Wednesday, January 30, 2013

Smackdown Of FatSmack: A Critique Of An Anti-Obesity Ad Campaign That Fails in Advertising Theory – Page O’Leary

Smackdown Of FatSmack: A Critique Of An Anti-Obesity Ad Campaign That Fails in Advertising Theory – Page O’Leary

            In the past twenty years obesity rates in the United States have risen dramatically.  Currently more than 35% of U.S. adults and 17% of children and adolescents age 2-19 are obese (1).  From 1980 to 2008 the rate of obesity in adolescents age 12-19 increased from 5% to 18%, and rising obesity rates were accompanied by increased risk for chronic disease including heart disease and type 2 diabetes (3).  The costs associated with rising obesity rates are astronomical.  Health care costs related to obesity and obesity related chronic disease exceeds $147 billion per year nationally (2).
Between the damaging health effects and associated health care costs of rising obesity rates, obesity has become the focus of many public health campaigns.  Research has shown that obese children and adolescents are more likely to grow up to be obese adults and to suffer the negative health effects associated with obesity, so many public health interventions have focused on children and adolescents in an attempt to decrease future obesity rates and improve the overall future health of the country (3).
Other efforts to target anti-obesity public health campaigns have focused on the causes of obesity.  The most commonly accepted cause of obesity is energy imbalance caused by the consumption of more calories each day than calories that are burned each day.  The prevalence of processed foods, refined grains and added sugars in the modern American diet has been blamed for the increase in caloric consumption leading to this imbalance.  Specifically, intake of added sugars, as high fructose corn syrup, has been shown to have increased 1000% between 1970 and 1990, and is suspected to be a major contributor to the rise in obesity rates in the U.S. (4).  The 2010 Dietary Guidelines for Americans, published by the U.S. Department of Agriculture and the U.S. Department of Health and Human Services identified soda, energy drinks, and sports drinks as the single greatest contributor to sources of added sugars in the diets of the U.S. population ages 2 years and older (5).  Dietary added sugars provide “empty calories,” that increase caloric intake without contributing nutritional value.  Additionally, it has been shown that calories from beverages do not satiate hunger (4,6).  A study of overweight teens showed that decreasing intake of sugar sweetened beverages lead to weight loss and lower BMI, with participants that started with the greatest BMI showing the greatest weight reduction (7).
With these facts in mind, one approach to anti-obesity public health campaigns has been to educate the public, and specifically children and teens, about the empty calories in sugar sweetened beverages.  In 2011, the city of Boston launched a public health campaign intended to do just that.  The campaign, called FatSmack, featured a TV commercial (, four posters ( and a web site ( aimed at teens.  The ads show healthy weight attractive teens drinking from sugar sweetened beverages and getting hit in the face with a gelatinous blob meant to represent fat, accompanied by the print message “Don’t get Smacked by Fat.  Calories from sugary drinks can cause obesity and Type 2 diabetes” (8).  The obvious message of the campaign is that the sugar in sugar sweetened beverages can contribute to obesity and the obesity related complications of diabetes and heart disease (8).  The website features a rotating banner of factoids related to the message, including: the amount of money that Coca-Cola spent on advertising in 2008 ($2.67 billion), the number of teaspoons of sugar in a 20 oz. soda (16 or more), the percentage of overweight or obese students in the Boston public school system (40%), and the number of calories per day that youth age 12-19 consume from sugar sweetened beverages, per day (300 calories) (8).  The web site also contains web pages devoted to Sugary Drink Facts, as well as The Beverage Industry, with information about how the beverage industry markets to teens (9,10).
FatSmack is a well-intentioned campaign that seems on the surface like it would appeal to teens with its young, hip looking models in the ads, but upon closer inspection it is found to be lacking in behavioral theory and execution, which will lead to failure to connect with the target audience and have the desired effect of getting teens in Boston to reduce their sugar sweetened beverage consumption.
Critique Argument 1
            The primary failure of the FatSmack campaign is its reliance on the Health Belief Model (HBM), one of the founding theories on which traditional public health efforts are based (11).  The HBM was developed in the 1950s to describe the decision making process about health (12).  The theory posits that health seeking behavior in the individual is motivated by four factors: perceived susceptibility, perceived severity, perceived benefits of an action, and perceived barriers to taking that action (11).  Amendments to the initial model include cues to action, needed to motivate the individual to act, and the concept of self-efficacy, or an individual’s belief in their ability to take an action (11).  Public health interventions based on the HBM attempt to influence people’s behavior by affecting one of the six factors.  Basically, the theory suggests that by educating individuals about their susceptibility to, or the severity of, a health outcome, the benefits of an action, lowering perceived barriers to taking a healthy action, providing cues to motivate individuals to action, or increasing the individual’s sense of self-efficacy about the action, the behavior of the individual can be changed (11).  The HBM assumes that we can influence individual health behaviors by predicting an individual’s attitude toward health related behaviors and implementing an intervention designed to change these attitudes (13).  The effectiveness of the HBM is limited by the assumption that behavior is reasoned, the lack of designation of a separation between the intention to act and the actual execution of the action, and by the focus on changing behavior on the individual level rather than on the group level.
            The design of the FatSmack campaign makes the assumption that by educating teens that about the risks of consuming sugar sweetened beverages (obesity, diabetes) teens will then see that the benefits of forgoing sugary drinks outweigh the risks of drinking sugary drinks, and will therefore skip the soda and opt for water or some other sugar free beverage.  The web site is full of data about soda consumption, rates of obesity, and obesity related illnesses. The FatSmack campaign assumes that teens will weigh the risks and benefits of consuming sugar sweetened beverages and make a rational decision about how to act based on that knowledge.   However, teens are still developing cognitively and are not capable of rational thought to the extent that mature adults are (13).  Furthermore, studies have shown that when consumed, sugar elicits the same response in the brain as narcotic drugs, so the drive to drink sugary beverages goes far beyond the rational decision to consume or not to consume (14).  Both of these factors will influence the thought process related to beverage choice, and neither supports the theory that teens will make a decision based on rational thought. 
The campaign also fails to take into account other reasons that teens in Boston might be drinking soda. The campaign overlooks the influence of social groups and peers on the decisions made by teens, or that teens may want to change their behavior but not be able to because of their circumstances.  Teenagers are particularly susceptible to peer pressure, so much so that even if a teen is aware that the consumption of sugar sweetened beverages can contribute to the consumption of excess calories, it is an abstract idea that may be very motivating in the face of a group of peers who are choosing sodas and other sugar sweetened beverages (19).  In addition to neglecting the social influences on teen behavior, this construct fails to take into account the political, environmental and personal contexts that influence the behavior of an individual (15).  It may be that soda or other sweetened beverages are what is available at the markets or bodegas where teens are buying beverages, or that money is a factor and soda is the least expensive choice available.
Lastly, reliance on the HBM as the basis for a public health campaign focuses all of the effort on educating the individual to produce behavior change on the individual level.  Instead of trying to change behavior one person at a time, the campaign could have the power to influence the opinions of the masses, if it were designed based on a group-behavior model such as advertising theory.
Critique Argument 2
            Another shortcoming of the FatSmack campaign is that it fails to take advantage of advertising theory.  Advertising theory suggests that advertisements sell products not with facts or reason, but by convincing the audience that their product will lead the audience to achieve their aspirations.  The message in advertising theory is then supported with stories or images that reinforce the promise (16).
            Advertising theory is a group-level alternative model which attempts to overcome the shortcomings of the traditional behavior theory models by approaching behavior change at the level of the population rather than the individual, and by playing on people’s irrationality and dynamicity to persuade them to make behavioral changes, rather than assuming that people behave rationally and relying on their rationality to lead to behavior change.  Advertising theory postulates it is possible to change people’s knowledge and attitude by changing their behavior first.  Rather than using rational thought to convince them to change, advertising theory seeks to motivate people to change by playing to visceral desires and base aspirations, and assumes that once the behavior has changed, the attitude about the behavior will change as well.
            FatSmack is an advertising campaign that fails to employ any of the strengths of advertising theory.  Rather than using the advertisements to appeal to the base desires of a teenager to motivate them to give up sugary beverages, the ad campaign instead tries to convince teens that drinking sugary beverages is bad with comical and almost nonsensical images of hip-looking normal weight teens making cringing/laughing faces while holding a sugar sweetened beverage and getting hit in the face with an amorphous blob of goo intended to represent fat, accompanied by the message that sugar in drinks can lead to obesity and diabetes.  The ads try to use rational arguments to convince teens to change their behavior, instead of using the power of media to play on teens’ desires and emotions.  These ads contain no promise to the consumer that giving up sugar sweetened beverages will lead to contentment and fulfill their aspirations.   Furthermore, the representation of teens in the ads is goofy, and there is little to link teens viewing the print ads or the commercial to the teens represented in the ads.
Critique Argument 3
            Another way in which the FatSmack campaign fails to take advantage of alternative models of health change is that it fails to create a sense of ownership or belonging for viewers, and as such does not get buy-in for the message that that the campaign is trying to deliver.  The concept of ownership says that once a person feels like they own something, the value of that thing goes up.  Traditionally public health campaigns are at odds with ownership because the goal of the campaign is to get people to give up an unhealthy behavior.  Even though people might rationally know that a behavior is unhealthy, if they feel ownership of the behavior they will be motivated to keep it, as a means of maintaining control over their lives.  They will react with cognitive dissonance to rationalize their unhealthy behavior, in the end strengthening their connection to the unhealthy behavior.  By trying to convince teens to give up drinking sugar sweetened beverages, the FatSmack campaign may in fact be reinforcing that behavior (17).
Proposed Intervention – Hydr8 and El Hydratado
            The proposed intervention is designed to reduce teen consumption of sugar sweetened beverages while taking into account the shortcomings of the FatSmack campaign.  The format of the intervention will be similar to that of FatSmack, featuring an Internet/TV/Print ad campaign that promotes drinking water and non-sugared beverages.  However, rather than educating teens about the health risks associated with drinking sugar sweetened beverages, it will focus on drinking water or non-sugar sweetened beverages as a way for teens to assert their independence from beverage companies/advertisers, to give themselves the freedom to live the life they want without obesity or diabetes preventing them from attaining their aspirations.  The ad campaign will use Framing Theory to create a message for teens that associates drinking non-sugared beverages with the core value of freedom.  The video advertisements will then use Advertising Theory to package the core value of freedom with the promise that drinking non-sugared beverages will enable them to achieve their aspirations, supported with images and music that tie back into the core value of freedom.  Lastly, the new campaign will create an identity, El Hydratado, for teens that choose non-sugar sweetened beverages.  This community will address peer pressure and ownership by creating an identity for teens that choose water over sugar sweetened beverages, and provide a nucleus around which the movement can build buy-in and gain momentum.
Defense of Intervention 1
            Rather than educating teens about the detrimental health effects of drinking sugar sweetened beverages and then expecting them to rationally weigh the risks and benefits and choose to give up sugar sweetened beverages, the Hydr8 campaign will develop ads that appeal to the core value of freedom to motivate teens to change their behavior.  Freedom is the strongest core value, and teenagers in particular are drawn to things that give them a sense of freedom as they mature and try to develop a sense of individuality and personality while making the transition from childhood to adulthood. 
            The Hydr8 campaign will present the core position that choosing water or non-sugar sweetened beverages will give teens freedom from manipulation by beverage companies and retailers, who strive to influence teens to buy their products for the monetary benefit of the seller, and will give teens freedom from the constraints of health issues such as obesity and type 2 diabetes that can be caused in part by over consumption of calories from sugar sweetened beverages.  The core position will be strengthened by catch phrases repeated in the print and video ads such as “you choose” and “be free,” along with images that link teens drinking water with freedom to choose and rebellion from corporate control.  Together, these will tie the core position to the core value of freedom, which all teens can relate to.
A similar approach was used in Florida’s “Truth” anti-smoking campaign, which strove to appeal to the teen core value of rebellion, taking that away from tobacco companies and using it to strengthen their anti-smoking campaign (18).  The Truth campaign succeeded in lowering teen smoking rates by 7.4 percentage points in middle school students and 4.8 percent in high school students.
Defense of Intervention 2
            The Hydr8 campaign will rely on Advertising Theory to influence the population of teens in Boston, using ads that make the promise that they will achieve their goals if they choose water over soda.  By crafting subtle and creative ads that make the audience feel that choosing water over soda will give them freedom and help them to achieve their goals, the advertisements will get teens to change their behavior before they change their beliefs about sugared beverages and their health. 
Both print and video ads will feature teenage subjects that average teenagers can relate to choosing water over soda and having totally fantastic but relatable experiences.  The video ads will include music (Nick Drake, of course) and imagery that support the promise of the ads.  The promise, imagery and music will all tie in to the core value of freedom, which will hold together the various aspects of the new ad campaign.  The subjects in the ads will be the American “everyteen” with a range of body weights from slim to obese, so that the intended audience of the commercials and ads will see themselves in those that are delivering the message, which will reinforce the strength of the ad campaign by self-referencing.
By using Advertising Theory, the Hydr8 campaign will reach a large audience and get teens to change their behavior around drinking sugar sweetened beverages before they adopt the attitude that sugar sweetened beverages are bad for their health.
Defense of Intervention 3
            Lastly, the new campaign will create an identity for water and non-sugar sweetened beverage drinkers that creates a sense of ownership and buy-in for teens.  This will be similar to a successful anti-smoking ad campaign in Massachusetts, The 84 (, which created an identity for non-smoking teens and a group for them to belong to (19).  Teens will be invited to become part of “El Hydratado”, The Hydrated in Spanish, a group that is identified by the decision to drink water or non-sugar sweetened beverages over soda, sweet teas, sports drinks and other sugar sweetened beverages.  Creating an identity for teens that choose non-sugared beverages will give them a sense of ownership, which will necessarily strengthen their commitment to the cause. 
Another way that El Hydratado will serve to reinforce member commitment to choosing non-sugared beverages is by getting members involved in the movement.  People’s connection with a cause is strengthened when they are given a task to do in support of the cause.  Members of El Hydratado will be encouraged to take a pledge not to let beverage companies take away their freedom by manipulating them to buy sugar sweetened beverages, and schools will be enlisted to start El Hydratado clubs that will host events for members and be involved in the process of schools transitioning to healthier beverage choices in vending machines and in cafeterias. 
            Creating an identity and group for teens that choose not to drink sugar sweetened beverages will provide a nucleus around which the non-sugar sweetened beverage movement in teens can form.  If this movement becomes popular enough, other teens may be influenced to follow their example just by virtue of the existence of the group (17).  Members of El Hydratado will be trained at section meetings about how to set a good example and “nudge” their peers toward choosing water or other non-sugar sweetened beverages in school and at extracurricular activities. 
  The FatSmack campaign, launched by the Boston Department of Public Health in 2011, aims to reduce sugary beverage consumption in Boston teens with a print and video ad campaign that showed teens drinking soda getting hit in the face with blob of gelatinous goo meant to represent fat.  The images are accompanied by the message “Don’t the Smacked by Fat. Calories from sugary drinks can cause obesity and Type 2 diabetes.”  The effectiveness of the existing ad campaign is diminished by its construction based on the Health Belief Model, and failure to put to use alternative, group level behavioral models of advertising theory and ownership.  The proposed modified intervention, Hydr8, would have the same intended effect as the FatSmack campaign, but would use Framing and Advertising Theory to emotionally motivate the target audience, and create an identity for teens that choose not to consume sugary beverages to give them a sense of ownership and build momentum for the movement.  By adopting these alternative approaches to public health intervention the Hydr8 campaign would have a greater likelihood of success in reducing the amount of sugar sweetened beverages consumed by teens in Boston.
1.       Center for Disease Control and Prevention.  Overweight and Obesity. Atlanta, GA: Center for Disease Control and Prevention.
2.      Finkelstein E, Trogdon J, Cohen J, Dietz W. Annual medical spending attributable to obesity: Payer- and service-specific estimates. Health Affairs 2009; 28:w822-31.
3.      Centers for Disease Control and Prevention. Overweight and Obesity Consequences. Atlanta, GA: Center for Disease Control and Prevention.
4.      Bray JA, Nielsen SJ, et al.  Consumption of high fructose corn syrup in beverages may play a role in the epidemic of obesity.  Am J Clin Nutr.  2004; 79:537-43.
5.      U.S. Department of Agriculture and the U.S. Department of Health and Human Services.  Dietary Guidelines for Americans 2010.  Washington, DC: U.S. Department of Agriculture and the U.S. Department of Health and Human Services, 2010.
6.      Berkey CS, Rockett HRH, Field AE, Gillman MW, Colditz GA. Sugar-added beverages and adolescent weight change. Obesity Research 2004;12:778–88.
7.      Ebbeling CB et al. Effects of decreasing sugar-sweetened beverage consumption on body weight in adolescents: A randomized, controlled pilot study. Pediatrics 2006; 117: 673-680.
8.     Boston Department of Public Health.  Fat Smack.  Boston, MA: Boston Department of Public Health.
9.      Boston Department of Public Health.  Fat Smack.  Boston, MA: Boston Department of Public Health.
10.  Boston Department of Public Health.  Fat Smack.  Boston, MA: Boston Department of Public Health.
11.   Edberg, M. Individual Health Behavior Theories (pp. 35-47).  In: Edberg, M.  Essentials of Health Behavior.  Sudbury, MA.  Jones and Bartlett Publishers, 2007.
12.  Janz NK, Becker MH. The health belief model: a decade later. Health Education and Behavior 1984; 11(1):1-47.
13.  Santrock JW. Physical and Cognitive Development in Adolescence (370-372). In: Santrock JW ed. Life-Span Development. McGraw Hill: New York, 2011.
14.  Fortuna JL.  The obesity epidemic and food addiction: clinical similarities to drug addiction.  Journal of Psychoactive Drugs.  2012;44(1):54-63.
15.   Thomas LW.  A critical feminist perspective of the health belief model: Implications for nursing theory, research, practice and education.  Journal of Professional Nursing.  1995; 11:4(246-252).
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18.  Hicks J. The strategy behind Florida’s “truth” campaign. Tobacco Control. 2001;10:3-5.
19.  The 84.  The 84 home page. Massachusetts: The 84.

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Scaring Our Children: A Critique of Georgia’s Attempt to Fix the Childhood Obesity Epidemic – Yvonne Morales

Scaring Our Children: A Critique of Georgia’s Attempt to Fix the Childhood Obesity Epidemic – Yvonne Morales


            The fact that childhood overweight and obesity is now an epidemic is no longer news. Results from the 2007-2008 NHANES report found that childhood around 16.9% of children and adolescents 2 to 19 years old are obese (1). The number of obese children has tripled since 1980 (2). The state of Georgia is one of the hardest hit by this epidemic, only falling behind Mississippi. Four in ten children are either overweight or obese in the state, the second highest in the country (3). Overweight and obese children are now suffering from diseases we use to think were only seen in adults (3). Children are suffering from joint pain, sleep apnea, hypertension, liver disease, high cholesterol and Type 2 Diabetes, which we use to call adult onset diabetes (3). The severity of the physical consequences of overweight and obesity action needs to reach a wide audience.

            Across the United States several strategies have been implemented to help combat childhood obesity. Common food policies implemented include altering the relative price of foods at schools, shifting the exposure to food and trying to improve the image of healthy food (4). Other strategies including increasing taxes on foods considered “unhealthy” and increasing taxes on these same foods have been considered (4). In Georgia the Children’s Healthcare of Atlanta Pediatric Hospital has taken matters into their own hands and created a 5 year 25 million dollar program, strong4life, aimed at reducing childhood obesity in the state (5).

This program started with the launch of a media campaign, named “Stop Childhood Obesity”, aimed at raising awareness about childhood obesity, which has created a lot of controversy nationwide (5). Using the tagline “Stop Sugarcoating It, Georgia” the campaign, which includes print and video ads, seeks to shock its citizens into action (5). The program goes beyond this ad campaign and includes a movement they named strong4life and other ads campaigns that were rolled out after the “Stop Childhood Obesity” campaign (3). For the purpose of this critique only the ad campaign launched as the first phase of the initiative will be discussed. In late 2011 and early 2012 when the campaign was launched a great deal of controversy was created. Some praised its boldness and directness while other criticized it for making a sensitive issue worse (5). The ads are shocking depicting sad little boys and girls that are either overweight or obese in an effort to raise awareness to childhood obesity.   

The campaign was very successful in getting people talking about the issue. A Google search for “Georgia childhood obesity ads” yields 322,000 results in 0.48 seconds. The campaign is so recent that we still don’t have any evidence on its ability to change what it set out to do yet many critiques agree that the possibility that it will do more harm than good is real (5). Even though it caused a stir the ad campaign fails to properly combat childhood obesity by alienating its target audience, failing to provide a viable model for children to follow and fails to create community awareness to the issue.

Critique 1: Stigmatizes overweight and obese children

            One of the print ads for the campaign stars an overweight girl who seems to be around 9 years old.  She is staring into the camera arms crossed, a banner runs at the bottom of the page, “WARNING: It’s hard to be a little girl if you’re not” (5). This is one of the images being plastered on billboards and online in Georgia. The other images are accompanied by the caption, “My fat may be funny to you but it’s killing me”, and “Fat prevention begins at home. And the buffet line” (6). The ads aimed at propelling parents and children into action may be instead further stigmatizing overweight and obese children.

Stigmatizing includes but is not limited to verbal teasing, physical bullying and relational victimization (7). Studies have shown that overweight and obese children are already the victims of bias and stereotyping by peers, educators and even parents (7). This has been well documented in scientific literature for more than 40 years (7). In a seminal study by Richardson et al in 1961 640 school children 10 and 11 years old were instructed to rank the pictures of six children in order of whom they would rather be friends with (7). The pictures included children with disabilities, and overweight child and an average child with no disabilities (7). On average the overweight child was ranked last and deemed least likeable (7). Many other studies have confirmed these findings (7). Stigmatizing associated with depression, low-self esteem, body dissatisfaction and difficulty establishing interpersonal relationships (7). So instead of pushing these children into action they are being pushed further into a cycle of low self-esteem, depression and further weight gain.

Critique 2: Fails to promote self-efficacy

            One of the video ads titled “Video Games” that forms part of the campaign stars Jaden, a young African-American boy, who likes to play video games, by himself, so he doesn’t have to be around the other kids that make fun of him (8). The ad is very effective in showing how lonely being overweight or obese can be. Most children that are overweight or obese already know this. The campaign “Stop Childhood Obesity” seems to be based in part on the health belief model. This model stipulates that there are six main constructs that propel people into action (9). These include perceived susceptibility, perceived severity, perceived benefits of taking action, perceived barriers, cues to action and self-efficacy (9). Self-efficacy refers to a person’s belief in his or her ability to take the action (10). The ad depicts Jaden in a dark light, and he talks about how he retreats to his video games so he doesn’t have to be around other kids. Jaden is not being given the tools or even told that he can change his situation. It seems he is condemned to playing video games, since “being fat takes the fun out of being a kid” (8). Every single ad that forms part of this campaign ends on a negative not or makes you feel sad.  If as an adult looking at this you don’t feel empowered to make a change, children will not either.

            This campaign was designed to raise awareness and create a buzz around the issue. It accomplished that but, how effective is an intervention that fails to empower those that they intend to help. Another huge issue with the campaign ads that only depict children in them is that they make it seem that this is an individual issue.  Given the large range of factors that contribute to childhood obesity it is clear that this is not an individual issue (11). Those behind the campaign, Children’s Healthcare of Atlanta, do admit that what they want to do is push parents into action saying that they need to be pushed out of a state of denial (12). Yet, they are not transmitting a message that promotes self-efficiency to parents either. None of these ads even suggests a course of action to be taken, we are just asked to stop sugarcoating it. Studies, like the one conducted in Australia by Lewis et al. have shown that obesity public health campaigns can cause more harm than good when targeted to adults (13). It would be interesting to study the effect these ads are having on parents. They are probably having similar effects, which included feeling stigmatized and blamed for their situation (13). 

Critique 3: Fails to create a model for children to follow

A TV ad shot in black and white stars Bobby and his mother, they are sitting face to face on two foldable chairs. Bobby asks his mom point blank, “Mom, why am I fat (14) ?” The conversation is set in the same tone all the other ads portray, dark, cold and seemingly hopeless. By bringing in Bobby’s mother into the picture the campaign is bringing in the environment into the picture. The Social Cognitive Theory (SCT) describes the dynamic in which personal factors, environmental factors and human behavior influence each other (10). The SCT says that there are three main factors that will increase the probability that a person will change a health related behavior (10). These factors are self-efficiency, goals and outcome expectancies (10). This theory later evolved to the Social Learning Theory that postulates that people learn by observing others, this is where this campaign fails completely (10).

Bobby isn’t given even a suggestion or anything that resembles an answer (14). We are just told, “75% of Georgia parents with overweight kids don’t recognize the problem” (14). So even if we look at the ad from the perspective of a parent that may have an overweight child and doesn’t recognize it we are not told how to do this. There is no suggestion of behavior to model at all. This is another huge missed opportunity. If we want to get parents on board with the program we have to show them where the door is.

Proposed Intervention

Successful interventions need to have impact on the individual and societal levels (11). Relying solely on children or even children and their parents to solve the childhood obesity crisis would be wasting some of the most important resources we have as a society, each other.  An effective intervention that will help combat childhood obesity in state like Georgia where the prevalence is high is to include everyone in the fight, not alienate those affected and make them feel like they are to blame. Yes, there is some blame to assign but this will not solve the problem. Working together and making the solution as easy as possible is the way to go.

            A great example of a campaign doing just this is the do® groove campaign created by Blue Cross Blue Shield of Minnesota (15). This campaign targets adults but could serve as a great model for a children’s campaign. The campaign features TV, print and online ads that promote a positive message towards achieving meaningful weight loss. The ads for the do® groove campaign include taglines like, “walk a mile in your own shoes”, “we hear the Joneses have been exercising”, “Groove. Breathe. Repeat.”, “put some step in your spring” among others (15).  

The TV ads star everyday people sharing their successful weight loss stories weight loss stories (15). The factor that is key here is that the people sharing their stories are not now super skinny health fanatics. They are people that are still in the trenches still struggling with the problem (15). Modeling a program for children that provides relatable models for both parents and children and empowers them to take action could be more successful that scaring children and pointing the blame at parents. A great way that the do® groove ads used advertising theory is that added a comedic element to the TV spots that is consistent throughout.  The same man appears at the end of all the ads, he stars in one, and invites everyone sharing their story to “groove” with him. Ending the spot with an uplifting moment even if the story might not have been.

            The Stop Childhood Obesity campaign makes good use of advertising theory and marketing theory. These strategies should be continued in the new campaign, with a different tone. The ads in Georgia were very effective at getting the community talking. Every media outlet picked up the story and discussed at length. This is a great way to et even more exposure and even free advertising for the campaign. Finding a creative way to accomplish this in a more positive tone will be hard since usually this type of attention goes to controversial topics (5). Making use of creative agencies and experts in advertising could help achieve this goal.

Defense 1: Providing a model to follow

            In the stop childhood obesity program that I am proposing TV ads would feature children that have been successful at losing weight. This will provide children with a model from which they can learn. According to the Social Learning Theory observational learning or modeling is behavioral changes that occur by watching the actions and outcomes of other’s (10). Portraying children that have been successful or are currently trying to lead a healthier lifestyle is important. The current campaign in Georgia doesn’t give children a better model to follow. Overweight and obese children need to see that changing is possible and shown how to do it.

            A second model that also needs to be provided is a parental model of how to help your child lose weight. Many parents don’t know how to help their children. Instead of casting them in the role of enabler or cause like they do in the Stop Childhood Obesity ads we can cast them in the role of support or better yet example. Getting parents to lead a healthy lifestyle will at the same time help children lead a healthy lifestyle. In other words providing parents a model on how to be good role models for their children.

Defense 2: Create a sense of community
            The initiative should create a sense of community; we got into this problem together we will fix it together. The cause of childhood obesity can be simplified to an excess delivery of calories (11). How we ended up having children that consume an excess amount of calories and don’t exercise enough is extremely complicated (11). So blaming the current generation of children and their parents for letting their weight get out of control is absurd. The current obesity epidemic is the result of many factor coming together is a sort of perfect storm. Many of these factors that caused the childhood obesity epidemics are environmental.  If the cause of the problem lies in the community so can the solution. According to the Social Cognitive Theory there is a dynamic process in which personal factors, environmental factors and behavior influence each other (10). Changing one of the three factors will later cause changes in the other two.
Defense 3: Create a sense of self-efficacy

            One really important thing that creating a sense a community and providing both children and parents a model to emulate does is that it creates a sense of self-efficacy. Each of these factors act together to empower both children and their parents. Some consider self-efficacy the most important personal factor that leads to behavior change (10). Its the factor that appears in every behavior change model (10). If self-efficacy is created this will eventually lead to action. In order for this to happen the campaign has to provide easy to follow and easy to access steps for both children and parents to take. Again looking at the do® groove campaign as an example they have a tab on the website called “Get Started Now” (15). Here people can find 3 easy steps that will get them on their way to a healthier lifestyle (15). A similar approach can be taken and adapted to children. There is still a lot to learn about how to motivate children to lose weight without causing eating disorders in the process (6). So instead of asking people to find their healthy weight like on the do® groove website children could be asked to set other type of achievable goals which are important to change behaviors (10).


            The childhood obesity epidemic is a real problem that must be dealt with now. The Children’s Healthcare of Atlanta Pediatric Hospital has that much right there is no more time to waste when it comes to confronting the issue and finding a solution. The way they are going about this is going to cause more harm than good. Further stigmatizing an already vulnerable population without proving actions to be taken can make the problem worse.  We can stop sugarcoating the issue without scaring a generation of vulnerable children. The Do® groove campaign created by Blue Cross Blue Shield of Minnesota does this for adults (15). A similarly positive and serious campaign can be crafted for children. Empowering them during a very vulnerable stage of life can create better end results. We need to stop sugarcoating the issue across the country; we just have to be careful not to create a bigger problem.

1.       Products - Health E Stats - Overweight Prevalence Among Children and Adolescents 2007-2008. (n.d.). Retrieved December 12, 2012, from
2.      Obesity and Overweight for Professionals: Childhood: Data | DNPAO | CDC. (n.d.). Retrieved December 13, 2012, from
3.      We Are Strong4Life. (n.d.). Retrieved December 12, 2012, from
4.      Frieden, T. R., Dietz, W., & Collins, J. (2010). Reducing Childhood Obesity Through Policy Change: Acting Now To Prevent Obesity. Health Affairs, 29(3), 357–363. doi:10.1377/hlthaff.2010.0039
5.      Controversy Swirls Around Harsh Anti-Obesity Ads: NPR. (n.d.). Retrieved December 13, 2012, from
6.      Gray, E. (2012, January 3). Georgia Anti-Obesity Ads Say “Stop Sugarcoating” Childhood Obesity. Huffington Post. Retrieved December 12, 2012, from
7.      Puhl, R. M., & Latner, J. D. (2007). Stigma, obesity, and the health of the nation’s children. Psychological Bulletin, 133(4), 557–580. doi:10.1037/0033-2909.133.4.557
8.     Stop Childhood Obesity: Video Games. (2011). Retrieved from
9.      National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, pp. 9-21 (NIH  Publication No. 05-3896). Available at:
10.  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.
11.   Vos, M. B., & Welsh, J. (2010). Childhood Obesity: Update on Predisposing Factors and Prevention Strategies. Current gastroenterology reports, 12(4), 280–287. doi:10.1007/s11894-010-0116-1
12.  Do Georgia’s Child Obesity Ads Go Too Far? (2011, May 2). Huffington Post. Retrieved December 13, 2012, from
13.  Lewis, S., Thomas, S. L., Hyde, J., Castle, D., Blood, R. W., & Komesaroff, P. A. (2010). “I don’t eat a hamburger and large chips every day!” A qualitative study of the impact of public health messages about obesity on obese adults. BMC Public Health, 10, 309. doi:10.1186/1471-2458-10-309
14.  Stop Childhood Obesity: “Why am I Fat?” (2011). Retrieved from
15.   What is Do Groove, How Can it Help You Get Healthier & more. (n.d.). Retrieved December 13, 2012, from

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Banning Large Sodas to Decrease Obesity- A Critique on New York Soda Ban- Disha Shah

Banning Large Sodas to Decrease Obesity- A Critique on New York Soda Ban- Disha Shah
Obesity is one of the most daunting challenges for the public health, worldwide. Obesity rates in the United States are among the highest in the world. According to CDC, during the past 2 decades, there has been a dramatic increase in the obesity trend in the United States. More than one-third of U.S. adults (35.7%) and approximately 17% of children and adolescents aged 2—19 years are obese.1
The prevalence of obesity in New York State is 24.5%.2 As a step to control obesity, Mayor Bloomberg imposed a ban on super-sized sugary beverages larger than 16oz in public places such as restaurants, food carts, movie theatres, and delis. The ban won’t impact fruit juices, milkshakes, diet sodas or alcoholic drinks.3 Enforcement would be conducted by an existing corps of city restaurant inspectors. A violation of the law would lead to a $200 fine. This type of ban is first of its kind, and is becoming a growing national debate. The city pioneered in banning trans-fats, and it subsidizes fruits and vegetables for the poor through its Health Bucks  program.5 The intention behind this soda ban is to cut the intake of excessive calories from the large sized soda, thus to control obesity. Thomas Farley, commissioner of New York City’s Health Department, writes that if the new regulation “leads to New Yorkers simply reducing the size of one sugary drink from 20 ounces to 16 ounces every other week, it would help them avoid gaining some 2.3 million pounds a year.”Thomas Farley may be right here, but there are so many alternatives to a supersized soda, which might be responsible for obesity, and which are not addressed by this ban.

1.      Does Not Create a Sense of Perceived Susceptibility:
To start with the flaws, the proposed ban on large, sugary drinks actually is not really a ban on anything. According to the ban, people will not get the choice of drinks larger 16oz. A large drink of soda (34 oz.) has about 108g of sugar.4   A small sized drink (16 oz.) has about 39g of sugar. People still aren’t completely prevented from drinking soda. It doesn’t cover beverages sold in supermarkets or most convenience stores (which are not regulated by the city). Drinks are also exempt if they contain more than 50 percent milk (so people are permitted to have a large Frappuccino with whole milk and sugar, which might contain more calories than a large soda). Alcoholic beverages are not included in the ban as well. "This is the largest single driver of the obesity epidemic," said Dr. Thomas Farley, health commissioner of the city. "It is the largest source of added sugars to our diet."6 So what about the sugar content in 16 oz. drinks? Is it safe to consume 16 oz. soda? Or is it safe to have 2-3 donuts on a daily basis? So looking to all these aspects, the ban on large drinks is not a ban at all. According to Health Belief Model, perceived susceptibility, also called perceived vulnerability, refers to one's perception of the risk or the chances of contracting a health disease or condition.9 One of the important determinants is whether or not a person believes that the problem could happen to him or her. If people think that they cannot get a particular disease or have a particular problem, they often will not take an action to prevent it. By imposing a ban on large drinks, people are not informed about the harmful effects of the smaller portions of drinks which can be equally responsible to be one of the factors contributing to obesity. Also, other high calorie food are not being identified as risk factors and people are not made to understand that they are susceptible to obesity if they drink ‘soda’ and not if they drink ‘large soda’.
2.     Invokes Psychological Reactance:
Psychological reactance is an aversive affective reaction in response to regulations or impositions that impinge on freedom and autonomy.10 Psychological reactance occurs in response to threats to perceived behavioral freedoms. If a person’s behavioral freedom is reduced or threatened, the person will become motivationally aroused. Because of the fear of losing the freedom of that particular behavior, they get motivated to restore their freedom, by doing exactly opposite of what is desired. This brings them a sense of ‘re-establishing’ their freedom and regaining back the control of their lives.13 This ‘boomerang effect’ is psychological reactance.
According to the above explanation for invoking reactance in the masses, it can be concluded that this policy has all the ingredients to invoke the reactance in the target population. 6 in 10 New York residents were in opposition of this ban.11
This policy is actually not a ban, just a cap on large sodas. But it has been framed as a ‘ban’. This is one of the factors giving rise to ‘liberty issues’ and ‘freedom to choice’ in the target population. The soda companies will be affected directly by this policy. The American Beverage Association, whose members could stand to lose millions of dollars in revenue if the mayor’s plan is approved, has argued that there is little correlation between soft drinks and obesity. The industry group has led a big-budget public-relations effort urging New Yorkers to “make their own choices” on soda. These commercials are being aired on local television and radio. This has added to contribute in the psychological reactance.
Many researches show that when people are restricted or told to exhibit certain behavior, they choose to do exactly the opposite of what they are being told.12
This is one of the major flaws of this intervention. It completely violates the psychological reactance theory. “I know what’s best for you” kind of attitude has created an image of ‘nanny Bloomberg’.14
In general, policy makers should be aware of reactance and should recognize that individuals may respond in a counterproductive manner to policies that appear to threaten their ability to choose freely.
3.     Violates the Social Cognition Theory
According to social cognition theory, self efficacy and environmental factors play an important role in determining whether a person will change health behavior. In this case, environmental factors are not in favor of the desired behavior. The change does not make a favorable environment for the public to show the desired behavior. It's important to look at where people acquire such large drinks. An average New Yorker does not go to a movie theatre often, and attends sports venues even less regularly. In fact going to a grocery or a convenient store are much more common occurrences. So there is every possibility of the city resident buying his/her drink from such stores and gulp as much as soda he/she wants relaxing at home. The ban does not consider the complexity of how and why people acquire food and drink, and instead applies a simplified solution to a layered problem. It does nothing to do the self efficacy of the people or does not consider creating a ‘healthy’ environment. Thus, it is likely, that the desired behavior cannot be obtained in the target population. Self efficacy which means strong intention, knowledge and skills to carry out likely behavior is a strong determinant of human behavior. This behavior is reinforced when there are no or very less environmental constraints and rewards for change in behavior. By introducing ban, the self efficacy of the people is being questioned. ‘Ban’ seems to be more like an enforcement, which in social sciences can be called a ‘punishment’ without obvious rewards. Punishment is less effective than reinforcement for teaching and modifying behavior.8 Moreover this policy fails to reach at the core of the issue by not being able to change core belief of the target population. They are not able to achieve this because still there are plenty of catchy advertisement floating all over media which lure them to buying more and more of unhealthy drink. Have they been able to add a knowledge element simultaneously such as making it compulsory to show that drink consumed in large portions is harmful to health just like it is mentioned on the cigarette packs. Therefore, it is pretty much less likely to impact New Yorkers in reducing obesity. On the contrary ban portrays something which restricts freedom and people tend to believe that their choices are controlled by higher authority and this will cause fewer acceptances and eventually will not modify behavior which is primary goal for introducing this policy.

Articles published in some of the medical journals suggest that rising levels of obesity may be linked to increases in soft drink portion sizes; this implies that reducing the consumption of sugary beverages may lead to better health outcomes.  However, the manner in which Mayor Bloomberg is attempting to achieve this goal ignores a number of important insights from behavioral science. It stimulates rebellion and distrust with elected officials. If we want people to drink less soda then we have to make people not want it and not telling them that they can’t have it.

Counter-proposals for the critiques:
1.      Counter-proposal for critique 1:
As stated in critique 1, a state of perceived susceptibility is not being demonstrated by this policy. There have been researches conducted which demonstrate that perceived susceptibility leads to a desired behavior.15
To develop a perceived susceptibility amongst people regarding the fact, that high calorie drinks such as soda, can lead to obesity, number of things can be done. One way is to create a graphic warning (and not verbal message) on the soda cups. For example, the large cups of soda should portray a fat, obese family with a sad pictorial representation of heart. And on small cups, a slim, healthy family with a smiling heart.  In this way, the message can be conveyed implicitly and obesity can be projected as a ‘cardio-vascular hazard’ and not just ‘being fat’.
 This can be mandated to all the large sized high-calorie drinks and not just soda. Thus, it will be considering for all the drinks which contribute to obesity and not just soda. Pictures can help to increase the message’s accessibility by people with low levels of literacy and can help visualize the actual message to be conveyed. Color pictures can be used to make it more effective and attractive.
These types of graphic warnings are made mandatory on the cigarette packs. Researchers have shown that these warnings are actually effective to decrease the rates of smoking.16
2.     Counter-proposal for critique 2:
As stated in critique 2, a ‘ban’ can induce a reactance in the target population, even though it is not ban but just a cap. There are many possible actions which can be taken to decrease the reactance. One simplest way is taxation on the sugary beverages. This type of ‘soda tax’ has already been imposed in certain states in US and has been effective.17 Such tax can be imposed on all high calorie drinks and not just soda. Another option is increasing the price of drinks and discontinuing the increase volume discounts.
Along with this, messages should be effectively conveyed with the help of popular celebrities regarding relation between high calorie diet and obesity. The media and especially actors and actresses have a huge influence on today’s youth. If these celebrities are sought to educate the masses what is right for their health, it will have a much higher impact and will be acceptable as they are not forced but are shown a direction towards healthy living from their role model.
Simultaneous implementation of these steps may lead to decrease the psychological reactance as well as see the desired behavior.
3.     Counter-proposal for critique 3:
Self efficacy and environmental factors play an important role in determining behaviors of the population. So it is very important to look at the issues pertaining to the self efficacy and environmental factors when planning to change the behavior of the populations. Here the word ‘ban’ causes havoc as it is in direct conflict to the behavior we want to achieve. This causes negative reinforcement as it tend to make people think that they are being controlled and they do not have right to choose what they want. Instead of banning the choices that people want, one should focus on adding a knowledge element so that it can help people make better choices. Environmental factors can be controlled by imposing a soda tax. So, people have to pay more at all the places from where they can get a soda, and not just movie theatres or a restaurant.
Regarding self efficacy, it has been found that self efficacy operates best in concert with general life style changes, including physical exercise and provision of social support. Self-confident clients of intervention programs were less likely to relapse to their previous unhealthy diet. Chambliss and Murray (1979) found that overweight individuals were most responsive to behavioral treatment where they had a high sense of efficacy and an internal locus of control. Other studies on weight control have been published by Bagozzi and Warshaw (1990) and Sallis, Pinski, Grossman, Patterson and Nader (1988).18  Self efficacy can be increased by increasing  self-confidence of the people. One way to do this is to start a campaign named “I can do it by myself!” Through such campaigns, the obese and over-weight people can be motivated to reduce their weight and improve their life style by giving them real life examples from people who have been successful in doing so. Also, the people who achieve their goals can be rewarded (like replacing the previous people in the campaign commercials). This can act as a positive reinforcement.
Exercise should be made a part of school curriculum. It should be made compulsory in every school for the students to take part in any form of exercise, such as yoga, dance, or other gymnastics. This way, we can make them efficient to live a healthy life style from their childhood.
Thus, it should be our fight against “obesity” and not “soda consumption”.


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2.      Obesity and Overweight for Professionals: Data and Statistics: Adult Obesity - DNPAO - CDC. (n.d.). Centers for Disease Control and Prevention. Retrieved from

3.      N. (2012, September 14). Why Soda Ban Will Work In Fight Against Obesity; Food Regulations Have Proven Record. Forbes.

4.      How Much Sugar in Sodas and Beverages? (n.d.). Sugar Stacks - How Much Sugar Is in That?. Retrieved from

5.      D. (n.d.). New York City looks out for health of its own; It's a shame the notion that governments should promote well-being is so derided. newsday.

6.      Large-size soda pop likely to be banned in NYC. (n.d.). korea times.

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10.   Psychological reactance theory Psychlopedia (n.d.). Retrieved from

11.    Grynbaum, M. (2012, August 22). 60% in City Oppose Bloomberg’s Soda Ban, Poll Finds. the new york times.
12.   Abel , Barksdale. (2012). Freedom of choice and adherence to the health regimen for african americans with hypertension. Ans Adv nurs sci. Retrieved from

13.   Quick BL, Bates BR. (2010). The use of gain- or loss-frame messages and efficacy appeals to dissuade excessive alcohol consumption among college students: a test of psychological reactance theory. J Health Commun. Retrieved from

14.   'Nanny Bloomberg' Ad In New York Times Targets N.Y. Mayor's Anti-Soda Crusade. (2012, June 4). Huffington post. Retrieved from

15.   Rahman M, Berenson AB, Herrera S. (2012). Perceived susceptibility to pregnancy and its association with safer sex, contraceptive adherence and subsequent pregnancy among adolescent and young adult women. Retrieved from


17.   Why Mike Bloomberg’s 'Soda Ban' Could Actually Work. (2012, September 14). the daily beast. Retrieved from

18.   Ralf Schwarzer & Reinhard Fuchs (n.d.). Self-Efficacy and Health Behaviours. Userpage < ZEDAT < ZEDAT - Hochschulrechenzentrum. Retrieved from

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