Wednesday, January 30, 2013

Where Are the Apples in the Big Apple? A Critique of New York City’s Approach to the Obesity Epidemic - Nina Burke

Where Are the Apples in the Big Apple?
A Critique of New York City’s Approach to the Obesity Epidemic
- Nina Burke

With nearly 40% of the U.S. adult population obese, the obesity epidemic is a high priority issue on the nation’s health agenda (1). The consequences of obesity are seen in morbidities such as coronary heart disease, stroke, hypertension, fertility problems, and many more health problems (2). In 2008, obesity cost the United States an astronomical 147 billion dollars in health care expenditures (2). At the state and local levels, obesity prevention programs are fast emerging.
In New York City, 58% of the adult is overweight/obese, and 40% of NYC public school students 8th grade and below are overweight/obese (3). One in three New Yorkers has diabetes or pre-diabetes (3). With these unfortunate statistics, New York City began stepping up obesity prevention efforts in 2008.  Two laws have been passed and an advertising campaign was launched in NYC in efforts to curb obesity in the city. The first law, passed in 2008, modified the NYC Health Code and requires all restaurants with 15 or more nationwide locations to post calorie counts on menu boards (4). The second and more recent 2012 law bans restaurants, theatres, stadiums, food carts, and other food service establishments (FSEs) from selling sugar-containing drinks in containers larger than 16 ounces (5). The first advertising campaign was launched in 2009 and involves a variety of grotesque posters in public places around the city. New York City’s current three-pronged obesity prevention approach does not take into account models and theories that are effective in promoting behavior change.
Critique 1: Amendment of Article 81 of the Health Code- Menu Labeling Law
            In 2008, the Board of Health of New York City amended Article 81 of the NYC Health Code to require all food service establishments with 15 or more nationwide locations to include calorie counts on their menu boards (4).  The NYC Department of Health is charged with the task of preventing and controlling disease, including chronic disease (4). As obesity is a chronic disease, the Department of Health has the power to enact and launch prevention efforts, including laws. This menu-labeling law, as quoted directly from a public hearing notice, is rooted in the idea that “Calorie information provided at the time of food selection in FSEs would enable New Yorkers to make more informed, healthier choices and can reasonably be expected to reduce obesity and the many related health problems which obesity causes” (4). While the Department of Health was certainly acting with good intentions for the health New Yorkers, the law relies on flawed health models.
            Although menu labeling does provide consumers additional freedoms and autonomy in making food decisions, the law assumes that people will use this new information to make healthier eating choices. Unfortunately for the NYC Department of Health, a study published in the British Medical Journal in 2009 demonstrated that the law has not created substantial change in consumer behavior (6). The average amount of calories purchased showed no change among consumers, and only 1 in 7 consumers even utilized the caloric information posted (6). The menu labeling law relies on individual behavior models, such as the Health Belief Model and the Theory of Reasoned Action.  Both of these models assume that people, consumers of food outside of the home in this case, make decisions in a rational manner (19). They also do not consider external environmental factors that affect behaviors (19). The Health Belief Model states that people will weigh the perceived benefits versus the perceived costs and then make a decision (19).  Applying the menu labeling law, the Department of Health assumed that people would read the calorie count and then weigh the costs and the benefits of consuming the foods on the menu. The Theory of Reasoned Action relies on intention leading to behavior (20). This theory would translate into calorie information shaping consumers intent of purchasing healthier food and then the consumers actually choose the healthier options. However, the flaw in this theory is that intent does not always lead to behavior. Intending to choose healthier food based on calorie counts does not always lead to the consumption of the healthier foods. It has been demonstrated that NYC consumers’ behavior has not improved with calorie information on menus (6), which is due to flaws in the city’s approach to obesity prevention.
Critique 2:  New York City Soda Ban
            In September of 2012, the New York City Board of Health voted to ban the sale of sugar-containing beverages larger than 16 ounces at restaurants, theatres, stadiums, food carts, and other food service establishments. The impetus behind this law is that sugar-containing beverage attribute on average to more than 300 calories daily (per person), and that these calories are directly related New York City’s obesity epidemic (12). Again, although the NYC Department of Health voted on this ban for the benefit of New Yorkers’ health, the department did not consider how this legal approach to the obesity epidemic would affect health behaviors.
            Public health laws exist to protect the health and the rights of the public. While some laws may restrict an individual’s freedom, they restrict freedom in order to protect the health of the public. New York City’s soda ban is not unconstitutional, as states have the power to enact laws that protect the public, however, the foundation of this law is unlikely to achieve its purpose of protecting the public. 
Americans arguably value their freedom more than any other American core value.  This love of freedom tends to lend itself to strong opposition towards restrictive laws.  The NYC soda ban is based on restricting freedom, albeit the freedom to buy unhealthy drinks, but freedom nonetheless.  The ban, which will go into effect in March of 2013, has already received backlash from more than half of NYC residents (7).  Mayor Bloomberg believes this law is “the single biggest step any city, I think, has ever taken to curb obesity” (8).  This may be the biggest “step,” but how far will this step get New Yorkers?  By attempting to curb obesity by restricting freedom and autonomy, one can expect this law to invoke psychological reactance come March 2013.
Psychological reactance is the motivational state directed toward reestablishing a threatened or eliminated freedom (10). The premise of this theory is that when people have their control taken away, they do what they can to regain control (10). In the case of this soda ban, people can easily regain control by utilizing the loopholes of the law.  The law does not prevent people from buying two 16-ounce sodas; therefore, the law may actually cause an increase in soda consumption through consumers purchasing multiple sodas. Now, instead of consuming 24 ounces of soda, because it is illegal to sell that quantity, people will consume 32 ounces of soda at the Yankees game because they can purchase two 16-ounce sodas. Another aspect of the theory of psychological reactance states that the more explicit the message, the more reactance it invokes (26). A soda ban is a rather explicit message, and therefore it is expected to invoke psychological reactance. An article in the Journal of Consumer Research discussed the effect of loss of freedom on consumer purchasing (9). Clee et al. discuss that laws are often considered the highest threat to personal freedom, and “these laws are often flouted.” (9). Based on the opposition from residents, it is highly likely the soda ban too will be flouted.
A study conducted at the University of Arizona examined how psychological reactance can occur with the implementation of a health program (11). Using University of Arizona students, Rains et al. created a mock health program called the Healthy Campus Initiative, and told the students it was mandatory to participate. The results of the study indicated that even with the best intentions for the students, the health program still invoked psychological reactance (11).
Regardless of good intentions with health in mind, people do not like their freedom encroached upon. Public health programs should enhance autonomy in decision-making, as opposed to restricting it. Piloting health interventions to test for psychological reactance is important. Although a law cannot exactly be piloted, the Department of Health could have asked for residents’ opinions or ideas on the proposed ban and/or requested their input on alternatives to a law.
Critique 3:  New York City Obesity Prevention Advertising Campaign
            The New York City Department of Health and Mental Hygiene launched an obesity prevention advertising campaign in August 2009 (12). The campaign highlighted the increases in sugary-beverage consumption and their consequences on health.  In January 2012, a second advertising campaign was launched with nearly an identical platform as the 2009 campaign, focusing on an increase in portion sizes. In a press release announcing the 2012 campaign, the Department of Health was hopeful that the “hard-hitting” campaign would be a successful tool in obesity prevention (13).  The success of the campaigns has not yet been measured.  However, social and behavioral theories would suggest that the content and images of the advertisements have not and will not have the effect on health behavior that the NYC Department of Health is hoping for.
            Unfortunately for public health professionals, the public values its negative health behaviors much more than one would expect.  People use defense mechanisms as a way to cope with and justify these unhealthy behaviors and have ways of self-reinforcing their unhealthy behavior (21). A successful advertising campaign would not invoke defense mechanisms in the audience. The creators of this NYC obesity prevention campaign did not seem consider the campaign’s potential to invoke defense mechanisms, which would in turn perpetuate the residents’ unhealthy behaviors.
            The 2009 advertising campaign indeed had many flaws, and it is shocking that the 2012 campaign would choose to use the same tactics. The advertisements are grotesque and negative. The main slogan from the 2009 campaign asks New Yorkers if they are “pouring on the fat” (12). The posters are focused on soda and sugary beverages making consumers fat. The images are nauseating and repulsive. One advertisement has 10 pounds of fat on a plate with another showing fat being poured into a glass from a soda bottle (14, 13). These advertisements are not consistent with psychology of human behavior.  Messages that form positive associations are more likely to initiate behavior change (27). It has been shown that people who have positive reactions to beer advertisements are more likely to consume alcohol because the commercials create or add to positive beliefs about alcohol (22). Based on this, it is appropriate to say that having positive associations with healthy behaviors would make people more inclined to change their lifestyles. The current disgusting obesity advertisements do not have any positive associations attached to them, making them unlikely to spark healthy behavior change.
            The 2012 campaign does not demonstrate any improvement in advertising technique. The slogan of the recent campaign is “cut your portions, cut your risk” (13). The advertisements attempt to demonstrate the various health consequences of increased portion sizes. One poster includes a man with both legs amputated and three sizes of soda (13).  The poster says: “Portions have grown, so has Type II diabetes which can lead to amputations” (13). Another poster includes an obese woman climbing the stairs of the subway in the background of three different French fry containers (15). The content of this poster says: “Portions have grown, so has obesity which can lead to many health problems” (15). These campaigns ignore important and useful elements of Marketing and Advertising Theory. The NYC Department of Health attempts to sell health in all of its advertisement. Health does not sell, as it is not a core value of Americans.  All of the posters rely on the weak core value of health and do not make any promises to consumers. In addition, there is a lack of self-referencing in the ads. Not many people identify with a man who has no legs (although his legs were actually just cropped out for the advertisement), and people who identify with the obese woman may feel shame in identifying with her. The obese model herself was quoted in the New York Times criticizing her own poster. She said, “This [ad] is so negative. If they think they are going to reach overweight people with these ads, they’re not going to do it. I don’t think they would make someone go, ‘You’re right, I need to change” (15). The model also said that the ads are “too negative to inspire” (15). The creators of this ad campaign should have put more thought into how these graphic and negative advertisements would affect the emotions and behaviors of their target audience.
Summary of Critique:
            New York City’s three-pronged obesity prevention efforts fail to take into account the social and behavioral models that predict behavior change. Each of the three interventions, the two laws and the advertising campaign, are unlikely to promote health eating habits among New Yorkers due to assumptions about decision-making, the restriction of freedom, and the lack of advertising theory. The boldness of prevention efforts shows the City’s dedication to health; however, there are more effective ways to promote healthy behaviors than the actions taken by the Department of Health.

Proposed intervention:
            From experience spending time in the city and knowing a fair share of New Yorkers, people from NYC have an immense pride for their native New York status. This New York pride could provide an amazing basis for a new advertising campaign. The current advertising should be scratched completely. The negative and repulsive ads should be stripped from the subway to make way for fresh campaign.
            The new obesity prevention advertising campaign for NYC should utilize effective Marketing Theory.  Promoting weight loss and healthy eating is certainly not an easy task.  It is not as simple as persuading people to buy a product or show up to a one-time event. Obesity prevention is about changing people’s behaviors for a lifetime. In order to succeed, the new campaign will have to make people want to change.  The new advertising campaign will need multiple components, not just posters hanging from the subway. The new campaign will engage New Yorkers, not disgust them. The components of the campaign will include a cohesive trio of posters across the city, television commercials, and free public events. A brand will be created for this intervention. This new approach to obesity prevention addresses the flaws of the current approach.
Defense of Intervention 1:
            The new obesity campaign will not rely on assumptions of individual behavior models, such as the Health Belief Model or the Theory of Reasoned Action.  It has already been shown that providing information about calories does not change eating habits, therefore, this intervention will not focus on giving New Yorkers the hard facts about food. Additionally, intent to change behavior does not always lead to behavior change (19,20), therefore it is useful to change people’s behavior first and their attitudes second (25). Changing behavior can begin through public events. The possibilities of events include promotions in the subway to encourage people to use the stairs, spin classes in Central Park and various fitness events in popular public spaces (including in the Burroughs). Modeling Theory will be used through plain-clothes ‘models’ hired by the Department of Health or the City to take the stairs in the subways, shopping centers, and other places where stairs are ignored over escalators. Lastly, although these public events are geared towards adults, it has been shown that a familial approach to obesity, with behavior change stemming from the parents, is an effective model for lowering BMI in children (16).  
Defense of Intervention 2:
            The new approach to obesity prevention in New York City will use Marketing Theory effectively. Marketing Theory is rooted in the use of core values. The core values of the advertising campaign hold the entire campaign together (23). In order to be a successful campaign, the obesity advertisements cannot rely on health as a core value. Health is a weak value in eyes of Americans.  Therefore, the campaign must utilize strong American core values in order to initiate behavior change.
            The core values used in the ad campaign will be those that the soda ban restricted - freedom and autonomy. Giving NYC residents the ability to make choices about their lifestyle can employ freedom and autonomy. Both the posters and television commercials will need to provide health behavior options that residents can choose from. Examples include: Go for a short walk during your lunch break to perk yourself up for the afternoon; Go for a bike ride with your son before the weather gets too cold. The core value of family will also be employed by the advertisements. Not only is family a strong American core value, but a family approach to the obesity epidemic has been suggested by many researchers (17). By not restricting freedom, the advertisements will hopefully not invoke psychological reactance. However, the posters and commercials will piloted in a small group of New Yorkers to ensure that psychological reactance is not a product of the campaign.
Defense of Intervention 3:
            The proposed intervention will effectively use Advertising Theory. Advertising Theory is based on the idea of making a promise to consumers. The current posters sell ‘products’ that no one wants.  Through the amputation poster and the poster of the obese woman on the stairs, the Department of Health is selling disappointment, shame, and unhappiness. If obesity prevention efforts are to be successful, the ads need to sell what people want and who they aspire to be. No one wants to be shamed, embarrassed, or a disappointment.  The new poster and television ads will sell happiness, inspiration, determination, and love.  The television ads will also be accompanied by inspirational music.   If New Yorkers have positive experiences and associations with the advertisements, psychology of persuasion suggests that behavior change is more likely to occur (23).
            The new material will also consider self-referencing when choosing spokespersons and models. It has been demonstrated that if the campaign spokesperson is in congruence with the product, the spokesperson is perceived as truthful and the product is viewed more positively (24). This fact leads us deduce that people are more likely to change their health behavior if they identify with the spokesperson giving the message.  Obesity is a difficult problem to deal with, physically and emotionally, so it is important the advertisements only encourage and do not discourage people from changing their behavior.
            Finally, the new advertising campaign needs to capitalize on the idea of New York pride! New Yorkers are known for their community and hometown pride. By incorporating New Yorker-isms into the brand of the campaign, New Yorkers will feel a sense of unity in the fight against obesity.
The Future of Obesity in NYC:
            Mayor Bloomberg and the New York City Department of Health are working to reverse obesity trends in NYC and have many goals and indicators set for 2016 (18). However, if they continue the current obesity prevention efforts, the obesity statistics of NYC are unlikely to improve. With one law that has been proven fruitless, another that is strongly opposed, and a disturbing advertising campaign, the residents of NYC are in need of an inspiring impetus to change their lifestyles.  A fresh, multi-faceted advertising campaign that adds to the pride of New Yorkers is very much in need. Obesity is not a health problem to joke about, and a campaign that considers factors that influence behavior change is in order.

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