A Critique of Why NYC’s “Cut Your Portions, Cut Your Risk” Campaign is Futile Attempt at Weight Loss – Natalie Nachef

Introduction

            As of 2010 more than one-third of U.S. adults, 35.7%, were obese.  Over the last decade, there has been a significant rise in obesity (1).  However these values tend to vary from state-to-state.   In New York State the amount of obese adults has increased by nearly 40% from 17.7% in 2000 to 24.5% in 2010.  This increase was seen across several types of demographics – men, women, older adults, younger adults, more educated, and less educated (2). In New York City, over half of adults (58%) were overweight or obese in 2010 (3).  Overweight and obesity are conditions that don’t only affect adults; increasing weight trends have also been seen among children and adolescents.  New York City public school students in grades K - 8 had a 20.9% rate of obesity in 2010 (4).  As the rate of overweight and obesity increase among all age groups, New York City health officials have become eager to find a way to reduces these rates.

With this rise in the prevalence of obesity, there has also been a rise in the portion sizes of food and beverages offered in restaurants and fast-food establishments.  Today portion sizes are two to five times larger than they were in the 1950s, and they are continuing to increase (5).  For instance, a portion of McDonald’s French fries has increased 225%, from 2.4 oz to 5.4 oz, while the size of a hamburger has increased from 3.7 oz to over 10 oz (6).  With this increase in portion sizes comes an increase in weight and the risk of developing a chronic disease.  It is both the expanding waistlines of New Yorkers and the large upsizing of food portions that has driven the New York City Health Department to launch a public health campaign to prevent and reverse the continuation of these trends.

            In January 2012, the Health Department of New York City launched a new ad campaign called “Cut Your Portions, Cut Your Risk,” which highlights the growing portion sizes of food.  The ads specifically portray how serving sizes have dramatically increased over the years and they emphasize the detrimental consequences of not controlling portions.  The campaign is an effort to get New Yorkers to realize the detrimental effects of the super-sized portions of the food and beverages they are consuming.  This effort is part of an attempt to meet New York City’s objective of “informing, educating, and engaging New Yorkers to improve their health and the health of their communities” (7).  The Cut Your Portions, Cut Your Risk campaign provides a call-to-action for New Yorkers to make dietary changes and embark on a more healthful life.

            This campaign reaches out to its audience through a series of advertisements that can be found on subways and around New York City.  The ads depict “then” and “now” images of the growing portions of food items such as soda, French fries, and hamburgers.  The backdrop of the portion-control messages feature images of the detrimental consequences of oversized food.  For example, one of the ads displays an overweight man in the background with an amputated leg with a message that reads: “Portions have grown, so has type 2 diabetes, which can lead to amputations.”  The ads also feature the campaign slogan “Cut your portions, cut your risk,” which is also translated into Spanish in some posters.  Despite the valiant effort of the NYC Health Department in bringing attention to the health consequences of growing portion sizes, the campaign is quite flawed and could be better designed to create a stronger and more effective message.

Critique 1: The Message Tells People What to Do

            The way that a message is delivered is a critical factor to consider when attempting to create a behavior change among people.  In particular, preaching or dictating tones are not recommended when trying to deliver health messages (8).  The New York City campaign has an imperative tone to its message: “Cut your portions, cut your risk.”  These words appear blatantly across all of the advertisements in an urgent fashion that seems to dictate what people should do.  While it may appear as though the message is implying a cause-and-effect attitude (if you cut your portion sizes, you will cut your risk of chronic disease), the message is actually quite blunt, especially with its use of all capital letters and the distinct declarative punctuation marks after each phrase.  The entire slogan and the way that it is presented would undoubtedly stimulate rejection and offense among those who read it.  Simply by telling people what to do, the message and the whole campaign become resistant to compliance among its target audience.

            This phenomenon can be explained by the Psychological Reactance Theory.  This theory was developed by Jack W. Brehm in 1966 in an attempt to explain people’s reaction to the threat of their loss of freedom (9).  The fear of this threat is what drives people to act in a way opposite to what they are told to do; this can include ignoring the message, criticizing the source, or behaving opposite to the message in an act of defiance (10).  The correct composition of a public health message is crucial for gaining the attention and support of a campaign’s target audience.  The tone of a message is an important factor to consider when trying to change behaviors through campaigns.  The “Cut Your Portions, Cut Your Risk” campaign demonstrates authority and forcefulness for an action to be complete.  In order to prevent psychological reactance from occurring, a more receptive and less condoning message must be developed.

Critique 2: Reliance on the Health Belief Model

            This campaign assumes that its audience makes it decisions with a black or white decision-making process.  This follows the rationale that is behind the Health Belief Model.  This model was created in an attempt to explain and predict if a person will engage in a certain health-related behaviors.  It utilizes a cost-benefit analysis in which a person must assess the perceived benefits of an action and compare it to the perceived costs of that action (11).  The model takes into account three main factors: 1) sufficient health concern to make an issue relevant, 2) the belief that one is susceptible to a health problem, making it a threat, and 3) the belief that following a health recommendation will alleviate the threat (12).  However, the Health Belief Model fails to incorporate the fact that people make rational decisions and that they need a sense of self-efficacy to be successful.

In the case of the Cut Your Portions, Cut Your Risk campaign, an individual is faced with assessing the benefits of not being at risk of poor health and potentially becoming amputated from diabetes, and the cost of decreasing portion sizes.  The campaign uses scare tactics to influence people to make the decision of decreasing portion sizes.  While the advertisements make a strong case on why people should cut portions from a health perspective, the use of the Health Behavior Model is flawed because it assumes that people make rational decisions and it does not account for self-efficacy.

The campaign assumes that if people are aware of the detrimental health effects of obesity and realize the perceived benefit of reducing portion sizes, they will certainly change their behaviors and immediately begin to act on it.  This assumes that people make rational decisions and that by seeing a man amputated from obesity and diabetes in their ad, people will make a change.  While people may be shocked by the ad, they may not be thinking about it later when they are hungry and happen to pass by a fast-food restaurant.  The campaign fails to regard the fact that people’s decisions are influenced by environmental factors.  Human desire is dynamic and is often affected by external factors (13).  The use of this model for this particular campaign is ineffective because there are several other factors that are related to obesity other than portion control.

The Health Belief Model also assumes that the individual is the sole factor that determines the outcome of a health decision.  What the campaign fails to recognize is that there is a huge perceived economic implication that drives people to eat larger portions at fast-food chains.  The cost of food has been cited as one of the top reasons that people choose to eat at a fast-food establishment (14).  The low-cost, convenience, and satiety that are part of a fast-food meal drive people to continue choosing these options instead of opting for healthier choices.

Another flaw that arises from following the Health Belief Model is that the campaign does not allow for self-efficacy.  According to Albert Bandura’s Social Learning Theory, self-efficacy refers to “beliefs in one’s capabilities to organize and execute the courses of action required to produce given attainments”(15).  Having the frame of mind that one can successfully perform an action to achieve the perceived benefits is an essential aspect to modifying behavior.  The portion size campaign primarily focuses on what to do, but neglects how to do it, a critical component for aiding self-efficacy.  Overall, the use of the Health Belief Model for this campaign results in a failure to take into account several other factors that may be underlying causes for poor dietary intake.

Critique 3: Poor Education Thwarts the Usefulness of the Campaign

            Of those who are obese in New York City, the highest rate is prevalent in low-income people.  Low-income adults had a 29% rate of obesity in 2010, compared to only 14% of those with the highest incomes (2).  Not surprisingly, with a low income comes with lower education levels.  Having less than a high school diploma provides and average weekly earning of $451, compared to those with a bachelor’s degree who make an average of $1,053 per week (16). According to a 2011 report from the Centers for Disease Control and Prevention, lower education levels and income levels have higher rates of obesity and other chronic diseases, compared to those with a higher income and education level (17). Less education make it difficult for people to know how to make the necessary changes to cut their portion sizes and having a low income makes it difficult to purchase healthier options, which are often perceived to be more costly.  The Cut Your Portions, Cut Your Risk campaign assumes that New Yorkers are aware of the correct portion sizes they are supposed to eat and that they are able to make this change on their own.  The campaign primarily emphasizes the detrimental health consequences rather than providing the solution.

            Consumers may not even be aware of the importance of portion sizes and their relation to overweight and obesity.  Several studies have shown that people tend to misperceive what is considered an appropriate serving size and the how many calories they may contain (18-19).   In one study, subjects were asked to select the amount of food that is considered to be an appropriate serving size.  The study found that the participants significantly overestimated the correct portion sizes for many of the foods presented such as cereal, butter, whole milk, and chips (19).  It is evident that, in general, most people have poor knowledge on what a correct serving size.  The Cut Your Portions, Cut Your Risk campaign is severely limited in its ability to make a meaningful change because of the general lack of knowledge provided about food and nutrition, and especially about portion sizes.  Given the lower education levels of many obese New Yorkers, the campaign must make this the forefront of effectively creating behavior change.

Redefining the Campaign

            These flaws that I have presented are major factors for the failure of a public health campaign.  Obesity is a growing issue that plagues more and more people every year.  An effective public health campaign is necessary to make positive changes and have a serious impact on the health of New Yorkers.  While the campaign is targeting an important issue, the methods of outreach are ineffective and are likely to be poorly received by the campaign’s intended recipients.  For the duration of this paper, I will present alternative interventions that address and rectify the aforementioned critiques in an attempt to create a more successful campaign.

Intervention 1: Create an Alternate Message

            The Theory of Psychological Reactance shows us that a forceful, demeaning attitude of a campaign can thwart its efforts by provoking actions opposite to those intended due to fear of the lack of freedom (9).  To address this, the campaign should no longer use the “Cut Your Portions, Cut Your Risk” slogan, but should rather develop a message that allows the audience to feel in control.  The sense of being in control of one’s own health is a factor in itself that produces health (20).  The new message should be inspiring to its audience, and should steer away from harsh words or a shameful tone.  A study from the International Journal of Obesity asked participants to rate the messages of several different obesity-related public health campaigns as being stigmatizing or motivating.  More favorable responses occurred with messages that emphasized specific health behaviors and personal empowerment for health compared with those that imply shame and stigmatize the obese.  Among obese participants, the message “Skip seconds… lose your gut” was stigmatizing, whereas “Eat well. Move more. Live longer.” elicited a positive response (21).  Evidently, certain phrases can evoke certain reactions and behaviors.

            A new, more optimistic message for the Cut Your Portions, Cut Your Risk campaign should include positivity.  Some examples of positive messages would be “Eat Right to Live Great” or “Better Choices for Better Living.”  Other than positivity, giving individuals a sense of control can also help to relay an effective message.  Slogans such as “Take Control to Reach Your Goals” or “Control Your Portions, Don’t Let them Control You” elicit the use of words that puts the individual in charge of their actions.  This can be an extremely effective way to modify and influence behavior.  The value of health is not intrinsic, but is valuable because it assures an individual’s freedom and control (20).  By giving an individual control of a situation, they are more likely to respond favorably to a message.

On the advertisements these messages should be accompanied by images that invoke a healthy environment and activities.  For instance, an advertisement could show a person choosing an apple as a side to his or her meal instead of a bag of chips, or choosing a smaller sized meal instead of a supersized one.  The person in the image should not be a model or an unrealistic, very healthy looking individual.  The person should be one who relates to the audience.  Since the majority of overweight and obese New Yorkers are of Hispanic or Black races (2) the image would be most effective using an ethnic person who is not necessarily skinny to deliver the message.  The words and the images together will display easy and attainable changes that do not threaten people’s freedom, but instead will empower them.  A Boston Medical Public Health study showed that people resent campaigns that depict images of overweight men or women eating unhealthy foods (22).  The use of an average sized person eating healthy meals, however, seems to elicit a better response.

Intervention 2: Let People Feel Self-Efficient

            The current campaign utilizes the traditional Health Belief Model to try to alter people’s behaviors.  As aforementioned, this model lacks the factor of self-efficacy, which is crucial for allowing behavioral change and fulfillment.  The campaign’s imagery of the detrimental health consequences of obesity depicts a sense of hopelessness and doom.  Rather than scaring the population into adopting a health behavior, a sense of empowerment should instead be brought forth through the use of the advertisements.  Rather than applying the Health Belief Model to this campaign, an alternate model that should be adopted is that of Social Cognitive Theory.  This theory asserts that behavior is affected not only by an individual’s decision, but by the people surrounding the individual and by the environment (15).

            To rectify the problem of a lack of self-efficacy, the campaign needs to provide more resources and more support to its audience.  This can be achieved by reaching out to people through a means other than poster advertisements.  The campaign should create commercials to get people more engaged and show how easy it is to make a change.  Some of the goals of these commercials should be: to provide information on healthy food choices, to inform the audience of ways of cutting portion size, and to show the ease and simplicity of an action so that an individual can feel like they can overcome any obstacle.  Having a can-do attitude is associated with better outcomes for weight loss (23).  Instilling people with this attitude can be useful for creating a behavioral change.

            A recent commercial by Nike does an excellent job of empowering overweight and obese people to embark on their weight loss journey.  The commercial depicts a young, overweight boy running down a street, clearly exerting a lot of effort as sweat drips down his face.  A narrator discusses greatness and says, “We’re all capable of it. All of us” (24).  This advertisement is poignant, shows empowerment and self-efficacy, and relates to several people, overweight or not.  The Cut Your Portions, Cut Your Risk campaign should adopt a similar strategy in which relatable people are shown performing doable tasks.  An example of an effective commercial for this portion-control campaign would possibly be one that shows a group of girlfriends going out to dinner and wanting to order dessert.  Instead of ordering one per person, they would all share one.  A narrator could say, “Share fun, share dessert, share good health.”  A commercial like this is relatable to many people and relays the message that you can still have fun and enjoy food, but do so in moderation.

Intervention 3: Offer Tips and Goals to Fill the Education Gap

            To get people to make a behavioral change, especially ones that involve a health and lifestyle change, it is important that people know what they need to do in order to make that change.  New York City’s higher rate of obesity among those with a lower education gives good reason for the campaign to implement some aspect of health education into its advertisements.  Less education is generally associated with poorer health knowledge, health literacy, and health behaviors (25).  Education for positive health behaviors does not necessarily have to come in the form of a college degree.  The promotion of healthy eating strategies through the use of tips and advice has been found to be an effective tool for weight loss (26).  The Cut Your Portions, Cut Your Risk campaign provides no guidance on what individuals should do to take action.  Providing different tips and useful information on each ad can increase the knowledge of the public and give them a particular behavioral goal to work toward.  The use of short-term, specific goals has been found to be effective for weight loss, compared to goals focused on overall weight loss (27).  To implement this, an intervention for the current campaign would be to have one goal or tip placed on each advertisement.  These goals could be different on each advertisement so that every new ad they see will give them new information.

Since the original intent of the campaign is to get New Yorkers to reduce the portions of the foods they are eating so that it ultimately results in weight loss, the goals and tips should focus on achievable ways to effectively cut portion sizes.  One of the goals could be “Fill one half of your dinner plate with vegetables.”  Eating more fruits and vegetables increases satiety, decreases caloric intake, and lead to weight loss (28).  A tip like this can indirectly cause people to reduce their portions of energy-dense foods without having a forceful tone to the message.  Another tip could read “Mix your soda with seltzer to cut down on sugar.”  Again, this message gives advice on portion control, but is not demeaning or imposing.

Conclusion

            New York City’s new campaign to target overweight and obesity, Cut Your Portions, Cut Your Risk, is a great approach to getting people to eat less and lose weight by consuming less food.  Targeting one specific aspect of obesity prevention such as portion control is a useful way of narrowing down the many causes of obesity and working to fix it.  However, this campaign presents several flaws that are likely to attract poor support and compliance, but rather increase resistance to the campaign.  In an attempt to rectify these flaws, I have proposed some variations to the current campaign.  These variations are focused on altering the tone of the message, ensuring that audiences know how to implement behavioral and lifestyle changes, and making the message recipients feel empowered and motivated to make a change on their own.  All of these variations were developed in an effort to attain a receptive audience while combating the effects of psychological reactance.  With the changes, the New York City campaign to cut portions are likely to be better received and more effective for producing a behavioral change and ultimately decreasing the incidences of overweight and obesity.

REFERENCES

1.    Ogden CL, Carroll MG, Kitt B, Flegal K. Prevalence of obesity in the United States, 2009-2010. NCHS Data Brief. 2012 Jan;82:1-8.

2.   New York State Department of Health. Adult Overweight and Obesity in New York State, 2000-2010. 2011. Available at: http://www.health.ny.gov/ prevention/obesity/statistics_and_impact/

3.   New York City Department of Health and Mental Hygiene, Community Health Survey 2010. Available at: http://www.nyc.gov/html/doh/html/community/community.shtml.

4.   CDC. Obesity in K-8 Students – New York City, 2006-07 to 2010-11 School Years. MMRW 2011;60:1673-1678.

5.    Young LR, Nestle M. Reducing portion sizes to prevent obesity: A call to action. Am J Prev Med. 2010; 43:565-568.

6.   Department of Health and Human Services. Portion Distortion. Available at: http://hp2010.nhlbihin.net/portion/.

7.   NYC Department of Health and Human Services. Take Care New York: A policy for a healthier New York City. 2012. Available at: http://www.nyc.gov/html/doh/ html/tcny/index.shtml.

8.   National Collaborating Centre for Methods and Tools (2010). Assessing health communication messages. Hamilton, ON: McMaster University. August 2011. Available at: http://www.nccmt.ca/registry/view/eng/63.html.

9.   Brehm J. Toward Freedom: Reactance Theory Revisited (Ch. 1) In: Brehm J, ed. Theories in Social Psychology. New York: Academic, 1966.

10.  Dillard JP, Pfau M. Revisiting the Therory of Psychological Reactance: Communication Threats to Attitudinal Freedom. (pp. 213-232). In: Dillard JP, ed. The Persuasion Handbook: Developments in Theory and Practice. California: Sage Publications Inc, 2002.

11.Sheeran, P, Abraham, C.  The Health Belief Model (pp.23-61).  In Conner M, Norman P, ed. Predicting Health Behavior. Philadelphia, PA: Open University Press, 1996.

12.  Rosenstock IM, Stretcher VJ, Becker MH. Social learning theory and the health belief model. Health Education Quarterly. 1988;15:175-183.

1     13.  Elster J. Emotions and economic theory. Journal of Economic Literature. 1998; 36:47-74.

      14.   Glanz K, Basil M, et al. Why American eat what they do: Taste, nutrition, cost, convenience, and weight control concerns as influences on food consumption. J Am Diet Assoc. 1998;98:1118-1126.

      15.Bandura A. Theoretical perspectives (pp.1-10). In: Bandura A, ed. Self-Efficacy,: The Exercise of Control. New York, NY: W.H. Freeman, 1997.

      16. Bureau of Labor Statistics. Employment Projections. Current Population Survey. Washington DC: March, 2012.

      17.   National Center for Health Statistics. Health, United States, 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville, MD: 2012.

      18.   Edwards JS, Engstrom K, Gustafsson IB. Body mass index (BMI), perceptions of portion size, and knowledge of energy intake and expenditure – a pilot study. J. Culinary Science & Technology. 2008;6:151-169.

      19.   Shah M, Adams-Huet B, et al. Food serving size knowledge in African American women and the relationship with body mass index. J Nut Edu Beh. 2010;42:99-105.

      20.  Siegel M, Lynne D. Marketing Social Change – An Opportunity for the Public Health Practitioner (pp. 45-72). In: Seigel M, ed. Marketing Public Health: Strategies to Promote Social Change. Sudbury, MA: Jones and Bartlett Publishers Inc, 2007.

      21.  Puhl R, Peterson JL, Leudicke J. Fighting obesity or obese persons? Public perceptions of obesity-related health messages. Int J Obes. 2012:doi: 10.1038/ijo.2012.156.

      22.  Lewis S, Thomas S, et al. “I don’t eat a hamburger and large chips everyday!” A qualitative study of the impact of public health message about obesity on obese adults. BMC Public Health. 2010;10:309.

      23.  Hensrud, D. Positive attitude key in tackling weight loss. Mayo Clinic, 2010. Available at: http://www.mayoclinic.com/health/positive-attitude/MY01150.

      24.   Nike: Find your greatness [Video]. YouTube. https://www.youtube.com/ watch?v=LsXRj89cWa0. Published July 31, 2012. Accessed December 4, 2012.

      25. Robin Wood Johnson Foundation. Education Matter for Health. Education an Health Issue Brief 6, 2009.

      26.  Norman GJ, Kolodziejczyk KJ, et al. Fruit and vegetable intake and eating behaviors mediate the effect of text-message based weight loss program. Prev Med. 2012; http://dx.doi.org/10.1016/j.ypmed.2012.10.012.

      27.   Nothwehr F, Yang J. Goal setting frequency and the use of behavioral strategies related to diet and physical activity. Health Educ Res. 2007;22:532-538.

      28.  CDC. Nutrition for Everyone: Fruits and Vegetables. Atlanta, GA: Center for Chronic Disease Prevention and Health Promotion, 2012. Available at: http://www.cdc.gov/nutrition/everyone/fruitsvegetables/index.html.