How Anti-Obesity Campaigns Fail to Address Some Fundamental Issues Underlying Obesity in Black and Hispanic Adults- Jasmine Plummer

Statistics indicate that the majority of Americans are either overweight (Body Mass Index between 25 and 30) or clinically obese (Body Mass Index above 30). However, obesity statistics (and their related comorbidites) differ with race and socioeconomic status. Therefore, while 60.2% of white Americans are overweight or obese, 63.2% of Hispanic and 68.4% of Black Americans are overweight or obese. (1) Comparably, people of lower socioeconomic status are more likely to be obese than those of higher socioeconomic status. (2) People who are overweight and obese carry “excess” body fat, and while a couple of extra pounds is not particularly problematic, a true excess of body fat is a risk factor for a number of debilitating (and sometimes deadly) diseases. Overweight and obesity are risk factors for the development of diabetes, high blood pressure and cholesterol, asthma, and arthritis.(3) As debilitating as these diseases are on their own, diabetes, high blood pressure and cholesterol, obesity and diabetes are all risk factors for coronary heart disease, which is the currently the leading cause of death in America. (4)

The current burden of obesity on America’s healthcare system and finances is astounding; obesity cost America approximately $147 billion in medical costs in 2009.(5) Obesity accounted for at least 111,909 excess deaths in 2000, and this number has most likely increased since then.(6) Clearly the “obesity epidemic” is unsustainable, both in human and financial terms. There are a number of large-scale campaigns aiming to stem the growth of the obesity epidemic, and most of these campaigns focus on childhood obesity as though the challenge of adult obesity is either insurmountable or less important. When perusing anti-obesity campaign websites, one cannot help but wonder whether or not organizations and agencies realize that there are adults involved in the cultivation of obese children, and that those adults are probably obese as well. (7) Not only do most large-scale anti-obesity campaigns neglect to address obesity in adults, but they also fail to address the specific factors contributing to the obesity epidemic in minority populations. The prevalence of overweight and obesity in black and Hispanic Americans is continuing to grow despite public health efforts, and is projected to continue growing in the future.(8)

Ultimately, most public health campaigns and interventions do not address the root causes of obesity in the black and Hispanic population despite the fact that overweight and obesity afflict a greater percentage of these minority groups as compared to white Americans. In fact, anti-obesity campaigns are built upon the assumption the cause of obesity in all races, genders and ages is a lack of knowledge about healthy eating and a lack of motivation to exercise. Anti-obesity campaigns like the CDC’s “Fruits & Veggies — More Matters™”, the politically-focused “Campaign to End Obesity,” the Massachusetts “Mass in Motion”, the “Small Step” program sponsored by the Department of Health and Human Services, and even parts of First Lady Michelle Obama’s “Let’s Move!” campaign fail to fully recognize the main factors that are contributing to the obesity epidemic in minority and disadvantaged adult populations. All of these interventions are constructed upon traditional social and behavior change models, like the Health Belief model, the Theory of Reasoned Action and Social Cognitive Theory. However, a public health intervention that successfully addresses the prevalence of obesity in black and Hispanic communities would have to address food deserts and food insecurity, the unhealthy female standard of beauty that exists in communities of color, and the issue of discounting.

I. Food Deserts

One of the most significant factors contributing to the prevalence of obesity in minority communities is the lack of access to healthy food. Many black and Hispanic Americans live in areas where large supermarkets, stocked with affordable fresh fruits, vegetables and meats are not commonplace. One study found that there were four times as many supermarkets in white neighborhoods as compared to black neighborhoods. (8) Places where fresh, healthy, low-fat and nutritious food is inaccessible or unaffordable are known as “food deserts”. (9) In urban, rural and tribal areas where the majority of the population is low-income and/or minorities, the most efficient and sometimes most affordable option is a processed or canned meal, or fast food.

Yet anti-obesity campaigns promote healthy eating as though it is a simple, conscious choice that one makes every second of every day. The “Fruits & Veggies — More Matters™” website announces that “Meal planning that includes plenty of fruits and vegetables will help save time and money.” (10) While this may be true in some cases, it is overly idealistic in a number of ways. As aforementioned, in urban and rural areas, fruits and vegetables are no more affordable than other, less healthy foods. In addition, planning a meal, shopping for and preparing it is quite time consuming, and it is unrealistic to imply that families of all socioeconomic backgrounds can afford to do so. Last, but not least, the Fruits and Veggies campaign implies that people can (and are interested in) planning meals in advance. It is as though this and similar campaigns assume that people always utilize the transtheoretical model when deciding what to eat- moving consciously from contemplating to preparing a meal and then eating it, while weighing the risks and benefits involved with the consumption. This is unrealistic, as hunger presents a challenge to anyone’s perceived self-control, and overweight and obese people already tend to favor energy-dense foods. (11)

Contrary to popular belief, most Americans are aware of the fact that fast food is unhealthy and would eat healthier foods if they were equally as accessible. No American is so misinformed as to believe that fruits and vegetables are not a major component in a healthy, balanced diet. Even large chain restaurants like McDonalds have publically admitted that their food is not meant for excessive (or even daily) consumption, due to its high fat, high cholesterol and high calorie content. (12) However, both the dearth of supermarkets found in minority (both rural and urban) communities and the exceptionally low prices of “energy dense” foods present both a real and a perceived barrier to healthy eating habits. (8,13)

Therefore, simply encouraging healthy eating and informing the public about recipes and benefits of fruits and vegetables ultimately does not address food prices and the food environment. Michelle Obama’s “Let’s Move!” campaign does recognize these “food deserts” as a problem, and the US Departments of Treasury, Agriculture and Health and Human Services have launched the Health Food Financing Initiative to increase access to healthy, affordable food. There is currently significant reinforcement of healthy eating principles at the state and national levels, and yet for many Americans, such healthy eating habits still seem like a fantasy.

At the end of the day, finding a fresh variety of vegetables, purchasing them and making a salad for dinner is not an option for many minorities, not because of a lack of understanding, but because of a lack of access. It is arguably more expensive and less convenient for large-scale anti-obesity campaigns to address food deserts, but it is also absolutely essential that such campaigns recognize that obesity is not solely due to bad decision-making and a lack of knowledge. In fact, an anti-obesity campaign that does not address food access can “generate frustration and culpability among the poor and less-well educated,” (13) at which point people may disengage completely from the goal of eating well, or eat unhealthy foods specifically in reactance to the perceived threat of the campaign. (14,15)

II. Alternative Standard of Beauty

Echoing this theory of reactance, there is noticeably little discussion surrounding whether or not overweight and obesity in minority communities could be, at least in part, a reaction to American society’s clear preference for and preoccupation with thinness. There is a significant difference in the prevalence of obesity in minority populations as compared to the greater population, and as aforementioned, a lack of knowledge and a disinterest in exercising cannot account completely for the difference. The CDC estimates that approximately 25.6% of Americans are obese, while 39.2% of African American women and 28.7% of Hispanic women are obese. (16) In 2002, approximately 80% of black women over 40 were overweight, and over 50% were obese. (17) Women of color therefore account for a significant number of obese Americans, and these high rates of obesity are also associated with the disproportionately high rates of diabetes and hypertension in minority women. (18)

Therefore, a well-founded anti-obesity campaign should appeal specifically to black and Hispanic women, who are at the highest risk of becoming overweight or obese, regardless of their socioeconomic status. (19) However, while most anti-obesity initiatives aim to be inclusive by featuring images of and commentary from a diverse group of people, such campaigns cannot address one of the main enabling forces behind female obesity in minority populations: the skewed perception of beauty. Many black and Hispanic Americans view an overweight figure as the ideal female body type. Such beauty values are continuously reinforced within black and Hispanic cultures, both by men and women. Much like the reactionary nature of hip-hop culture to the white establishment of power, minorities have also created a black and Hispanic standard of beauty in reaction to the thin, European, model-like standard of beauty. (20)

This “subcultural” standard of beauty is well documented, and while it seems positive in some ways, it is now contributing to a health crisis among minority women. It is possible that minority communities do not stigmatize obesity to the same extent as white Americans because it is already so prevalent in minority men and women. (21) On the other hand, the acceptance of obesity could be a direct rejection of the mainstream ideal, which is known as “disidentification”. (21) Due to America’s history of racism and stereotyping, many black women simply “disidentify” with any number of European-American values and ideals, including that which equates thinness to happiness and attractiveness. The theory of disidentification incorporates labeling theory, stigma theory and psychological reactance theory, but its focus is on the reduction of cognitive dissonance in reaction to a threat to a person’s integrity. (22)

This theory is quite important in understanding how and why the obesity rates for minorities are showing no signs of abating despite various public health campaigns. Disidentification with white ideals of health and beauty can be a way for many black people to maintain self-esteem in the face of the seemingly insurmountable challenge of weight loss. Maintaining a positive body image (despite evidence of personal excess weight or obesity) while confronted with anti-obesity campaigns and wafer-thin models is a defensive, protective measure. Therefore, the most effective anti-obesity campaign would create a sense of “ownership” for minority women; a minority woman would have to redefine what beauty and health mean to her in absence of her community’s ideas concerning weight.

However, most large-scale anti-obesity campaigns address the family as a unit or children independently. The “Let’s Move!” campaign focuses on children, schools and families, while the Massachusetts Mass in Motion program focuses on the family as well. The “Small Step” adult and teen campaign is one of the few national campaigns that address adults apart from children. It is possible to speak to mothers as members of a family unit, but such campaigns cannot create the same sense of personal autonomy and responsibility that could be created by an anti-obesity campaign for women as individuals. Rather than addressing children, mothers, or the family unit, there should be an anti-obesity message geared specifically towards minority women; one that creates a sense of pride that is inextricably linked to a healthy, but culturally relevant lifestyle.

There is a plethora of scholarship concerning the effectiveness of weight-loss interventions on minority children, but a noticeable lack of studies focusing on weight-loss interventions for minority women. There is evidence of Church-based and primary care-based interventions being successful in increasing minority women’s activity levels and facilitating weight loss. (23,24) However, these interventions do not correct the lack of importance that minority women attribute to thinness and fitness; many black women, in particular, do not view a “healthy weight” (non-obese or non-overweight) as integral to attractiveness or personal success. (21) This lack of preoccupation with thinness contributes to discounting, which is the third issue that goes unaddressed by anti-obesity campaigns.

III. Time Preference and Discounting

It is very hard for an anti-obesity campaign to effectively communicate the exigency of the obesity epidemic without lapsing into a de-motivational, unappealing, or unrealistic message concerning weight and risk of disease or death. Obese and overweight people do not decide to drastically change their diets just because excess weight is a risk factor for disease. Even overweight individuals who understand the significant health risks involved with excess weight believe that various diseases and disorders only plague people who are “extremely overweight” or clearly obese. (25) In actuality, they attribute the risk of disease only to those who weigh more than they do. Much like any other form of risky behavior, people have unrealistic expectations of risk and ignore the possibility of a future unfavorable outcome. (26) This tendency relates to time preference and discounting.

Anti-obesity and healthy eating campaigns seldom deal with time preference and discounting appropriately, if at all. Time preference is the rate at which people are willing to trade current usefulness for future benefit. (27) Time preference is based on a number of social, economic and psychological factors, and it is especially pertinent in any analysis of overweight and obesity. Discounting, otherwise known as hyperbolic discounting, is a general disinterest in a future consequence. (28) This preoccupation with immediate utility is a human trait, and it is not confined to overweight and obese persons. However, it is particularly useful in analyzing the obesity epidemic in the black and Hispanic population.

Studies show that there is positive relationship between obesity and time preference. However, there is evidence to suggest that this time preference is even more pronounced among the Black and Hispanic population; more specifically, a “higher time preference is associated with an elevated risk of obesity among black men.” (29) While there are many possible socioeconomic explanations for this positive relationship, researchers have theorized that economic insecurity, an inability to save money, and even the aforementioned alternative standards of beauty all have correlations to minorities’ time preference and rates of obesity.

As aforementioned, many black and Hispanic Americans live in food deserts, or socioeconomically disadvantaged communities where affordable, healthy food is inaccessible. For these people, the instant (and affordable) gratification offered by easily accessible food outweighs the possibility of future weight gain. It is easy to understand why the prospect of locating, paying for and preparing healthy food and reaping the health benefits in the future could be unattractive for people without the time or economic means to do so conveniently. In fact, there is evidence to suggest that even daily discounting can influence caloric intake, in which people consume an excess of calories today despite a real economic cost tomorrow. (30)

In a study of the spending and eating habits of people receiving food stamps, an economist found that food stamp recipients spent the majority of their funds and consumed the greatest number of calories at the very beginning of the month, immediately after receiving the funds. (30) By the end of the month, the overwhelming majority of the food funds were depleted. This spending trend repeated itself month after month, signaling that people, especially those of low socioeconomic status, have exceptionally short-term discounting in terms of food consumption. (30) In this case, their caloric consumption evidenced daily discounting, which has great implications for obesity interventions. If the immediate gratification of consumption today outweighs a real benefit tomorrow, it makes it that much harder for an anti-obesity campaign to convince overweight and obese people of a potential health benefit that is months, if not years in the future.

Comparably, another study found that obese women had greater delay discounting as compared to healthy-weight women, which authors hypothesized was a factor leading to the development of obesity. (31) Such delay discounting can also reinforce obesity, so an anti-obesity campaign must also contend with overweight and obese peoples’ understanding of their current health status and their disinterest in the potential long-term (delayed) benefits of losing weight. Public health campaigns geared towards American adults make general, lackluster statements like “Eating plenty of fruits and veggies may help reduce the risk of many diseases, including heart disease, high blood pressure, and some cancers.” (10) This kind of statement is neither convincing nor motivating, and any attempt to overcome discounting in minority populations must contend with a larger, socially and environmentally influenced time preference for immediate results. Simultaneously, such a message cannot seem as though it is chastising, patronizing, or further stigmatizing poor food choices.

Time preference goes unaddressed even in the many anti-obesity campaigns geared towards children. Perhaps this is due to a misunderstanding of just how much it influences eating behavior (and all behavior). Ultimately, these campaigns assume that eating healthy and exercising are rational decisions that adults and children make far in advance. However, time preference and hyperbolic discounting have specifically been described as irrational beliefs and behaviors, and they have been shown to be positively related to an increase in BMI in adult minorities.(29,32) This is clearly a problem that deserves more attention, and any anti-obesity campaign geared towards the black and Hispanic adult population should acknowledge this seemingly socioeconomically- influenced time preference.

Conclusion

While positive, the majority of anti-obesity campaigns in the United States fail to address some of the most important underlying causes of obesity in the black and Hispanic adult populations. Food deserts in minority communities, the Black and Hispanic perceptions of female beauty, and the time preference for immediate rewards as opposed to future benefits are all extremely important factors contributing to the overweight and obesity epidemic among American minorities. There are very few campaigns geared specifically towards adults, and those that do speak to adults are overly simplistic, relying on theories of rational behavior and ignoring the social, cultural and economic forces that influence diet and exercise. While the “Let’s Move!” and Mass in Motion campaigns trumpet the fact that obese children are likely to grow up to become obese adults, they are less vocal about the fact that obese parents are likely to raise obese children. (33) The obesity epidemic is especially problematic in the black and Hispanic communities, and black and Hispanic men and women are more likely to be obese than white men and women. (1) Ultimately, a truly effective and inclusive anti-obesity campaign would address the factors underlying adult minority obesity with the understanding that the positive effects of such a campaign would trickle down to minority children. The incidence and prevalence of obesity in the United States will only depreciate significantly if large-scale anti-obesity campaigns better reach those at greatest risk of becoming overweight and obese.

A Truly Diverse Anti-Obesity Campaign

To adequately address the many factors leading to the disproportionately high risk of overweight and obesity in minority populations, a large-scale anti-obesity campaign will have to employ a number of methods that are currently noticeably absent from campaigns like “Let’s Move” and “Fruits and Veggies- More Matters”. There are three factors contributing appreciably to the prevalence of obesity in black and Hispanic Americans: food deserts, alternate standards of beauty and time preference. While hard to address, all of these issues must be brought to the forefront of any anti-obesity effort. The ideal vehicle for better recognition of these issues would be Michelle Obama’s “Let’s Move!” campaign, with slight alterations to the campaign’s objectives and methods. As it stands, Let’s Move! is focused on fighting childhood obesity with the help of parents. This is a well-executed and attractive campaign, but it does not address adult obesity apart from its relationship to the health of children, nor does it address adult obesity in minority communities.

The “Let’s Move!” campaign is beginning to address the issue of food deserts with the assistance of various government agencies. This week, the USDA introduced a food desert locator, allowing people to locate food deserts (low-income and low-food -access communities) all over the country.(34) In addition, the Obama administration created the Healthy Food Financing Initiative last year with the specific intent of increasing healthy food access in underserved and rural communities. The initiative is a partnership among the Department of Health and Human Services, the US Department of Agriculture and the US Department of the Treasury. The diversity of the government offices involved in addressing these food deserts offers an indication of just how complex and widespread the problem actually is. The next step in promoting knowledge of food deserts would be to publicize the existence of food deserts and the food desert locator. The Let’s Move! Website should include a link to the food desert locator, so that an adult (or child) can easily and immediately determine the status of his or her city or town. It is important that minority communities are aware of the existence of food deserts, especially if they are living in one. This knowledge can help to minimize the reactance they may feel to campaigns like “Fruits & Veggies — More Matters™”, and it could even motivate adults to build a garden or call for local food merchants to alter their practices. Minority and low-income communities must begin to feel empowered in the fight against obesity, and knowledge of food deserts would definitely help to create a sense of local ownership of the issue.

Michelle Obama’s “Let’s Move!” campaign has proven especially effective in creating a certain amount of excitement around the idea of exercising and eating well. The campaign now includes a “Let’s Move! Flash Workout” featuring popular music celebrity Beyonce Knowles dancing in a school cafeteria with children. This “star power” lends more support to the campaign, and it is particularly attractive to black and Hispanic girls, who are especially fond of Beyonce and her music. This strategy is very positive, and it could apply to black and Hispanic women as well. Perhaps if older women of color (or even Beyonce’s mother) were shown in a Let’s Move! video doing the workout, it would help to motivate minority women to exercise as well. Ideally, such a video would be universally appealing while allowing for self-referencing, as described in advertising theory. (35) As aforementioned, the minority preference for a larger female body is due, at least in part, to a disidentification with mainstream beauty values. (21) Black and Hispanic women can identify with Beyonce (who is 30 years old) and older women of color, which will help to modify the perception of health and exercise as being “white” values. So instead of attacking the subcultural beauty value directly, it seems easier and equally as effective to elevate the importance of physical activity and health for minorities. With the help of Beyonce and other physically fit minority women, perhaps the importance of a heavier external appearance will be eclipsed by an interest in attaining and maintaining a certain level of physical fitness.

Last, but not least, Let’s Move! should address the influence of time preference on overweight and obesity discounting in minority communities. This is perhaps the hardest issue to address because health messages can (and oftentimes do) trigger reactance. (36) However, rather than emphasizing the negative effects of eating poorly and not exercising, the Let’s Move! Campaign can emphasize the positive effects of eating well and exercising regularly. To tailor this message specifically to black and Hispanic adults, the campaign can begin by altering the website such that some parts speak specifically to adults about their health. For example, the “Eat Healthy” (http://www.letsmove.gov/eat-healthy) page should include a portal for “Healthy Adults” or even “Healthy Men” and “Healthy Women”. This area would then go on to describe the immediate benefits of eating well and exercising, i.e. “increased energy, better mood, clearer skin today”. It could also recommend exercises that a person could do at home, and cheap, accessible food options, like low-fat milk and pretzels rather than soda and chips. As evidenced by mainstream advertising of normal products, the exercise and healthy eating claims would not have to be supported by statistics, or be completely factual. However, they do have to overcome the lack of urgency felt by so many minorities with regards to obesity and overweight, and one of the best ways to do so is to convince minorities that eating healthy food or exercising today will in turn yield a benefit today.

These improvements to the Let’s Move! campaign would likely have positive effects on the prevalence of and opinions about overweight and obesity in the adult minority population. It is so important to incorporate messages geared towards adults into large-scale anti-obesity campaigns like Let’s Move! because the adult obesity epidemic is encouraging the childhood obesity epidemic and vice-versa; the two are intertwined and inseparable. It is clearly imperative that such campaigns recognize the social, cultural and economic factors contributing to obesity amongst minorities because minorities are at a greater risk of becoming obese as compared to the general population. All anti-obesity campaigns should address adults because it is never too late for a person to lose weight and thereby drastically improve his or her health, and it only seems fair that an exclamation like “Let’s Move!” includes all of us.

REFERENCES:

1. Kaiser Family Foundation. State Health Facts. Overweight and Obesity Rates for Adults by Race/Ethnicity, 2009. Retrieved From http://www.statehealthfacts.org/comparebar.jsp?ind=91&cat=2 Accessed on 4.24.11

2. Zuelke, E. For Women in the U.S., Obesity Links to Socioeconomic Status and Poor Diet. Population Reference Bureau, 2010. http://www.prb.org/Articles/2010/usobesity.aspx

3. Mobley, L. Root, E., Finkelstein, E., Khavjou, O. Farris, R. Will, J. Environment, Obesity, and Cardiovascular Disease Risk in Low-Income Women. American Journal of Preventive Medicine 2006; 30: 327-332.

4. Centers for Disease Control and Prevention. Heart Disease Fact Sheet. Atlanta, GA: Centers for Disease Control and Prevention, 2010.

5. Finkelstein, EA, Trogdon, JG, Cohen, JW, and Dietz, W. Annual medical spending attributable to obesity: Payer- and service-specific estimates. Health Affairs 2009; 28: 822-w831.

6. Centers for Disease Control and Prevention. Obesity and Overweight. Health Consequences. Atlanta, GA: Centers for Disease Control and Prevention, 2010.

7. Agras, S. Does Early Eating Behavior Influence Later Adiposity? Childhood Obesity: A Behavioral Perspectice. Eds. Krasnegor, N., Grave, G. Kretchmer, N. New Jersey: The Telford Press. 1988. 49-66

8. Morland, K. Wing, S. Diez Roux,A., Poole, C. Neighborhood characteristics associated with the location of food stores and food service places. Journal of Preventive Medicine. 2002; 22: 23-29.

9. Centers for Disease Control and Prevention. Food Deserts. (2010) http://www.cdc.gov/Features/FoodDeserts/

10. Produce for Better Health Foundation. Fruits and Veggies More Matters TM. Meal Planning and Shopping http://www.fruitsandveggiesmorematters.org/?page_id=4

11. Mela, D. “Determinants of Food Choice: Obesity and Weight Control. Obesity Research 2001;9:249–S25

12. Pelman v. McDonalds Corp. 237 F. Supp. 2d 512 - Dist. Court, SD New York, 2003

13. Drewnowski, A. Obesity and the Food Environment: Dietary Energy Density and Diet Costs. American Journal of Preventive Medicine. 2004; 27(3):154-162

14. Brehm, J. W. A theory of psychological reactance. New York: Academic Press, 1966.

15. Wrosch,C. Miler, G., Scheier, M., Brun de Pontet, S. Giving Up on Unattainable Goals: Benefits for Health? Personality and Social Psychology Bulletin. 2007;33:251-265.

16. Centers for Disease Control and Prevention. Differences in Prevalence of Obesity Among Black, White, and Hispanic Adults --- United States, 2006—2008. Morbidity and Mortality Weekly Report. (2009) Centers for Disease Control. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5827a2.htm

17. Wang, Y. Beydoun, M. The Obesity Epidemic in the United States—Gender, Age, Socioeconomic, Racial/Ethnic, and Geographic Characteristics: A Systematic Review and Meta-Regression Analysis. Epidemiology Review. 2007; 29: 6-28.

18. Black, S. Diabetes, Diversity, and Disparity: What Do We Do With the Evidence? American Journal Public Health. 2002; 92 (4):543–548

19. Blanchard, S. Variables Associated with Obesity Among African American Women in Omaha. American Journal of Occupational Therapy. 2009; 63: 58–68.

20. Ransby, B. Matthews, T. Black popular culture and the transcendence of patriarchal illusions. Race and Class. 1993; 35: 57-68

21. Hebl, M. Heatherton,T. The Stigma of Obesity in Women: The Difference is Black and White. 1998; 24: 417-426.

22. Steele, C. M. The psychology of self-affirmation: Sustaining the integrity of the self. Advances in experimental social psychology 1988; 21: 261–302.

23. Young, D. and Stewart, K., A Church-based Physical Activity Intervention for African American Women. Family and Community Health. 2006; 29: 103-117

24. Martin, P. Dutton, G., Rhode, P., Horswell, R., Ryan,D. Brantley, P. Weight Loss Maintenance Following a Primary Care Intervention for Low-income Minority Women.Obesity. 2008; 16 :2462–2467.

25. Kan, Kamhon and Tsia, Wei-Der. Obesity and Risk Knowledge. Journal of Health Economics. 2004; 23: 907-934.

26. Weinstein, N. Unrealistic Optimism About Future Life Events. Journal of Personality and Social Psychology. 1980; 39: 806-820.

27. Rosin, Odelia. The Economic Causes of Obesity: A Survey. The Journal of Economic Surveys. 2008; 22: 617-647.

28. Frederick, S. Loewenstein, G., O’Donoghue, T. Time Discounting and Time Preference: A Critical Review. Journal of Economic Literature. 2002; 40: 251-401

29. Smith, P. , Bogin, B., Bishal, D. Are time preference and body mass index associated?: Evidence from the National Longitudinal Survey of Youth. Economics and Human Biology. 2005; 3:259-270

30. Shapiro, J.M. Is there a daily discount rate? Evidence from the food stamp nutrition cycle. Journal of Public Economics. 2005;89: 303-325.

31. Weller, R. Cook, E., Avsar, K. and Cox, J. Obese women show greater delay discounting than healthy-weight women. Appetite. 2008; 51:563–569

32. Feldstein, M. The Social Time Preference Discount Rate in Cost Benefit Analysis. The Economic Journal. 1964; 74: 360-379

33. Wardle, J., Guthrie, C., Sanderson, S., Birch, L. and Plomin, R., Food and activity preferences in children of lean and obese parents. International Journal of Obesity. 2001; 25:971-977

34. Carr, Heather. USDA Introduces Food Desert Locator. Retrieved from http://eatdrinkbetter.com/2011/05/05/usda-introduces-food-desert-locator/. Accessed on 5.5.11

35. Debevec,K., Spotts, H., Kernan, J. THE SELF-REFERENCE EFFECT IN PERSUASION IMPLICATIONS FOR MARKETING STRATEGY. Advances in Consumer Research. 1987; 14:417-420.

36. Rains, S., and Turner, M., Psychological Reactance and Persuasive Health Communication: A Test and Extension of the Intertwined Model. Human Communication Research. 2007; 33: 241–269