Tuesday, January 1, 2013

Is Strong4Life Strongly Flawed? A Critique of Georgia’s campaign to end childhood obesity – Ashley Floreen

            One of the greatest public health issues today is the growing rate of childhood obesity in the United States.  Within the past thirty years, the obesity rate has nearly tripled, resulting in 17% of children and adolescents meeting the criteria for obese (1).
In 2011, the Strong4Life campaign was initiated by the Children’s Healthcare of Atlanta to combat the growing childhood obesity epidemic in Georgia.  According to Strong4Life, nearly 40% of children in Georgia are obese and are now at risk for diseases such as hypertension and Type II Diabetes that were previously only seen in adult populations.  The Strong4Life campaign addresses the dangers of childhood obesity by providing ways to decrease obesity by promoting healthy eating habits, increasing exercise, and offering support to families (2).
However, in addition to its website, Strong4Life launched numerous advertisements on television and on billboards which shamed obese children and parents.  One ad, featured in black and white, has a child named Bobby sitting across from his mother who is also obese, and asking “Mom, why am I fat?” The mother says nothing.  A billboard shows a photo of an obese young girl with the message “WARNING. It’s hard to be a little girl if you’re not” (3).  While there are numerous sides to this particular public health campaign, the advertisements and billboards carry a flawed message because they do not recognize a number of issues: perceived dangers and risks associated with obesity, how behavior is influenced by a child’s environment, a positive role model for children, and the importance of providing solutions for childhood obesity and a pathway to success. 
Perceived Dangers of Childhood Obesity
Strong4Life claims that 75% of Georgia parents do not recognize their child as obese (2).  Although that statement of truth is effective for raising awareness of the issue, it fails to explain the health risks that accompany obesity.  As a result, the population may not believe they are at risk for obesity and therefore will not take action to prevent this condition or reverse the effects if they have already been diagnosed.  This theory is known as the Health Belief Model, which originated from a failed tuberculosis screening in the 1950s sponsored by the United States Public Health Service.  The screening was free and conveniently located directly in neighborhoods across America, yet very few people actually took advantage of this service.  Godfrey Hochbaum, a USPHS social psychologist, developed the Health Belief Model after discovering that people were more likely to get screened if they believed they were at risk of contracting tuberculosis and that there was a benefit to getting an early diagnose.  It now comprises of six major components: Perceived Susceptibility, Perceived Severity, Perceived Benefits, Perceived Barriers, Cues to Action, and Self Efficacy (4).
The Strong4Life ads and billboards completely disregard this theory.  For example, the ad with Bobby facing his mother contains nothing of perceived susceptibility because it does not show the child or parent feeling at risk for being classified as obese, nor does it discuss the perceived severity of obesity, in that neither child nor parent acknowledges any consequence of being obese.  Additionally, the audience does not gain any perceived benefits because no positive outcomes of losing weight are discussed, nor do they recognize any perceived barriers because no negative consequences of not losing weight are mentioned (4).  The ad ends with Bobby and his mother simply staring at each other, with no motivating event that would suffice as a cue to action to change the behavior that led them to become obese.  It also lacks self-efficacy, or the mother and son’s belief that they could actually change their behavior. On the contrary, the silence at the end of the ad suggests the disease is so depressing and severe that the child and his mother are beyond help. 
Environmental Factors
Another flaw to the Strong4Life billboards and ads is the lack of understanding as to why so many children in Georgia are obese.  Without acknowledging the underlying reason for the disease, it is nearly impossible to change the behavior needed to reverse the effects of obesity and halt this epidemic.  According to the Ecological Perspective, a person’s behavior both affects and is affected by many levels of influence.  Additionally, behavior is shaped by and shapes the social environment of the person, or reciprocal causation.  Five levels of influence were created by McLeroy and colleagues, defined as: Intrapersonal Level, Interpersonal Level, Institutional or Organizational Factors, Community Level, and Public Policy (5). 
At the intrapersonal level, an adolescent may feel ashamed of her weight and know that she should change her eating habits.  However, she may also be afraid to make this step because she knows it will require more work to prepare healthy foods and she will miss the comfort of her favorite junk foods.  At the interpersonal level, she sees all of her classmates eating the same school lunches in the cafeteria, who tell her they do not think she needs to eat differently because they all eat the food she does and are not worried about their health. 
At the organizational level, her mother may be the only caretaker for her and she does not have time to go grocery shopping because she is working two jobs to support her family.  Additionally, the local supermarket may be located in an unsafe neighborhood and it is not wise for the young adolescent to walk to the store herself to buy healthy food.  Researchers found that the average BMI was higher for those living in disadvantaged neighborhoods or whose supermarket was located in a disadvantaged neighborhood (6).  Moreover, there may not be any safe parks for her and her friends to go to for exercise after school, if her state is experiencing budget cuts.  This public policy limits the likelihood in which she is able to increase her daily physical activity.  
Another example of environmental issues responsible for childhood obesity revolves around peers.  According to the Social Norms Theory, a person’s behavior is influenced by their perception of how others in their social circle behave (7). If fifteen year old Susie sees all of her friends eating pizza and fries for lunch every day at school and they are also overweight, Susie will believe this is normal.  Fortunately, the good news is that based on the Social Norms Theory, people can just as easily be taught to partake in healthy behavioral choices if those around them do the same (7).  If Susie and her friends learn in health class about the importance of eating fruits and vegetables and exercising on a daily basis, they will likely feed off of each other’s positive behavior and increase the likelihood of maintaining their new lifestyle. 
The ability for humans to conform to social influences, even when they know people are not doing what is right or healthy (choosing soda over water, pizza over salad) was illustrated by social psychologist Solomon Asch.  Asch conducted a series of experiments to determine this theory.  When given a test, without the judgment or influence of others, participants gave the correct answers.  However, when others gave an incorrect answer, participants also gave an incorrect result nearly one-third of the time, against their better judgment (8).  This phenomenon can also be applied to making healthy choices.  If a person is in line at the cafeteria and knows that bottled water is the best choice for him, but he sees everyone in front of him choosing soda, he is more likely to fall under the social influence of others and be nudged to choose soda over water, despite his awareness of the calories and sugar he would consume with soda. 

Lack of Positive Role Models
There is no doubt surrounding the notion that people model their own behaviors after those around them.  In Strong4Life’s commercial of the mother and her son, it is clear that the obese mother leads the audience to believe that the boy is fat because she herself is fat.  This is the opposite role model which that should be featured.  Instead of having a healthy physician or a soccer coach as model to explain to the child why he is obese and set goals to improve his health, the public only sees an obese parent, highlighting the mother as the cause of the problem instead of offering healthy role models. 
Albert Bandura recognized this concept and created the Social or Observational Learning Theory in the 1960s.  One of the main concepts in this theory is the idea of imitation combined with reinforcement (9).  For instance, if a child sees his mother eating ice cream to relieve her stress after a busy day at work, the child is likely to imitate his mother and also use food to comfort his stress.  Strong4Life uses this theory in a negative way not only in the commercial described above, but on a billboard featuring a boy and stating “He has his father’s eyes, his laugh, and maybe even his diabetes” (10). This automatically assumes children will inherit the same diseases as their parents, if their parents are overweight.  Although it is a risk factor, the focus should not be giving up on our nation’s youth and letting them become obese.  Instead, it should re-direct its focus to producing positive role models who practice healthy behaviors to teach families how to change their lives and improve their health.
No Plan of Action to Change Behavior
Another flaw in the Strong4Life billboards and ads is the lack of a plan to help people make lifestyle changes slowly.  For obese individuals and families, it is crucial that they understand this is not a diet, this is a new way of life.  The Stages of Change Model, founded by Prochaska and DiClemete, illustrates this theory quite well.  This model is based on comparing the experiences of smokers who quit on their own without professional help and smokers who receive treatment to stop smoking.  The main belief is that changing behavior is not a process that happens overnight (5).  Instead, it explains how there is a process to adapting a new lifestyle which occurs in stages.  The first stage is precontemplation, during which the person has no intent to take action to change his behavior within six months.  The second stage is contemplation, in which the person does intend to take action within six months.  In the third stage, preparation, the individual plans to change his behavior within thirty days and is making a plan to follow through on this new path.  The fourth stage, action, occurs when the individual has changed his behavior for less than six months.  In the final stage, maintenance, the individual has successfully changed his behavior for longer than six months (5). 
The Stages of Change Model is not a straight path to success.  Instead, it shows that the process of achieving a new lifestyle takes many steps and can often include relapsing to a previous stage (a woman starts eating McDonald’s again, a smoker who has not smoked in three months lights up with friends at a bar one night).  A billboard featuring an obese child with the statement “Big bones didn’t make me this way. Big meals did” (10) offers no explanation or hope that this child, or any child, could change their behavior.  There are no facts about his weight resulting in hypertension or the benefits of eating fresh fruits and vegetables to improve his cholesterol.  There is no motivation for the young girl to make specific plans in order to contemplate losing weight to prevent other kids from teasing her.  Bobby’s mother does not help him develop an action plan or create goals to help them both eat less and increase physical activity.  While one tagline mentions the dangerous relationship between diabetes and obesity, none of the statements offer social support or feedback when a setback occurs or reinforce goals already met.  Additionally, they do not provide hope that maintenance is even plausible, given that one ad states “Fat kids become Fat adults” (10).  This particular slogan completely undermines everything in this model and simply assumes children will be heavy throughout their entire lives and nothing can be done to change this fact. 
Additionally, this theory believes individuals in an audience can be at different stages.  For example, a thirteen year old girl may know she is obese and has heard the dangers from her pediatrician and is going to her first appointment with a nutritionist next week when she sees these billboards on her way home from school.  She suddenly feels hopeless and eats two large candy bars to console herself and begins to lose faith that she can successfully change her behavior.  Across the street, an eight year old boy named Joe, whose father is also obese, views the ad with Bobby and his mother and realizes that if nobody is telling Bobby to change his behavior, and he has obese parents like him, there is no reason Joe should change his behavior either.  Tina, meanwhile, is eleven years old and has lost fifteen pounds in the past five months and is on her way to achieving her goal of losing twenty five pounds by her twelfth birthday in eight weeks.  Where are the models for her to look at who are making similar healthy choices and who can offer encouragement to keep her on the right track?   Without a clear message showing children at different stages of weight loss and choosing healthy options, the campaigns will not invoke the results intended. 
Intervention to a New, Healthy Lifestyle
A new way to combat the alarming increase in childhood obesity is to frame the message in a way that teaches families how to change their lives, not shaming them into the dark.  My intervention is to create a new campaign which highlights healthy choices such as choosing fruits and vegetables, increasing physical activity, showing the importance of families eating meals together, and having a success story in a popular role model share her experience with children so they can model their behavior after her, as well as setting small goals families can achieve together with tips to maintain their new lifestyle.
The Strong4Life ads and billboards were created in black and white, undertook a negative tone in the messages displayed, and were seen as stigmatizing obese children and blaming their parents for failing to look out for their health.  However, one study found that public health obesity campaigns were most likely to see positive results from those that focused on promoting healthy eating through fruits and vegetables as well as promoting multiple positive health behaviors.  On the other hand, people responded negatively to campaigns which stigmatized obesity (11).  This study shows the importance of framing the issue of obesity not as something to be ashamed of, but merely a problem that can be improved upon by making small changes to everyday living. An additional study further proved the dangers of stigmatizing obese people in that it poses a significant risk to their psychological health and may even interfere in obesity prevention programs (12).
Instead of having a billboard featuring a child in a black and white photo looking ashamed of her weight and not having a happy childhood, the billboard will feature a picture of children of all different ethnic backgrounds enjoying a picnic and eating fruits, vegetables, and drinking water, not sugary drinks.  The slogan will read “Healthy Food Choices Makes Happy Kids”.  This ad frames healthy behaviors in a way that results in happy children.  Instead of negatively stigmatizing obesity and blaming parents for not caring about their children’s health, this ad connects healthy with happy, leading parents to see that their children will actually be happier and feel better about themselves if they consume healthy foods.
Regarding advertising on television, instead of having a son and his mother staring at each other in the dark, not knowing why they are obese, an ad could feature a group of boys of all shapes and sizes attending a basketball clinic with Michael Jordan.  According to Dr. Seigel’s lecture on October 4th regarding the Communication Theory, familiarity is a major component of a successful campaign.  If a celebrity whom the audience is familiar with is the messenger, the message of the campaign will be more effective because that person will be more influential.  Moreover, the recipients of the message must like the person delivering the message in order for the campaign to be effective.  Additionally, showing children of all sizes shows how this ad applies for everyone and not solely overweight children.  As noted in the Stages of Change Model, children could be just beginning to make changes in their lifestyle or they could be having their first day of a sports clinic.  Michael Jordan could remind them of the importance of keeping active so they can keep up with him on the basketball court.  This increases a general healthy behavior which applies to children of all sizes, whether they are obese or not and promotes a healthy lifestyle for everyone.
Another ad could feature a group of young teenage girls in a community drama club. Some are eating healthy snacks while talking to their friends.  The teacher could announce the special mentor for the day is here, and the girls gather around in awe as Jennifer Hudson walks in.  Jennifer became a spokeswoman for Weight Watchers and has shed 80 pounds.  She is not only a celebrity, but she is a success story for lifestyle behavior changes that have paid off.  Jennifer states in article for Good Housekeeping “The only way you can sustain a permanent change is to create a new way of thinking, acting, and being” (13).  Jennifer is likely in the maintenance stage in the Stages of Change, as her weight has been kept off for over two years.  She could act as a positive role model for young people to aspire to when looking to change their current eating habits and recognize the achieving and maintaining a healthy weight is possible.  Jennifer would speak to the adolescents about how important it is to eat well so they can perform their best and improve their health while increasing self-esteem.  By having a male role model (Michael Jordan) and a female role model (Jennifer Hudson) children of both genders are able to relate to a healthy individual to further their changes of emulating the healthy celebrity’s behavior. Furthermore, the messages from Michael Jordan and Jennifer Hudson are positive messages and meant to empower young people to make healthy decisions.  This is crucial in the success of a campaign, as it gives the freedom and power to the audience, not invoking a response to being told what is best for them. 
Another advertisement could feature a young mother sending her smiling children off to school with water bottles.  She will say “Did you know fruit juice and sugary beverages are the number one reason for childhood obesity? I didn’t, until our pediatrician’s office gave us this list of healthy behaviors when our son’s weight increased this year.  Instead of drinking juice which contains excess sugar and calories, my kids drink water at school, and they love their new colorful water bottles.  Plus, you will not believe all the money I save at the Piggly Wiggly each week!”  This advertisement follows the Health Belief Model in that it recognizes a common problem (excessive consumption of sugary drinks) followed by an action cue to solve the problem by switching to water, and illustrates self-efficacy in that it is a normal mother who became aware of an issue and easily solved the problem. 
The choice of language in a public health campaign is crucial for appealing to a targeted audience.  By using words such as “did you know” instead of telling people what to do by forcing facts and regulations at people, it follows the Psychological Reactance theory by not confronting the consumer or taking their freedom away. As Paul Silvia notes in Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance, people will react by trying to regain control if any source of such freedom is removed (14).  Florida’s “Truth” campaign exemplifies this theory, in that the tone of the message matters greatly.  Youth did not want to be told that smoking is as simple as choosing life over death, nor did they wish to be bombarded by messages of what to do.  Instead, they wanted to be presented with the facts and left to make decisions on their own (15).
My campaigns will feature positive messages from both celebrities, which increase the influence of the product (healthy lifestyle) to the audience, and average citizens of Georgia, or peers, who also carry weight in convincing others to follow their lead and do what is best for their health.  The people of Georgia will feel empowered by these billboards and advertisements  to make healthy decisions but also realize that these many small changes in behavior are not simply steps to losing weight, they are steps towards a longer, brighter, and healthier future, allowing themselves the ability to follow their dreams and not succumb to the weight of obesity.

1)   Centers for Disease Control and Prevention. Overweight and Obesity: Childhood Overweight. Atlanta, GA: Centers for Disease Control and Prevention.
2)     Strong4Life. The Facts. Atlanda, GA. Children’s Healthcare of Atlanta. http://strong4life.com/pages/about/aboutDetailPage.aspx?articleid=0&sectionid=facts
3)   Teegardin C. Grim Childhood Obesity Ads Stir Critics. The Atlanta Georgia- Constitution. Atlanta, GA. 2012. http://www.publichealth.uga.edu/hpb/news/grim-childhood-obesity-ads-stir-critics
4)   Edberg M. Individual health behavior theories.  (pp. 35-49). In: Edberg M. Essentials of Health Behavior. Social and Behavioral Theory in Public Health. Sudbury, MA. 2007
5)   Theories and Applications (pp.10-21). In Theories at a Glance. A Guide for Health Promotion Practice. NIH Publication, 2005; No. 05-3896.
6)   Inagami S, Cohen DA, Finch BK, Asch SM. You Are Where You Shop: Grocery Store Locations, Weight, and Neighborhoods. American Journal of Preventative Medicine. 2006; 31(1):10-7.06.
8)     Thaler R, Sunstein C. Following the Herd (pp. 53-71). In: Nudge. Improving Decisions about Health, Wealth, and Happiness. Yale New Haven Press. New London, CT. 2008.
9)     DeFleur M, Ball-Rokeach S. Socializing and theories of indirect influence (pp. 203-227). In: Theories of Mass Communication 5th Edition. White Plains, NY: Longman Inc., 1989.
10)  Victory: Strong for Life Billboards Coming Down. 2012. http://www.mamavation.com/2012/02/victory-strong-4-life-billboards-coming-down.html
11)                  R Puhl, JL Peterson and J Luedicke. Fighting Obesity or Obese Persons? Public Perceptions of Obesity Related Messages. International Journal on Obesity. 2012; 1-9.
12)  Puhl, R Obesity Stigma: Important Considerations for Public Health. American Journal of Public Health. 2010; 1019–1028.
13)  Jennifer Hudson’s Weight-loss Wisdom. Good Housekeeping. http://www.goodhousekeeping.com/family/celebrity-interviews/jennifer-hudson-diet-tips#category1-3
14)                 Silvia P. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Psychology 2005; 27(3), 277-284.
15)                  Hicks J. The Strategy Behind Florida’s “truth” Campaign. Tobacco Control 2001; 10:3-5.

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