Strong4Life: A Dismal Approach to Childhood Obesity and How to Better Incorporate Mass Media to Deliver a More Effective Message – Jamie Klufts

Strong4Life: A Dismal Approach to Childhood Obesity and How to Better Incorporate Mass Media to Deliver a More Effective Message – Jamie Klufts

Introduction:

            Recently, the media have shed light on the prevalence of obesity in the United States. The most recent data indicates that over one-third of Americans are overweight or obese and approximately 17% of children and adolescents are obese in the United States (4). Thanks to the media, many are aware of the prevalence of obesity in America and that it can have many serious implications on one’s health, but little has been done to resolve this epidemic. The state of Georgia has an extremely high frequency of obesity, but it is their rate of childhood obesity that is truly astounding. Nearly 40% of children in Georgia are overweight or obese.

The Children’s Healthcare of Atlanta is a pediatric healthcare system in Georgia that recognizes the severity of this problem. They recently implemented a campaign called Strong4Life that aims to affect change in the weight of the state through small, incremental changes (6). Most notably, they initiated a series of commercials and posters called “Warning Ads” to bring attention to the obesity issue throughout the state (18). These commercials and posters have become the topic of much discussion and have caught the attention of the entire nation, but arguably for the wrong reasons. Three major flaws of the media component of this campaign are that they focus too heavily on the Health Belief Model, they poorly frame the obesity issue, and the delivery of the message is in violation of communications and agenda-setting theories.

Critique Argument 1: The Health Belief Model

Georgia’s Strong4Life media campaign focuses heavily on the individual and his or her state of being overweight or obese, thus victimizing the child without acknowledging behaviors that led to his or her weight classification (13). A major problem with obesity campaigns, especially Stong4Life, is that they pay little attention to behaviors causing obesity. Instead, they focus on the individual’s outcome: his or her current state of obesity. Acknowledgement of this state is intended to inspire the individual to change his or her own behaviors. This focus on the individual largely stems from the Health Belief Model. The Health Belief Model is an individual-level health belief theory that assumes that health behavior is motivated by perceived susceptibility, perceived severity, perceived benefits of an action, perceived barriers to taking that action, an experienced cue to action, and experienced self-efficacy with respect to that action (10). These components are believed to lead an individual to seek health and behavior change.

The campaign aims to get parents to recognize the problem depicted in the advertisements in their own children and to lead them to the Strong4Life website to begin to make changes within their own families. This reliance on perceived susceptibility is a major limitation of Strong4Life. The “Warning Ads” show very overweight children who are saddened by their condition, but do not acknowledge how they got to be that way or offer them a way out of their predicament (13). It is assumed that parents and children viewing these commercials will see themselves and their own emotions reflected by the children depicted in the advertisements, inspiring them to reach out to the Strong4Life website to access tools and resources necessary to make behavior changes. This assumption is barred by the fact that many parents deny that their child is overweight or obese. The viewer cannot see himself or his child in the deliverer of the message, chiefly because the commercials do not acknowledge the behavior that led the deliverer to their state of obesity. By not demonstrating what behaviors cause obesity, solutions to treat or prevent it cannot be formulated either. Without perceiving one’s susceptibility to obesity, they ignore the severity of the issue and do not seek to make behavior changes. The Strong4Life media campaign’s reliance on the Health Belief Model distances the viewer from the problem instead of drawing them closer to it. The commercials are intended to function as a cue to action, but instead cause the viewer to dismiss the message entirely.

Critique Argument 2: Framing and Tools for Attack

           

In addition to too little attention paid to the behaviors of the individual, the campaign provides people with information already widely known about obesity without offering solutions or tools to attack the problem or prevent it (13, 15). Although the Strong4Life website provides many tips and tools for both reversing the effects of obesity and preventing it, the media aspect of the campaign does not reflect that. The commercials and posters used in this campaign are visually stimulating and offer strong statements such as “Stop sugarcoating it, Georgia” without telling them how to do so (18). Instead, the media messages stigmatize overweight and obese individuals, making them less likely to acknowledge the problem or to “stop sugarcoating” the obesity issue (15). This stigmatization causes viewers to reject the message, craving positive reinforcement instead (1). The campaign developers call for “tough love” regarding the issue, but research has found that making people feel bad about their weight is not an effective instrument of change (12, 15). Harsh messages without offering solutions or encouragement to make changes are not effective means to fight obesity.

            These harsh messages and overall “tough love” approach do little to achieve the campaign’s goals of encouraging people to identify the obesity problem in themselves and to begin to take steps to make changes. Framing is a tool used to present values and images in a way that leads individuals to believe the message being portrayed (5). In public health the value of health is often used, but is frequently outweighed by stronger values such as freedom, control, and family. Framing can be used as a way to both promote a behavior and instill a message in the viewer. By focusing on health and using images and messages that inhibit core vales stronger than it, Strong4Life is seriously hindering its ability to resonate with viewers by failing to demonstrate how obesity prevention and treatment can occur while promoting freedom, control, and family.

In one of the commercials used in the Strong4Life media campaign, a young overweight boy is shown with his obese mother and asks her “Mom, why am I fat?” (18). The mother responds with a heavy sign and the commercial ends with the message “Stop Childhood Obesity”. Framing the obesity issue in a way that focuses solely on health and using messages like “why am I fat?” suppresses the strong core values aforementioned and stigmatize overweight and obese individuals, leaving them more likely to deliberately find ways to counteract the messages being delivered than to try to find solutions to the problem. This is further reflected in the theory of psychological reactants. Messages that take away control or threaten freedom like the ones used in the Strong4Life campaign encourage people to act in a way that opposes the advertisement’s intent (8). Reframing the message to promote, rather than hinder, feelings of freedom, control, and family, while offering solutions to the obesity problem, would allow the viewer to not only absorb the message, but would encourage him or her to begin to make behavioral changes to combat obesity.

Critique Argument 3: Communications and Agenda-Setting Theories

            Of great concern is the inability of the advertisement messages to reach their target audience through use of a deliverer who the audience cannot or will not relate to. In addition, the commercials and posters emit a dark and dismal tone that is depressing and discouraging. The aim of these tactics is to draw attention to the problem in order to invoke action. Communications theory is based on the idea that peoples’ behaviors can be predicted and automated through the use of familiarity, similarity, and associations (8). Familiarity increases the persuasive effect of a message by delivering it from an individual who is well known and well liked. This is most often done through celebrity endorsement. The technique of familiarity as it applies to communications theory was not incorporated into the Strong4Life campaign. By not using a familiar source to endorse and deliver the anti-obesity message, Strong4Life reduces the chance that individuals will attempt to stop childhood obesity. Instead, the advertisements attempt to persuade the viewer to practice anti-obesity behaviors by using a messenger that campaign developers believe to be similar to the target audience, one that viewers can relate to. This is the concept of similarity. Ordinarily similarity increases the reception of a message and its persuasive effects. Research has shown that negative messages that evoke more serious emotions as opposed to emotions such as happiness and humor are more effective, but research also shows that making people feel bad about their weight does not work as a vehicle of change (12, 15). The negative, dark and depressing feel of the advertisements stigmatize obesity, distancing the target audience from the problem, inhibiting the ability of the messenger to call people to action.

            The agenda-setting theory serves to fill a void in communications theory by taking the recognition of a topic one step further by getting people to talk about the issue at hand (14). Agenda-setting theory is believed to cause change by increasing the hype over a certain subject through the use of mass media. This is a more social approach to acquiring behavioral change. The idea is that by increasing discussion about obesity and the thought that it should be “stopped” will influence a social “nudge” (16). A small nudge should influence multiple individuals to perform some intended action, influencing a massive social change. This is the concept of peer pressure; humans are easily nudged by other humans and likely to conform due to others’ influence. It is often said that obesity is “contagious”. By this, it is meant that peoples’ eating habits are influenced by the food choices of others. The failure to demonstrate this as a behavioral limitation to obesity prevention is a major flaw of Strong4Life. Without presenting the obesity issue as something largely influenced by the behaviors of others, including food industry advertisers, Strong4Life limits its aims to counteract obesity. The Strong4Life advertisements are designed to draw attention, which they do, but fail to fulfill the other aim of agenda-setting theory to effect change. Not demonstrating how or why change can or should be made causes this failure. These advertisements lack a component that draws attention to the root of the problem, nudging society away from its messages instead of towards them.

Behaviors are influenced by what a person thinks, knows, and believes, but an inability to change an individual’s beliefs renders both agenda-setting theory and communications theory ineffective (14). Research has shown that many individuals are aware of the obesity epidemic but do not believe themselves to be susceptible to it or impacted by it (13). These two theories are severely limited by the campaign’s use of the Health Belief Model and a poor framing strategy. By presenting the deliverers of the messages in a way that victimizes them without offering a solution, Strong4Life enhances the stigmatization surrounding childhood obesity and distances parents and children from a desirable intervention. Failure to represent the obesity issue as one people can relate to by neglecting to demonstrate the behaviors that cause it and how to change them severely inhibits Strong4Life’s ability to bring about the desired behavior changes.

Articulation of Proposed Intervention:

            Georgia’s Strong4Life childhood obesity campaign has been effective in bringing attention to the subject, but its ability to affect change is questionable. In order to make the media component of Strong4Life more persuasive in its aim to “make small changes for positive progress” the following interventions are being proposed: reframe the campaign, incorporate social expectations theory, and utilize advertising theory. These strategies will be used to demonstrate how to use the existing campaign and the goals it represents to most effectively reach its target audience and obtain the desired result of obesity treatment and prevention. The interventions proposed are designed to improve upon Georgia’s Strong4Life campaign as advertisements can serve as an impactful medium to deliver messages with the ability to reach many people. The American Heart Association reports that young people are exposed to more than 40,000 advertisements on television per year (2). With some alterations, the Strong4Life media campaign has the potential to influence thousands of individuals to help them recognize an obesity problem and to perceive themselves susceptible to it, leading to a desire and enact a change in behavior.

Intervention 1: Reframing

            Reframing is a tool to take the core values of a successful message and apply them to an opposing view to elicit a better response (5). Earlier it was acknowledged that core values of freedom, control, and family are stronger than the core value the Stronge4Life campaign is currently using, health. Frames incorporate components such as catch phrases, visual imagery, identification of the source of the problem, predicted outcomes, and appeals to principle in order to resonate with the viewer and support values he or she deems important (17). With the obesity issue, the opposing view is that of the food industry. Research shows that aggressive advertising and marketing of unhealthy foods to children are contributing to the nation’s obesity epidemic (2). These messages are successful at enticing people of all ages to purchase and consume unhealthy products without regard to their health. Although specific research on the framing of food advertisements was not conducted, the affect of reframing can be assessed through another medium: tobacco.

            Florida’s “truth” campaign serves as a model for effective reframing in the context of public health. The campaign focuses on “empowering” youth to remain tobacco-free (3). The messages delivered in this campaign were designed to “deglamorize tobacco use and portray the tobacco industry as manipulating youth for profit”. By basing their movement on persuasive cigarette advertisements, “truth” reframed the values of autonomy, freedom, and control to support their own argument to suppress smoking (11). These values became tools for youth to rebel against the industry who were framed as suppressing these fundamental values. By turning the desire to limit smoking among teens into a crusade for autonomy, freedom, and control, the anti-tobacco movement became a success.

An intervention that would promote freedom, control, and family in relation to the anti-obesity movement would serve as a means to increase the effectiveness of the Strong4Life campaign. By learning from the truth campaign, a successful anti-obesity campaign could be performed in a way that promotes freedom and control, rather than hinders it. Reframing anti-obesity behaviors to be a solution to regain control in one’s life by breaking free from the food industry’s hold over their desires would be successful. Presenting the food industry as a manipulative force that inhibits an individual’s personal freedoms and ability to exert control over one’s own life would be an effective way to get the obesity issue to resonate with individuals. This was a successful reframe in the truth campaign that depicted the tobacco industry as a force trying to control and limit one’s freedom and ability to make autonomous decisions in regards to cigarette smoking and tobacco use. Reframing the obesity issue in this same way would inspire parents and children to regain control over their own behaviors. This would also allow for demonstration of solutions to the obesity epidemic without portraying the Strong4Life campaign as trying to control actions, but promoting ones that allow individuals to have control over their own lives in a way that supports anti-obesity behaviors.

Intervention 2: Social Expectations Theory

            Social expectations theory aims to influence behaviors on a group-level basis by changing social norms (8). Social expectations theory is a more encompassing approach to obesity prevention as it builds upon communications theory and agenda-setting theory. It not only draws attention to the issue at hand, but also can influence behavioral changes by altering the social norms of the community or society at large and nudge people towards anti-obesity behaviors. Successfully using agenda-setting theory demonstrates the importance of interpersonal contacts (14). It is not enough to influence attitudes about obesity; behavior itself must also be changed and this can be accomplished through the influence of social movements.

            Social nudges can be used to change social norms, thus achieving the aims of social expectations theory. An intervention that acknowledges the power of peer pressure in relation to health behaviors will be most effective. Presenting physical exercise and healthy eating as both group activities and behaviors that other people are doing will encourage individuals to perform them. Shifting behavior with a nudge can be as simple as informing people that others are exercising or eating healthfully also (16). This is how social norms can be changed. By stating that an activity is the social norm, it may, in fact, become the social norm.

The environment needs to be addressed in order to change obesity-related behaviors (13).  This is most effectively done through the enactment of social policies. Policies that build upon the reframing of the obesity problem as an issue of control inhibited by the food industry would aid individuals in maintaining anti-obesity actions. Policies that limit or restrict food industry advertisements would be most effective to create environmental changes that promote healthy activities. In addition, social expectations theory can change the social norms about nutrition and physical activity by promoting non-traditional ways of acquiring healthy foods and performing exercises (15). These can further be promoted through the existence of social policies. The Strong4Life messages can be used to influence new social norms by changing behaviors on a group-level scale through nudging and can encourage social policies that further support the anti-obesity movement and enforce these changes in social norms.

Intervention 3: Advertising Theory

            Advertising theory is an extremely effective approach to portray messages in a way that both stimulate the viewer and lead him or her to engage in a certain behavior (9). Advertising theory encompasses many other tools to cause changes in beliefs and behaviors, including reframing, communications theory, agenda-setting theory, and social expectations theory. Advertising theory is a powerful tool to effectively reach a target audience, but it must be well thought out and executed efficiently. The idea is that advertising can jolt an individual to action through the ubiquity and persuasiveness of advertisements. This jolt is the result of an advertisement’s promise to fulfill some aspiration of the individual and support for that promise of fulfillment through the use of images, stories, and music.

            The best way to understand advertising theory and its role in public health is through examination of Florida’s anti-tobacco campaign, “truth”. Truth was a media campaign that successfully incorporated the components of advertising theory to successfully achieve the campaign’s aims of influencing anti-tobacco attitudes and increasing youths’ perceived susceptibility (11). Not only was the campaign able to properly employ advertising theory, through the use of a professional advertiser to help develop the campaign, it also had considerable funding and was able to obtain desirable television spots that increased its effectiveness. These aspects are often neglected in public health campaigns, but are crucial to success.

            The truth campaign was developed with the target audience in mind. By looking to youth for inspiration, campaign developers were able to package their desired outcome of smoking attitude changes and perceived susceptibility in a way that youth found to be “aspirational, relevant, and ‘cool’” (11). They modeled their campaign after new products and brands that youth liked such as Nintendo, Mountain Dew, and Sketchers. The campaign reiterated the conception in advertising that facts are not a successful way to provide support to a campaign. The youth were unmoved by the fact that 1,200 people die everyday from tobacco related illnesses in the USA. Instead, tobacco use was discovered to be an act of rebellion, a form of control. This demonstrates the ineffectiveness of health as a core value in framing. The core value of control is much more potent than the value of health. Reframing the issue by promoting refraining from using tobacco as a way to ultimately gain control over one’s life and to rebel against the manipulative tobacco industry was most effective. This promise of control was well supported through striking visual images, music, and stories while offering youth alternatives to smoking. This movement empowered youth to “lead community action against tobacco” (3). Truth became a social movement that reframed the tobacco industry’s core value of control and used young people viewers could relate to in order to change the social norms about smoking.

            Truth’s approach to anti-tobacco can effectively be used to approach anti-obesity in the Strong4Life campaign. By incorporating advertising theory in the context of public health, behavioral changes are attainable with repeated exposure to highly effective, well-executed commercials and posters. Like in the truth campaign, knowledge is not the problem. The issue of obesity is widely known, just as the dangers of tobacco smoking are (11, 13). Creating commercials that portray overweight prevention as a right to be free from obesity and an act of defiance to the manipulative hold the food industry has over Americans would be an effective reframe of the issue. In addition, selecting individuals who are not just morbidly obese and depressed to deliver the anti-obesity messages can effectively incorporate communications theory. Choosing individuals who practice behaviors that put them at risk for obesity would shift the focus of the intervention not just on the outcome, but on recognition of how the problem develops and how it can be resolved. Demonstrating how these identifiable and relatable individuals can combat obesity through non-traditional means and group efforts would also be effective. One must be able to self-reference, or see himself or herself, in the deliverer of the message.

 Anti-obesity advertisements must aim to turn values such as freedom, control, and family into the only means for having these feelings. These must become the aspirations that ground the Strong4Life campaign. Promising freedom, control, and family through pursuit of health behaviors should become the campaign’s main objective. Empowering people to effect change through images, stories, and music that deepens their core value aspirations will further increase the campaign’s effectiveness. Reframing the campaign in a way that is conducive to advertising theory will not only increase its effectiveness at influencing the behavior of the individual who views it, but lead to changes in social norms that will influence policy to help maintain these anti-obesity behaviors. The critical limitations to the current Strong4Life movement will be reversed, allowing individuals to recognize the problem in themselves, desire to change their behaviors, acquire the knowledge how to do so, and ultimately influence social norms that can permanently reverse the obesity epidemic.

References:

1. Abrams, L. Obesity campaigns: The fine line between educating and shaming. The Atlantic. 2012. http://www.theatlantic.com/health/archive/2012/09/obesity-campaigns-the-fine-line-between-educating-and-shaming/262401

2. American Heart Association. Facts: Unhealthy and Unregulated Food Advertising and Marketing to Children. Washington, DC: Advocacy Department, 2012. http://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_301781.pdf

3. 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.

4. Centers for Disease Control and Prevention. Childhood Overweight and Obesity Data. Atlanta, GA: Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, 2011. http://www.cdc.gov/obesity/data/childhood.html

5. Certain Trumpet Program. Framing Memo: The Affirmative Action Debate. Washington, DC: Advocacy Institute, September 1996.

6. Children's Healthcare of Atlanta. Strong4Life. Atlanta, GA: Children’s Healthcare of Atlanta. http://www.strong4life.com

7. D'Arcy J. Strong4Life campaign: shocking us into caring about childhood obesity. Washington Post. 2012. http://www.washingtonpost.com/blogs/on-parenting/post/strong4life-campaign-shocks-us-into-caring-about-childhood-obesity/2012/01/02/gIQAwCdYYP_blog.html

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

9. Vakratsas D, Ambler T. How advertising works: What do we really know? Journal of Marketing 1999; 63: 26-43. http://www.jstor.org/stable/10.2307/1251999

10. Edberg M. Individual Health Behavior Theories (pp. 191-195). In Edberg M, ed. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.

11. Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.

12. Johnson T. Hard-hitting public health ad campaigns sparking awareness: new tactics gaining results, controversy. The Nation's Health. American Public Health Association 2012; 42.5: 1-10. http://thenationshealth.aphapublications.org/content/42/5/1.3.full

13. Katz D. Exploring Effectiveness of Messaging in Childhood Obesity Campaigns. Childhood Obesity 2012; 8.2: 97-105. http://online.liebertpub.com/doi/pdfplus/10.1089/chi.2012.0082.roun

14. Shaw EF. Agenda-Setting and Mass Communication Theory. International Communication Gazette 1979; 25: 96-105. http://xa.yimg.com/kq/groups/22925642/1944236267/name/Shaw-%20AgendaSetting%20and%20Mass%20Communication%20Theory.pdf

15. Teegardin C. Grim Childhood Obesity Ads Stir Critics. The Atlantic Journal-Constitution 2012. http://www.ajc.com/news/news/local/grim-childhood-obesity-ads-stir-critics/nQPtQ

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

17. Winett L. Advocates guide to developing framing memos (pp. 420-432). In: Iyengar S, Reeves R, eds. Do the Media Govern? Politicians, Voters, and Reporters in America. Thousand Oaks, CA: SAGE Publications, Inc., 1997.

18. Youtube. Strong4Life: Warning Ads. Atlanta, GA. Strong4Life. http://www.youtube.com/playlist?list=PL3B99758F38961860