Why Do Public Health Communicational Campaigns Fighting Obesity Fail? A Critique of The “Strong 4 Life” Movement- Ivi Papaioannou
According to a 2012 report by the Institute of Medicine
(IOM) (1), one third of the children in the United States are overweight or
obese, and two thirds of the adults fall under the same categories. The
implications of these high levels of obesity are multiple. The health
consequences are well established, including cardiovascular disease, type 2
diabetes, hypertension, sleep apnea and depression. Additionally, health care
costs associated with obesity- related illness are rising reaching 21% of the
total annual medical spending (1). Taken into account the health, social and
economic burden posed by the obesity epidemic the need for interventions is
becoming of paramount importance.
The most effective way to communicate health and
nutritional information to the public is still under investigation. The goal of
the policy makers is to create interventions which will be based on well
established scientific data and at the same time take into account factors
which might influence social behaviors (2). Moreover, mass media are dominating
our lives, and thus public health campaigns communicated through the TV, radio,
press, internet etc. are important components of public health interventions.
Successfully, conveying a health recommendation to a well received message, is
a complex procedure including different parameters like: sufficient exposure to
the message, creation of a supporting environment, use of social marketing
tools, assessment of exposure and at last, deep understanding of social
behavior theories (3). Besides the theoretical background providing adequate
knowledge for a successive intervention, the effectiveness of mass media
campaigns is often questioned.
An example of a controversial campaign is the “Strong 4
Life” (S4L) intervention (4). The campaign is an initiative of the “Children’s
Healthcare of Atlanta”, to fight obesity in children. As mentioned in the website
of the campaign, Georgia has the second highest rates of childhood obesity in
the country and 75% of the parents seem still unable to recognize the problem.
In order to address the importance of the epidemic, the movement S4L was
initiated and includes several “aggressive” catch phrases in its campaign in
order to awake the members of the society and motivate them to take action.
Some of the messages communicated to the public are: “Fat kids become fat
adults”, “Chubby kids may not outlive their parents”, “Big bones don’t make me
this way. Big meals did”, “He has his father’s eyes, hid laugh and maybe his
diabetes”, “Being fat takes then fun out of being a kid”, “Fat may be fun to
you, but its killing me” and other. All these very direct phrases are posted
under the pictures of overweight children at bus stations, billboards and many
other public spaces in the state of Georgia generating a great controversy
around the appropriateness of tools used for this initiative. Creators of the
movement argue that the situation shouldn’t be sugarcoated and underscore that
straight talk is the only solution (5). But on the other side , health experts
are concerned that this type of campaign is not only ineffective but it is also
damaging for the obese kids (5).
In 2012 a one of its kind study by Puhl et al. (6) was published. The authors examined how the public
perceived the messages of different mass media campaigns fighting obesity.
Among the interventions included in the analysis was the S4L. The results
demonstrate that among the 29 messages evaluated, those of S4L (“Fat kids
become fat adults”, “Chubby kids may not outlive their parents”, “Being fat
takes then fun out of being a kid”) were the less motivating and the most
stigmatizing. This finding suggests that when issues of personal responsibility
and blaming are implied there is less intention to comply with the
intervention. S4L is an excellent example to demonstrate that even though
behavioral theories should be a fundamental component of the mass media campaigns
they are often ignored (3).
Critique #1: S4L stigmatizes children and fails to
take into account the importance of self- esteem
There are not a few public
health actors who believe that by stigmatizing bad behavior, in this case
excess weight, individuals would be motivated and take action. This opinion is
fully endorsed by the policy makers of S4L, as words like fat, chubby and big
are the cornerstone of the “movement”. It may be a paradox, but it is believed
that stigmatization may be the only solution. However, blaming individuals
fighting on a daily basis with social isolation because of their weight
contradicts basic assumptions of behavior theories. After all we live in a
society bombarded by weight stereotypes, and if stigmatization was the gold
solution the obesity rates wouldn’t keep rising. Stigma was first defined by
Goffman in 1963 (7). According to Goffman stigma is a “deeply discrediting
attribute” resulting in a “discounted person”. In our society the “thin norm”
is promoted as it is synonymous to health, beauty and responsibility, whereas
obese individuals are stigmatized by their appearance, and the visibility of fat.
As a result, overweigh people are considered unhealthy, irresponsible, weak and
ugly (8). In addition, it is suggested that overweight individuals tend to
accept their role in the society and they function as expected by a “fat”
person. They internalize the characteristics following the stigma of obesity,
and they rarely challenge any negative perceptions (9). They learn to live with
the stigma. By characterizing a child as “chubby” in the S4L campaign, there is
a great risk that the kid will have extremely low self esteem and passively
accept how the society thinks about him, as being fat and weak.
Several studies prove the above theories in practice. It
has been suggested that overweight individuals who feel bad and ashamed engage
in unhealthy behaviors. In a study by Vartanian et al. (10) in 100 female
college students, participants which suffered from weight stigma had lower
levels of body image satisfaction and, most importantly, were more likely to
avoid exercise compared to non- stigmatized students. According to research,
weight teasing among adolescents could be a risk factor for engaging in eating-
disordered behaviors such as binge eating and use of laxatives (11). As an
innate response to the social expectation for dieting, obese individuals may
also overeat (12). It is probable that stigmatized children in Georgia will not benefit from physical activity and
will also not experience the benefits of weight loss. Even though obesity is a
complex phenomenon with metabolic, genetic and social causes, nowadays mass
media tend to award complete responsibility to the individual. It is highly
probable that the S4L campaign in Georgia will deteriorate the physical and
psychological health of overweight children. Moreover, it is expected that
stigmatization will reinforce disparities. This would be of particular
importance as the majority of obese kids already belong in low income or
minority groups. The S4L may also mask the need for another more intuitive,
efficient and effective anti- obesity intervention as other causes of obesity
are overlooked. Stigmatization is a concept which needs to be addressed in
public health campaigns, as it threatens both the individual and the social
values (13).
Critique #2: S4L overlooks the importance of self-
efficacy
The anti- obesity messages,
which are part of the S4L campaign, are certainly direct, strong and shocking.
However, they lack a fundamental component of the social behavior theories, and
especially of the Social Cognitive Theory (14). This component is called “self-
efficacy”. Self- efficacy is defined as the “belief that one has the power to
produce that effect by completing a given task or activity related to that
competency”. In other words, it reflects how empowered and capable someone
feels in order to reach a goal. It is hypothesized that a positive results is
produced if the situation is mastered. At this point it is important to
distinguish between self- efficacy and self- esteem described above.
Self-esteem is associated to self- worth, whereas self- efficacy is the
perception of the ability to achieve a goal (14). Moreover, according to the
theory of self- efficacy, the more someone believes he can achieve a goal, the
more likely he will put much effort and will persist in achieving it. In the
case of the present S4L obesity campaign, children are poorly empowered to
engage in a persistent behavior to fight obesity. Again, the focus of the S4L
is to present raw facts and it doesn’t allow for motivation and goal setting.
Given these characteristics of the S4L, children are less likely to set any
proximal or distal goals, and thus reduction in calorie intake and weight loss
will not be achieved (15). A common feeling of obese children, exposed to
messages for “fat kids”, could be the creation of failure scenarios, resulting
from doubting their capability to achieve weight control. Procrastination and
avoidance are other characteristics (16).
Several studies have been performed in the domain of self-
efficacy as an important contributor in weight loss. Original research was
performed by Bandura and Simmon (15). In order for Bandura, the father of the
Social Cognitve Theory, to test his hypothesis, he recruited a population of
obese participants which were randomized in different groups of: 1) goal
setting or 2) no treatment in order to achieve weight reduction. The results of
this early trail contribute significant findings in the theory of self-
directed change. Specifically, a motivational and self- regulatory environment
was a positive risk factor against obesity. Thus, we understand that obesity
was the perfect example for Bandura to evaluate his theory. Since then a number
of scientific data have been published and are in accordance with these
findings. A characteristic example would be the prospective study of 2006 by
Linde et al (17), in which overweight and obese participants followed treatment
including cognitive interventions for weight reduction. The findings suggest
that during the treatment period high self- efficacy was predictive of
successful weight management. However, this association was not observed during
the follow-up period, after completion of the treatment. This unique finding
suggests that self- efficacy is a strong predictor for the initiation of a new
behavior, but if the individual will adhere to the change depends on how
satisfied they may or may not be. This is an important concept to keep in mind when
designing an intervention.
The procedure of evaluating our self begins in childhood
and it is an ongoing procedure. The environment created by the S4L adds has a
significant effect in damaging the ego of overweight and obese children. The
theory of self- efficacy fully explains why children in Georgia will eventually
become obese adults who put the needs of the society above their needs.
Critique #3: S4L fails to take into account the
interaction between an individual, the environment and behavior
Social Cognitive Theory
(SCT) is a useful tool for explaining the etiology of different behaviors and
for designing activities that will result in attitude changes. The SCT was used
in several health promotion interventions to manipulate factors influencing
individual behavior (18). The SCT (19) is a multi- factorial model which takes
into account self- efficacy, described above, alongside with “cognized goals,
outcome expectations, and perceived environmental impediments and facilitators
in the regulation of human motivation, action, and well-being”. In other words,
SCT takes into account both personal and socio- environmental determinants of
health, and looks at how these reflect back to the self- efficacy of the
individual.
The S4L campaign fails to take into account the conditions
which contribute, or not, in the initiation of a change. By reviewing the catch
phrases of the messages (ex. “won’t outlive their parents”, “take the fun out
of being a kid”) one could easily conclude that no action is proposed. After
been exposed to such a slogan a child, or a family, are left with no advice.
Underlying the problem will not necessarily lead into action, especially in
absence of solutions. Health policy recommendations should be applicable and
well endorsed by the society. Recent research (6) has shown that individuals have a positive perception about
nutrition campaign messages, if they are focusing on specific changes in
dietary patterns, for example “eat more fruits and vegetables”. Other slogans
receiving high intent to comply were those including multiple health and
lifestyle advices, like “Eat well. Move more. Live longer.” It is well accepted
that the prevalence of obesity is higher in lower socio- economic classes. It
is of great importance to understand that in many cases unprivileged
populations acknowledge the problem but they don’t have the education to treat
it.
Moreover, S4L could be characterized as ignorant, because
it fails to take into account the environment and the social milieu where these
kids grow up. Emerging literature suggests that when planning a dietary
intervention, policy makers should shift their attention from the level of the
individual to the environment (20). Obesogenic environments are suggested to
impact both food choices and physical activity levels resulting in positive
energy balance and subsequent weight gain. In a 2011 review (20) by Giskes et al., living in a neighborhood
with greater access to supermarkets and lower accessibility to takeaway
outlets, was a protective risk factor against obesity. On the contrary limited
access to supermarkets and increased access to fast- food was correlated with
higher levels of obesity. Moreover, another predictor of obesity is living in a
socioeconomically deprived area which will increase the chance of reliance to
convenience stores for food supply. These data add another reason to why S4L
may fail.
With 23% of Georgia’s population living in poverty, with
the median annual household income being lower than the national average ($45,642
vs. $50,443) and with minority levels being higher than in other states (21),
we understand that Georgia is a state that needs particular attention when it
comes to designing an intervention for obesity. There are more factors than
overeating and lack of physical activity which might influence the epidemic. A
shocking campaign is not the solution. Based on the social theories and
scientific data presented above, it seems like S4L is predetermined to fail. A
multi- disciplinary approach, tailored on the specific high risk population is
considered necessary.
The Intervention: Changes proposed in the mass media
campaign of S4L
According to a 2007 review on policy making (22) for
obesity there is a “cacophony” dominating the field. In other words, policy makers
have not yet identified what the target of the intervention should be and as a
result complex schemes of intervention are proposed. This is highly attributed
to the multiple causes of the disease. In anti- tobacco campaigns the solution
would be to stop smoking, but when it comes to losing weight more than one
advices can be given. Furthermore, and as already mentioned in the present
paper, obesity is not a problem of the individual anymore, it is the problem of
our society and that is the reason why policy makers are asked to contribute in
the efforts to halt the epidemic.
The present intervention will focus on changes which can be
made in the S4L to address the critical points mentioned earlier in the present
paper. The main focus will be on messages included in the campaign, and how
these could become effective, while in accordance with the social theories for
behavior. Before describing the main points of the campaign, it is important to
identify our goal and our population. The ultimate goal is to lower the
prevalence of childhood obesity in Georgia, the state with the second highest
levels of childhood obesity in the US. Our main target population is children
from families with a low socio- economic status (21). However, because it is
difficult to create a different campaign for each target group (18), we assume
that our intervention will have as recipients all groups involved in the
obesity epidemic, from obese children and their families, to political actors,
producers and food industries.
The most important component of the proposed campaign are
the messages adopted. The “slogans” should: have an explicit point in relation
to why people may- or may not- engage in certain behaviors, be specific and
give advice for actions instead of including general guidelines, provide easy
to follow “how” and “when” information, encourage positive behaviors instead of
discouraging bad ones and appear to the irrational part of the brain rather
than the rational (18). How to frame the issue is critical. It is suggested
that focusing on the benefits to gain, as well as recommending a specific
solution are positive elements of such a frame (18). Moreover, research (6) has
shown that people are positively predisposed to messages which do not emphasize
on the word “obesity”. Again, focusing on the overall health of the body rather
than the weight seems to be more effective. Taking into account these guidelines,
some of the messages which could be incorporated in S4L are: “You have the
power to do it, walk to school and change your life”, “Eat health, walk more,
live better”, “Want to help your kids? You can! Cook more at home, exercise all
together, enjoy family time more!”, “Take action! Make half of your plate
fruits and vegetables”, “Want to eat healthier and cheaper? Make a small step
and start using frozen vegetables”, “Add a fruit in every meal! Make a small
change in your plate, make a big change in your life”, “Eat cheap, cook at
home! Join the cooking classes at S4L”, “Give your child a better life! Learn
what healthy eating involves S4L community cooking classes”, “Take action! You
talk to your parents about 10 teaspoons of sugar in you soda can! Learn more at
www.S4L.com”, “You chose what to eat
for dinner! Visit www.S4L.com and help your parents make
a healthier visit at the supermarket” and “Help your child have a healthier
life. Join the S4L movement” (6). In order to take into account any rational
disparities, and acknowledging that obesity levels among Latinos are
skyrocketing, it would be a good idea to have some of the slogans in Spanish.
Another component of the campaign is where are these
messages going to be included? Young kids and more affluent and educated
individuals tend to spend more time on the internet, while adults and poorer
people respond better in printed material. Television is uniformly effective
for all groups (18). In the present campaign exposure theory will be
considered. According to this theory, “variation in exposure of a message, is
more important than variation in the quality of a message” (23). Moreover, the
more a person is exposed to a message the more likely it will take action,
frequent exposure to a slogan increases the chances of reaching the individual
in a state ready to receive it and finally, a message repeated multiple time
and by various sources appears important. The intention of the present campaign
would be to maximize exposure of the messages through: billboards, bus
stations, public transportation, schools, playgrounds, tv adds, movie theaters,
magazines, web, even public restrooms!
In the next three sections the present analysis will go
into the specifics of the intervention in order to address the issues which
came up during critiques 1, 2 and 3 according to the principles of social
behavior theories.
Defense #1: Combat the stigma
“Fat” kids are definitely stigmatized for their whole life
by reading with big bolded letters that they are at risk to die. Specific steps
and ideas should be implemented to combat the formation of stereotypes.
Firstly, as already mentioned, emphasis should be given in the overall health
of the individuals. A recent study (24) suggests that obese individuals, who
were metabolically healthy, had a better prognosis for mortality and morbidity
compared to the metabolically unhealthy subjects. Thus the slogans of the
intervention do not set as a goal losing weight but improving health and
enjoying a better quality of life. After all, healthy dietary practices are
beneficial for the population as a whole and not only for obese individuals.
Secondly, in the S4L campaign pictures and testimonies of
existing children are included. This could be the ultimate form of
stigmatization, as you can watch the 10 year old school- kids calling
themselves fat. It seems that these children have learned to live with this
stereotype, and they have passively assumed the role our society has chosen for
them. As an effort to change the components of the original S4L initiative, I
would substitute the pictures of overweight kids, with drawings- sketches of
normal weight children and adults promoting healthy attitudes.
Another approach to stigmatization, moves responsibility
from the individual to the “social justice” (25). According to this hypothesis
a conductive social environment should be created, and this should eliminate
disparities. All the individuals in the society should have equal access to
resources to fight the obesity epidemic (ex. education, supermarkets, fresh
produce). In terms of the present intervention, this could be part of a
multidisciplinary approach of a general anti- obesity policy, accompanying the
S4L slogans. It is only after the reallocation of resources is achieved that an
individual can assume any responsibility about being overweight. Moreover,
again in a more general spectrum, stigma could be combated through legislation
against weigh discrimination, at school, work environment or health care (13).
Defense #2: Promote self- efficacy
Depending
of the feelings of the individual, responsible/ irresponsible, attractive/
unattractive etc, one is going to act accordingly. Thus, the messages of the
intervention should focus on how the individuals can take action. Such
empowering messages include phrases like:
you have the power to do it, you can!, take action! , make a small
change, give your child a better life! etc. By creating an image of
responsibility and capability about one’s self this will be turned into
reality, and overweight children and their families will find the emotional
strength to make a small change for themselves or for their loved ones (26).
A
characteristic example of how mass media campaign may result in significant
weight loss of obese participants is the BBC’s “Fighting Fat, Fighting Fit”
(FFFF) campaign(27). In this large scale intervention (N= 2,112 at follow up),
participants were exposed to the main message of the campaign (“fight obesity
with small and permanent changes to diet and exercise”) for 7 weeks through the
BBC network. One of the cornerstones of the campaign was promoting self-
efficacy, self- monitoring of behavior change and encouraging participants to
take action, join groups, and make life- style changes by using the resources
available in the community. According to the findings, 75% of the individuals
experienced some weight loss and increase in their physical activity. The take
home message of this study, which could apply to the present S4L campaign, is
that repeated exposure to an empowering message can actually be beneficial for
weight management.
VERB
was another successful intervention, managed by the Department of Human and
Health Services and the Centers of Disease Control and Prevention (28). This
mass media campaign was designed to empower twins and engage them in physical
activity. The VERB initiative contributed significant results and provided
guided for future research. One of the implications of VERB is that “persuasion
should be used beyond education”. This is a component also adopted in the
proposed catch phrases of the modified S4L , as many among them aim for the
irrational part of the human brain (ex. Want to help your kids, change your
life, live better, make a big change in your life).
It
has also been suggested (17), that high self- efficacy itself is not an
adequate predictor for weight loss. Self- efficacy may promote weight control
behaviors, which effectiveness is not guaranteed. As a result, the messages
used to empower receptors of a campaign should be carefully chosen, and should
have high specificity (ex “make half of your plate fruits and vegetable”,
“exercise for 30 minutes on a daily basis”, “visit our website etc.”). In other
words our modified intervention will focus not only in motivating our target
groups, but will also provide guidance to engage themselves in effective
practices.
Defence #3:
Take into account the social milieu, and adopt a multidisciplinary approach
Shifting our attention from the individual to the
environment begins with framing the issue differently in a mass media campaign.
It is the society’s role to create an environment in which it will be easier
for the obese individual to make a healthy choice. This would include not only
motivation to consume more fruits and vegetables, but also making them more
accessible as a part of a multidisciplinary policy (29). Part of this notion could
be the solutions provided to low income families (ex. “Want to eat healthier
and cheaper? Make a small step and start using frozen vegetables”), and the translation
of the messages in Spanish.
Moreover, policy campaign terminology should evolve. Excess
weight should be associated with the context in which the behavior occurs, in
other words with the environment and the circumstances. In the specific milieu
the individual should become aware of which are the healthier choices (ex.
fruits and veges, cook at home), what does more active mean, etc. Additionally,
using descriptive phrases such as healthful eating are considered effective
(29).
The obesity campaigns are at the point where tobacco
campaigns were 30 years ago. After many years tobacco policy makers learned how
to distribute the responsibility between the individual and the society. By
now, it is clear that smokers should make a great effort to quit smoking, but
at the same time social actors should provide a smoking-free environment (29).
Mass media campaigns are only one tool used in public
health policy. In order to reverse the obesity trends a multidisciplinary
approach is necessary, which will be based on a holistic approach of the
system. Moving from increasing physical activity time and modifying dietary
factors to concomitant changes in agriculture, food industry, taxation and
education, is considered critical (22).
REFERENCES
1. Institute
Of Medicine. Measuring progress in obesity prevention. Workshop report.
Washington DC. The National Academy Presss. 2012.
2. Marian
Fitzgibbon, PhD, Kim M. Gans, PhD, MPH, LDN, W. Douglas Evans, PhD, K.
Viswanath, PhD, Wendy L. Johnson-Taylor, PhD, Susan M. Krebs-Smith, PhD, Anne
B. Rodgers, BA, Amy L. Yaroch, PhD Communicating
Healthy Eating: Lessons Learned and Future Directions Journal of
Nutrition Education and Behavior, 2007, Volume 39, Issue 2.
3. Whitney
Randolphand K. Viswanath. Lessons learned from public health mass media campaigns: marketing health in
a crowded media world. Annu
Rev Public Health. 2004;25:419-37
4. Children’s Healthcare of Atlanta.
Strong4Life. Atlanta, GA. http://www.strong4life.com/pages/about/about.aspx Last accessed 12/02/2012.
5. ABC News. 'Stop Sugarcoating' Child Obesity Ads Draw
Controversy. Lara Salahi. 2012. http://abcnews.go.com/Health/Wellness/stop-sugarcoating-child-obesity-ads-draw-controversy/story?id=15273638#.ULvko-ThKSp
Last accessed 12/02/2012.
6. Puhl R, PetersonJL, LuedickeJ.Fighting obesity or obese persons? Public perceptions of obesity-related health messages.
Int J Obes (Lond). 2012 Sep 11. doi:
10.1038/ijo.2012.156. [Epub ahead of print]
7. E. Goffman Stigma: Notes on the
management of spoiled identity Prentice-Hall (1963)
8. Lewis S, Thomas SL, Blood RW, Castle DJ, Hyde J, Komesaroff PA. How do obese individuals perceive and respond
to the different types of obesity stigma that they encounter in their
daily lives? A qualitative study. Soc Sci Med. 2011 Nov;73(9):1349-56. Epub 2011 Sep 10.
9. M.M. Rogge, M. Greenwald, A. Golden Obesity, stigma, and civilized oppression ANS Advanced Nursing Science, 27 (2004), pp.
301–315
10.
Vartanian LR, Shaprow JG. Effects of weight stigma on exercise motivation and
behavior: A preliminary investigation among college-aged females. J Health
Psychol 2008; 13: 131–138.
11.
Neumark-Sztainer, D., Falkner, N., Story, M., Perry, C., Hanna, P. J., &
Mulert, S. (2002). Weight-teasing among adolescents: Correlations with weight
status and disordered eating behaviors. International
Journal of Obesity, 26, 123–131.
12.
Myers, A., & Rosen, J. C. Obesity stigmatization and coping: Relation to
mental health symptoms, body image, and self-esteem. International Journal of Obesity,
1999, 23, 221–230.
13.
Puhl RM, Heuer CA. Obesity stigma: important considerations for public health.
Am J Public Health 2010; 100: 1019–1028.
14.
Bandura, A. Self-efficacy: Toward a unifying theory of behavior change.
Psychological Review, 1977, 84, 191-215.
15.
Bandura, A., & Simon, K. M. The role of proximal intentions in
self-regulation of refractory behavior. Cognitive
Therapy and Research, 1977, 1, 177–193.
16.
Schwarzer, R., & Renner, B. Social-cognitive predictors of health behavior:
Action self-efficacy and coping self-efficacy. Health Psychology, 2000, 19,
487–495.
17. Linde,
Jennifer A ; Rothman, Alexander J ; Baldwin, Austin S ; Jeffery, Robert W. The
Impact of Self-Efficacy on Behavior Change and Weight Change Among Overweight
Participants in a Weight Loss Trial. Health psychology : official journal of
the Division of Health Psychology, American Psychological Association, 2006,
Vol.25(3), pp.282-91
18. Fitzgibbon M, Gans KM, Evans WD, Viswanath K, Johnson-Taylor WL, Krebs-Smith SM, Rodgers AB, Yaroch AL. Communicating healthy
eating: lessons learned and future directions. J Nutr Educ Behav. 2007 Mar-Apr;39(2
Suppl):S63-71.
19.
Bandura A. Social Foundations of
Thought and Action. Englewood Cliffs, NJ: Prentice-Hall; 1986.
20. Giskes K, van Lenthe F, Avendano-Pabon M,
Brug J.A systematic review of environmental factors and
obesogenic dietary intakes among adults: are we getting closer to understanding
obesogenic environments? Obes Rev.
2011 May; 12(5):e95-e106.
21. Kaiser Health News. State Health Facts: Individual State Profiles,
Georgia. http://www.statehealthfacts.org/profile.jsp
Last accessed: 12/03/2012.
22. Lang T, Rayner G..
Overcoming policy cacophony on obesity:
an ecological public health framework for policymakers.
Obes Rev. 2007 Mar;8 Suppl 1:165-81.
23. Hornik R, Kelly B. Communication and diet: an overview of
experience and principles. J
Nutr Educ Behav. 2007 Mar-Apr;39(2 Suppl):S5-12.
24. Ortega FB, Lee DC, Katzmarzyk PT, Ruiz JR, Sui X, Church TS, Blair SN.
The intriguing metabolically healthy but obese phenotype: cardiovascular prognosis and role of fitness.
Eur Heart J. 2012
Sep 4. [Epub ahead of print]
25. Adler NE, Stewart J. Reducing obesity: motivating action while not
blaming the victim. Milbank Q. 2009; 87(1):49–70.
26. Cochrane G. Role for
a sense of self-worth in weight-loss treatments:
helping patients develop self-efficacy. Can Fam Physician. 2008 Apr;54(4):543-7.
27. Miles A, Rapoport L, Wardle J, Afuape T, Duman M.Using
the mass-media to target obesity: an analysis of the characteristics and
reported behaviour change of participants in the BBC's
'Fighting Fat, Fighting Fit' campaign.Health
Educ Res. 2001 Jun;16(3):357-72.
28. Robert McKinnon Lessons from VERB: A
Case for Branding in Nutrition Education
Journal of Nutrition Education and Behavior, Volume 39, Issue 2, Supplement, March–April 2007,Pages S53-S54
Journal of Nutrition Education and Behavior, Volume 39, Issue 2, Supplement, March–April 2007,Pages S53-S54
29.Lori Dorfman, Lawrence Wallack Moving Nutrition Upstream: The Case for Reframing Obesity Original
Research Article Journal
of Nutrition Education and Behavior, Volume 39, Issue 2, Supplement, March–April 2007, Pages S45-S50
Labels: Adolescent Health, Diabetes, Green, Health Communication, Nutrition, Obesity
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