Challenging Dogma - Fall 2009

Thursday, December 16, 2010

The New San Francisco Happy Meal Ban Fails to Address Underlying Issues and May Backfire—Priyanka Bearelly

The issue of childhood obesity is certainly not a new topic in the scene of public health; however, the severity of the issue is rapidly increasing as the rate of obesity in youth has more than tripled in the past 30 years (1). The prevalence of obesity among children of ages 6 to 11 years has increased from 6.5% in 1980 to 19.6% in 2008 (1).
Numerous organizations under the Department of Health and Human Services conduct various surveys and surveillance systems in order to gather information. Additionally, several interventions, such as the Body Mass Index Measurement in Schools, have been presented as means to combat this affliction (2). However, on November 9, 2010, a more dramatic change within the realm of fast food industries was passed and set to be implemented by December 2011 (3). In the city of San Francisco in Northern California, the Board of Supervisors banned the inclusion of toys in Happy Meals that do not meet certain requirements regarding nutritional value (3). These nutritional standards include reduced calories, salt, fat, and sugar as well as the addition of fruits and vegetables. With an 8 to 3 voting majority, the decision was practically unanimous (3). In fact, this ban goes beyond McDonalds and affects about a dozen fast food chains and some family-owned restaurants, which can all face fines up to $1000 per violation (3).
The idea behind this public health intervention is that children are not attracted to the food in the Happy Meal, but the toys. The subsequent conclusion is that in order to get those toys, the children will now only have the option of consuming foods with higher nutritional value. The original issue stems from the clever use of Marketing Theory by the fast food industry. “Packaging has become a form of advertisement, as companies innovate by putting food into “cool” new containers or adding licensed characters, games, and ads for other branded foods” (4). Therefore, children’s desires to follow the trend of collecting toys manifest as their desire for Happy Meals. Thus, this intervention tries to attack what the marketers do, by ensuring that the trendy thing to do is to eat healthy. However, there are several aspects of this approach that leave some room for potential failure.
The Happy Meal ban may inspire the opposite reaction.
The first problem can be explained by Reactance Theory. This idea, formulated by theorist Jack W. Brehm, addresses people’s reactions to threatened or eliminated freedoms and explains that people are likely to respond by reasserting their freedom (5). The theory suggests that they will do this by overreacting in the negative direction, usually doing the opposite of what they are told, also known as the Boomerang Effect (6). In the case of this intervention, consumers are losing this option of toys with their Happy Meals and may perceive this as a threat to their freedom. The actual consumers, in this case the children, may in fact still be too young to strongly react to this infringement on their freedom to choose, although psychological reactance does indeed begins at an early age. However, many parents undoubtedly will feel that they are being explicitly told how to be a good parent while further prohibiting them from purchasing the traditional Happy Meal. Essentially, they will lose their freedom to choose what to feed their children. Moreover, this ban will likely only draw more interest from children by presenting the traditional Happy Meals as forbidden. Therefore, these children will only be more attracted to the Happy Meal once it becomes unavailable.
The new law has been passed for only one month, and the backlash has already begun. In a letter to the board of supervisors who made the legislative vote, a frustrated parent wrote, “Do you really think the government needs to make these decisions for the citizens you represent? Are we not capable of deciding what we will eat and where we will take our children? Back off.” (7). This is a clear example of a person who does not appreciate being instructed by someone else how to live their own life and consequently feels a serious threat to their freedom. According to the Boomerang Effect, consumers will merely end up doing the opposite of what the government has aimed to achieve (6). According to a 1990 study examining nursing practices, one aspect of health education was the communication of information to certain people who were perceived to live “in ignorance” of their health (15). Patients did not appreciate being classified as such and were less receptive to any advice (15). It was concluded that this type of approach would be more likely to cause the individual to actively oppose the health intervention by even increasing their involvement in the unhealthy behavior (15).
Parents, as well as McDonald’s, can now respond to this threat in a variety of ways. For instance, the fast food restaurant can simply sell the toys separately, allowing for parents to regain their freedom to purchase the toy and meal of choice. This would certainly work against the efforts of the intervention. Thus, although parents may agree with the idea of combating obesity, they may in fact end up standing against the government as their own personal means of rebellion. Clearly, placing a prohibitory ban is not the most effective way to glean support among the population of interest.
The Happy Meal ban does not address the overall choice of diet.
The Health Belief Model (HBM) explains that people will essentially weigh the perceived benefits against the perceived barriers to engaging in a particular behavior (9). This decision is dictated by a person’s perceived susceptibility to the disease as well as the perceived severity of the disease, if contracted (9). In this case, the disease is obesity. According to the 2009 National Youth Risk Behavior Survey Overview, only 13.8% of high school students ate vegetables three or more times per day and only 22.3% had eaten fruits and vegetables five or more times per day (8). Moreover, 29.2% of students had drunk a can of soda, bottle, or glass of soda at least one time per day (8). Although the Happy Meals affect a much younger age group than is evaluated in this survey, their dietary behavior when young will still carry on to their choice of meals when older. Unfortunately, this current intervention addresses no aspect of the HBM. Just as before, the only factor affecting the consumer’s decision to purchase the Happy Meal is the toy. There is no certainty that the child will even eat the nutritionally improved food. There is no evaluation of the food being eaten—no recognition that the food is even healthier. Thus, neither the child nor the parent is taking an active role in making healthier decisions.
Moreover, the overall message of this new meal is telling people to eat fewer calories, as well as less sodium, fat and sugar. However, this is not a steadfast rule. For a growing child, it is important to get enough calories and fat, but the right kinds (23). In reality, kids older than 2 years-old should receive 30% of their calories from fat so that the brain and nervous system can develop correctly (23). This fat, or certain oils, can come from various products including peanut butter, fish, milk, etc. (23). This educational side of the obesity affliction is not merely a contributing aspect. It is crucial for the consumer to make the connection between the food he or she is eating and the subsequent health effects. People should be able to accurately recognize their susceptibility to obesity by being conscious of the quality and quantity of food that they are eating. However, this Happy Meal ban almost completely looks past the rudimentary, yet nonetheless important, values presented by the HBM. The intervention essentially forces consumers to select the healthier option and does not teach them to choose the healthy meal.
Although a rather simple model, the HBM has indeed proved effective in other diet-related settings. For instance, in the year 1982, the Food and Drug Administration along with the National Heart, Lung, and Blood Institute sponsored a sodium initiative in order to educate the public and increase awareness of the association of sodium consumption and the risk of hypertension (11). This was accomplished via display of sodium content on food labels (11). In fact, awareness in the American population across all societies of differing education levels increased by 38% in the following year and by 50% by year 1988 (11). As efforts to improve, or even merely maintain, such a level of dietary education began to diminish, people’s awareness slowly began to drop again (11). Similar studies regarding the associations between fiber consumption and the risk of cancer, between consumption of dietary fats and risk of heart disease, and between cholesterol and risk of heart disease all showed similar trends (11). Thus, while the values of the HBM may not be strong enough to serve as a sole solution, it is necessary and can be successful to use as a means of educating the population.
The Happy Meal ban is saying that it’s okay to eat the new Happy Meal?
Not only is the new law prohibiting the marketing of nutritionally-poor food to children, but they are also setting nutritional standards for the new Happy Meal. Such close governmental regulations may make it appear as though the new meals are now no longer a threat to people’s overall health. This may translate into the idea that it is still okay to eat at fast-food restaurants now with these healthier menus, when in reality the truth is that it is only okay to eat at these places in moderation. In fact, when children of the age 7-17 eat out at restaurants, they consume on average 55% more calories than when they eat at home (12).
This traces back to the very basic approach of using the principle of liking to sell a behavior. This stems as a subcategory of the Communication Theory, specifically as a topic termed Compliance Gaining Strategies by theorist Robert B. Cialdini (13). This refers to specific efforts that must be put in place in order to gain the compliance of the target population (13). One of these efforts is the principle of liking that “is based on warm ingratiatory behaviors and attractiveness” (13).
For instance, in 2005, Carl’s Jr. featured Paris Hilton in a commercial to promote their newest product. The target population, young males aged 18-34, tend to positively respond to the sexual appeal of attractive famous figures, such as Paris Hilton (10, 14). Therefore, their liking of Paris Hilton translates into their liking the new Carl’s Jr. product. According to the 2005 CKE Restaurants Sales Report, the sales for this particular burger rose 15.1 % over two years (22). The only difference in the case of this Happy Meal ban is that the government may not have intended to create this association. The primary restriction is that this phenomenon will predominantly only apply to the portion of the U.S. population that respects the government and tends to heed the advice given by political officials. Thus, it is possible that, according to this concept of liking, certain people will create this link between the government and the new and improved Happy Meal. With the belief that the government is a positive influence, they will view the new meal as a positive change and may eat it more frequently. Subsequently, they may end up eating at McDonald’s more often, which instead only exacerbates the issue of increased fast-food consumption. In the late 1970’s, children were eating 17% of their meals outside of the home, and fast food accounted for 2% of those meals (4). By the late 1990’s, children were eating 30% of meals outside, 10% of which being fast food (4). Clearly, it is important, at the very least, to not increase people’s attraction to fast food and hopefully sometime in the near future even reduce this appeal. Thus, for some people, this ban may only increase exposure to fast food restaurants as a result of people constructing this association between the government and the Happy Meal.
Proposal for improved intervention.
This more appropriate intervention will no longer entail the existence of a ban. Instead there will merely be a healthier addition to the McDonald’s menu. This new meal will still adhere to the new nutritional requirements, but will also contain the same toy as the regular Happy Meal option. Moreover, a small informative booklet will be included in the packaging that serves to educate the parent and the child about the effects of their dietary decisions. Finally, with the implementation of the intervention, the government will release an information sheet regarding their position on obesity and fast food as well as “The Healthy List,” that aims to promote nutritional foods and to encourage eating at home.
New intervention provides solution to psychological reactance.
The key idea behind any such resolution is to preserve the consumer’s ability to choose. Once this option vanishes, so does the increased efficacy of the intervention program. Therefore, the goal of this intervention is to present alternate choices to the consumer without them feeling as though the government is suggesting people’s freedom to choose should be limited.
Whereas the current ban in San Francisco may in fact even increase demand for the traditional Happy Meal, at least this altered approach will ensure that people will not be more attracted to the original product. A classic example demonstrating the potential opposing results of these two different situations is seen in one of Brehm’s earlier studies. There were 3 design groups differing based on the availability of certain phonograph records, and one group under the impression that all records would be present, at the last minute was informed that one of the records was missing (6). This group showed an increased desire for this particular lost record in comparison to the control group that was free to choose from all records (6). Equating the missing record to the traditional Happy Meal, people will only show an increased desire for it. Therefore, by maintaining options, consumers will not feel this enhanced attraction to the original meal, much like Brehm’s control group.
One possible approach would be to add this new Happy Meal to the menu in addition to the more traditional one, both containing the same toys. This way, no one is directly telling the parents how to feed their children, but this option of a healthier choice will still cause the parents to acknowledge that this problem exists and that there are solutions. Instead of running in the opposite direction due to the oppression by rules and regulations, parents will feel that they are now finally presented with a more complete list of options. Similarly, the reactance would decrease on McDonald’s behalf. Although making additions to the menu will still require some force on the government’s part, board members can present this approach to McDonald’s administrators as a part of an effort to work together. This way, the fast food chain’s administrators would not feel as though the government is telling them how to run their restaurant, and would therefore be less likely to search for ways to work against the government.
New intervention provides solution to lack of health education.
Even if people find themselves forced to choose a healthier option, they will fail to make more permanent lifestyle changes if they do not properly understand the consequences of their dietary decisions. Moreover, obesity rates are much higher in certain minority populations that include Hispanics as well as non-Hispanic blacks (16). According to measurements from 2006 to 2008, the overall prevalence of obesity in Hispanics across the United States was 28.7% and was 35.7% for non-Hispanic blacks (16). One of the explanations for this trend is that these minority populations have less access to healthy, affordable supermarkets. Furthermore, in low-income communities, their educational levels are much lower, and they do not necessarily understand how to evaluate the nutritional quality of their food (16). Therefore, it is clear that lack of proper education regarding nutrition is still an issue in some populations.
Alternately, it is certainly true that older age groups, not necessarily the target population of the Happy Meals, tend to have a better understanding of the overall importance of a healthy diet. A 1978 study concluded that 67% of the adult population acknowledged that they would be healthier if they ate better (17). However, in this case today with childhood obesity, parents are making dietary decisions for their young children who may be too young to make such evaluations on their own. Some parents may in fact be knowledgeable when it comes to their own dietary choices, but may not be as well-informed about the stark nutritional needs and limits of their children. In a 2001 study done in an Australian primary school to evaluate parental awareness of nutritional health, 42% of parents with obese children, 81% with overweight children, and 70% with underweight children did not report any concern (18). Certainly, this does not reflect a group of parents that can recognize the nutritional inadequacies from which their children suffer.
Therefore, in an effort to resolve this issue, small nutritional booklets may be included in both Happy Meals. These booklets, due to such a young target audience, will have to make more of an impact on the parents rather than the children. These booklets may include information regarding the nutritional quality of the food in the Happy Meal as well as the standard nutritional needs of growing children. According to the U.S. Department of Agriculture’s new Food Pyramid, these needs include five servings of fruit and vegetable per day, whole grain breads and cereals, fairly conservative amounts of lean meat or nuts and eggs as sources of protein, and the list continues (23). To ensure that the booklet is not simply thrown away along with the container, a coloring page or crossword can be included and advertised on the box. Moreover, specifically due to their young age, these children almost certainly do not know enough about their nutritional needs. In a 2010 study evaluating the effects of a health education program implemented in two Jewish schools in Chicago with grades 1 through 8, the results were significant (19). The students in grades 2-4, compared to their baseline knowledge from 2 years prior, were more capable of identifying the healthier foods after steps to improve health education were put in place (19). For instance, in the baseline survey, only 75% recognized that wheat bread is healthier than white bread, compared to 93% two years later (19). Thus, the younger age groups can also successfully respond to measures that promote health education. Therefore, this intervention can have a positive effect on both the parents and the children.
New intervention offers solution to government’s indirect perceived advocacy of the Happy Meal.
Firstly, eliminating the prohibitory portion of this intervention, based on the aforementioned explanation concerning psychological reactance, will minimize the overall attention given to the legislation. Secondly, it will be difficult for the government to pass legislation while trying to remain neutral or trying to avoid creating any possible associations that the public might conceive. To avoid this ambiguity, the government should actively take a position about where they stand with the Happy Meal situation and be clear about it. Currently, most media and news regarding this ban fail to clearly explain the San Francisco board’s principal goals, leaving much room for interpretation. For instance, the most direct explanation given in an article by The Huffington Post is that the legislation “would limit toy giveaways in children's meals that have excessive calories, sodium and fat. It also requires servings of fruits or vegetables with each meal” (20). This is certainly the truth, but with incomplete information like this, the public will not fully understand the motivation behind this proposal.
Thus, the federal group that proposes this new intervention should also release an information sheet, explicitly stating their ultimate goals and the messages they hope to send. It should be clear that the new Happy Meal is not a new regulation, but rather a compromise between McDonald’s and the government, since federal officials cannot, nor do they wish, to control the fast-food restaurant business. In this sheet, they can also list foods and grocery stores that they believe actually do their best to cater to the health of consumers in a financially reasonable manner. Making such a list for restaurants would only encourage people to continue to eat out, thus only specific meals that can be made at home and particular grocery stores that provide healthy products should be the primary focus. For instance, the George Mateljan Foundation, a non-profit organization that has been in existence since the year 2000, has focused on what it calls “The World’s Healthiest Foods” (21). Offering new recipes, foods or ingredients of the week, tips on how to select fresh produce, and much more, the organization presents a healthier lifestyle as positive and enjoyable (21). Mateljan’s dietary advice over the years has achieved much popularity by gaining the support of the New York Times, ABC News, Yale University School of Medicine, and many other well-known associations (21).
The goal is that this new government-released list of healthy foods and stores will hopefully inspire similar support and attention as did Mateljan’s foundation. Examples of healthy, affordable foods include bell peppers, carrots, and garbanzo beans (21). As for the stores, most large local supermarkets, such as Stop n’ Shop in Boston, MA, have a wide selection of relatively inexpensive fresh produce, as well as other groceries. With this clear information provided to the public, it would be rather difficult for a person to believe that the government is in any way advocating McDonald’s or is coercively intervening in the fast food business.
As mentioned before, the original issue of the Happy Meal is the extensive marketing of the product to the children. Therefore, it seems reasonable that this intervention would try to acutely attack this underlying problem by forcing the McDonald’s representatives to use their deceitful tactics, currently aimed toward children, to instead market healthier food. However, history has shown that force and implied obligations fail to play a positive role in improving communities. Moreover, an effective intervention should strive to change the intrinsic decision-making process involved in people’s dietary choices.
The newly-designed intervention attempts to address all of these flaws present in the original proposal. It is certainly difficult for one single intervention to address all the issues of childhood obesity and attempt to resolve them. It is much more likely that a campaign that involves several interventions would be capable of encompassing all aspects of this problem. However, it is still crucial to strive for completeness with even just one intervention, as does this new intervention. Eliminating the greater possibility of immediate opposition, improving the nutritional knowledge of consumers, and avoiding any misconceptions concerning the opinions of any major players of this intervention, this proposal offers a more comprehensive solution.

1. Centers for Disease Control and Prevention. Childhood Overweight and Obesity. Atlanta, GA: Department of Health and Human Services, 2009.
2. Centers for Disease Control and Prevention. Body Mass Index Measurement in Schools. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion, 2007.
3. McKinley, J. You Want a Toy With That? New York, NY: New York Times.
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14. Sarracino, C., & Scott, K.M. Introduction (pp. ix-xx). In Sarracino, C., & Scott, K.M., ed. The Porning of America: The Rise of Porn Culture, What It Means, and Where We Go from Here. Boston, MA: Beacon Press, 2008.
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19. Benjamins M.R., Whitman S. A culturally appropriate school wellness initiative: results of a 2-year pilot intervention in 2 Jewish schools. J School Health 2010; 80: 378-386.
20. Sterling, C. San Francisco Bans the Happy Meal. New York, NY: The Huffington Post.
21. Mateljan, G. The World’s Healthiest Foods, Essential Guide for the Healthiest Way of Eating. Seattle, WA: George Mateljan Foundation, 2006.
22. Broussard, I. CKE Restaurants, Inc. Reports 26th Consecutive Period of Same-Store Sales Increases at Carl’s Jr. Carpinteria, CA: CKE Restaurants, Inc.
23. National Institutes of Health. Child Nutrition. Bethesda, MD: U.S. National Library of Medicine, 2010.

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