getting control over our lives again. Images of young people who are fighting with fast-food companies and controlling their own lives would be used to support the promise.

The real stories of people who suffered from being obese and subsequent health problems are also given by the advertisements of proposed intervention. It would help to address the unrealistic optimism bias. Parents will decrease the unrealistic optimism and realize their family’s equal opportunities to become obese through deeply impressed by real stories and images.

The proposed intervention realizes that we can not take away people’s ownership of old behavior without giving them an alternative option (25,26). Control over life, freedom, attractiveness, independence and rebellion are provided by the proposed intervention to exchange people’s old behavior.


The “Change4life” campaign assumes food consumption and physical activity behavior are rational, fails to consider some important environmental and social influences on behaviors and fails to apply advertising and marketing theory appropriately. Therefore, it is unlikely to realize its objective and change people’s unhealthy lifestyles as it expects. With modification in several aspects, including using asymmetrical paternalism to address the irrational behaviors of population, incorporating important environmental and social influences and nudge people into making healthier decisions as well as applying advertising and marketing theory appropriately, “Change4life” can take some effects to change families’ unhealthy lifestyles but still needs to find out more effective strategies to reach its goal.


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