Challenging Dogma - Spring 2011

Monday, May 23, 2011

Don’t Drink Yourself Fat: Do Scare Tactics Create Behavior Change? – Elizabeth Suarez

In August of 2009, the New York City Department of Health and Mental Hygiene introduced its new advertising campaign encouraging New Yorkers to give up sugary beverages. In the fight against obesity, sugar sweetened beverages have come under fire for the added calories they contribute to Americans’ diets, often unknowingly.
Consumption of soft drinks, including sugar-sweetened drinks such as soda, fruit drinks and iced tea, has been found to have increased by 135% between 1977 and 2001 (1). The extra calories added from sugary beverages could cause weight gain of 15 pounds in one year (1). In 2007-2008, 33.8% of American adults were considered obese (2), and approximately 16% of children are obese (3). With obesity rates rising, health experts are broadening the targets for unhealthy diets and including sugary beverage consumption as a significant contributor to the obesity epidemic.
The “Pouring on the Pounds” campaign shows graphic images of human fat and negative health effects of obesity and diabetes. Subway posters make up the majority of the campaign’s exposure. The posters show human fat pouring from soda, iced tea and sports drink bottles with the text, “Are you pouring on the pounds? Don’t drink yourself fat. Cut back on sodas and other sugary beverages. Go with water, seltzer or low-fat milk instead.” (4). Accompanying videos, made popular for their graphic images through YouTube, show a young man drinking fat out of a glass and eating multiple packs of sugar. The latest installment changes the slogan slightly to “Don’t drink yourself sick”, and includes images of toes decaying from diabetes complications and obese people. The images are meant to draw awareness to the amount of sugar people may be unknowingly consuming throughout the day.
While the images may catch the attention of many New York subway riders, the campaign isn’t likely to produce long term behavior change and health effects. Shock and scare tactics rarely translate into behavior change because they often rely on exaggerated information. These over the top messages can lead to psychological reactance and resentment towards an intervention in individual choice. The campaign fails to appeal to core values of Americans and will not promote lasting change.

Scare tactics can be misleading
New York’s campaign claims to be one of awareness and relies on a “gross-out factor” to get attention. Later installments rely on startling images of obesity and diabetes. While these images may be strong emotional appeals, they lack the motivational appeal to be successful in creating behavior change. Focused on the need to grab the attention of the public in the face of so many advertisements and campaigns, health related or not, campaign designers may be inclined to exaggerate or bend the truthfulness of the health claim they are making (5). Information that is not direct may be seen as tentative, and research has shown that people resent messages aimed at behavior change when a clear connection between the behavior and disease has not be established (5). This desire to avoid resentment from the population may encourage campaign designers to stretch the truth, even if only through implication.
A successful mass media campaign must accomplish two things: dissemination of information to the public and redefining of an issue to attract attention and offer suggestions for change (6). The widespread posters and viral YouTube videos are widely available to the population, and the issue is redefined in an attention getting manner that implies sugary beverages are fat. Where the campaign lacks is in its suggestions for change. More emphasis is put on the “gross-out” factor to make people stop drinking sugar laden beverages than suggesting healthier options. The tagline “Go with water, seltzer or low-fat milk instead” is the only offer for suggestions of behavior change, and does not explain why these drinks are better choices. Also, options such as diet beverages are not suggested, which could be a more realistic option for someone who exclusively consumes sugary beverages.
A 20 oz bottle of classic Coca-Cola contains 240 calories and 65 grams of sugar, yet 0 grams of fat. The fine print on the nutrition labels reads: “Not a significant source of fat calories, saturated fat, trans fat…” (7). The average American, not fully knowledgeable about the mechanisms between sugar, fat, calories and obesity, may assume that sodas and sports drinks therefore will not make you fat. The “Pouring on the Pounds” campaign’s most attention grabbing advertisements show human fat pouring from soda bottles and a man drinking human fat from a glass. This could imply that sugary drinks contain fat and therefore will make you fat. This disconnect in information and understanding can be a source of confusion and could cause many people to ignore the campaign completely.
The latest video created by the campaign shows decaying toes, a serious complication of diabetes. Since the campaign aims to curb sugar consumption, the easy conclusion to make is that eating sugar and obesity cause diabetes. While it is true that rates of type 2 diabetes have risen concurrently with rates of obesity, the underlying causes of type 2 diabetes, including environmental influences and genetics, are not fully understood (8). This implication of causality can lead to a distrust of the campaign message. Not every obese or overweight person has diabetes, and not every diabetic is overweight. Those with a lack of personal experience with diabetes may underestimate the probability that they will develop diabetes if they continue to consume large amounts of sugar. This concept of unrealistic optimism states that individuals believe that negative events are less likely to happen to them than to others (9). They may attribute other people developing diabetes to additional factors beyond drinking sugary beverages, such as overall unhealthy diets and lack of exercise, minimizing the importance of cutting out unnecessary sugars. Weinstein also notes that the more serious a negative event is perceived to be, the less likely an individual believes it will happen to him. In the context of health behaviors, those who believe that diabetes is a serious disease will be less likely to think they will develop diabetes, regardless of their dietary habits. The graphic images of decaying toes in the advertisements increases the perceived seriousness of diabetes and could encourage this effect. On the other end of the spectrum, individuals who do not believe diabetes is a serious disease may be inclined to believe developing the condition is inevitable, so small behavior changes will not make a large impact on health.

Failing to appeal to core values
A successful advertisement must offer three basic things to the viewer: a promise, support for that promise, and core values that underlie both the promise and support. Selection of the right promise is key to a successful advertisement (10). However, the magnitude and plausibility of the promise can matter little if the support and underlying core values speak to the audience. A key element of successful branding is displaying an “aspiration to an appealing external ideal” (11). The population exposed to the campaign must want to live up to the underlying message being presented. We can analyze the “Pouring on the Pounds” campaign in terms of its promise, support and core values to highlight a major flaw of the campaign.
First, what is the campaign’s promise? Summed up concisely, drinking sugary beverages such as soda, sports drinks and lemonade are the same as drinking fat. The advertisements continue on to promise sugary beverages will cause obesity, which in turn will give you diabetes, heart disease and cancer. The support is fairly obvious as well; the campaign’s first round of videos and subway advertisements show a young man drinking a glass of human fat and fat pouring out of soda and sports drink bottles. Later videos flash images of an obese man being revived and decaying toes from complications with diabetes (4).
Where the campaign falls flat is in identifying the core values it hopes to register within its audience. Health later in life is the only value demonstrated by the advertisements. Health is not a core value for that majority of the American public, demonstrated by rising obesity levels from year to year. The campaign fails to appeal to core values such as family, sex, freedom, power and rebelliousness (11), and therefore will fail to sustain the attention of the population of New York City long enough to incite serious behavior change. In fact, the ending line in many of the advertisements, “Don’t drink yourself fat”, may unintentionally incite feelings of rebellion and cause reactance, as discussed in the next section.

You can’t tell me what to drink!
The New York City Health Department intends “Pouring on the Pounds” to be a campaign of awareness. In a recent press release the city health commissioner states, “This new campaign shows how easy it is to drink a staggering amount of sugar in one day without realizing it. We hope that this campaign will encourage people to make the simple switch to healthier alternatives such as water, seltzer or low-fat milk. If this campaign shifts habits even slightly, it could have real health benefits.” (12) However, the campaign is littered with messages such as “Don’t drink yourself fat. Cut back on soda and other sugary beverages.” (4). Directly telling New Yorkers to cut out sugar beverages or they will get fat could be seen as a direct threat to their freedom of choice. Formally, this is called psychological reactance.
Most of the time, a person is free to choose what activity to take part in, what product to buy, what food to eat, etc. When this freedom is threatened, a person becomes motivated to restore that freedom, often by engaging in the exact behavior they were told to avoid (13). Brehm calls the behaviors that a person could reasonably take part in “free behaviors”. The level of reactance incited is based on the importance of the free behaviors eliminated, the proportion of free behaviors eliminated, and the magnitude of the threat to take away free behaviors. Brehm differentiates between personal and impersonal eliminations of freedom. People perceive personal threats to freedom as direct and intentional attacks on their behaviors and choices. Impersonal elimination of freedom is not perceived as a direct threat, and a person may not feel it applies to him. More reactance is often seen in personal threats to freedom (13).
The campaign can be personal or impersonal dependent on the audience. Those already obese or diagnosed with diabetes may feel the advertisements specifically target them and their consumption habits. Reactance to this personal threat to freedom of choice would therefore occur in the population that needs the information in the advertisements the most – those already with health problems from poor diets and lack of exercise. Those who are not obese or experiencing health problems may only see the campaign as an impersonal attack on freedom. They consume sugary beverages and have not had the adverse effects of obesity and diabetes, and may not believe the message applies to them. While not causing reactance in the form of elimination of freedoms, this would also result in a continued consumption of sugary beverages.
Another extension of Brehm’s original theory involves the characteristics of alternatives to the blocked behavior or activity as indicators of the level of reactance. The less similar the alternatives are to the restricted behavior or activity, the more reactance induced (14). This was demonstrated though a study of two-year-olds and their reactions to physical barriers and objects. Males in the study were more likely to be attracted to a toy behind a large barrier when the free object was dissimilar to the barricaded object.
New York’s campaign against sugary beverages fails to take this idea into account. The campaign offers water, seltzer and low-fat milk as alternatives to sugary beverages such as soda, iced tea and sports drinks. These options are not at all similar to the sweet taste that appeals to people who prefer soft drinks as their most common beverage choice. People are not likely to choose water over other “better tasting” drinks. However, if the campaign had offered diet drinks as an alternative to the full sugar varieties, people may embrace the easier transition. The campaign’s suggestion of healthy alternatives may actually act as a source of reactance for New Yorkers instead of a source of information about alternatives.
Alternative campaign approach – counter-marketing
A more appropriate campaign will unite people under a common feeling, using easily understandable facts and comparisons. It will not tell people to change their behavior, but rather give people the information they need to decide on their own. A campaign that does this successfully is the “Truth” anti-smoking campaign. A campaign against sugary beverages can be modeled after this idea.
Aimed at youth, the “Truth” campaign creators realized two important factors: a successful behavior change campaign cannot pass judgment on unhealthy behaviors, and cannot tell people what to do (15). These basic ideas can be transferred to a general community campaign as well. Avoiding judgment and “don’t” statements will decrease reactance, as people will not feel their choices are threatened. “Truth” also focuses on youth culture and the need to be in control and rebellious against what is expected of them. The campaign took up its premise as counter-marketing against the tobacco companies, pointing out the manipulation the industry uses to market its products (15). While rebellion is a core value that may resonate more with youth then the general public, a similar idea of lack of honestly can be applied to the makers of sugary beverages.
An alternative campaign against sugary beverages could be one that points out the lack of disclosure in the beverage industry about the weight gain potential of drinking multiple sodas or iced teas a day. Beverages are marketed as refreshing and thirst quenching, and many people do not attribute beverage consumption to weight gain. The campaign would point out the disagreement between the slogans and the actual characteristics of certain types of beverages. For example, a tagline for the campaign posters could be, “Refreshing. Joy. Life. And CALORIES? What the ads aren’t telling you.” Different types of beverages would have different tag lines based on popular advertising slogans for the drinks.
The advertisements would highlight the basics of obesity and weight gain: obesity occurs when there is an imbalance of energy, and energy comes from calories (16). If more calories are consumed than used, weight gain ensues. Posters in the campaign would display the nutrition facts label from a bottle of a sugary drink and highlight the important factors. For example, in the advertisement for a standard size bottle of Coca-Cola of 14 ounces, it would be highlighted that while there are zero grams of fat, the bottle contains 170 calories (7). Similar advertisements would be created for popular iced teas, juices and sports drinks. The closing line could say something such as, “Would you rather drink 170 extra calories with lunch, or 0? Balance the equation and take control of your health. It’s your choice.” Alternatives would be shown such as water and seltzer, and also diet varieties of the sugary beverage in question. This information would have to be synthesized briefly and simply for public display. Some additional information about the relationship between calorie intake and weight gain could be made available online and in informational handouts, similar to the pamphlets the “Pouring on the Pounds” campaign distributes to offices.

Incite thought, not fear
Shock and awe may not be effective for the reason that they compromise truth and credibility for attention. However, that attention will only be negative if the audience does not buy into the message being communicated. The new campaign stays away from shocking images and large claims. Instead, a common idea of freedom of choice and control will help people consider their habits and make a change.
One goal of a public health campaign is to redefine the issue in a way that attracts attention and offers suggestions for change (6). Instead of framing drinking sugary beverages as fattening and culprit for serious disease, the new campaign frames the issue around choice and freedom. It offers information in a simple manner so the audience can come to easy conclusions, yet frames this information under the idea that large beverage companies are not painting the whole picture. Since the new advertisements do not mention the negative health effects of drinking too much sugar, they avoid inciting optimistic bias. By not showing the extreme consequences, people are less likely to assume the negative health effects are too unlikely for their concern.

Appealing to the masses
Two effective marketing elements that can be translated into the terms of a public health perspective are the presentation of an appealing idea or value and the demonstration of a socially desirable behavior (11). The new intervention works with the notion that Americans value freedom and honesty. By offering suggestions including diet beverages as well as water and seltzers, individuals still have the ability to decide what they prefer to drink without making huge changes to their daily routines. Presenting the discord between popular soft drink slogans, such as “Joy” for Pepsi and “Life” for Coca-Cola, alongside the actual unhealthy effects of choosing these beverages suggests a lack of truthfulness between the producer and consumer. Hopefully these ideals of freedom of choice and honestly will unite the audience in rejecting sugar laden beverages. Also, the advertisements are straight forward in their presentation of how extra calories lead to weight gain through an imbalance of energy intake and usage. Unlike the original campaign, the audience isn’t speculating about how sugar make you fat, and why drinking soda is like drinking fat though it contains none.
Marketing health as a socially desirable behavior is a difficult task. While many people would like to be healthy, they do not value it enough to make changes that may seem inconvenient or take extra time and effort. The new campaign tries to make switching to healthy beverages easier and more desirable by offering diet beverages as an alternative and suggesting change rather than requiring it. Suggesting only water, seltzer and low-fat milk, which are very different in taste from sweetened soft drinks, may discourage people who are unwilling to part with the taste they are accustomed to.

Present facts and suggest conclusions – don’t preach
Avoiding reactance is key to a successful campaign. If your message is informational and attention grabbing yet incites resentment, it will not be embraced. As recognized by the creators of the “truth” campaign, eliminating commands such as “don’t” can reduce reactance (15). The new campaign instead offers the public a choice: “Would you rather drink 170 extra calories with lunch, or 0?” While suggesting the healthier option, the advertisements never tell the viewer what to do. By offering clear and concise information about the relationship of fat and calories to weight gain and presenting the nutrition facts for popular drinks, the viewer is able to make the decision to “balance the equation” and switch to healthier alternatives.
As Brehm points out in her study of barriers and reactance among two-year-olds, the similarity of the alternatives to the “blocked” item or behavior influences the amount of reactance (14). “Pouring on the Pounds” limited their suggested alternatives to water, seltzer and low-fat milk. These suggestions may not seem like reasonable alternatives to someone who exclusively drinks sugar-sweetened beverages. To help ease the transition to healthier options, the new campaign also offers diet beverages in addition to water and seltzer. Reactance will decrease if individuals do not feel they have to give up all factors of their sugary beverage behaviors, such as taste.
Eliminating words such as “fat”, “obesity” and “diabetes” may help to reduce reactance by making the messages more impersonal (13). No group of people is signaled out by the new advertising campaign. The new campaign highlights informed choice and does not label the behavior of drinking sugary beverages as disgusting. The goal is to catch the attention of the public through the idea that the soft drink industry has been trying to conceal the negative health effects of sugar, while at the same time pointing out realistic healthier options.

The “Pouring on the Pounds” campaign ran in San Francisco in 2010, and focus groups were held to shed light on its effectiveness and public perception. While most contributors agreed the images were shocking and gross, they felt the extreme amount of fat shown was too much of an exaggeration to be taken seriously (17). Group members shared the sentiment that the connection between fat and sodas or other sugary drinks was not clear. While the overall effectiveness of the campaign in San Francisco could not be determined, the groups pointed out flaws in the campaign that relate to the dangers of relying on scare tactics to motivate change.
Instead of emphasizing negative effects, present positive and factual information. Instead of telling people what to do, give them the tools they need to make informed conclusions and frame the information in a way that motivates interest and change. The “Pouring on the Pounds” campaign could be improved by using information rather than shock, avoiding statements that incite resentment, and building interest through a core value familiar to the audience.

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