Minnesota Blue Cross Blue Shield Anti-Obesity Campaign - Marie Leinberger

Part One: Your Body Is An Epidemic.

Introduction

            Since the 1980’s, the US government has recognized America’s increasing collective BMI as a serious health concern.  However, only in the past decade or two has any effort been put towards fighting back against the increasing bulk of America.  The problem is that almost every campaign against the “obesity epidemic” has directed financial resources and creative energy at the wrong part of the issue.  Campaigns have dedicated millions of dollars towards fighting the symptom, and not the root cause, of obesity.  The recent Minnesota Blue Cross/Blue Shield campaign against both adult and childhood obesity is no different.  The three television adds used for that campaign will be critiqued here.  For clarity’s sake, I will refer to the ad featuring the mother buying unhealthy food as the “first ad”, the ad featuring the father buying fast food as the “second ad” and the ad featuring the procrastination behaviors as the “third ad”.   

            The first two ads focus on the issue of parental responsibility for childhood obesity.  The third ad attempts to address a lack of personal responsibility for obesity and the tendency towards procrastination in adopting health lifestyle habits.  In the first two ads, there is a lightbulb moment for the adults in which they come to the sudden realization that their own unhealthy behaviors have been noticed and appropriated by the children around them.  The third ad involves everyday people engaging in unhealthy personal behaviors while claiming they will change “tomorrow” with a clear underlying message that they probably will not.  These campaigns are relatively new, but there are several reasons they will fail.  Using three different theories of behavior, these ads can be broken down into the individual aspects that will render them ineffective in creating the types of behavioral change necessary to fight obesity.   The first critique will focus on how these ads model the very behaviors they are attempting to discourage, visually normalizing the unhealthy behaviors.  These ads are using the concept of “social nudging” in exactly the incorrect way.  The second critique is that the first two ads assume that the Health Belief Model is effective, when there is ample evidence to show that it is not.  The third critique will focus on the theory of psychological reactance and how all three ads seem to not consider it at all.  All three ads are meant to produce feelings of guilt, shame and lowered self esteem as a result of unhealthy behavioral choices, as if this will motivate behavior change, when in fact we know that those feelings produce just the opposite effect.   

Critique One - Social Nudging and Tipping Points

            All three of these public health ads feature very specific behaviors.  In the first two ads, parents are buying or eating very unhealthy foods.  In the third ad, consumption of chips, ice cream, burgers, fries, massive buffet plates, and slushies all occur.  In the third ad, sedentary and lazy behavior are also featured.  The ads violate the principle that modeling a behavior has powerful influence over the choices of a population exposed to that modeling (1).  Social science research has shown that when people participates in a behavior with a high enough percentage, the rest of the population will eventually follow the herd (2).  The idea that modeling an unhealthy behavior to a population and then telling them “...but do not do this!” is not logical and actually contributes to an environment which is “tipping” more towards unhealthy behaviors than healthy behaviors (1). 

            These ads do not produce the social encouragement that is necessary for people to feel supported when changing their behaviors.  The ads normalize behaviors such as laying on the couch all day, eating mass amounts of unhealthy food and purchasing unhealthy products because they are modeled by “typical” people in recognizable social situations.  Visually (imagine if one were to turn off the sound), all three ads attach identity to, and normalize, the following behaviors: the average white mother grocery shops for chips, ice cream and soda, the African American business man takes the elevator to work, the white working man has a tray of fast food for lunch, the soccer mom eats burgers by the pool, the pretty blond eats from the buffet line and the young Asian American man lays on the couch all day (3-4).  Viewers can identify with these people, and are thus ‘nudged’ towards acting the same way (2).     

            These ads appeal to the strong core value of social acceptance.  Instead of creating social support for making healthy choices, they show social acceptance of the exact behaviors they are attempting to discourage.   This is an example of “social nudging”, which has a strong influence on personal behavior (2).  When the third ad shows unhealthy behavior as normalized, but verbally attests that healthy behaviors will be adopted “tomorrow”, the tongue in cheek aspect of this type of intervention is overridden by the social nudge to participate in those unhealthy behaviors, that is, until “tomorrow”.  There is no social nudging to actually change the behaviors which contribute to obesity; instead, there is social nudging to participate in just thinking about changing the behaviors.   

            If the incidence of messages, products and behaviors spread just like viruses do, as postulated by Gladwell in The Tipping Point, the obesity epidemic is no different (5).  All three of these anti obesity ads violate principles of the Tipping Point theory.  Contagion, a major principle of the Tipping Point theory states that words, images and trends in behavior are contagious between people, just as viruses are (5).  The images in all three ads are planted in the viewers mind each time the ad is seen.  Chips, ice cream, pizza, watching TV, lounging by a pool are all images people are familiar with, and most people already associate these things with positive, happy and familiar situations.  Preforming these activities(unhealthy eating) in response to the environmental stimuli (sitting by the pool/lunching at a fast food restaurant) will reinforce the unhealthy behaviors because they give the viewer a feeling of reward for conforming to a modeled social norm (1).  The real life choice between the ice cream and the fruit at the grocery store will be impacted by the memory of the mother buying the ice cream in the ad.  The real life choice between the apple slices and the french fries at McDonald’s will be influenced by the memory of the man and his tray of junk food.  Those public choices will influence the choices of other people in the environment, and so on and so forth, jumping contagiously from person to person, just like a flu virus (5).

            These ads are all essentially creating massive road blocks on the path to achieving the critical mass of behavior change that is required to reach the tipping point of enough people adopting healthy behaviors to fight obesity.        

     

Critique Two - Health Belief Model

            These ads follow the components of the Health Belief Model.  Showing many different types of people is an effective way of reaching a large diverse group of people and convincing them that no matter what they look like, they are susceptible to obesity(6).  These ads show that obesity is a problem for adults and children of all races.  Everyone is potentially at risk (6).  The severity of the consequences of eating unhealthy food  is shown through the portrayal of overweight children and the conversation about the mass amounts of food the boys fathers can consume(3-4).  Other sources have widely reported on the health problems that can result from obesity in childhood, and the children shown in these ads are not just a little chubby, they are obese.  The perceived benefits of changing the unhealthy behavior is clear,  i.e. becoming less obese.  The “push to act” in these ads is the motivation of parental love and responsibility (6).  The desire to protect and foster the health of your child is used as the motivation for change.  The last piece of the HBM, self efficacy, is only hinted at, but the message is that now the parents know how their choices are effecting the children, they have to make healthier choices, put down the fast food tray and eat healthier foods (6).  The problem with all of this is, of course, that the HBM does not actually cause people to change their behavior (7). 

            The HBM asserts that facts are only valid when they are observed (8).  In these ads, the people are buying unhealthy food and they and their children are obese.  This is presented as a true, observed, direct cause and effect relationship.  Unhealthy food consumption leads to obesity, therefore, if you cease eating the unhealthy food, you will cease to be obese.  While this may be true, it will not create change because the HBM does not account for economic or social factors on behavior change (8).

            These ads place all the responsibility for obesity and childhood obesity on individual people.  These ads fail to address the economic, social and environmental causes of obesity, all important aspects of behavior change that the HBM fails to address(8).  Within this campaign, there is no corresponding social service project aimed at making it easier for adults to make better choices.  There is no social support or financial support for buying healthier foods or participating in healthy activities.   

            Advertising influences on food choice are strong as well, which the HBM also fails to take into account.  Food companies have created advertising environments which make it almost impossible to avoid unhealthy food choices (9).  Television ads promoting unhealthy foods to kids promise magical things to children who eat sugary cereals, super powers to children who drink unhealthy drinks and increased social status to those who eat unhealthy lunches.  Constant bombardment with this powerful advertising means parental “choice” in what products to buy is often dictated by their children, not the other way around (9).  Adults are also not immune to food advertising (9).  This mother probably knows the bucket of ice cream is unhealthy, but she is buying it because she has seen a thousand and one ads telling her how amazing it is. 

            Neither ad addresses the issue of cost.  It assumes that the mother and the man have unlimited ability to purchase healthier choices and they are failing to do so because they o not understand the true impact of their choices.  Healthy options can be more expensive than cheaper foods, due in large part to government subsidizing of corn, soy and wheat products, making unhealthy food artificially cheaper than fruits and vegetables (9).  The purchasing of unhealthy food is often not due to lack of knowledge about how unhealthy ice cream and fast food are, but rather financial constraint (9).  Socio-economic class is not a matter of personal choice.

            Neither ad takes into account any of these various factors, and instead depends on the HBM.  Assuming the HBM is successful, the mother has now realized that her own personal buying habits have been appropriated by her daughter, and now that she knows this, she will change her buying habits.  Her daughter will now make healthier choices as well.  These principles remain true for the second ad, when the man experiences the lightbulb moment as he is bringing his unrealistically full fast food tray to his table and over hears two young boys trying to one up each other on how much their fathers can eat at one sitting.  Now that the man knows that the young boys have noticed and appropriated his unhealthy behaviors, he will be motivated to change those behaviors in order to protect the health of the children.  Neither of these things will actually happen, and the ads will have little to no effect on obesity because they depend on a flawed theory of behavior. 

Critique Three - Psychological Reactance

            Another reason these ads will fail is because they produce psychological reactance in the viewer.  Psychological reactance produces a very low intention to comply with the message of the ad (10).  While these ads achieve success in presenting people who are similar to the viewer, the ads are designed to cause the viewer to feel guilt over their unhealthy eating habits.  The ads are trying to convey the message that unhealthy eating is shameful because it causes childhood obesity.  As seen in anti-smoking campaigns, ads that engender feelings of guilt or shame actually increased rates of smoking in the viewers(11).  Campaigns against marijuana smoking in teens did the same thing.  Appealing to the core values of rebellion in teens has been extremely effective in ad campaigns for cigarettes, and the core value of health in most of the anti smoking campaigns just can not compete (11).  Health and wellness are the core values in these ads.  The adults are ashamed of their food choices because they are unhealthy.  This will likely produce increased amounts of stress, causing viewers to eat more than they would have if they felt calm and supported (12).  Unlike smoking, eating is a biological necessity, so these ads might produce an even stronger psychological reactance effect than the anti-smoking campaigns (10).  Feeling stressed and ashamed combined with the biological need to eat would magnify the effect of the reactance (12).  The core value of adults is not health or wellness, nor is it parental affection (10).  These ads have failed to identify and appeal to the core values of their audience.

            Another way these ads produce psychological reactance is that they portray socially accepted practices at the same time they are telling the audience that they must cease these practices.  Telling a population what they should not do is a very good way of getting that population to do exactly the opposite.  One analysis of anti obesity ads showed that the lowest intent to comply rates were found in campaigns which mandated or forbade certain activities (10).  The core value of rebellion does not completely fade away with adulthood, and core core values of freedom and choice are strong (13).  These ads take away the very person choice of what food to eat at a meal, and in order to regain that feeling of control, people may choose to eat exactly the foods they want (12).  Given the national addiction to fat, sugar and salt, the foods people “want” tend to be the very foods featured in the ads.  If psychological reactance were to be measured with questions such as “How guilty did this ad make you feel?” “How angry did this ad make you feel?” or “Did this ad make you more or less likely to eat a healthy meal” it would have been clear to the producers of this ad that it would be ineffective.     

Part Two: Your Body Is A Temple

Intervention:

            The intervention I propose to address the three critiques of the MN anti-obesity campaign is two pronged.  Part one of the intervention is a Television/Social Media ad campaign featuring celebrities who have been open about their choice to follow a healthy diet.  Alec Baldwin, Bill Clinton, Kevin Eubanks, Paul McCartney, Russell Brand, Peter Dinklage, Brad Pitt and Mike Tyson are options for the male celebrities.  Natalie Portman, Kristin Bell, Ellen DeGeneres, Leona Lewis, Olivia Wilde, Sandra Oh, Carrie Underwood, Shania Twain, Ashley Judd and Betty White will be included for the female celebrities.  The first ad will feature the celebrities in the campaign merchandise (available for purchase) against a simple background.  In the style of the “Don’t Vote” ad, the celebrities will have lines such as “Do not eat vegetables”... “Do not go for a walk, there is something on TV you’ve only seen four times...” ... “Do not drink that water”... “Do not eat {Insert Vegetable/Fruit Name Here}”.  These phrases would all start with some variation of “Don’t”.  At the end of the ad, the newly designed sexy brand symbol(yet to be designed) would flash across the screen with the simple message “Your Body Is A Temple”. 

            The second ad would feature the same celebrities, this time “caught” in typical paparazzi shots, eating a wide variety of vegetables and fruits, whole grains(oatmeal/dark bread/dark pasta, always recognizable things, nothing unfamiliar to the general public) and nuts/seeds.  Images would also be included of walking, running, biking, doing yoga.  Some images or video clips will be sexy, some will be funny, but all will feature a healthy behavior.  This time however, images and “home movie” type video of “typical” American people(including young children) enjoying healthy food and activities will be spliced in between the celebrity shots, given equal time and culminating in a final image of all the images on the screen at the same time in small squares, filling up the whole screen.  The song playing in all the ads will be popular and there will be several different image/video montage sets.  The slogan “Your Body is A Temple” and the brand symbol will then flash over the images to end the commercial.  Both of these commercials will be released to television and social media sites such as Facebook, Youtube, Twitter and Tumblr. 

            In the second prong of the intervention, people will be encouraged to post pictures of their own healthy behaviors with the hash tag “TempleBod” and receive in response motivational messages and coupons for healthy food.  Products will also be produced and sold with the logo and slogan “TempleBod” and “My Body Is a Temple”.  All proceeds from these sales will be donated to local farmers markets so that they may double the value of SNAP benefits.  While some farmers markets do this, not all are in a financial position to do so.  All profits of merchandise sales will go towards this initiative. 

Defense One - A Better Use of Social Nudging and Tipping Points

            The ad featuring paparazzi shots of people eating healthy food in the Temple campaign uses social nudging and tipping point theory to influence the behavior of the viewer.  Social nudging can be used to great effect to get people to change their behaviors.  Social nudging can be achieved through a very simple mechanism: telling people what other people are doing (2).  The scientific and health community does not know exactly how to combat obesity, but they have several very well accepted theories.  Eating more vegetables and fruits, whole grains, smaller portions and lots of water are all commonly accepted theories of how to lose weight and keep it off.  Telling, or more accurately, showing the viewers of the Temple campaign that people everywhere are eating more fruits and vegetables will socially nudge them into eating more healthily themselves.  Using celebrities adds another layer of influence.  The power of celebrity has been used in almost every successful ad campaign for new product.  Healthy behaviors should be treated just as a new product is.  Selling healthy behaviors must begin with telling the viewer that everyone else is participating, and they should too.  Using positive messages instead of negative ones will increase the power of the social nudge (2).

            The tipping point theory comes into play with the second ad as well. This theory states that the bulk of the population needs to see that a certain percent of the population is participating in a behavior before they “get on board” with that behavior (5). This campaign will make it seem as though that percentage has already been achieved.  Through including many short duration images or video clips(no more than 1-2 seconds in duration) depicting healthy behaviors, and then keeping those images on the screen (in a smaller form) to create a “quilt” of images of people being healthy, the illusion of mass participation will be achieved. 

   

Defense Two - Anti-Health Belief Model

            Many people feel as though they have been hearing messages about how terrible the obesity rates are in America for a very long time.  It is unrealistic to assume that people are not aware of the epidemic.  People know they are at risk for obesity, they know the health consequences that come after obesity as well.  With a rate pushing 50% in some populations, most people know someone who has gotten sick or died from obesity related complications.  The Temple campaign ads assume that knowledge already exists.  The problem is not that adults are unaware that their choices influence their health and the health of the children around them.  The problem is they are not socially supported in making better choices.  It is not a matter of personal choice in many situations, it is a matter of social support and economic ability (8). 

            The second prong of the Temple Campaign will be geared towards addressing this part of the issue.  The merchandise will be designed to appeal to adults as well as children, and include a wide range of products, from inexpensive to designer level.  The celebrities in the TV ads will all wear the merchandise as well as promote it during a variety of events.   All proceeds from the sale of the merchandise will go to supporting SNAP use at farmers markets.  Enabling farmers markets to double the value of SNAP benefits will make it easier for the population most at risk for obesity to gain access to healthy foods.  Partnering with farmers markets will also stimulate local economies.        

Defense Three - Taking Advantage of Psychological Reactance

            Instead of trying to limit the production of psychological reactance in both of the ads, one ad attempts to harness its power.  Most people are aware that unhealthy eating is bad for them, but research has shown a sharp decrease in intent to participate in ads which engender feelings of shame or negativity (10).  Instead of appealing to the core value of health, this ad will appeal to the core value of freedom, a much stronger value (13).  Taking away someones freedom of choice in what to eat is a powerful motivator to take that freedom back (14).  Telling people to not eat vegetables, to not eat fruit, to not eat nuts and seeds or whole grains will motivate them to take back their control over eating exactly those items.  Shame and guilt over unhealthy eating habits will be replaced by a rebellious motivation to eat healthier food. Hopefully the tongue in cheek nature of this ad will also amuse the viewer sufficiently so that they will remember it for long after seeing it, in order to be continuously influenced. 

            There has also been research showing that ads which never mention “obesity” or “overweight” are much more positively viewed (10). Neither ad mentions obesity as the target issue, which would be seen as targeting and negative.  Instead, these ads promote similarity, a common way to combat reactance (14). Both ads also feature healthy normal weight individuals, but they never bring attention to that fact.  Instead, the concept of similarity in reducing psychological reactance is used in choosing celebrities who represent a broad range of body types, races, ages, genders, disability status and sexual orientation.  In the second ad, non-celebrities will also be featured, opening up more possibilities for diversity, including socio-economic class and geographic region.  Most people who view both ads will see someone who looks like them engaging in healthy behaviors, decreasing the psychological reactance (14). 

Conclusion

            The issue of obesity in America is more serious than any other chronic health issue in recent memory.  The facts and figured are sobering.  Many children who are obese may have shorter lifespans than their parents.  The physical ramifications of obesity are only one part of the epidemic, the emotional impacts of obesity are important as well.  Being an obese person can lead to discrimination in the workplace and bullying at school.  Interventions should not only consider how to influence the physical health of the public, but also the emotional health.  The MN intervention shamed obese adults, blaming them for childhood obesity.  These ads will not effect obesity rates and they might have a detrimental effect on the mental health of the viewer.  Assuming obesity is an issue of personal choice, that it is based around a lack of information, and can be influenced by knowledge alone is a mistake. The misuse of social nudging, the dependence on the health belief model and completely ignoring the impact of psychological reactance are all weaknesses of this ad campaign. The issue of obesity is far too serious an issue to not put serious efforts into developing a research supported, effective campaign to fight back.  Until such a campaign is developed, organizations such as MN Blue Cross Blue Shield should stop employing ineffective and offensive ads.

Resources

1. DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5^th edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.

2. Following the herd (Chapter 3). In: Thaler RH, Sunstein CR. Nudge: Improving Decisions About Health, Wealth, and Happiness. New Haven, CT: Yale University Press, 2008, pp. 53-71.

3. Minnesota Blue Cross Blue Shield.  Better Example Campaign. http://www.youtube.com/watch?v=1gCTX2EfUUs

4. Minnesota Blue Cross Blue Shield. Better Example Campaign http://www.youtube.com/watch?v=Vtil_kFMvoU

5. Introduction. In: Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference. Boston: Little, Brown and Company, 2000, pp. 3-14.

6. 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.

7. Ogden J. Some problems with social cognition models: a pragmatic and conceptual analysis. Health Psychology 2003; 22:424-428.

8. Thomas LW. A critical feminist perspective of the health belief model: implications for nursing theory, research, practice, and education. Journal of Professional Nursing 1995; 11:246-252.

9. HBO. Weight of the Nation Parts 1-4. 2012.http:/ theweightofthenation.hbo.com/

10.          Puhl, R. Peterson LJ, and Luedicke J.  Fighting obesity of obese persons? Public perceptions of obesity-related health messages. International Journal of Obesity 2012; 0: 1-9

11.         Bauer UE, Johnson TM, Hopkins RS, Brooks RG. Changes in youth cigarette use and intentions following implementation of a tobacco control program: Findings from the Florida Youth Tobacco Survey, 1998-2000. JAMA 2000; 284:723-728.

12.         West, L. Jezabel.  Is it hard enough to be a fat kid without the government telling you you’re an epidemic?. Weighty Issues.  http://jezebel.com/5945955/its-hard-enough-to-be-a-fat-kid-without-the-government-telling-you-youre-an-epidemic?post=52940676

13.         Menashe CL, Siegel M. The power of a frame: an analysis of newspaper coverage of tobacco issues – United States, 1985—1996. Journal of Health Communication 1998; 3(4):307-325.

14.         Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.

15.         Abrams, L. The Atlantic.  Think of the (Fat) Children: Minnesota's 'Better Example' Anti-Obesity Campaign. 2012.  http://www.theatlantic.com/health/archive/2012/09/think-of-the-fat-children-minnesotas-better-example-anti-obesity-campaign/262674/

16.         Simmons-Duffin, S. NPR News. New Anti Obesity Ads Blaming Overweight Parents Spark Criticism.  The Salt, http://www.npr.org/blogs/thesalt/2012/09/27/161831449/new-anti-obesity-ads-blaming-overweight-parents-spark-criticism