Challenging Dogma - Spring 2011

Friday, May 6, 2011

Are You Pouring on the Pounds? A Critical Analysis of the Pouring on the Pounds Campaign-Anonymous

In the United States, over the past twenty years (1985-2009) obesity has significantly increased (1). Obesity effects most states, such that Colorado and the District of Columbia are the only states that had a prevalence of obesity less than 20% (in 2009) (1). On the other hand thirty –three states (9 states include Alabama, Arkansas, Kentucky, Louisiana, Mississippi, Missouri, Oklahoma, Tennessee, and West Virginia) had a prevalence of obesity equal to or greater than 30% (1). The Center of Disease Control (CDC) defines obesity as a body mass index (BMI) of 30 or greater, which is a result of taking in more calories than those that are burned (1).
Obesity is a major risk factor for cardiovascular disease, certain types of cancer, and type 2 diabetes (1). Obesity also impacts the United States economy, as in 2008 an estimated 147 billion dollars was spent to cover medical care costs attributed to obesity (2).
New York City
On average, Americans consume 200 to 300 more calories every day than we did thirty years ago and approximately half of those calories are from the consumption of sugary drinks (3). According to the New York City Department of Health and Mental Hygiene (DOHMH) 3.2 million New York residents are over weight or obese (3). The health department researchers’ found that 2 million New York residents drink at least one sugar-sweetened soda or beverage every day, which has about 250 calories a drink (3). The findings also indicate that Bronx adults have the highest sugary drink consumption rates, followed by (in this order) Staten Island, Brooklyn, Queens and Manhattan (3). Furthermore, men tend to consume more sugary beverage drinks compared to women and the prevalence is amongst people who are 18 to 44 years old.
Overall, the highest adult rates of sugary beverage consumption tend to be amongst Hispanics and blacks (3). When public high school students were asked “whether they drank at least one soda a day over the course of a week” the trend of highest rates mirrored the adult rates, with the proportion answering yes was as follows “29% in the Bronx, followed by Staten Island (25%), Queens (23%), Brooklyn (22%) and Manhattan (21%)” (3). In addition, the findings show that teens drink approximately 360 calories a day, which can easily be avoided (3).
Pouring on the Pounds
In 2009, Mayor Michael R. Bloomberg and the New York City Department of Health and Mental Hygiene (DOHMH) launched a new public health campaign titled: Pouring on the Pounds. There are two primary tactics used by this campaign, which include public ads (posters) on subway carts and viral videos on you tube (4-9). The ‘signature image’ on the public ads include someone pouring soda into a cup, but disgusting fat substitutes the soda as it pours into the cup (5). One of the viral videos follows the same theme and has a man drinking fat, while the fat repulsively drips down his face (7). The campaign is trying to inform New Yorkers that they are literally pouring on the pounds by drinking sugary beverages. The public ads and viral videos ask people to drink healthier beverage options such as water, seltzer, or low-fat milk. The campaign also informs New Yorkers of the health risks associates with drinking sugary beverages, which includes obesity, type 2 diabetes and heart disease (3-9). The goal of the campaign is to get New Yorkers (teens and adults aged 18-44) to drink lower-calorie alternatives. The public ads are posted on highly trafficked New York City subway carts and the viral videos help reach a broader audience (Refer to Appendix A and B). However, the Pouring on the Pounds campaign has various flaws, which will inhibit New Yorkers from adopting the desired health behavior. I will argue three distinct reasons why this campaign is flawed.
Critique 1: Assumes Individuals are Rational and Ignores Fundamental Causes

The Health Belief Model is a basic cost benefit analysis, which historically and continues to be the main framework used to develop public health interventions (10). The Health Belief Model “addresses the individual’s perceptions of the threat posed by a health problem (susceptibility, severity), the benefits of avoiding the threat, and factors influencing the decision to act (barriers, cues to action, and self-efficacy)” (11). This model assumes that individuals are rational and simply weigh the benefits and costs of adopting a certain behavior. The Pouring on the Pounds campaign relies on providing individuals with the appropriate information so that they are well informed to make a decision. The Health Belief Model assumes that once individuals weigh the benefits and costs, they will develop a new attitude or belief, which will influence their intentions and thus their behavior (10-13). The Health Belief Model and this campaign overestimate individuals’ ability of self-control (24). For instance, people often have the same intent to want to eat or drink healthier, but their healthy behavior is not adapted or sustained (10). A major flaw of this campaign is that it assumes people are rational and if they become aware of the severity/susceptibility of the problem (in this case that sugary drinks leads to risks, such as obesity, type 2 diabetes and heart disease) people will minimize (or stop) drinking sugary beverages (3, 4). The Health Belief Model is simplistic in the sense, that it also assumes if people are aware of how much sugar is in certain beverages, they will stop drinking those beverages (10). Intuitively, it seems to make sense, but practically the impact is different (14-16). The difference is attributed to people not being rational, but rather irrational in their decision making processes (14). One example of how people are irrational can be explained through the optimistic bias concept.
Optimistic Bias concept recognizes that people overestimate their susceptibility of enduring positive events/outcomes, but underestimate their susceptibility of experience negative events/outcomes (17). Even though the campaign provides factual information such as drinking “a 20-ounce bottle of soda can contain 16 ½ teaspoons of sugar,” leads to obesity, type 2 diabetes, and heart disease, this does not translate into an improved behavioral change (17). According, to the Optimistic Bias concept, the target audience of this campaign will most likely underestimate their risk of developing health consequences from drinking sugary beverages. This concept recognizes and research supports, that when people are asked about the general publics risk, they tend to be accurate, but when asked to evaluate their own risk a bias is introduced (17, 18). Even the DOHMH research, which influenced the launching of this campaign, clearly demonstrates New Yorkers Optimistic Bias. Researchers found that approximately 39% of obese adults, when asked to define themselves, stated they were “very overweight” instead of obese (3). The findings illustrate that New Yorkers have a heightened sense that they are not as susceptible to negative health consequences such as obesity (3, 17). People do not rationally make decisions, but rather there are multiple complex contributing factors. For instance, there are fifteen theories, models and frameworks devoted to explain the power of persuasion. The Pouring on the Pounds campaign fails to recognize who and what influences peoples decisions (18).
The campaign is flawed because it focuses strictly on the individual and fails to acknowledge the complexities of developing a healthy lifestyle, such as drinking healthier beverages. The campaigns themed question focuses on the individual by asking: “Are you pouring on the pounds?” There is an emphasis on individual level risk elimination underlying causal factors. The design of this campaign sets out unrealistic goals for individuals to attain, such as “Do not drink sugary beverages,” which automatically sets individuals up for failure. Research and group level models support that broader environmental factors and peers are more influential in predicting or changing peoples’ behaviors (18-23). The campaign fails to recognize that their might be more institutionalized reasons why people living in the Bronx have higher consumption rates of sugary drinks compared to other burros (3). Research shows that low-income neighborhoods such as the Bronx are often over crowded with fast food restaurants and bodegas, which has fewer healthier food and drink options. Furthermore, healthier food options tend to be more expensive, which influences peoples’ behavior to purchase more affordable unhealthy foods (37). A Critical Feminist Perspective would further critique this campaign for utilizing the Health Belief Model, which blames individuals, who are often already marginalized and further contributes to their oppression (25). The Health Belief Model is not an inherently flawed framework, as it can be helpful in predicting simple behaviors, but theory and research demonstrates it is ineffective means to instill lifestyle behavior changes (18-23).
Critique 2: ‘Fear Tactic’ Method Promotes Rationalization of Unhealthy Behaviors

The campaign attempts to scare New Yorkers by showing graphic images of gruesome blobs of fat being poured onto a cup, or down a man’s face (5-9). One viral video shows a graphic image (most extreme case) of type 2 diabetes, an obese person in a wheel chair (next to another obese person) and an unconscious man in a stretcher trying to be revived by a doctor (9). The ‘Fear Tactic’ is a strategy many public health interventions use, which is supported by the Health Belief Model (10-12). The Health Belief Model supports the idea of scaring people of the risks associated with their unhealthy behavior as a tool to change their behavior (11, 12). The ‘Fear Tactic’ is flawed as one study demonstrated that participants who were smokers and shown shock images of the potential effects of smoking, consequentially resulted in participants smoking more (26). The reason was because the smokers began to rationalize their risk, such as “if I am going to die, I might as well continue smoking.” Unfortunately, New Yorkers will react to the Pouring on the Pounds campaign in a similar manner. They will continue their unhealthy behavior by rationalizing, if they are going to become obese (develop type 2 diabetes and heart disease), they might as well drink what they want. The ‘Fear Tactic’ is an ineffective method to instill healthy lifestyle changes, such as drinking healthier. Furthermore, this method is detrimental, because shock images reinforce negative behaviors’ such as drinking more sugary beverages, which is the opposite intent of this campaign (26).
Specifically, Cognitive Dissonance Theory helps explain peoples’ decision making process and reveals the potential for people to disassociate themselves from the unhealthy behavior (19). New Yorkers will most likely feel there is a conflict between the evaluation of drinking healthier and their actual behavior (drinking unhealthy) (19). For instance, New Yorkers will feel a level of discomfort and will try to rationalize drinking sugary beverages as a way to provide a sense of comfort (19). New Yorkers will respond to the shock images by rationalizing that they do not drink three sugary sodas a day, thus the public ads and viral videos do not apply to them. Another rationale is that they may know that they drink many sugary beverages, but they resolve the conflict by owning their behavior by developing an explanation for doing it; such as, “I’m never going to be so fat that I will need a wheel chair.”
Shock images are often of the most extreme cases, which through people dissociating themselves (because they can not relate) will consequentially stigmatize others (9, 19, 26). If the target audience can not relate to the message, they are less likely to believe the campaign applies to them; thus people will disassociate themselves from the proposed behavior, in this case drinking healthier. In a viral video which shows a graphic image of type 2 diabetes, an obese person in a wheel chair and an unconscious man, provides an opportunity for the New Yorkers to exclude themselves from those extreme cases. New Yorkers will gain an understanding of being different from those who are so obese that they need a wheel chair, while stigmatizing people who can relate to those extreme cases (25). Overall, there is a lack of research which supports the effectiveness of using shock images as a way to instill positive behavioral changes. On the contrary, research does demonstrate the ineffectiveness of using shock images to improve lifestyle behaviors (26). Unfortunately, the ‘Fear Tactic’ method is still widely implemented in many public health interventions (19).
Critique 3: The Message and the Messenger Increases Reactants

The campaign focuses on telling people not to engage in an unhealthy behavior and suggests healthier alternatives. Many of the public ads and viral videos explicitly tell New Yorkers: “Do not to drink yourself fat,” and after suggests them to instead drink water, seltzer and low-fat milk (4-9). One concern of this strategy is that by telling people not to do something it can cause people to actually do the opposite, which can be explained through Psychological Reactance Theory (27-30). The Psychological Reactance theory recognizes when a person’s freedom is threatened, he/she will immediately react to restore that freedom (27-30). Researchers Brehm and Weinraub conducted a study, which exposed two year old boys and girls to one of the three physical barriers “(a) large barrier, identical objects behind the barrier and standing free from the barrier; (b) large barrier, dissimilar objects; and (c) small barrier, dissimilar objects” (31). Their research demonstrated that two year old boys were more likely to choose option b, a dissimilar object (toy) in a large barrier, compared to the other two options (31). The reason was because the boys felt their freedom was most threatened by option b and the only way for them to restore their freedom was by trying to gain access. Two-year old girls primarily chose the object in the open cage, but further research demonstrates that by the time girls reach adolescence they too react in the same manner as the boys (31). Another study, which coined the “Romeo and Juliet effect,” researchers found that parent’s who interfered in their child’s relationship by expressing disapproval of their significant other; often pushed their child into marrying that person, compared to parents who did not interfere (32). The reason was because when parents told their child not to be with someone or how awful their significant other was, the child reacted in a way to restore their threatened freedom (ability to choose who they wanted to be with) by doing the opposite (32). Similarly, when the Pouring on the Pounds campaign instructs New Yorkers not to drink sugary beverages, this will cause New Yorkers to restore their threatened freedom (ability to choose what they want to drink) by increasing their consumption of sugary beverages.
The campaign uses dominance and authority, manipulation and lack of similarity, which consequentially increases peoples’ reactants (19, 30). The campaign is publicly being endorsed by Mayor Michael R. Bloomberg and the New York City Department of Health and Mental Hygiene (DOHMH) (33). An authority figure delivering the message can often increase peoples’ reactants, because it is often perceived that this entity is taking away their freedom, such as their ability to choose what they can or can not drink (29-31). Specifically, the mayor’s nutritional focused policies directly conflicts with his own unhealthy diet. The mayor was exposed in using excessive salt on foods, such as popcorn and even pizza. One reporter witnessed the mayor put six dashes of salt on a slice of pizza at Denino’s Pizzeria Tavern on Staten Island (33). Even more damaging is the mayor does not drink healthy, as he primarily drinks three to four cups of coffee a day (33). A person, who often dines with the mayor, mentioned that the Mayor Bloomberg rarely drinks water (33). The mayor’s unhealthy eating habits truly expose the complexities of adopting a healthy diet, which the campaign he endorses assumes is simplistic (16). Ironically, the mayor helped regulate chain restaurants to post calorie counts and initiate restaurants to use less salts (33). In 2009, Mayor Bloomberg confessed to his bad eating habits, as he once said “I like a Big Mac like everybody else,” but then said “I just want to know how many calories are in it” (33). The reality is that people knowing how many calories are in certain foods or drinks, will not deter people from drinking or eating high calorie foods and drinks (12-14). This information is extremely damaging to the mayor’s credibility, because the campaign ‘Pouring on the Pounds’ directly contradicts his behavior and exposes him as a hypocritical. New Yorkers will feel manipulated by knowing that the endorser of the campaign does not drink healthy beverages, making New Yorkers react by also not drinking sugary beverages.
In addition, the campaign’s messenger lacks the ability to appeal to a diverse New York City population. In the context, that New York City is extremely diverse, yet the Campaign chooses for the public ads to only use a white hand and for the viral video a white man who appears to be in his thirties. By the campaign only using only one race to deliver the message, it minimizes the opportunity for people from more diverse backgrounds such as New York teens and adults living in Bronx, Staten Island, Brooklyn, Queens and Manhattan (3). Bronx adults and Hispanics and blacks have the highest sugary beverage consumption rates and will most likely find it challenging to relate to a white hand or white male actor. Communication Theory recognizes the importance of the messenger/persuader to be someone the target audience can relate too, such as looking like them or having a similar personality, or representing something they value, such as being attractive or a hard worker (19, 34). The reason is not simply that people of varying ethnic/racial backgrounds can not relate to each other (because they can), but the messenger and/or storyline does not possess qualities that most people universally value. Universal values which hold true cross-culturally include family, love, work-ethic, belonging, freedom, attractiveness, sex, youthfulness, rebellion and justice (43). The campaign misuses the Psychological Reactance Theory, by telling people not to do something, using an authoritative figure, and minimizing the feeling of similarity, which together substantially increases reactants (27-32). Thus, New Yorkers will most likely continue drink sugary beverages as a way to gain control of their freedom, which is the opposite intention of this campaign (28-32).
The New Direction of the Pouring on the Pounds Campaign

The Pouring on the Pounds campaign’s communication methods are effective, which includes public ads in highly trafficked subways in New York City and posting viral videos on you tube. Thus, the mediums of communication will continue to be used. The title of the campaign: Pouring on the Pounds will also be included, because it captures the essence of the intervention. However, I propose the campaign take a shift in the content and delivery, in order to reconcile the previous mentioned flaws. The improved Pouring on the Pounds campaign will incorporate three distinct components, which are supported by research and social behavior theories. The three elements include: 1. Raising Awareness of Disparities, 2. Blaming Big Corporations and 3. Strengthening Overall Appeal. The new campaign strives to properly use Psychological Reactance Theory at a neighborhood and city level. In addition, the campaign will incorporate Advertising and Marketing theories to strengthen the campaign’s overall appeal to New Yorkers. These three innovative and comprehensive changes will substantially reduce New Yorkers sugary beverage consumption rates, thus decreasing obesity rates.
Suggestion 1: Raise Awareness of Disparities in Low-Income Neighborhoods: As a Strategy to Target those at Greatest Risk.

The causes of obesity are multi-faceted, such that environmental factors are a major predictor for the obesity epidemic (37, 38). Specifically, socio-economic disadvantage is a contributing factor to obesity, as the epidemic is most prevalent in low-income neighborhoods (37). As the New York City Department of Health and Mental Hygiene (DOHMH) own research exposes that the Bronx has the highest sugary consumption rates, but is also a low-income neighborhood (3, 37). Initially, the Pouring on the Pounds campaign focused on individual behaviors, because it was easier to address compared to changing fundamental causes. The new proposed campaign will raise awareness around low-income neighborhoods (such as the Bronx) limited access to healthy and affordable food options. By re-framing the issue into being about an injustice this will shift the blame away from the individual and towards disparities (20, 45). As a consequence people will feel empowered to rebel against inherent disparities in their communities. This is an example of using Psychological Reactance Theory to get people to adopt a healthy behavior versus reinforcing an unhealthy behavior (28-32). Re-framing issues have been shown to be an effective way to improve public health interventions. Dr. Michael B. Siegel once re-framed a proposed policy to ban smoking in restaurants from a health issue to a workers rights issue, because workers (outside their free will) were being subjected to second hand smoke; a frame the opposition could not work against (39-42, 45). The Pouring on the Pounds campaign will re-frame the issue to be more of a citizens’ right issue, such that all people living in New York City, despite socio-economic status should have access to the same resources.
The viral videos will use local people who live in the Bronx (or other low-income neighborhoods in New York City) to convey the campaign’s new message. Using local New Yorkers from varying racial/ethnic backgrounds will allow the target audience to better relate to the messenger and the message (27, 43-45). The viral videos will utilize a documentary style to reveal neighborhood disparities. For instance, on viral video will expose how many fast food restaurants, small shop bodegas and energy-dense foods are in their neighborhood compared to grocery stores with healthier options (37, 38). The viral videos will create a buzz in the neighborhood attracting more people to want to be involved in the movement against an injustice. The Cognitive Dissonance Theory recognizes when people feel apart of a group, even if it is simply an idea, they are more likely to be committed to a proposed behavior (19). The importance of environmental context and group dynamics has been researched in relation to the Obesity epidemic (46). One particular study’s finding shows that an individual is significantly more likely to be obese if they have a friend, and/or a sibling and/or a spouse who became obese during a certain time frame (46). Having one aspect of the campaign focus on low-income neighborhoods recognizes the power of peers influencing each others behaviors (14, 15, 19, 34). As a potential result, low-income neighborhoods such as the Bronx will achieve drinking healthier as a community and will collectively reduce their obesity rate.
Strategy 2: Blame Big Corporations: As a Strategy to Include all New Yorkers.

The Advertising Theory acknowledges universal core values all people can relate to, which include: family, love, work-ethic, belonging, freedom, attractiveness, sex, youthfulness and rebellion and justice (43). The reasons why these core values are universal are because each one can instill an emotional response in people. However, the campaign’s previous strategy focused on providing health education, which is not effective because health is not a core value (35, 36, 43-45). The campaign will continue to use the signature image of pouring soda into a cup, but will remove disgusting fat to substitute for soda. The hand which is used will incorporate different racial and ethnic backgrounds in order to increase a feeling of similarity, which is shown to decrease negative reactants (27). A major premise of Advertising Theory is that in order for a campaign to be successful there has to be a relatable promise and support for the promise (43-45). The Pouring on the Pound campaign will no longer focus on promising health, but rather justice which will develop a group level support system. Furthermore, the public ads and viral videos will not use shock images, because it reinforces unhealthy drinking behaviors and has the potential to stigmatize people (19, 26).
Many big corporations such as Coca-Cola and Nike are not selling a product, but rather core values, which is why they are very successful (35, 36, 43-45). The campaign’s content will shift away from health education and towards revealing the public to how big corporations contribute to their consumption of sugary beverages. In order for the campaign to reach a broader audience of New Yorkers (from five burros who represent diverse backgrounds) the utilization of core values that were used in the low-income community level, such as belonging, justice and rebellion can also be used in the entire city’s context. Average New Yorkers, from varying burros, will disclose to the public through viral videos that Coca-Cola opposes majority of legislation led “by public health groups to improve school nutrition and reduce the consumption of unhealthy, sugar-sweetened beverages” (47). In addition, can reveal that Coca-Cola opposes all taxes on sugar-sweetened beverages, which is in direct conflict with their sales. However, Coca-cola also opposes legislation which reveals the “ingredients of products, tax on candy, bottle bills, standards for food processing and school nutrition standards” (47). The campaign content should focus on the fact that Coca-Cola and other big food companies do not even support the minimal nutritional standards for children or bottle bills, which is a sustainable way to collect beverage bottles and cans for recycling (47, 48). Furthermore, the campaign can reveal that Coca-Cola and other big food companies have partnered with public health organizations, such as the American Academy of Pediatrics, the American Academy of Family Physicians, and the American Dietetic Association, only to improve their image and broaden their consumer base (47).
The campaign’s question will shift towards “Are Big Corporations Pouring on the Pounds?” Specifically, it would be more effective if the campaign could state a company’s name, such as “Is Coca Cola Pouring on the Pounds?” In order, to avoid being sued it might be safer for the campaign to use the well known signature Coca Cola bottle and colors, instead of using the Cocoa- Cola name. Researchers will reveal information on various food companies, in order not to single out Coca- Cola for peoples’ unhealthy drinking behaviors. There is evidence that creating an anti-big corporations campaign can be effective. For instance, the Truth campaign, effectively utilizes advertising and marketing theory to inform youth that they are being manipulated by big tobacco. The Truth Campaign has been successful in substantially decreasing smoking rates among teens, by getting teens to rebel against big tobacco by not smoking (49). The Truth Campaign provides some evidence, that if the Pouring on the Pounds campaign adapts a similar model; it may also result in people drinking less sugary beverages (49, 50).
Suggestion 3: Strengthen Overall Appeal
In addition, the Pouring on the Pounds campaign should use similar tactics which big corporations use, such as elements from advertising and marketing theories (43). Coca-Cola does not have to state how tasty their drinks are, but rather their advertising focuses on selling universal core values (35, 36, 43-45). The Pouring on the Pounds campaign was previously influenced by the Traditional Public Health Paradigm, which tells people the benefits of adopting a behavior and it hopes people will adopt the behavior. On the contrary the Marketing Paradigm focuses on what people want and packages their product around their wants (45). The Marketing Paradigm is stronger, because it is guided by research, which investigates what inspires people and appeals to their target audience based on their interests (45). Using celebrities to endorse this campaign will better attract New Yorkers than using a white man or an authoritative figure, such as Mayor Bloomberg. Although, if Mayor Bloomberg continues to endorse the campaign he should regain the trust of New Yorkers, by publicly acknowledging his unhealthy eating habits. This will provide him an opportunity to reframe the healthy eating as a collective New York City challenge and not an individual one.
The campaign can take note from Smart Water, which uses celebrities to endorse their product. The Smart Water ads include identifiable celebrities such as athlete Tom Brady and actress Jennifer Aniston (52, 53). The ads do not to tell people to drink Smart Water, but rather simply uses attractive, youthful celebrities to get people to identify with their product (52-53). As previously, noted Psychological Reactance Theory recognizes that telling people to do something (or not to do something) increases reactants, causing people to do the opposite of the intended behavior (28-32). Furthermore, Social Modeling Theory recognizes the importance of showing people a behavior compared to telling them to do a behavior (19). Having public ads and viral videos showing celebrities model drinking healthier, will influence people to adopt the same behavior. The first Lady’s initiative to end child hood obesity the ‘Let’s Move’ campaign, recently released a Beyonce video titled “Move Your Body” (53). In the video Beyonce leads a dance routine and elementary school children follow. The video is effective because it shows people how to move their bodies and invites children to participate versus telling children the importance of exercising has important health benefits (53, 54) Children (and adults) can relate to Beyonce as she also represents someone who is attractive and youthful. At the end she bits into an apple, which is subtle, yet effective in modeling to children that it is cool (belonging) to eat an apple and not that it is healthy (53). In conclusion, these three distinct components will significantly enhance the Pouring on the Pounds campaign, by substantially reducing New Yorkers sugary beverage consumption rates and the New York City’s obesity rate.

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