Why Calling a Fat Kid a Fat Kid Doesn’t Solve Childhood Obesity -Jessica Ochalek

Today over one third of U.S. adults and 17% of U.S. children are obese. In the last three decades, obesity rates for adults have doubled and rates for children have tripled. However, the burden of obesity is not evenly distributed, and falls heavily on minorities. The 2009 Behavioral Risk Factor Surveillance System report showed that “blacks were 51% more likely and Hispanics were 21% more likely than non-Hispanic whites to be obese” (1). It is also geographically unevenly distributed with the American Midwest suffering higher obesity prevalence rates than the rest of the country. Cincinnati, Ohio is a beautiful Midwestern city situated at the southern edge of Ohio, across the Ohio River from Kentucky. However, like many Midwestern cities and states, Cincinnati has seen an alarming increase in obesity among adults and children in the last few decades. According to CDC 29.6% of Ohioans were obese in 2009. This increase has serious health consequences for adults and children. Obesity related diseases like type 2 diabetes, which previously only affected adults, is now affecting children (1). Obese children are also at higher risk of suffering cardiovascular disease. Obesity, including childhood obesity, is known to be a risk factor for a number of diseases including cancers, stroke, respiratory problems and reproductive health problems. The annual hospital costs related to childhood obesity increased from $35 million in the period from 1979-1981 to $127 million in the period from 1997-1999 (1).

In 2008 the nonprofit Center for Closing the Health Gap (2) in Greater Cincinnati began a campaign aimed at preventing childhood obesity. Childhood obesity prevention is a goal that fits perfectly within CCHG’s mission, which includes increasing awareness about health disparities (2). The childhood obesity epidemic in the Greater Cincinnati area disproportionately affects minority children. CCHG’s website reports that the rate of overweight and obesity in Hamilton County is 43% among Black, Non-Hispanic children and 21% among White, Non-Hispanic children. The negative consequences to health that may result from obesity are grave. The city was seeing children with hypertension and worrying rates of type II diabetes. Secondly CCHG saw that obesity disproportionately affected children of low-income parents and minority children, particularly Black, Hispanic and Appalachian children. To work toward preventing childhood obesity the organization initiated a campaign called “Do Right!” The specific target of the childhood prevention portion of the program aimed at “improving the health and well-being of children at Rockdale Elementary that are overweight and obese” (2). Rockdale Elementary is part of the Cincinnati Public Schools system and enrolls about 500 preschool and elementary school students from grades PK-8.

The “Do Right!” children’s program is multi-faceted. Its in school components include screening for BMI to identify overweight and obese children, referral for obese children to an after school physical activity and nutrition program. The program includes nutrition every other week by a dietician, physical activity and bi-weekly parent education and information sessions to discuss nutrition. The program also included 1-minute health tips on the radio, parent workshops in development and City School Awareness Presentations (2). Finally, the program ran a concurrent obesity awareness campaign that included billboards, bus shelters, radio advertisements, ads in minority newspapers and the website: www.dorightcincy.org. They feature obese children mowing down on big, greasy burgers in front of plates of onion rings with the words “Are we feeding our kids to death?” in large print. Below, they provide the Do Right! campaign’s website and phone number with the words “for information on how to combat obesity.” These ads are the focus of this critique.

Defeating Self-Efficacy

First and foremost it alienates the very population it aims to help. Dwight Tillery, the executive director of CCHG, purports that the campaign was designed to serve as a wake-up call for families. It aims to incentivize parents to take the health of their children more seriously by showing them just how serious obesity is. Tillery said, “We can’t afford to be politically correct on this issue” (3). Political correctness or lack thereof aside the means simply do not justify the end. Whether or not parents are shocked into understanding the gravity of childhood obesity, children who see these ads are sure to feel alienated. The ads effectuate a pervasive sense of hopelessness, powerlessness and defeat. They say, “you’re obese and you’re being fed to death.” There is nothing in this message that engenders a sense of self-efficacy, or the idea that a lower, healthier weight is an attainable goal. This deficiency is the ad’s primary shortcoming. Self-efficacy as defined by psychologist and father of Social Cognitive Theory, Albert Bandura, is one's belief in one's ability to succeed in specific situations. The concept of self-efficacy is central to Social Cognitive Theory (4). Social Cognitive Theory asserts that behavior is based on the interaction between one’s environment, the behaviors one witnesses, and the individual themselves. Ads like these posted by CCHG construct a negative outcome expectation and in so doing dismantle whatever self-efficacy they could otherwise have fostered. It simply isn’t enough to provide a website and helpline when the ad itself effectively destroys self-efficacy.

Labeling and Normalizing Obesity

Not only do these ads beget powerlessness as shown in the last paragraph, but they concurrently label and normalize childhood obesity. The relationship between labeling and normalizing obesity presents a double-edged sword for potential public health interventions aimed at preventing childhood obesity. The normalizing of obesity comes with a hefty price tag including rising economic costs. According to the Brookings Institution, “the total costs of obesity in the U.S. alone may exceed $215 billion annually” (5). The direct medical costs resulting from obesity in the U.S. have been estimated to account for over 9% of the national medical bill (6). Societal costs are also extensive. Obese children are less likely to be sent to college by their parents (6). Obese adults are less likely to be given jobs, and miss more work, overall costing employers something on the order of $4 billion. Obese children are at much higher risk of becoming obese adults than their thinner peers (7 - 8). In sum, normalizing obesity, particularly in children, presents a great hazard to personal health and has a major negative impact on costs at the society level.

On the flip side of normalizing, labeling obese children forces them to contend with the heavy stigma associated with obesity, decreasing the likelihood that they will overcome the many hurdles to health and wellness placed on them by society. Obesity is the fourth most common type of discrimination people report experiencing in the U.S. (9). Simply labeling children as obese has the potential to greatly influence their behavior. While the ads don’t literally use the word “obese”, they make it visually quite clear that they’re targeting obese children, and point a finger at poor eating habits. Labeling Theory (which is also known as Social Reactance Theory) posits that labeling an individual influences their behavior and more often than not causes them to conform to the stereotypes of the label in a self-fulfilling prophecy (10 - 11). Obese children must endure negative stigma not only from their peers, but also by their teachers and themselves (9). They are often ascribed negative characteristics including mean, stupid, loud, sloppy, ugly, lazy, sad, and lacking in friends (12 - 14). Obese children can become trapped within this self-fulfilling prophecy and may thus accept these traits as part of their role in society as an “obese child”. Studies have shown that the stigma associated with obesity causes an increase in coping methods like binge eating instead of being a contributing factor to motivation to lose weight and stay healthy (9, 15).

Not only are the children taught how to act by the characteristics attached to their label, but they learn through cognition in conjunction with observing behaviors within their environment. These elements operate reciprocally. For example, the environment in which one is raised affects one’s cognition and perceptions of behaviors that one witnesses. In state where approximately 30% of people are obese and where television stations air shows like “More to Love” or “Ruby” (in which the star, Ruby, spends three seasons trying lose weight only to end the third season having gained over 50 pounds) obesity is not likely to be perceived as abnormal (1). It is likely seen simply as the status quo. Posting health billboards featuring obese children eating is wading into dangerous territory. It risks adding more obesity normalizing media to the local environment and simultaneously reinforces the stereotypes and stigma associated with obesity, particularly qualities like lack of self-control.

SCAREMONGERING

Proponents of the campaign cite the fact that 93% of parents of obese children didn’t perceive their kids as being an abnormal weight (16). Research backs up this frightening assertion and shows that parents of overweight children consistently underestimated their children's weight (17 - 18). CCHG’s Childhood Obesity Awareness Campaign aims to inform parents that their children are at risk for serious health outcomes and the organization has deemed that shocking parents is necessary to do so. This scaremongering tactic assumes that by informing parents that their children are at risk of very serious health outcomes like death, they will be moved to act. This assumption takes for granted that people are rational decision makers. Rational decision-making generally entails defining the problem, identifying criteria relevant to the problem, considering all possible solutions, calculating the potential consequences of each solution, and choosing the best option. Many public health interventions are based on this same assumption. It is in fact the very basis of the Health Belief Model, which is commonly used in public health interventions. This model postulates that a behavioral change at the individual level depends on a person’s attitudes toward expected outcomes, the strength of those attitudes and the resulting outcome expectancies, as well as the individual’s perceptions of how others see them, and what the societal norms are (4). All of these factors meld to produce intention, which is followed by behavior. When applied to a parent’s role in preventing childhood obesity, as CCHG has done, the model suggests that if parents become aware of the potential hazardous heath outcomes of obesity and their attitudes toward obesity change, they will intend to prevent or reverse obesity in their children and that intention will lead to a change in behavior. This progression assumes rationalism prevails. Unfortunately assuming rationality fails to account for an individual’s subconscious thought process, irrational decision-making, group behavior and societal and environmental factors, all of which are crucial variables guiding behavior (4, 19, 20).
Irrational decision-making often relies upon the way that a particular issue is introduced or framed. Framing is a method of presenting a fact, topic or idea in a specific light so as to change how it is received among the audience to whom it is being presented. The concept of framing is central to Prospect Theory. Put simply, Prospect Theory states that people value gains and losses differently and that individuals make decisions based on perceived gains rather than perceived losses (21). Given two options with equal outcomes, an individual would choose the outcome expressed in terms of possible gains instead of the one expressed in possible losses. CCHG’s billboard frames childhood obesity in terms of the expected health outcome as a loss. Presenting the issue of childhood obesity by framing it within the context of not only a negative outcome but its most terrifying potential outcome, premature death from obesity related health problems, sets the campaign up for failure.

DO RIGHT! SUCCESSES: A SPRINGBOARD

While CCHGs program’s billboard and ad campaign are majorly flawed, there are a number of things the Do Right! campaign as a whole has gotten right. The organization was correct to take multi-faceted and all-encompassing approach to targeting childhood obesity prevention. Research suggests that families, schools and communities should all be included in programs aimed at preventing and reducing childhood obesity (22). Targeting parents exclusively has also been shown to be effective in reducing the BMI of overweight and obese children. A recent study from the United Kingdom showed that the BMI percentile of children whose parents were provided with eight sessions of cognitive-behavioral therapy for weight loss decreased significantly by 2.4% in the treatment group (23). Community involvement or not, targeting parents is crucial childhood obesity prevention programs. Children of obese parents are more likely to be obese themselves. Children aged 15 to 17 years old with at least one obese parent are over twice as likely as children with no obese parents to be obese adults. Children aged 1 to 2 years old were three times as likely to be obese as their peers who didn’t have an obese parent (24). Beyond the nuclear family, recent research has shown that obesity also spreads through social networks. A study conducted using data from Framingham, MA found that the chances of someone becoming obese increase 57% if they had a long-term friend who was obese (25). However, succeeding in utilizing parent and community involvement in childhood obesity prevention programs is challenging. As anyone who has ever tried to lose even a few pounds knows, attempting to lose weight can be daunting. For an obese person the barriers to weight loss, potentially including difficulty engaging in physical activity, addiction and lack of social support, can often seem indomitable. At any rate, with at minimum an adequate level of support within the environment and from family and community members, childhood obesity can be overcome. Methods to resolve each of the previously outlined failings within the billboard and ad campaign are presented in the following three sections.

POSITIVITY-MONGERING

As addressed in a previous section of this paper, the Health Belief Model as a champion of rational decision-making, and as it was implemented, was not an effective archetype from which to create the childhood obesity prevention billboard and ad campaign. On the other hand, framing, as delineated within Prospect Theory, can be an incredibly useful tool with which to begin to reconstruct this intervention. Bearing in mind that the original intent of the ad was to create awareness of childhood obesity as a serious problem among parents of obese children, the following proposed ad is aimed at both parents and children who will inevitably see the ads as well. This approach utilizes an entirely novel angle that frames health, with regard to weight, as a desirable and attainable outcome.

The proposed billboards will feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This sends the following messages; physical activity is fun; obese children are also entitled to fun; obese children can do sports. In this way fighting childhood obesity through physical activity is framed in a positive light, as a fun and attainable goal. Making weight-loss and health attainable completely reverses the billboards, taking them from negative to positive and fomenting self-efficacy in children.

ENGENDERING SELF-EFFICACY BY NORMALIZING HEALTH

Labeling and normalizing obesity both have serious negative consequences at the individual and thus also societal level. They contribute to lower levels of self-esteem among obese children, and contribute to extensive monetary costs at the national level. A good public health campaign will succeed in achieving improved health and preventing obesity without further contributing to the extensive and damaging effects of labeling. While the billboard proposed in the prior section may be argued as normalizing obesity, it should be seen as normalizing activity among children of all shapes and sizes. Obese children are usually stereotyped as stupid, sloppy, ugly and lazy. In personal stories shared on blogs obese adults recount experiences that, in line with research published in peer reviewed journals, illustrate the cyclical nature of the self-fulfilling prophecy. In a blog published on Newsweek, Leslie Kinzel wrote,

“Prior to being told I was fat by my well-intentioned pediatrician … I'd spent my life as an active and athletic child, my fatness no obstacle in keeping up with my peers (and frequently besting them). As I got older I came to understand what being fat meant: fat kids were lousy at sports, and those who tried to play were to be mocked for it. Fat kids were always picked last, and though I was never picked last, I came to fear that it would inevitably happen. So I stopped playing. I backed away from sports and games altogether.” (26)

Her account is unfortunately not uncommon and characterizes the major negative impacts that labeling has on obese children. Obesity carries such stigma that for many children it becomes the single characteristic by which they feel most defined. At the end of her post Kinzel pleads,
“Call it a campaign against childhood couch-sitting. Call it a drive to get kids to go outside and play. Call it a movement to educate children on basic nutrition and how their amazing growing bodies work for them. But don't single out the fat kids. If I am any indication, doing this will only ensure that this generation will be fatter than ever, dragging behind them some heavy baggage around food issues and low self-esteem.” (26)

Kinzel’s well-put conclusion holds true given what has been learned from the failures of the Health Belief Model and the potential outcomes associated with Label Theory and Social Reactance Theory. It is absolutely necessary to change the personal characteristics associated with the obesity label. Getting obese children re-involved in sports and other physical activities will help to get rid of the stereotype that obese children can’t play sports. This will serve a dual purpose. It will encourage other obese children to take up arms so to speak and join the revolt against stereotypes. At the same time becoming involved in sports once again or perhaps for the first time will have positive health effects. While these effects certainly can’t be expected to be immediate they will have a positive effect on the local environment that should grow exponentially.

ENGENDERING SELF-EFFICACY BY REVOLTING AGAINST THE LABEL

Inciting obese children in Cincinnati to rise up against the fat label takes advantage of the mechanisms described in Psychological Reactance Theory. This theory asserts that perceived limitations to freedom or autonomy provoke an aversive affective reaction in people (27). In other words, if an individual perceives that their freedom has somehow been limited they will become provoked to regain it. A wonderful example of psychological reactance at work is the Truth campaign, which aims to curb youth use of tobacco by inciting a rebellion of sorts among young people. The campaign’s theme is “truth, a generation united against tobacco” (28). The Truth campaign successfully framed the tobacco industry as a liar that was hiding the truth from teens. In doing so they provoked teens to rebel against big tobacco and its lies, successfully decreasing youth smoking initiation rates.

The proposed alternative billboards showing obese children standing up to the labels and stereotypes associated with childhood obesity will do the same. This reaction is particularly common when individuals feel obliged to adopt a particular opinion or engage in a specific behavior (27). The billboards will bring to light these expectations and the violation of freedom that they cause for obese children, inspiring rebellion. In inciting this silent, healthy insurrection the campaign will be rekindling self-efficacy in obese children, which has a powerful effect on an individual’s level of motivation. “Boredom and apathy occur when a challenge is too small; anxiety and withdrawal occur when a challenge is too great; curiosity and engagement occur when the challenge is optimal” (29). If children don’t feel like they will succeed in losing weight or getting healthy they are much less likely to try to do so. Engendering self-efficacy through these billboards is an indispensible component of a successful childhood obesity prevention public health campaign. Recent work has found that “exercise’s association with weight loss was better explained through psychological, rather than physiological (ie, caloric expenditure), pathways” proving even further the importance of self-efficacy in weight loss (30). Giving obese children a common cause and an enemy to take down will help to create this self-efficacy, aiding in reducing and preventing childhood obesity over time.

CONCLUSION

Childhood obesity is a serious public health threat that requires sincere and practical interventions. The potential health consequences that are associated with childhood obesity are grave. They are harmful both to the individual and at the national level. Obese children are at increased risk for type II diabetes, cardiovascular disease, respiratory problems and future reproductive problems. They have added to increased medical costs at the national level, and as childhood obesity prevalence rates are higher among lower income quintiles the increased prevalence of childhood obesity has contributed to growing government expenditures on health (1). Practical, effective solutions are crucial in the fight to prevent and decrease childhood obesity.

In order to create a billboard campaign that effectively reduces and prevents childhood obesity while carefully avoiding potential adverse affects that such a billboard could so easily have, as evidenced by the one used by CCHG, social and behavioral sciences theories should be employed. Social Cognitive Theory, Labeling Theory (which is also known as Social Reactance Theory), the Health Belief Model, Framing Theory (as well as Prospect Theory) and Psychological Reactance Theory were used to analyze and critique CCHG’s billboard and ad intervention. CCHG’s billboard intervention was found to be inappropriate on the grounds that it contributed to defeating self-efficacy among obese children, added to labeling and normalizing childhood obesity and resorted to terrorizing parents in an effort to create awareness and incite a behavior change among parents and children. These same theories were then employed to suggest an appropriate intervention to replace CCHG’s billboard ads. The proposed replacement intervention consists of billboards that feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This intervention is based on engendering self-efficacy by reframing the childhood obesity issue in a positive light, normalizing healthy choices among obese children and using Psychological Reactance Theory to empower children to fight against the labels associated with childhood obesity. Casting a glow of optimism on the problem will help to bring back to life self-efficacy that has been squashed by labeling and stigma. Social and behavioral sciences theories were instrumental tools in understanding the effects that the Cincinnati CHG’s billboards could be expected to have on the target population, as well as any projected externalities, and in creating a better alternative.

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Not Even Once: A Critique of The Meth Project’s Graphic Ad Campaign –Elyse

In 2010 The Meth Project “Not Even Once” Campaign was named as the third most effective philanthropy in the world (1). The program originated in 2005 in Montana as the Montana Meth Project and has since spread to Arizona, Idaho, Illinois, Wyoming, Colorado, Hawaii and Georgia (2). In 2005, Montana had one of the highest rates of meth use in the country and in 2006, 50% of those incarcerated in Montana were in jail for meth-related offenses (3). Methamphetamine use has been shown to have a substantial economic burden of roughly $23.4 billion in the United States and is predominantly used in Western and Midwestern states (3). Evaluations of supply-side meth interventions, such as regulating the sale of products containing ephedrine, have shown to be expensive and only temporarily effective (3). The Montana Meth Project was started by business executive Thomas Siebel and was primarily aimed at teenagers. The campaign is a demand-side intervention designed to prevent the first time use of methamphetamine (3). It uses graphic television, radio, internet, billboard and print ads in a saturation-level ad campaign that show the negative consequences of meth use (4).

The explicit nature of the ads has been controversial. One billboard shows a young couple sitting on the floor of a room with the blinds closed. The teenage boy is looking past his girlfriend and the girl is looking at the floor. The writing on the billboard is says, “My girlfriend would do anything for me. So I made her sell her body” (4) The underlying message of the ad seems to be that meth addicts become so desperate they will do anything for money, even force their significant others into prostitution.

The video ads are just as graphic. One of the video ads begins with a teenager in a gray sweatshirt sitting in a Laundromat. As he sits waiting for his wash cycle to finish, a crazed young man walks through the door and begins yelling at the other Laundromat patrons to give him their money. He then proceeds to push a middle aged women on the ground, punch a man in the face, and scream at a woman with her young daughter and baby while stealing wallets and scrambling for money that they throw at him in terror. He then runs up to the young man in the gray sweatshirt who realizes that he’s looking at a future meth addicted version of himself. The meth-faced version grabs the sweatshirt of the surprised teen and screams in fury, “This wasn’t supposed to be your life!” (4) The message here is that meth will turn you into an unrecognizable, violent monster.

While these ads are shocking and memorable, their effectiveness is questionable. The Meth Project website states that since the introduction of the campaign teen Meth use in Montana has declined by 63% and Meth-related crime dropped by 62% (2). Other studies show otherwise. Data from the Montana Youth risk Behavior Study shows that from 2005 to 2007 the absolute drop in teen Meth use was 3.7% which is less impressive than the statistic the Montana Meth Project portrayed as a relative 45% drop (5). Studies also show that Meth use was already on a decline before the campaign began (5). From 2001 to 2003, Meth use fell 3.3%. Accounting for the pre-existing downward trend, the impact of the campaign is almost statistically insignificant (5). While The Meth Project has gained international praise and recognition, the campaign’s use of fear appeals to influence behavior may actually be having the opposite effect of the ads’ intentions. By implementing narrative rationality and action recommendations into their ads, The Meth Project may be able to develop more effective behavior change in their target population as well as reducing their psychological reactance response to the campaign.

Critique 1: Lack of Action Recommendation in Application of Drive Reduction Model

Fear arousing communications have been featured prominently in many public health interventions, especially in anti-smoking and anti-drug campaigns (6). The Meth Project relies heavily on the use of fear to invoke behavior change. Fear arousing communications consist of two parts: fear appeal and action recommendation (7). The fear appeal is meant to emphasize the individual’s susceptibility to the health risk as well as its severity. The action recommendation is meant to give a method of reducing or eliminating the health risk.

Many fear campaigns are based on the drive reduction model, proposed by Hovland, Janis and Kelley in 1953 (8). This model was developed in the 1950’s, and suggests that fear can act as a driver, or motivational factor (8). In the case of fear appeals, the motivational force is presented as threatening information. In response to this driver, an individual will search for actions to reduce the threat. Thus, behavior that effectively reduces the emotional tension caused by the threat will become enforced. However, if the action recommendation does not adequately reduce the threat, the individual may downplay the severity of the threat, actively reject the message content or ignore it altogether (8).

The effectiveness of a fear arousing communication depends on the level of fear invoked and the ability of the recommendation to decrease the fear (8). Many studies have shown that when the amount of fear invoked increases, the resulting change in behavior is also greater (7); however, some research has shown that higher levels of fear may result in rejection or ignoring of the message (7). This occurs when the recommendation is not considered adequate in satisfying the emotional tension of the threat. Not only must the recommendation be able to reduce the tension, but the individual must also feel that they have the self-efficacy to successfully perform the response.

The Meth Project uses fear as its main form of persuasion. The TV ads are difficult to watch. One particularly disturbing ad shows a girl taking a shower. As she showers she notices blood going down the drain. She looks to the floor of the bathtub and sees a crumpled creature looking up at her. She screams and realizes that it’s her future-self on meth. The scabbed, bleeding version of herself looks up at her and pleads “don’t do it”(4). This ad is visually disturbing and invokes a high level of fear into the viewer. Some of the ads have been deemed so disturbing that parent groups and religious groups have requested that they be removed (9). The billboard showed an apparently emotionless girl pinned down from behind by a faceless man with the words “15 bucks for sex isn’t normal. But on Meth it is” written across the ad (4). Montana agreed to remove the billboards containing this message (9). While this ad has been removed, other billboards that remain include those showing a Meth addict picking at his scabs and a mom who has been mugged by her own child for drug money (4).

While there is no lack of threatening messages, The Meth Project fails to provide any form of recommendation to reduce the threat. There are 19 television ads, 19 print ads and billboards and 70 radio spots; however, none of them mention any information or suggestions on how to avoid meth use or reduce their risk of coming into contact with the drug. They also do nothing to empower the viewer or increase their perceived ability to reject the drug. By not providing any form of behavior suggestion or recommendation, viewers use the defensive mechanisms mentioned earlier to cope with the emotional tension.

Intervention 1: Provide Action Recommendation with Delivery of Fear Appeal

As discussed earlier, there are two requirement of the action recommendation. Firstly it must reduce the emotional tension caused by the fear appeal. Secondly the perceived efficacy of the action recommendation must be greater than the perceived fear and the person carrying out the action recommendation must feel they are capable of performing the action.

The threat that the campaign uses as its fear appeal is that using meth can possibly transform a meth-free youth into a desperate, crazy and violent addict. One of the main goals of the campaign is to reduce the first time use of meth. Therefore, the goal of the action recommendation should be to inform youths on how to actively avoid initial use of the drug. This can be achieved by providing viewers with strategies on how to handle situations that could potentially result in them trying meth for the first time. Ads could incorporate scenes such as a teenage boy offering his friend some meth. He asks him if he wants to try it, but his friend immediately declines. Another example could show a group of teenage girls walking into a house party. Upon seeing people using meth, they leave to go to another party that is drug free.

In order to promote self-efficacy the ads should emphasize the ease of completing these recommendations. For example, after the teenager says no to his friend, the friend accepts his refusal, and puts the meth away rather than trying to peer pressure him. The ad showing the girls can show them apologizing to the hosts of the first party and arriving at the second party, which is just as lively as the first. By depicting these situations as normal and non-threatening, the action recommendation becomes easy to successfully accomplish, and youth develop the self-efficacy to carry out the recommendations.

The fear appeals must still be included in the ads in order to provide the viewers with the drive to carry out the action recommendation. The ads should be run as a split screen where one side shows the teenagers successfully carrying out the recommendation while the other side shows the same teenagers doing meth for the first time with the end result showing them as the same meth addicts depicted in the original ads. This will help to further promote the benefits of the action recommendation.

Critique 2: Anti-Meth Ads Possess Little Truth and Credibility

The Narrative Paradigm, a model proposed by Walter Fisher, claims that all people are storytellers and they develop understanding of their lives based on narrative context (10). In this theory narrations are symbolic words or actions that can take the form of “personal accounts, history, biography, argument, drama, poetry, and art”. Fisher coins these as “good reasons” (10). “Good reasons” provide meaning for “those who live, create, or interpret them” and are the driving force behind decision making (10). According to this theory, behavior is guided by the narratives because people use personal narratives as a way of understanding their lives. This in turn is what drives them to make decisions, and create meaning and perceptions. More specifically, narrative context is the basis for which an individual develops their rational and reasoning (10).

The Narrative Paradigm considers every person as a rational decision maker because of their innate ability to determine the narrative rationality of the stories they hear (10). There are two aspects of narrative rationality: narrative coherence and narrative fidelity (10). Coherence is used to analyze whether the pieces of the story fit together and whether the story is structurally stable and consistent. In other words, does the story make sense? On the other hand, narrative fidelity looks at whether the story matches, or rings true, with the ideas, values and experiences of the listener (10). In other words, does the listener accept the story as true? Fisher established five criteria that a person can examine when deciding on the truthfulness of a story: whether the statements that are claimed as factual indeed factual, the relationship between the story and the values it is trying to promote, the outcomes of following the promoted values, personal connection between the story’s values and the audience’s values, and the significance of the issues addressed (10). These criteria can be analyzed when an audience is examining the truthfulness of the message and ultimately decide whether the audience accepts or rejects the values espoused in the story.

The violent actions of the characters in the ads as well as the extreme situations they depict fail to provide narrative rationality and thus result in rejection or dismissal of their message. The stories portrayed in many of the ads may not be considered credible by teen viewers because the connection between using meth for the first time to the violent crimes and mutilated bodies portrayed is not a logical progression. For example, the ad that takes place in the Laundromat fails to show the sequence of events depicting the transformation of the character from a first time user to a full-blown addict. Rather it abruptly brings the two extremes together without explaining how one became the other. Thus, the ad lacks structural coherence and subsequently loses credibility (10). The ad also lacks characterological coherence (10). The boy in the Laundromat at the beginning of the ad does not behave in a way that would indicate that he is capable of the crimes the meth version of himself. The two versions of the teenager are so wildly inconsistent with one another that it almost makes the character unbelievable.

Viewers may also choose to dismiss The Meth Project’s messages because they also lack narrative fidelity. While it is certainly arguable that meth is a significant issue, the other criteria used to measure the fidelity of the message are not met. The reasoning used to discourage youth from trying meth show unlikely consequences of trying meth for the first time. Consequently, youth may not believe the claims made in the ads are factual. Secondly, many viewers may reject the messages because they cannot identify with the events or characters depicted in the ads. Since the behavior in the ads is so extreme, most viewers will not believe they are at risk and reject the message as a result.

Intervention 2: Incorporate Narrative Rationality into Ads

In order to communicate their messages successfully, the Montana Meth Project should focus on the narrative rationality of their ads and work to make sure that their campaigns follow the criteria of narrative coherence and narrative fidelity. This will increase their story’s credibility in the minds of their audience, making it more likely that they will trust and adopt the ad’s message.

One way for the ad to incorporate narrative coherence, would be to provide a sequence of events that clearly show the main character progressing deeper and deeper into addiction. By providing a cause-effect basis for the transformation of the character, the pieces of the character’s story fit together and the story builds structural coherence. Also, by showing the gradual change, the teenager’s behavior is more consistent and makes his character more believable, improving the story’s characterological coherence. In focusing on the narrative coherence of their story, ad developers will increase the credibility of their intended message to the viewer.

The ads should also possess narrative fidelity. In order to develop narrative fidelity, the ads should convey situations that viewers can align easily with the experiences, beliefs and values. While the extreme behavior and characters in the ads do have a high shock value, viewers are less likely to accept the story or message as true because it does not fit into their own experiences or views. Instead of focusing on shocking but unrealistic situations, ad designers should show consequences or actions that the youths can relate to. For example, rather than showing an ad or billboard depicting unrealistic or exaggerated behaviors such as pimping out a significant other for drug money, the billboards can show a more common or realistic consequence of drug use such as being arrested by the police at a party. By altering the ads in this way, the campaign is invoking enough fear that it will influence viewer’s behavior to avoid the negative consequences while at the same time the situation is not so unrealistic that viewers can’t relate to it. Since the story is more likely to align with the experiences and values of the audience, they will be more likely to accept the message of the ad which will in turn affect their rational and decision making.

Critique 3: Campaign Invokes Psychological Reactance Response

The psychological reactance theory states that in response to threats to real or perceived personal freedoms, people go into a motivational state called reactance where the individual responds by behaving in ways aimed at restoring the repressed freedom (11). The greater the perceived threat of the freedom, the more effort the person will put into restoring the freedom (11). Reactance magnitude can also be affected by the characteristics of the threat (12). One characteristic of threats that has been shown to increase reactance is coercion (12). As a form of reactance, the individual may view the lost freedom as more attractive than it was before, perform the freedom that was taken away, or lash out violently at the person taking away the freedom (11).

A study examining the effectiveness of a youth-oriented anti-marijuana ad campaign over the course of six years found that rather than having the intended effect of decreasing youth marijuana use pro-marijuana attitudes had increased (13). Researchers suggested psychological reactance theory as an explanation for this trend (13). They suggested that youths who were exposed to the ads reacted by expressing pro-drug attitudes and the greater the exposure, the stronger the reaction (13).

A study examining the effect of social norms messages on binge drinking college students found that subjects responded to exposure to the ads with reactance by not complying with the message in an attempt to regain control of their environment (13). Research has shown a similar response to the Meth Project ads. A 2008 critique of the campaign showed that the percentage of youths who reported strong approval of meth use quadrupled in six months after exposure to the ads (14). One of the reasons the reactance response is so large may be because the ads use coercive tactics with threats manifesting themselves as fear tactics suggesting they will become like the characters in the ad if they try meth. The graphic nature of the ads and the high frequency of exposure may also have increased the reactance by increasing the perceived threat of the freedom.

Intervention 3: Reduction of Reactance through Manipulation of Positive and Negative Forces

A 1971 study suggested that when a threat to freedom is made, it creates positive and negative forces (15). The positive forces push the individual towards compliance while the negative forces push the individual’s behavior towards reactance (15). The behavior of the individual is a function of the combination of the opposing forces (15). By manipulating these forces, reactance to the campaign can be reduced.

The implementation of the two interventions discussed earlier would reduce psychological reactance by increasing the positive forces. By providing an action recommendation showing ways to reduce the risk of taking meth, it is easier for viewers to address the problem by complying with the message of the campaign. Providing viewers with action recommendations along with fear appeals will push them towards compliancy because, as mentioned before, people with emotional tension actively seek an effective means of reducing the emotional tension.

The implementation of narrative rationality on the campaign will also affect the positive forces, pushing the individual towards compliance, and also reduce the negative forces pushing the individual towards reactance. Research shows evidence that a communicator can increase the positive forces towards compliance by increasing their credibility (17). By focusing on creating more believable, consistent, and realistic characters and situations for their ads, they are increasing the credibility of their message. In addition to the increase in positive forces, by toning down the graphic nature of the ads and the intensity of the messages, the perceived threat of the campaign on personal freedom may decrease and subsequently lower the negative forces, pushing the person even further to compliance.

Conclusion

Statistics have shown a decrease in teen meth use since the implementation of The Meth Project. However, when the pre-existing decline in teen meth use is taken into account, the effects of the campaign are almost statistically insignificant. While graphic ads are effective in invoking fear and increasing awareness of the negative consequences of meth use, studies have shown that they are not as effective as the organization boasts them to be. The effectiveness of the campaign could potentially increase with an introduction of action recommendations that provide a means of reducing the risks portrayed in the ads. The focus on narrative rationality in increasing the credibility and the ability of the ads to connect with viewers would also be beneficial for the campaign. These changes would also increase the positive forces pushing individuals towards compliance and decrease the negative forces pushing them towards reactance. The campaign would still operate primarily through the same media channels but with a slightly different and hopefully more effective approach to reducing first time meth use among at risk youth.

References

1. McGee S. The 25 Best Givers. The Wall Street Journal Digital Network. http://online.barrons.com/article/SB50001424052970204869904575620981420096098

2. The Meth Project. About Us. The Meth Project. http://www.methproject.org/About_Us/index.php

3. Anderson M. Does Information Matter? The Effect of the Meth Project on Meth Use among Youths. Seattle, WA: Department of Economics, University of Washington, 2010

4. The Montana Meth Project. View Ads. The Montana Meth Project. http://www.montanameth.org/View_Ads/index.php

5. Harding A. Benefits of graphic anti-meth ads questioned. New York, NY: Reuters http://www.reuters.com/article/2008/12/19/us-anti-meth-idUSTRE4BI5S620081219

6. Janis I. L., & Feshbach, S. Effects of fear-arousing communications. The

Journal of Abnormal and Social Psychology 1953; 48: 78-92.

7. Witte K. Putting the fear back into fear appeals: The extended parallel process model. Communication Monographs 1992; 59:329-349.

8. Hovland C.I., Janis I.L., & Kelley, H.H. Communication and persuasion:

Psychological studies of opinion change. New Haven, CT: Yale University Press, 1953.

9. The Economist. Shock tactics Graphic ads have reversed a trend. Helena, MT: The Economist. http://www.economist.com/node/11293880

10. Fisher W. R. Narration as a human communication paradigm: The case of public moral argument. Communication Monographs 1984; 51: 1-22.

Brehm J

National Health Reform And Nutrition Labeling Requirements -- Anon.

March 23^rd 2010 marked the inauguration of the Patient Protection and Affordable Care Act (ACA) into American law. The law was an attempt to reform the American medical system and reign in insurance companies abusive practices. Public health was arguably not the focus of the ACA, but hidden within the almost 1,000 page document was a provision for the Food and Drug Administration (FDA) to mandate nutrition labeling for “standard menu items at chain restaurants and food sold from vending machines” (1). The mandate signified an attempt to promote transparency within the restaurant industry so that consumers know the nutrition content of food. Moreover, the mandate reflected a general trend of thought that the federal government should and can respond to the growing obesity epidemic in the United States (2). However, as this paper will show, the reliance on nutrition labeling to influence food consumption behaviors is highly flawed. While it may present an opportunity for behavior change for some specific individuals, it should not be the sole effort to influence food behavior and the national obesity problem because it will not affect group behavior.

According to The National Health and Nutrition Examination Survey (NHANES), nationwide trends in overweight and obesity have increased steadily over the past fifty years in all age groups and races/ethnicities (3). Overweight is defined as having a body mass index (BMI) between 25 and 29.9 and obesity is a BMI over thirty (4). NHANES data from 2007-2008 indicates that the overall prevalence of obesity in the US exceeds 30 percent for all ages and genders except for men aged 20-39 years (3). The burden of the obesity problem lies in the southern states where the prevalence of obesity exceeds 30 percent in every state (5). There are also significant differences by race and ethnicity: in comparison to the white Non-Hispanic population, blacks have a 51 percent higher prevalence of obesity and Hispanics have a 21 percent higher prevalence (5). The concern over rising overweight and obesity levels stems from the fact that both have been associated with chronic diseases such as Type II diabetes, hypertension, high cholesterol, stroke, heart disease, cancers, and arthritis (3).

The ACA built upon a historical trend of government involvement in the campaign to curb the proliferation of obesity. The Nutritional Labeling and Education Act (NLEA) of 1990 authorized the FDA to require nutrition labeling for its regulated foods and control nutrient and health claims (6). NLEA specifically exempt foods served and sold in restaurants and foods sold for immediate consumption (6). Therefore, the ACA mandate for restaurant and vending machine labeling can be seen as an extension of the FDA requirements under NLEA. The ACA specifically requires that the caloric content of every standard menu item be placed next to the item and that the calories be placed “within the context of recommended total daily caloric intake” (7). Further nutrition information must be available upon consumer request, and a statement detailing such availability must be “prominent, clear, and conspicuous” (7). The ACA also supersedes state and local level labeling laws, such as the laws implemented in New York City in 2008 (8). However, state laws such as those in New York also point to the growing interest in government endorsed obesity prevention and “treatment.” Given the focus on labeling and government involvement, it is essential to look at the evidence base surrounding consumer knowledge and habits. Unfortunately, the evidence is not in favor of labeling requirements.

Flaw #1: Consumers are Nutrition Label Illiterate

The primary concern in the effort to influence consumers’ eating habits via nutrition labeling is the fact that few consumers actually comprehend and can effectively utilize nutrition information. A systematic review of consumer understanding and use of nutrition labeling found that “although some consumers could understand some of the information on nutrition labeling, in general they reported finding nutrition labeling confusing, especially the use of some technical and numerical information” (9). Consumers reported better understanding of the information when a benchmark was provided along with individual product information (9). The review identified twenty-one studies examining consumer nutrition knowledge and found that it was moderate to low (9). Moreover, the elderly and those with lower levels of education were least likely to comprehend the labels’ content (9). Another study identified differences in ethnicity, income, and gender in relation to nutrition knowledge (10).

Admittedly some consumers are more likely to read and understand labels, but this is a very specific subset of the population. For example, consumers who self-identify as interested in health and nutrition were more likely to report reading labels and using them to make food choices (9). Consumers who report recognizing a link between food consumption and risk for disease are also more likely to read and understand labels (10).

Dickson-Spillmann and Siegrist discuss two different forms of knowledge that are particularly appropriate for discussions of food choices. The first form, declarative knowledge, is described as knowledge of facts and things (11). On the other hand, procedural knowledge is knowing how to perform a specific task for a desired outcome (11). In the context of nutrition and food choices, declarative knowledge would be knowing the U.S. Department of Agriculture’s (USDA) Dietary Guidelines and procedural knowledge would be knowing how to follow those guidelines to make healthy food choices. Clearly both forms of knowledge must work in tandem in order to produce healthy food choices. Interestingly, the authors found that women had higher procedural knowledge scores in relation to nutrition than men; age and education level were also highly correlated with procedural knowledge levels (11). Consumers who followed specific and strict diets also reported high levels of procedural knowledge (11). In contrast, individuals who had low levels of procedural knowledge found it difficult to take the food pyramid into account and did not fully understand the term “balanced diet” (11). Less knowledgeable consumers also thought that eating healthy meant eating less and that fat should be completely eliminated from one’s diet (11).

This study and the others previously mentioned highlight the spectrum of nutrition knowledge within a population. Assuming that nutrition information via labeling will be effective does not account for this variation and has virtually no affect on the less knowledgeable members in the population.

Flaw #2: Knowledge does not always change behavior

Given this discussion of nutrition knowledge, it is worth exploring whether or not knowledge even changes or influences food choices. Ostensibly the goal of the ACA mandate is to influence consumers’ food choices and behaviors outside the home. However, the evidence base surrounding the issue of nutrition knowledge and food choices is inconclusive, which mainly stems from the inability to assess the multitude of proposed labeling mechanisms (12). Like the distinction between declarative and procedural knowledge, it appears that consumers’ knowledge of one does not always impact knowledge of or capability to perform the other.

Furthermore, the mandate is based on the flawed premise that knowledge leads to intention, which is a core value of the Health Belief Model and the Theory of Reasoned Action (13). Both models propose that once knowledge of a problem is acquired individuals will use such knowledge to change their behaviors. However, both approaches fail to account for the fact that people do not always act rationally; that is to say, knowledge does not always translate into calculated action.

One study examining the impact of calorie labeling and food choices following the New York City mandate did not find a statistically significant difference in calories purchased/consumed (8). Following labeling implementation just 54 percent of respondents reported noticing the nutrition information. Only 28 percent of those who saw the labels reported that the information affected their food choices, and of this group almost 88 percent “indicated that they purchased fewer calories in response to labeling” (8). However, those that reported that the calorie labels affected their choices did not actually purchase items with fewer calories. The researchers also found “non-significant decreases in calories purchased for groups who indicated that the labels mattered to them” (8). Overall, the study demonstrated an insignificant affect of calorie labeling on food choices and revealed that even those who think they are making good choices may be fooling themselves.

Another study randomized frequent fast food goers to receive a menu with calorie information or one without and had similar findings to the NYC study. This study is particularly informative because it mimics the menu standards the FDA set forth; that is to say, researchers included a column indicating calorie and daily value information in a column directly beside the menu item (12). Even so, among those with the calorie menu, just over half reported noticing the calorie listing (12). However, those who noticed the listings purchased items of similar caloric content than those who did not notice the listing. Interestingly, males in this study seemed to use calorie listings to purchase higher calorie foods. This finding recalls the idea that males and females possess different knowledge of nutrition and therefore make different food choices. However, this is certainly not the intent behind nutrition labeling in restaurants.

Flaw #3: An individual-level model in disguise

Even though nutrition labeling exemplifies a “population-based approach aimed at helping to make the food selection environment more conducive to healthy choices,” (9) the policy actually works on the individual level. The legislation will indeed affect entire populations nationwide, but the specific decision of whether or not to take the information into account occurs on an individual basis.

The tension between the population approach to an individual choice or action is exemplified through the Diffusion of Innovations Theory. This theory describes how a behavior is adopted in a population over time: early adopters will conform to the new behavior first, the general population will start to adopt the behavior at the “tipping point,” and the “laggers” will be the last to adopt (14). This theory recognizes that people conform to behaviors at different rates; it allows for a certain degree of individuality within the population rather than assuming people will be affected equally. In this way, the theory seeks to account for both population-level and group-level changes.

At its core the Diffusion of Innovations Theory relies on what several theorists and social scientists describe as human beings’ “herding” tendency (15). Simply put, humans tend to mimic the behaviors of others. Humans are social learners; they are easily influenced, or “nudged,” to behave a certain way (15). Moreover, humans like to conform and so they are highly susceptible to even the gentlest of nudges and especially to peer pressure (15). It is via this mimicking and nudging system that behaviors are diffused throughout a population and new behaviors are adopted.

However, it is unlikely that a group-based intervention like nutrition labeling will disseminate through the population the way the Diffusion of Innovations Theory would postulate (and they way the ACA framers would hope). Eating is a highly social activity and peer groups tend to have similar eating habits; as a result, eating habits are probably more likely to work through the social network mechanism that the Social Network Theory proposes (16). This theory suggests that behavior is spread through close contacts and peer networks (16), and there has been evidence of this in relation to obesity. One study found that a person’s “chances of becoming obese increased by 57% if he or she had a friend who became obese in a given interval” (17). Because of this clumping effect within the population of obese and non-obese, it is unlikely that they would affect one another’s eating habits and choices. If a behavior does not spread between different social groups it cannot achieve universality the way the Diffusion of Innovations Theory models.

Proposed Intervention to Remedy Identified Flaws

Nutrition labeling and calorie listings should not be used in isolation to influence healthy eating habits in the population. As it stands currently, the policy is poised to only affect a certain subgroup of the population: those who understand the labels and who choose to incorporate the information into their lifestyle. The proposed interventions will focus on the younger segment of the population as they will grow up under health care reform’s contributions. The interventions will need to address a knowledge deficit, while recognizing that knowledge does not always lead to behavior change. Finally, the interventions will need to attempt to infiltrate social networks so that it can be processed on a group level. In effect, the interventions will be presented as part of an ecological model that must be addressed if the ACA mandate is to influence consumers’ choices.

Nutrition Education

The first issue to address is undoubtedly the knowledge deficit if a policy like nutrition labeling is to have any impact on consumers’ food choices. This “intervention” will take the form of mandated education and guidance in primary and secondary schools on the Dietary Guidelines for Americans and the Food Pyramid Guide. As the CDC indicates, schools are an ideal location to initiate and disseminate nutrition information, and it should be the focus of nutrition education efforts (18).

Schools are an attractive location for dietary interventions because of the shear amount of children they reach and because of the opportunity for support systems. Schools reach not only a majority of the population, but a wide range of ages as well. School-based nutrition programs in health or physical education classes should be age-specific and appropriate for the child’s level of understanding. Moreover, because food is served in schools, children and adolescents have the opportunity to directly utilize the information to make healthy eating choices (provided that healthy options are available; there has been pressure to achieve this goal). The CDC reports that almost half of youth eat one major meal at school, and one in ten youths eats two major meals at school (18). Clearly, schools are poised to significantly impact the food knowledge, options, and choices of their students, and they should be considered a crucial ally in the attempt to curb obesity.

School-based intervention approaches to influence nutrition education are extremely varied and have reported diverse results. However, there is some indication that interventions based upon the Social Cognitive Theory (SCT) may be successful (18). SCT incorporates “outcome expectancies, self-efficacy, observational learning, and self-regulation,” (19) all of which are invaluable to approaching nutrition education and obesity in youth. One study looking at a nutrition education intervention based on SCT found that students who received the intervention had a greater decrease in BMI and increased their fruit and vegetable intake relative to the control group (19). Interestingly, the observational learning component of this intervention involved hands-on food preparation and taste trials of unfamiliar foods (19). This approach appears particularly effective for increasing youth’s knowledge of, exposure to, and comfort with new and unfamiliar foods. Interventions such as this should be considered for schools nationwide; however, further research into other effective approaches needs to occur to identify the best option.

Schools are also an appealing option because they often have considerable ties with the community at large; schools can and should be used as educational sites to reach parents and the greater community. Schools can establish health advisory councils to “engage community resources and organizations to respond to the nutritional needs of students” (18). Moreover, parents can also be reached through schools. Nutrition education interventions targeted towards adults should be offered at schools to complement the information children receive. Once school staff (teachers, food service personnel, and counselors) is trained in nutrition and in intervention techniques, they can lend their knowledge and expertise to community-wide interventions (18). In this way, knowledge can permeate into the community as well. Also, involving parents in nutrition education and the push for healthy eating will increase the likelihood that children understand and adopt similar healthy practices. Indeed, children are “most likely to adopt healthy eating behaviors if they receive consistent messages through multiple channels and from multiple sources” so partnerships between schools and parents are essential (18).

Eating Practices Among Social Groups

While expanding people’s knowledge of nutrition is essential if they are to understand nutrition labels, interventions must also address the fact that eating is a social practice and therefore exists on the group level. Interventions will need to be specific to the composition of the social group and use models appropriate to that composition.

Schools are perfectly placed to address the social component of eating because school staff can have considerable insight into students’ social groups. The CDC suggests that “schools can teach students how to resist social pressures . . .school-based programs can directly address peer pressure that discourages healthy eating and harness the power of peer pressure to reinforce healthy eating habits” (18). School staff implementing the intervention should be taught to recognize both advantageous and deleterious social eating practices. Furthermore, schools should use friend groups and social networks to its advantage to diffuse healthy eating practices and to broaden its reach beyond the school building and into the community.

While school and parental involvement may be key for younger children, for older children and young adults, interventions that delve into peer groups should be utilized in order to rectify unhealthy social eating practices. Recently, peer-led interventions have been used in educational settings to influence behavior change and are recognized as a particularly effective method for reaching teens (20). Peer initiatives have been used in a variety of domains from substance abuse to bullying to increase knowledge, and influence attitudes, behaviors, and self-efficacy (20). These interventions are effective because they take place in the “social environment, can provide positive role models, and can help change social norms” (20). Therefore, peer-led interventions do not work solely on the individual level, but rather endeavor to implicate the entire group or social network. This approach is more likely to be successful for older age groups because they account for the social aspect of eating.

Addressing Gap Between Knowledge and Behavior

In order to avoid the pitfall of increased nutrition knowledge not influencing food choices, the behavior itself (healthy eating) should be encouraged directly. This intervention will involve transforming the food environment so that healthy options are well placed and visually appealing.

Even though Americans’ knowledge of nutrition is generally low, and a component of any intervention addressing food choices and habits must certainly address this lack of knowledge, knowledge does not always lead to behavior change because humans are irrational (21). Rarely do people plan actions so meticulously the way the Theory of Reasoned Action would presume (21). On the contrary, people continue to eat unhealthy foods and lead generally unhealthy lifestyles not because they do not know better, but because what they do know does not affect them.

To address this gap between knowledge and behavior, the behavior itself should be encouraged first to allow for the effect of cognitive dissonance. The Theory of Cognitive Dissonance supposes that if there is a conflict between an attitude and a behavior one of them must change to regain equilibrium (22). This concept is linked to the idea of ownership in that once you own something you consider it of higher value (22). This belief change occurs so you can justify the purchase: if you spent money on an object you must convince yourself that it is worth it. In the realm of nutrition and food choices, the Theory of Cognitive Dissonance can be employed to encourage and provide appealing, healthy food choices in the environment, which would entice consumers to choose the healthy options versus the unhealthy ones.

Researchers have recently begun to exam “nutrition environments” in an effort to move away from individual knowledge and behavior and look to the “influences of the social and built environments on individuals’ access to affordable, healthful food and activity-friendly communities” (23). This effort is reflective of an Ecological Model of health and well-being, which “aims to identify the environmental causes of behaviour because they create opportunities for intervention and remove barriers for maintaining a healthy diet” (24). Going even further than a group-level model, the Ecological Model implicates the environment itself and the systemic causes of poor health.

The Ecological Model helps foster the notion of promoting action (healthy eating) to invoke cognitive dissonance. Interventions should utilize the Ecological Model to promote healthy options that are not only available in schools and restaurants, but also that are well placed and visually appealing. One study focusing on fruit appeal for children found that children chose the “visually appealing fruit” almost twice as often as the regular fruit (25). This approach lends to the notion that people are visual eaters and their behavior can be manipulated through just visual cues rather than education. This systems approach requires a transformation of the food environment, rather than relying on individuals to sift through the healthy and unhealthy options. This way, people are more likely to choose healthy options and invoke cognitive dissonance.

Conclusion

Every level and variable of social organization must be involved in order to curb the spread of obesity. These levels or variables include: policy variables, environmental variables, individual variables/sociodemographics, and finally behavior (23). The ACA mandate operates as a policy variable, but such efforts must be coupled with other components of the Ecological Model in order to be effective. Only mandating nutrition labeling in restaurants and on vending machines is a flawed approach because it does not address major barriers such as a general lack of nutrition knowledge or the fact that eating is a social process. This approach also presumes that knowing the calorie content of food will positively influence food choices. Taken form an ecological point of view, the ACA mandate signifies a top-down or policy-level approach to nutrition. While policy is certainly an integral part of the ecological model, it is not sustainable or effective without the other components. The proposed interventions outlined here seek to incorporate and influence all levels of the ecological model with a particular focus on children, as they will grow up under the new mandate. The ACA mandate can only succeed in affecting food choices and behaviors if it is viewed within a greater ecological context of food and nutrition.