Saturday, December 15, 2012

Why Bloomberg’s Nanny State Control of Soda Incorrectly and Ineffectively Uses Social Behavioral Theories to Combat Obesity- Michelle Samuel

Obesity is an epidemic that plagues the population of the United States. It is a harsh reality and grave threat to the nation’s health and economic wellbeing. Obesity affects more then 30% of adults, and approximately 16% of children and adolescents aged two to nineteen years (6). The Bogalusa Heart Study found that 61% of obese young people already had at least one additional risk factor for heart disease, and 39% had a least two additional risk factors (6). Childhood obesity is a risk factor for severe obesity over the life span and youth with a body mass index of greater then the ninety-fifth percentile have an increased likelihood of developing obesity related-chronic disease earlier, and would require long term management and care exponentially increasing healthcare costs (5).
            From First Lady Michelle Obama downward creating awareness of obesity, and especially childhood obesity, through public health campaigns has increased dramatically. Campaigns stressing better lifestyle choices, exercise and eating right have had minor impact on changing core health values in this largely American cultural issue. Sugary drinks provide 7% of the calories in the American diet, and are the single largest national source of calories (7). According to Harvard journals of public health, one soda doubles a woman’s risk of diabetes, and two sodas raises her risk of heart disease 40% (8). Despite the advertising and awareness campaigns about obesity and the health risks of sugary soda drinks, the percentage of people drinking sodas has risen (12). This increase can be attributed to increase marketing efforts of soda manufacturers, high cost of alternatives like fruit juices, and the dramatic decrease by over 48% of the cost of sodas in the past twenty years (12).  
            In New York City 58% of adults are considered obese, and one in eight New Yorkers suffer from diabetes (7). Five thousand New Yorkers died every year as a result of obesity health related problems, and it is estimated that New York City spends four billion dollars a year on medical care for overweight people (6). To combat this problem New York City’s Mayor Michael Bloomberg, who has introduced ambitious public health policies like bans on smoking in bars and city parks, and posting of calorie counts on menus in chain restaurants passed legislation through the Board of Health in 2012, to be enforced in March 2013, an essential “soda ban” on New York City (6). This hotly contested law restricts the sale of many sweetened drinks in containers larger then sixteen ounces at public places like movie theaters and stadiums (7). The soda law has given the restaurant owners nine months to adapt to the changes before facing fines by the city (7). This ban does not affect fruit juices, dairy based drinks, alcoholic beverages and zero calorie diet sodas (12). The law allows people soda in containers larger than 16oz from grocery stores for family consumption (12). Also, people can still buy the large two liter soda bottles from the grocery store. Despite Mayor Bloomberg’s efforts to move beyond creating awareness and actually enforcing change, a recent poll showed that 60% of New Yorkers thought the soda ban was a bad idea (18).
Psychological Reactance, An In-avoidable Fate
The law passed by the Health Board by a vote of 8-0 placing limitations of the volume and size of sugary sodas consumed by New Yorkers to combat the epidemic of obesity is a classic example of the theory of psychological reactance (12). The theory outlines the psychological response people have to perceived infringement of their behavioral freedoms (21).  According to this model, people react by aggressively trying to regain control and respond in ways that restores their perceived loss of freedom (21). This knee-jerk reaction results in the best-intentioned public health campaigns have an opposite outcome than intended. This is also illustrated in the Romeo and Juliet effect which demonstrated that more parental interference in the relationships of their children, discouraging them from their partner, actually drives couples closer together (21).
Similarly, the 16oz limitation on soda is perceived by people as an infringement on their core individual rights and freedom to what, where and how much of anything (in this case soda) and individual can consume in a public place. It is obvious 60% of New Yorkers do not consume larger than 16oz sodas they are opposed because they perceive it as restriction on their personal freedom (18). Opponents of the law, especially the soda companies, are framing their issue initially through ads and press conferences to the American public and legislators, stressing that the soda ban restricts the liberty of soda drinkers (12). The first website on an online search is, an organization opposed to the ban, currently having half a million supporters (4).  Further investigation reveals that the website is sponsored by hundreds of restaurants who may have provided supporters as they perceive the ban as a loss of business (4).
The law causes psychological reactance because it limits the size of the soda a person can get for their money and people rebel. Even if people do not supersize the drinks normally at the movie theater or public place, they had the option to supersize them, but the law takes away this right, which enrages the people as demonstrated by the poll results (18). The theory of psychological reactance comes into play, and people who may not have been keen on consuming such large volume soda’s may start consuming them as they believe, or led to believe by opponents of the ban, that it infringes on their personal liberties. This also infringes on a core American belief that government should not interfere in personal health and economics and should leave day-to-day decisions to the people themselves (3). People may also think that allowing their government control their diet may be socialistic and lead to other restrictions for their better health or conditions in the future (3). This may result in an increase in the consumption of sugary drinks defeating the purpose of the law (8).
Flaws of Health Relief Model Extends to the Soda Ban
            The well-intentioned law is centered on the core value of health benefits to New Yorkers, in terms of obesity, heart disease, and diabetes. The government, based on the rationale of the Health Belief Model of behavior change, assumed people will willingly comply, as they want to be healthier and are concerned about chronic illnesses like obesity.
The basic principle of the health belief model is that there is a basic assumption of health that motivates individuals to adopt new healthy behaviors (9). It is the rational model that is the basis of almost ninety percent on what we do in public health (14). In this model, a person weighs the benefits of taking actions as opposed to the perceived cost (14). Then a person makes a decision, which is the intention to act that will ultimately drive a person’s behavior (10). When a person weighs their perceived benefits, they take into account their perceived susceptibility and perceived severity, and look at barriers when they consider perceived cost (16). This individual level model centers on the belief about how one is getting the disease, in this case obesity.
            At the outset, the core belief that the obesity epidemic is due in large part by American’s consuming large amounts of soda has not been well established in the minds of the people (8). People are unaware of the impact that large daily soda intake has on people’s health (8). Other health campaigns have focused full lifestyle changes such as exercise and low calorie food to combat obesity. Even when campaigns are food specific they focus on fast foods generally, but do not create awareness about the impact soda’s have on obesity. Mayor Bloomberg’s supporters quote statistics from studies about how sugary drinks are the biggest source of calories, but only 7%, a number not large enough to have massive resonance with the average person (6). Stating Harvard studies about increased risk of diseases by consuming more soda does not have the same impact as visualization of pop stars and celebrities promoting soda consumption (8).
Lastly the model assumes people are rational and not emotional in their decision-making (16). The beliefs of the perceived benefits of adopting the behavior being less risk of diabetes and heart disease and obesity has a much less resonance as people naturally believe that their personal health will be fine (10). They have not been exposed to the health risks, nor has there been much media coverage directly linking or highlighting personal stories of tragedies caused by consuming large volumes of soda (17). Using the model to modify peoples diet by enacting a law is flawed, as one cannot motivate people to adopt healthy behaviors until they are convinced they are personally at risk, as most people are unconcerned about general health risk (14). The perceived threat of disease is the weakest motivator of the health belief model as most people are concerned with the issues of immediacy, not something that develops over time, which a direct link has not been established, and can be caused by factors other than soda (14).
Researchers have studied many of the perceived barriers of healthy eating among people and the biggest reason for the rise in junk food and soda in recent times is the economic recession (12). The profits of McDonalds were released for the month of November 2012, which surprisingly showed a 2% increase in sales because of the dollar menu that makes food more affordable for more people to feed their families (6). When faced with the core value of health, people in dire economic situations put the ability to provide some food and drink for their family above chronic illness that will develop much later instead of an early onset of illness that would develop if their family starves. The timing of the law is also questionable as large volume soda is cheaper, and theoretically can be consumed by more than one individual (6).
            Finally, the health belief model has been effective in interventions where a person needs to make a decision about their health once, like for a vaccine (14). In the case of the soda ban, people are faced with the fact that they cannot have more soda if they want everyday. Thinking about this issue everyday can lead to over-thinking, which would lead people to rationalize that the ban is unnecessary on some days and the core value of health benefit will be lost.
The Gradual Steps of the Transtheoretical Model, or Not
            The law banning the sale of soda larger then sixteen ounces in New York City was an intervention designed incorrectly using the transtheoretical model. The transtheoretical model describes the stages that people go through in adopting a new behavior (19). The stages are precontemplation, contemplation, preparation, action, and maintenance (19). The most important aspect of this model is that a person has to begin at stage one and move forward stage by stage without skipping a single stage (3). It is an individual model that does not predict how groups of people simultaneously move through the various stages (13). It is a gradual dynamic process that has effectively been used for individual interventions combating tobacco and substance abuse, but it can only be effective if it closely follows the guidelines of the theory (19).
Enacting the soda ban law violates the core principles of the transtheoretical model, by starting the entire population of New York City at step three – preparation. The preparation step is when a person takes concrete actions in order to combat the behavior; in this case the government of New York City passed a law restricting the size of soda sold (13). It skips the precontemplation stage where the person has not even thought about behavioral change. In this case, people are unaware that large soda intake causes obesity, endangering their personal health, therefore most have not thought about restricting their soda intake (22). The government incorrectly assumed that people were aware and had thought of soda resulting in obesity and impacting their health, but surveys reveal that 67% of New Yorkers were unaware that sugary drinks provided most of their calories, and they attribute obesity and health risks to fast food and lifestyle choices (18). The second step in the transtheoretical model, which is the contemplation stage when a person first starts thinking about the behavior, is also bypassed as the people are unaware of the health problems associated with soda, so how can think about reducing their intake (21). This ban assumes that the transtheoretical model first two stages have been completed, though no efforts have been made to determine if New Yorkers are contemplating changing their sugary soda habits, and then enacting legislation as a solution to problem (20). It naively assumes that people will change their habits overnight to comply with the ban. The government is also trying to apply an individual model, where everyone is at different stages, to a large group of people and assumes everyone is at the same level of awareness (22). They fail to understand that governments cannot enforce change, but can only provide the tools for change when the time is right.
Tax, Do Not Ban
            Psychological reactance to what Americans perceive as their freedom and liberties has always been strong. As mentioned, 60% of New Yorkers disapprove of the ban, and 15,000 petitions and letters have been sent to congressmen and legislators to repeal the ban (18). Researchers have come up with strategies to combat psychological reactance, which can be used in this case. Researchers believe that a person planning an intervention should never try to change someone’s belief or attitudes, but should try to reinforce their beliefs thereby not confronting the consumer, which reinforces their core beliefs (21). This changes people’s belief through framing to link what you want the audience to do by underlying their core beliefs (11). The last strategy researchers have tested successfully for the theory of psychological reactance is the omega strategy, which gets people to think about the regret if the intervention does not work (21).
Primarily they need to provide a rationale for people to support the intervention. They could use covert persuasion, as people are quickly receptive to attitudes that are similar to their point of view, but they will automatically reject beliefs contrary to their own (21). The core beliefs of liberty, individual rights, and freedoms are universal to the American people and they perceive the soda ban as a challenge to these beliefs. Instead of enforcing a ban the Mayor should have increased or imposed taxes to sodas above 16oz raising the price substantially (18). The people’s rights, liberties and freedom to choose would be intact, but it would force individuals to rethink their decision to purchase large sodas. Rather than having the perception that the government is restricting the size of their drinks, the government subtly places obstacles giving the people pause to think when they want to buy a large soda (11). People will be less inclined to oppose an increase in tax on the soda, as it could be coupled with a campaign that the revenue generated will be used to combat obesity and reduce the associated healthcare costs. 16+ oz. sodas is not being taken away from the people, they only have to pay more for it (18).
This method has been successfully used in Alaska with a tax on alcohol. Investigators in a study evaluated the effects of a tax increase on alcoholic beverages in 1983 and 2002 on alcohol-related disease mortality in Alaska. To evaluate how much alcohol consumption reduced, the investigators monitored the reduction in the number of deaths caused by alcohol related diseases. The results of the study showed an immediate statistically significant reduction in alcohol related deaths when the taxes were imposed on alcohol. The study also showed that after the first tax increase, the effect was not temporary but actually sustained itself over time (23).
Replace Health with Community and Citizenship
            Mayor Bloomberg’s ban on large soda sales in public place has at its core the imperfect health belief model. As mentioned, the core value of health is the weakest motivator for people to change their behavior, especially if they face the decision multiple times, a weak core value would be dethroned (22). In order to make this intervention stronger, the proponents of the law should reframe the issue from a health frame to a citizenship and community frame.
            A frame is used to communicate a point through images without delving into details. There are six parts to a frame: a title, core position, metaphor, catch phrases, symbols or images, and core values (24).  A core position is a sentence of what the frame is really saying. For the soda ban, the core position should be that New Yorker will work together to fight obesity by reducing soda consumption.  This can be metaphorically translated as a war on obesity and that large sodas are the enemy of New Yorkers health and wellbeing. A catch phrase that could be used is “we can do this together” demonstrating inclusiveness in New Yorkers fight against obesity. Symbols need to highlight the sense of patriotism, and the fight against obesity by protecting each other from this grave condition that afflicts neighbors and friends. Finally, the core values would be freedom, individual rights, and liberty (24).
Patriotism or citizenship has been central to the American ideal and culture since its inception (15). The ideals of patriotism are close to the hearts of most Americans, natural born or naturalized (15). A recent study indicated that Americans ranked patriotism one of the top five most important concepts to them (8). Obesity as an epidemic and American enemy should be eliminated so that obesity does not define the American image globally. Obesity should be reframed not as an individual health issue, but as a perceived weakness globally. Today Americans are considered obese and weak, and defeating this enemy within our midst is imperative to America’s image of a strong and powerful nation. Communicating that reducing soda intake directly results in reduced obesity and correspondingly a stronger nation starts with strong willed New Yorkers combating it on a war footing, something New Yorkers have been known to accomplish after September eleventh and hurricane Sandy. By reframing the issue, the message becomes stronger and more personal that resonates with people resulting in better compliance with the objectives of the law (22).
Order Matters
            The transtheoretical model is a very successful in tobacco and substance abuse. It is a gradual process, but the first dynamic model. As stated, it is most important follow every stage for the model to work, even though a person can slip at any stage right back to stage one. This model assumes behaviors are reasoned and proceeds through the stages step by step (2). In this case the transtheoretical model lets the groups creating the intervention to target different populations at the different stages, but the key is to bring everyone to the same level of stage one of the process.
            The first two stages of the transtheoretical model need to be included in order for the model to be a successful intervention. For the precontemplation stage, proponents of the ban could create advertisements, talk shows and create media buzz on television highlighting the harmful effects of soda and it’s direct relation to obesity and people’s health, making the conversations personal with real stories for it to create awareness among New Yorkers (1). They need to create a genuine concern among the population that the epidemic has got out of control, and ground swell among a wide swath of people thinking about the link between soda and obesity, heart disease, and diabetes. Once awareness reaches a level that people begin to question excessive soda consumption the platform is ready to move the marketing and advertising to the second stage of contemplation to suggest lifestyle change solutions to reduce the quantities consumed by adolescents and adults (1). People will start thinking about reducing their soda intake for the betterment of their community and their own personal health and will not be averse to accepting the   soda ban or tax when the government mandates a reduction of soda since they have already passed through the initial two stages. A majority of people will implement change themselves, while some may still require the tools the government provides, but there will be sustainable change in soda consumption habits as a community, and ultimately reduction in obesity and its associated disease (18).
            As with many well-intentioned public health programs, Mayor Bloomberg’s proactive step to reduce obesity by restricting the size of soda sold at public venues and in public places may result in a very different outcome due to psychological reactance, basing it on a weak health relief model, and not adhering to the transtheoretical model. However; only time will determine the bans success, as it sets a new social norm for New Yorkers, many of whom oppose the ban, but the mayor hopes people will ultimately accept the ban resulting in the improved health outcomes. In conclusion, the ban should be a tax on soda, be framed as a community and citizens battle against a common enemy, and should follow the transtheoretical model closely improving its chances of success.
        (1) Cialdini RB. Influence: The Psychology of Persuasion (Introduction and Chapter 1: Weapons of Influence). New York: Harper Collins Publishers, 2007: pp. xi-xiv and 1-16.
        (2) DeMartino B, Kumaran D, Seymour B, Dolan RJ. Frames, biases, and rational decision-making in the human brain. Science 2006; 313:684-687.
        (3) Dietz WH, Benkien DE, and Hunter AS. Public Health Law and the Prevention and Control of Obesity. The Milbank Quarterly 2009; 87: 215-227.
        (4) Freudenberg N, Galea S. The impact of corporate practices on health: implications for
health policy. Journal of Public Health Policy 2008; 29:86-104.
        (5) Frieden TR, Dietz W, and Collins J. Reducing Childhood Obesity Through Policy Change: Acting Now to Prevent Obesity. Health Affairs.
        (6) Frum, D. Bloomberg’s Visionary Move Against Obesity. CNN.
        (7) Grynbaum MM. Health Panel Approves Restriction on Sale of Large Sugary Drinks. New York Times.
        (8) Grynbaum MM. Will soda restrictions help New York win the war on Obesity? British Medical Journal 2012; 345: 68-69.
        (9) Individual health behavior theories (chapter 4). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp. 35-49.
        (10) King DE, Mainous AG, Carnemolla M, Everett CJ. Adherence to healthy lifestyle habits in US adults, 1988-2006. American Journal of Medicine 2009; 122:528-534.
        (11) Langer EJ. The illusion of control. Journal of Personality and Social Psychology 1975; 32:311-328.
         (12) Lerner, G. New York Health Board Approves Ban on Large Sodas. CNN.
        (13) Marcus BH and Simkin LR. The Transtheoretical Model: Applications to exercise behavior. Medicine & Science in Sports & Exercise 1994; 26: 1400-1404.
        (14) Marks DF. Healthy psychology in context. Journal of Health Psychology 1996; 1:7-21.
        (15) Marshall SJ, Biddle SJH. The transtheoretical model of behavior change: a meta-analysis of applications to physical activity and exercise. Annals to Behavioral Medicine 2001; 23: 229-246.
        (16) National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, pp. 9-21 (NIH Publication No. 05-3896). Available at:
        (17) New Yorkers for Beverage Choices.
        (18) NYC’s Soda Ban is a Good Idea, But a Tax Would be Better. Forbes Magazine.
        (19) Ogden J. Some problems with social cognition models: a pragmatic and conceptual analysis. Health Psychology 2003; 22:424-428.
        (20) Sarkin JA, Johnson SS, Prochaska JO, and Procaska JM. Applying the Transtheoretical Model to Regular Moderate Exercise in an Overweight Population: Validation of a Stages of Change Measure. Preventive Medicine 2001; 33: 462-469.
        (21) Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.
        (22) Velicer WF, Norman Gj, Fava JL, and Procaska JO. Testing 40 Predictions from the Trantheoretical Model. Addictive Behaviors 1999; 24: 455-469.
        (23) Wagenaar AC, Maldonado-Molina MM, and Wagenaar BH. Effects of Alcohol Tax Increases on Alcohol-Related Disease Mortality in Alaska: Time-Series Analysis from 1976 to 2004. American Journal of Public Health 2009; 99: 1464- 1470.
        (24) Winett L. Advocates guide to developing framing memos (Chapter 46). In: Iyengar S, Reeves R, eds. Do the Media Govern? Politicians, Voters and Reporters in America. Thousand Oaks, CA: SAGE Publications, Inc., 1997, pp.420-432.

Labels: , , ,


Post a Comment

Subscribe to Post Comments [Atom]

<< Home