Tackling Childhood Obesity in Atlanta: Creating A Movement out Of Controversy- Karan Shergill

Introduction

Childhood obesity is one of the most serious upcoming public health issues within the United States. According to the World Health Organization, obesity as a disease is defined as the condition of excess body fat to the extent that health is impaired (1). For practical purposes and among both children and adults, BMI is now widely used to assess obesity (2,3). BMI is closely correlated with body fat and obesity related health consequences (2).

 The ‘new’ BMI reference is provided in the 2000 Center for Disease Control and Prevention Growth Charts (3), which was developed for all US children aged 2-19 years. These ‘new’ BMI, 85^th and 95^th percentiles are recommended by the Centers for Disease Control and Prevention for screening overweight persons. Thus overweight children have their BMI within the range of 85 to 95 percentile, for the children of same age and sex and obese children have BMI greater than 95 percentile.  For children younger than age 2 years, there is no BMI- for-age reference to define overweight, and the weight –for-length 95^th percentile has been used(2).

The percentage of children and adolescents between 2- 19 years who are suffering from childhood obesity are estimated to be around 17% (4). The top 3 states where majority of the children are suffering from childhood obesity are Mississippi, Georgia and Kentucky (4). Childhood obesity is a multisystem disease with potentially devastating consequences. Obese youth are more likely to have risk factors for cardiovascular disease, such as high cholesterol or high blood pressure (5). Children and adolescents who are obese are at greater risk for bone and joint problems, sleep apnea, type 2 diabetes and social and psychological problems such as stigmatization and poor self-esteem (6).

Although there are some genetic and hormonal causes of childhood obesity, most of the time, it is caused by kids eating too much and exercising too little (7). Genetic, environmental, social and behavioral factors have been found to be related in determining an individual’s body weight (8,9). Advertising campaigns link food, beverage, candy products with enticing features such as movie and cartoon characters, toys, video games, branded kids clubs, the Internet, and educational materials (10-12).Such advertising is especially influential among children younger than 8 years because they have limited understanding of the advertisers’ persuasive intent (13). Adolescents, on average, get 11% of their calories from soft drinks and consume twice as much soda as milk (14). Low-income families face numerous barriers including food insecurity, lack of safe places for physical activity, and lack of consistent access to healthful food choices, especially fruits and vegetables (15)^. 

The Atlanta Campaign against Childhood-obesity:

In-order to raise awareness regarding the problems of childhood obesity by making use of billboards and the television media, an anti –obesity campaign was started by Strong4Life, run by Children’s Healthcare of Atlanta. The advertisements and billboard hoardings show obese children telling to the audience how do they feel about being obese and with taglines as "Chubby isn't cute if it leads to type two diabetes"; and "Being fat takes the fun out of being a kid" (16).  These advertisement campaigns are the topic of critique of this paper which will explain why the strategy employed by Strong4Life is ineffective in tackling childhood obesity.

Criticism 1:  Reinforcement of Stigmas

According to chief administrative officer of Children’s Healthcare of Atlanta, "We felt that because there was so much denial that we needed to make people aware that this is a medical crisis. We knew flowery ads don't get people's attention. We wanted to come up with something arresting and hard-hitting to grab people" (17).

 Though the advertisements are aimed to create awareness and attention to the epidemic, it is in a direction that may perpetuate stigmas for obese children. Messages like “Being fat takes the fun out of being a kid,"    accompanied by a picture of an overweight child looking extremely somber singles out obese children (16). This, in turn, makes them an easy target in society. Negative attitudes toward obese persons are pervasive in North American society. Numerous studies have documented harmful weight-based stereotypes that overweight and obese individuals are lazy, weak-willed, unsuccessful, unintelligent, lack self-discipline, have poor willpower, and are noncompliant with weight-loss treatment.(18).

Stigmas arise as a result of misconceptions about a particular aspect or outcome (19). Although Strong4life intended to separate out the obese children from the rest in order to motivate them for weight loss, there are number of reasons to believe that this move might be unhelpful. Attempts at weight loss cannot be achieved just on the basis of diet (20). Thus the message ‘Stop sugar coating- Georgia’ is not completely appropriate. By stigmatizing the obese children, they have ignored the harmful outcomes of stigma which include discrimination and negative impacts on health (19). The individual behavior of these children can be greatly influenced by simply labeling them as obese. According to the Labeling Theory, labeling an individual influences their behavior and more often encourages that individual to behave in a manner that justifies the label assigned with them (8-9). Obese children must endure negative stigma not only from their peers, but also by their teachers and themselves (7). It has been observed that when individuals feel shamed or stigmatized because of weight they're actually more likely to engage in behaviors that reinforce obesity: unhealthy eating, avoidance of physical activity, increased caloric intake (7).

Critique 2:  Lack Of Self-efficacy;

 Warning label like “My fat may be funny to you but its killing me” (16), bring out a sense of incapability, subjugation and melancholy.  There is nothing in this message that arouses a sense of self-efficacy, or the idea that a lower, healthier weight is an attainable goal. Although these ads depict a picture that childhood obesity is a serious concern among the children who suffer from it but the element of how one can manage this situation is missing, hence rendering the audience clueless of what can be done to tackle it. Self-efficacy refers to personal judgments of one’s capability to organize and implement behaviors in specific situations. The concept of self-efficacy is a central component of Social Cognitive Theory. According to the Social Cognitive, behavior of a person is a result of the interaction between one’s environment, the behaviors one witnesses, and the individual themselves (21). Such advertisements convey a pessimistic feeling in the minds of audience by showing worried kids who can’t do anything about their obesity. Hence Strong4Lifr is not sending a positive message of self- efficacy and should not expect other people to change their behavior by watching their advertisements or billboards, instead should expect the opposite to happen.

Critique 3: Employment of Fear Tactics:

In order to come up with an advertisement that is more assertive and hard hitting to the people, the Strong4Life have employed the use of fear tactics.

 By setting fear into the minds of audience, Strong4life want to force people to circumspect on the issue so that the parents can take necessary steps to curb it. The somber expression and direct gaze of the children reads as accusatory in some images and pleading in others.  The children stare down the camera, and the stark black and white of the images serves to emphasize the grim nature of their predicament.  Combined with the inflammatory captions, the ads consciously manipulate feelings of guilt and fear in an effort to capture attention. They are assuming people to make rational decisions by visualizing these children. But fear often results in making decisions which are irrational and tend to negate the intended effect. Fear creates an unnecessary pressure in the mind of the individuals and instead of thinking of a proper way to a quandary people tend to ponder upon the fear itself. Thus this move by Strong4life which although was meant to motivate the audience, instead is more likely to create reverse effect.

Interventions:

From the above discussion it is quite evident that due to serious flaws in the messages being conveyed to the audience this intervention is likely to fail.

The campaign will not work as it targets and separates out an individual in the community and makes him/her belief that they are inefficacious. Thus the Social Network Theory can be employed in such a situation to deal with the problem of segregation and discrimination and make people believe in themselves. It will work in the intended direction of mitigating the above mentioned problems as the social structure of the network will be responsible for determining and predicting individual behavior (22).

 A proposal of three different interventions has been presented below that might be able to remedy Strong4Life’s public health campaign against childhood and adolescent obesity.  To formulate a more effective public health campaign against childhood obesity for Strong4Life, these interventions discuss the elimination of stigmas and labels, encourage self-efficacy and discourage use of fear tactics.

Intervention 1: Elimination Of Stigmas and Stereotyped behavior

The stigmas against obesity created by the advertisements and in the society in general can be encountered with the use of Social Network Theory. By promoting healthy interaction between obese children and their peers and other members of the society, these stigmas can be removed. In one of the advertisements an obese child says,’ Playing video games is what I like to do by myself. I don’t have to be around with other kids because all they want to do is pick on me’ (16). As it not uncommon in for the obese kids to be teased, therefore advertisements showing these kids involved in sports or physical activity will not only convey to other obese children how to reduce weight but will also depict cordial interaction between children from various backgrounds and weights, which will send a positive message to the society.

It has been observed in studies, that sharing beliefs provides a means to affiliate with others and to achieve membership, attention, emotional support, acceptance and security in social groups (23-26). A person’s stigmatizing attitudes are affected by perceptions about whether they are shared by others and may change accordingly (27). Attitude change is more likely when relevant information comes from valued in groups than from other disliked groups (28,29). An example of how social network theory seems to work in real life is the “Peer Power” initiative in North Carolina which was a peer driven program that had produced remarkable positive health behavior changes in areas of health activity and nutrition, leading to decrease in average BMI BY 4% in two thirds of students (30). In this the high school students were trained to be educators and mentors for younger elementary and middle school children. Hence by showing all sorts of kids intermingling with each, Strong4Life can help reduce the discrimination faced by the obese children.

Intervention 2: Encouragement of Self-Efficacy:

Instead of creating a picture of hopelessness and helplessness, the advertisements should focus on positive ways to enhance self -esteem and encouragement of obese children. The tagline of “My fat might be funny to you but it is killing me” can be replaced by “I am killing my fat by dancing everyday- it’s fun”. The later line conveys to the audience that engaging in any sort of physical activity is enjoyable and that the obese children can also participate in any activity they like.

Similarly, if advertisements are developed on the basis of the Social Cognitive Theory, in which the obese children are trying to reduce their weight by working out or playing each day, the audience will witness a particular behavior being performed. Thus by observing the actions of others and the benefits of those actions the people will change their own attitudes from that of being a pessimist to that of an optimist which will promote self -efficacy. Perceived self -efficacy can affect health behavior in number of ways. Self-judgments of efficacy determine choice behavior; that is which actions will be attempted and which avoided. Self-efficacy also affects the amount of effort devoted to a task, and the length of persistence when difficulties are encountered. Realizing that they are self- efficacious, the obese children will feel empowered and that they are capable of achieving any challenges that come in their way.

Intervention 3: Discouraging Scare Tactics:

Instead of instilling fear in the minds of the obese children, Strong4life should come up with advertisements that should focus on healthy behaviors for all children. As opposed to showing children against a dark background in a desolate way, it is necessary that they should exploit the concepts of Social Network Theory. They should depict confidant and bright looking kids who are willing to find a solution to their obesity by keeping themselves involved in sports regularly for fixed duration of hours and eating healthy food. They can also show a child who was obese before and how he can become a role model to other children watching him.

Conclusion:

The Strong4Life campaign has some limitations because of which its effectiveness is restricted and rather seems to act in an opposite way. Although it is necessary to address the issue of childhood obesity, but it should not be done in a way which promotes un-equality for these children as they also have the equal rights and freedom enjoyed by every citizen of this country. By eliminating the fear based approach and reinforcement of stigmas and by promoting self -efficacy, it is possible that we can change the behavior of the concerned individuals. The new proposed campaigns would empower the caretakers and children to make a collaborative effort within their familial unit, as well as in the community, to make better and healthier choices for their health.

References:

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http://www.ccd.gov/obesity/childhood/basics.html

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4) Centers for Disease Control and Prevention:Overweight and Obesity: obesity rates among l children in the USA, Atlanta, GA. Centers for Disease Control and Prevention.2011

www.cdc.gov/obesity/data/childhood.html

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What role do media play in Preventing Obesity in Adolescent? – Mi Luo

No Person, as the poet John Donne said, is an island. Especially in recent years, mass media is full of adolescent 's lives, which can have a real impact on their decision-making. Actually, a numbers of adolescent obesity campaign were using media as a preventing tool, but did those messages affect adolescent having health behavior? This article, through the mass media’s influence on the individual level, the interpersonal level and the community level, to analysis its effectiveness of preventing obesity in adolescent.

Individual level – two problems have emerged on health benefit messages

The individual or intrapersonal level is the most basic one in health promotion practice. The Health Belief Model (HBM) and the Theory of Panned Behavior (TPB) explored the importance of individual’s perception and cognitive-behavioral in changing behaviors. In generally, almost every public health campaign has used media to explain the harmful of adolescent obesity and beneficial of losing weight. But, their advocate modes on promoting health benefit message were not target on adolescent and the overloaded health benefit messages did not play corresponding effect.

Advertisements, websites, magazines, medical journals, health lectures and health brochures, public health campaign use variety media channels and types to introduce the harmful of obesity in adolescent (1, 2). According to obesity epidemic studies, they shown overweight and obesity in adolescent was associated with hypertension, congestive heart failure and diabetes (3). And obesity girls will have higher risk on lifetime nulliparity (4). Adolescent are recommended to eat more fruits and vegetables, increase physical activities and stop overeating unhealthy calorie-dense foods and carbonated beverages in order to decrease the risk on picking up those lifelong illness. Although those study reports were scientific and rigorous, their academic style was not attractive to the adolescents. Indeed, a recent national survey reported that nearly 50% articles related to adolescent obesity had high click through rate. But only 28% of the audiences were 12- to 17-year-olds people (5), a finding consistent with another recent study (6). As a result, although the public health campaign used media-promote to let adolescent perceived the severity and benefits about obesity, the really perceivers were not the adolescent themselves but their parents. Lack of research and precisely targeting on subjects, they just succumbed to the “ EZ program structure illusion ”.

As mentioned above, obesity campaigns media also made health benefits an important means to influence desirable behaviors (7). However, as the key concepts shared by both the Stage of Change model and the Precaution Adoption Process Model (PAPM) - knowledge is necessary for, but not sufficient to produce, most behavior changes. Motivation is one of the key influences on behavior at the individual level. As a matter of fact, health communications researchers find that health benefit messages geared toward adolescents are not highly effective in changing behavior (8).

Several explanations are offered as to why health benefit messages in the healthy eating and physical activity contexts are not appealing to adolescents. In the area of healthy eating, adolescents, as a form of rebellion, generally shun the notion of messages that portray mom-approved, healthy foods (9). Adolescent populations are also thought to be more motivated to engage in or adopt a new behavior if that behavior is attached to an immediate reward (9, 10). Health benefits are not appealing because adolescents are often already aware of the associated health risks and tend to feel invulnerable to them with the assumption that they can engage in healthy behaviors in the future to avoid such problems (11). Therefore, the other flaw of media use was focusing on giving knowledge rather than mining really motivate, which could encourage them making specific plans on preventing obesity in adolescent.

Intervention on individual level – concentrate on giving motivations

According to the Stage of Change Model and the PAPM, the key point to increase the media’s effectiveness on the influence of individual levels is to find the way to motivate the adolescent progress in the Contemplation Stage in Stage of Change Model or Stage 3 in the PAPM. That is, let them intent to take an action to prevent the obesity in the next six month or deciding about acting.  The strategy for motivate people is never try to change their own attitude, never confront they already believed but to reinforce them. In terms of adolescent, their nature is to enjoy the life and have fun with their friends. It is common and even part of their life to enjoy unhealthy calorie-dense foods and carbonated beverages during the parties with their friends. If the media always gives information on how did this unhealthy food due to the obesity and the harmful consequent the obesity given to the adolescent. undoubtedly，for adolescent, those warning will just go in one ear and out the other.

To be effective, the correct way is shifting the overloaded message in prevention campaigns and the negative health consequences of obesity. Then try to echo adolescent’s attitude, showing them other choice such like having fruit salad with friends, participating in popular physical activities, walking out to enjoy the nature. Besides, both the images and the background music need to fit the adolescent style. The entire information, which media give, did not use health benefit messages, but rather identified them as an appealing lifestyle. Thus was equally to their behavior and attitude to life. The positive experience from the media will motivate them begin to have a try on those healthy life style and this was just a start, the positive effect will cumulated and eventually became their behaviors.

Interpersonal level - Focus on body-image bring undesirable behaviors

At the interpersonal level, theories of health behavior assume individuals exist within, and are influenced by, a social environment. The opinions, thoughts, behavior, advices, and support of the people surrounding an individual influence his or her feelings and behavior, and the individual has a reciprocal effect on those people. Apart from health benefit messages, public health promotion campaigns also focus on body image as another strategy of mass media. Incontrovertible，the media is influential in defining the thin ideal for adolescent. To some extent, it can promote adolescent control their weight, but it also result in unintended affects on social environment, which bring two extreme undesirable behaviors on adolescent.  

Obesity campaigns often depict thin people, or the ideal body - image, as popular and successful while also containing anti-obesity messages. But most of those anti-obesity messages had no instructive and meaningful to guide adolescent losing their weight or preventing obesity. Since the ideal body image is truly attractive, after repeated exposure to the multitude of those images, adolescent will formulate concepts that people around them, like their parents and friends were approved to have an ideal body- image. Because of the interpersonal interaction, after all, unhealthy social environments will develop. Adolescent, especially the adolescent girls will express body dissatisfaction.

Research has clearly shown that body dissatisfaction is a key risk factor for disordered eating behaviors and eating disorders (12) On the one hand, if an adolescent has already been obesity, compared with the ideal body – image and being in the social environment mentioned above. One will let oneself under a big social pressure and without confidence to change the dissatisfied appearance. This will became an obstacle for one’s to engage in health behaviors (13, 14). Both the Psychological theory of reactance and the Social Cognitive Theory (SCT) could explain this circumstance. The Psychological theory of reactance states that when the target audience feels their freedom to engage in health risk behaviors has been threatened or eliminated, they will be motivated to reestablish the threatened or lost freedom, resulting in an increased likelihood for them to engage in the health risk behaviors. The SCT declared when people faced with obstacles, if they do not feel that they can exercise control over their health behavior, they are not motivated to act, or to persist through challenges (15). On the other hand, one might expect body dissatisfaction to lead to higher levels of physical activity or increased consumption of fruits and vegetables in an attempt to change one’s body. Several correlational studies have found that girls’ magazine reading is associated with engaging in unhealthy weight-loss methods (16), wanting to look like thin models (17), and dieting to lose weight (18), which always due to nutritional deficiencies and other health problems.

Intervention on interpersonal level – proper use Social Cognitive Theory

To begin with, obesity campaigns need to avoid using body dissatisfaction as a motivator but promote a positive body image among all adolescents. However, according to SCT, if the mass media wish to real impact adolescent change to a health behavior. They should provide effective and available information to help them get self-efficacy and make reasonable goals. They also need to show the real experience about preventing obesity on other adolescent to let them gain intuitive feeling on outcome expectancies and get benefit by observing the actions of other adolescent.

Body mass index (BMI) seems to be only way to judge whether an adolescent is normal weight, over weight or obesity. But for over weight adolescent, especially the obesity, only using normal BMI as a goal was meaningless，vague and unadvisable. Media need to give adolescent scientific principles, such as losing 1,5kg/month, to help them setting small, incremental and achievable goals. This will help adolescent build self – efficacy, have clear vision on the outcome expectancies and get anticipations about how long could they have normal weights.

Medias need to insist that adolescent themselves but not their parents are active performers in preventing obesity, but they need to give support information for parents to let them using correct method to help their children. For instance, telling parents take formalized behavioral contracting with their children to establish goals and specify rewards. This could effectiveness monitoring and reinforcement the adolescent health behavior.

Based on advanced media technology, media need to make some documentary or Interview movie about the real life experience on adolescent preventing obesity, which could offer credible role model for adolescent to understand what may happened during perform the same targeted behavior.

Community level - stigmatizing obesity results in an inequality social networks and norms.

Social networks and norms, or standards, which exist as formal or informal among individuals, groups, and organizations, are considered an integral part of community level. Social networks and norms can be seen as backup force and replenishment to an individual. The more diversified forms and more close relation network the people have and more matching up with the norms and standards, the more support and positive energy the people will gain from the community level during their health behavior change. In some instances, however, the messages from the media in adolescent obesity-prevention campaigns imply personal blame and stigmatize the obese, which results in an inequality social networks and norms and eventually undercuts effectiveness of public health campaigns. (19)

A small number of stigmatizing obesity could make adolescent who are an unhealthy weight feel bad about themselves because they seem to shame the obese. This mental crisis will let them estranged from the people. As more blamed information were given by media, the previous cognitive in public of fighting obesity, to some extent, change into fighting obese persons (20), which let the obesity adolescent even more alienated from people. At last, unfair social network and norm are formed.

For adolescent, the two major social networks are their families and their schools. However, according to reports，in both the families and schools, overweight adolescents have experienced stigmatizing and weight mistreatment, such as being the victim of weight-teasing or being excluded from activities because of one’s weight.

A report shown, although after adjusting for baseline weight status, adolescents who were teased about their weight were at twice the odds for being overweight 5 years later. Additional cross-sectional and longitudinal analyses from Project EAT (21, 22, 23) and other studies (24, 25, 26) have found that weight teasing is associated with numerous negative behavioral and psychological measures, including body dissatisfaction, low self esteem, depressive symptoms, and problematic eating behaviors. These findings strongly suggest that weight teasing can have harmful consequences on various aspects of an adolescent’s well-being.

We could clearly find that the social network like this could not give any support on adolescent to prevent obesity but undercuts effectiveness of the entirety public health campaigns. Sometimes, it even alienates the adolescent they intend to motivate and hinder the behaviors they intend to encourage.

Intervention on community level – given personal empowerment for health and find the right way to give message.

First of all, obesity campaign for adolescent need to awareness their fault on using stigmatizing obesity words to give message. They should be mindful of adolescent who are obese are very vulnerable to stigma and prejudice.

However, to address this problem, more systematic research is needed in order to find what kind of message is motivate and what kind is stigmatic and then guide the content and messaging of these campaigns to and make sure they’re helping and that they’re not detrimental.

Besides, the campaign need to help the obesity adolescent recreate the helpful social network and set a fair norms and standards for them. Therefor, the media should let the adolescents known that they deserve not to be mistreated because of their weight. Furthermore, family members and student in schools need to know that weight teasing should not be allowed at home and that even comments made in a playful or joking manner are not funny and can have unintended detrimental effects. Health care providers may be reluctant to bring up these issues because they may be afraid that they won’t know what to do with the information. It can be helpful to remember that it may be most important to just listen. Through talking about these experiences, teens may be able to figure out how to deal with different situations.

Conclusion

The real world health promotion campaign involves more than simply education individuals about healthy practices. It will affected by multiple levels of influence and individual behavior both shapes, and is shaped by, the social environment. This article tries to use an ecological perspective to analysis the media role in preventing adolescent obesity. Actually, as the age of information, mass media have a huge influence in people’s life. The most significant characteristics of mass media is quickly transfer and spread all kinds of information. On the bias of this characteristic, media can be the most effective and powerful method to give appropriate, accurate and target health-promoting messages to audiences. But it could also bring widespread harmful impact if there exist flaws in the messages. Therefore, the modern public health practitioner need pay attention when using mass media campaign. 

Reference

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21. D. Neumark-Sztainer, M. Story, P.J. Hannan et al. Weight-related concerns and behaviors among overweight and non-overweight adolescents: Implications for preventing weight-related disorders. Arch Pediatr Adolesc Med 2002; 156: 171–178

22. M.E. Eisenberg, D. Neumark-Sztainer, M. Story. Associations of weight-based teasing and emotional well-being among adolescents. Arch Pediatr Adolesc Med, 2003; 157: 733–738

23. J. Haines, D. Neumark-Sztainer, M.E. Eisenberg et al. Weight-teasing and disordered eating behaviors in adolescents: Longitudinal findings from Project EAT (Eating Among Teens). Pediatrics 2006; 117: e209–e215

24. P. van den Berg, E.H. Wertheim, J.K. Thompson et al. Development of body image, eating disturbance, and general psychological functioning in adolescent females: A replication using covariance structure modeling in an Australian sample. Int J Eat Disord 2002; 32: 46–51

25. H.A. Hayden-Wade, R.I. Stein, A. Ghaderi et al. Prevalence, characteristics, and correlates of teasing experiences among overweight children vs. non-overweight peers. Obes Res 2005; 13: 1381–1392

26. R.M. Puhl, J.D. Latner. Stigma, obesity, and the health of the nation's children. Psychol Bull 2007; 133: 557–580

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5. Jones S, Fox S. Washington, DC: Pew Internet & American Life; 2009.

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19. Christine s. Moyer. Stigmatizing obesity undercuts effectiveness of public health campaigns.

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20. Puhl R, Pererson JL, Luedicke J. Fighting obesity or obese persons? Public perceptions of obesity-related health messages.Rudd Center for Food Policy and Obesity, Yale University, New Haven, CT, USA.

http://www.ncbi.nlm.nih.gov/pubmed/22964792/

Why Do Public Health Communicational Campaigns Fighting Obesity Fail? A Critique of The “Strong 4 Life” Movement- Ivi Papaioannou

          According to a 2012 report by the Institute of Medicine (IOM) (1), one third of the children in the United States are overweight or obese, and two thirds of the adults fall under the same categories. The implications of these high levels of obesity are multiple. The health consequences are well established, including cardiovascular disease, type 2 diabetes, hypertension, sleep apnea and depression. Additionally, health care costs associated with obesity- related illness are rising reaching 21% of the total annual medical spending (1). Taken into account the health, social and economic burden posed by the obesity epidemic the need for interventions is becoming of paramount importance.

          The most effective way to communicate health and nutritional information to the public is still under investigation. The goal of the policy makers is to create interventions which will be based on well established scientific data and at the same time take into account factors which might influence social behaviors (2). Moreover, mass media are dominating our lives, and thus public health campaigns communicated through the TV, radio, press, internet etc. are important components of public health interventions. Successfully, conveying a health recommendation to a well received message, is a complex procedure including different parameters like: sufficient exposure to the message, creation of a supporting environment, use of social marketing tools, assessment of exposure and at last, deep understanding of social behavior theories (3). Besides the theoretical background providing adequate knowledge for a successive intervention, the effectiveness of mass media campaigns is often questioned.

          An example of a controversial campaign is the “Strong 4 Life” (S4L) intervention (4). The campaign is an initiative of the “Children’s Healthcare of Atlanta”, to fight obesity in children. As mentioned in the website of the campaign, Georgia has the second highest rates of childhood obesity in the country and 75% of the parents seem still unable to recognize the problem. In order to address the importance of the epidemic, the movement S4L was initiated and includes several “aggressive” catch phrases in its campaign in order to awake the members of the society and motivate them to take action. Some of the messages communicated to the public are: “Fat kids become fat adults”, “Chubby kids may not outlive their parents”, “Big bones don’t make me this way. Big meals did”, “He has his father’s eyes, hid laugh and maybe his diabetes”, “Being fat takes then fun out of being a kid”, “Fat may be fun to you, but its killing me” and other. All these very direct phrases are posted under the pictures of overweight children at bus stations, billboards and many other public spaces in the state of Georgia generating a great controversy around the appropriateness of tools used for this initiative. Creators of the movement argue that the situation shouldn’t be sugarcoated and underscore that straight talk is the only solution (5). But on the other side , health experts are concerned that this type of campaign is not only ineffective but it is also damaging for the obese kids (5).

          In 2012 a one of its kind study by Puhl et al. (6) was published. The authors examined how the public perceived the messages of different mass media campaigns fighting obesity. Among the interventions included in the analysis was the S4L. The results demonstrate that among the 29 messages evaluated, those of S4L (“Fat kids become fat adults”, “Chubby kids may not outlive their parents”, “Being fat takes then fun out of being a kid”) were the less motivating and the most stigmatizing. This finding suggests that when issues of personal responsibility and blaming are implied there is less intention to comply with the intervention. S4L is an excellent example to demonstrate that even though behavioral theories should be a fundamental component of the mass media campaigns they are often ignored (3).

Critique #1: S4L stigmatizes children and fails to take into account the importance of self- esteem

There are not a few public health actors who believe that by stigmatizing bad behavior, in this case excess weight, individuals would be motivated and take action. This opinion is fully endorsed by the policy makers of S4L, as words like fat, chubby and big are the cornerstone of the “movement”. It may be a paradox, but it is believed that stigmatization may be the only solution. However, blaming individuals fighting on a daily basis with social isolation because of their weight contradicts basic assumptions of behavior theories. After all we live in a society bombarded by weight stereotypes, and if stigmatization was the gold solution the obesity rates wouldn’t keep rising. Stigma was first defined by Goffman in 1963 (7). According to Goffman stigma is a “deeply discrediting attribute” resulting in a “discounted person”. In our society the “thin norm” is promoted as it is synonymous to health, beauty and responsibility, whereas obese individuals are stigmatized by their appearance, and the visibility of fat. As a result, overweigh people are considered unhealthy, irresponsible, weak and ugly (8). In addition, it is suggested that overweight individuals tend to accept their role in the society and they function as expected by a “fat” person. They internalize the characteristics following the stigma of obesity, and they rarely challenge any negative perceptions (9). They learn to live with the stigma. By characterizing a child as “chubby” in the S4L campaign, there is a great risk that the kid will have extremely low self esteem and passively accept how the society thinks about him, as being fat and weak.

          Several studies prove the above theories in practice. It has been suggested that overweight individuals who feel bad and ashamed engage in unhealthy behaviors.  In a study by Vartanian et al. (10) in 100 female college students, participants which suffered from weight stigma had lower levels of body image satisfaction and, most importantly, were more likely to avoid exercise compared to non- stigmatized students. According to research, weight teasing among adolescents could be a risk factor for engaging in eating- disordered behaviors such as binge eating and use of laxatives (11). As an innate response to the social expectation for dieting, obese individuals may also overeat (12). It is probable that stigmatized children in Georgia  will not benefit from physical activity and will also not experience the benefits of weight loss. Even though obesity is a complex phenomenon with metabolic, genetic and social causes, nowadays mass media tend to award complete responsibility to the individual. It is highly probable that the S4L campaign in Georgia will deteriorate the physical and psychological health of overweight children. Moreover, it is expected that stigmatization will reinforce disparities. This would be of particular importance as the majority of obese kids already belong in low income or minority groups. The S4L may also mask the need for another more intuitive, efficient and effective anti- obesity intervention as other causes of obesity are overlooked. Stigmatization is a concept which needs to be addressed in public health campaigns, as it threatens both the individual and the social values (13).

Critique #2: S4L overlooks the importance of self- efficacy

          The anti- obesity messages, which are part of the S4L campaign, are certainly direct, strong and shocking. However, they lack a fundamental component of the social behavior theories, and especially of the Social Cognitive Theory (14). This component is called “self- efficacy”. Self- efficacy is defined as the “belief that one has the power to produce that effect by completing a given task or activity related to that competency”. In other words, it reflects how empowered and capable someone feels in order to reach a goal. It is hypothesized that a positive results is produced if the situation is mastered. At this point it is important to distinguish between self- efficacy and self- esteem described above. Self-esteem is associated to self- worth, whereas self- efficacy is the perception of the ability to achieve a goal (14). Moreover, according to the theory of self- efficacy, the more someone believes he can achieve a goal, the more likely he will put much effort and will persist in achieving it. In the case of the present S4L obesity campaign, children are poorly empowered to engage in a persistent behavior to fight obesity. Again, the focus of the S4L is to present raw facts and it doesn’t allow for motivation and goal setting. Given these characteristics of the S4L, children are less likely to set any proximal or distal goals, and thus reduction in calorie intake and weight loss will not be achieved (15). A common feeling of obese children, exposed to messages for “fat kids”, could be the creation of failure scenarios, resulting from doubting their capability to achieve weight control. Procrastination and avoidance are other characteristics (16).

          Several studies have been performed in the domain of self- efficacy as an important contributor in weight loss. Original research was performed by Bandura and Simmon (15). In order for Bandura, the father of the Social Cognitve Theory, to test his hypothesis, he recruited a population of obese participants which were randomized in different groups of: 1) goal setting or 2) no treatment in order to achieve weight reduction. The results of this early trail contribute significant findings in the theory of self- directed change. Specifically, a motivational and self- regulatory environment was a positive risk factor against obesity. Thus, we understand that obesity was the perfect example for Bandura to evaluate his theory. Since then a number of scientific data have been published and are in accordance with these findings. A characteristic example would be the prospective study of 2006 by Linde et al (17), in which overweight and obese participants followed treatment including cognitive interventions for weight reduction. The findings suggest that during the treatment period high self- efficacy was predictive of successful weight management. However, this association was not observed during the follow-up period, after completion of the treatment. This unique finding suggests that self- efficacy is a strong predictor for the initiation of a new behavior, but if the individual will adhere to the change depends on how satisfied they may or may not be. This is an important concept to keep in mind when designing an intervention.

          The procedure of evaluating our self begins in childhood and it is an ongoing procedure. The environment created by the S4L adds has a significant effect in damaging the ego of overweight and obese children. The theory of self- efficacy fully explains why children in Georgia will eventually become obese adults who put the needs of the society above their needs.

Critique #3: S4L fails to take into account the interaction between an individual, the environment and behavior

          Social Cognitive Theory (SCT) is a useful tool for explaining the etiology of different behaviors and for designing activities that will result in attitude changes. The SCT was used in several health promotion interventions to manipulate factors influencing individual behavior (18). The SCT (19) is a multi- factorial model which takes into account self- efficacy, described above, alongside with “cognized goals, outcome expectations, and perceived environmental impediments and facilitators in the regulation of human motivation, action, and well-being”. In other words, SCT takes into account both personal and socio- environmental determinants of health, and looks at how these reflect back to the self- efficacy of the individual.

          The S4L campaign fails to take into account the conditions which contribute, or not, in the initiation of a change. By reviewing the catch phrases of the messages (ex. “won’t outlive their parents”, “take the fun out of being a kid”) one could easily conclude that no action is proposed. After been exposed to such a slogan a child, or a family, are left with no advice. Underlying the problem will not necessarily lead into action, especially in absence of solutions. Health policy recommendations should be applicable and well endorsed by the society. Recent research (6) has shown that   individuals have a positive perception about nutrition campaign messages, if they are focusing on specific changes in dietary patterns, for example “eat more fruits and vegetables”. Other slogans receiving high intent to comply were those including multiple health and lifestyle advices, like “Eat well. Move more. Live longer.” It is well accepted that the prevalence of obesity is higher in lower socio- economic classes. It is of great importance to understand that in many cases unprivileged populations acknowledge the problem but they don’t have the education to treat it.

          Moreover, S4L could be characterized as ignorant, because it fails to take into account the environment and the social milieu where these kids grow up. Emerging literature suggests that when planning a dietary intervention, policy makers should shift their attention from the level of the individual to the environment (20). Obesogenic environments are suggested to impact both food choices and physical activity levels resulting in positive energy balance and subsequent weight gain. In a 2011 review (20) by Giskes et al., living in a neighborhood with greater access to supermarkets and lower accessibility to takeaway outlets, was a protective risk factor against obesity. On the contrary limited access to supermarkets and increased access to fast- food was correlated with higher levels of obesity. Moreover, another predictor of obesity is living in a socioeconomically deprived area which will increase the chance of reliance to convenience stores for food supply. These data add another reason to why S4L may fail.

          With 23% of Georgia’s population living in poverty, with the median annual household income being lower than the national average ($45,642 vs. $50,443) and with minority levels being higher than in other states (21), we understand that Georgia is a state that needs particular attention when it comes to designing an intervention for obesity. There are more factors than overeating and lack of physical activity which might influence the epidemic. A shocking campaign is not the solution. Based on the social theories and scientific data presented above, it seems like S4L is predetermined to fail. A multi- disciplinary approach, tailored on the specific high risk population is considered necessary.

The Intervention: Changes proposed in the mass media campaign of S4L

          According to a 2007 review on policy making (22) for obesity there is a “cacophony” dominating the field. In other words, policy makers have not yet identified what the target of the intervention should be and as a result complex schemes of intervention are proposed. This is highly attributed to the multiple causes of the disease. In anti- tobacco campaigns the solution would be to stop smoking, but when it comes to losing weight more than one advices can be given. Furthermore, and as already mentioned in the present paper, obesity is not a problem of the individual anymore, it is the problem of our society and that is the reason why policy makers are asked to contribute in the efforts to halt the epidemic.

          The present intervention will focus on changes which can be made in the S4L to address the critical points mentioned earlier in the present paper. The main focus will be on messages included in the campaign, and how these could become effective, while in accordance with the social theories for behavior. Before describing the main points of the campaign, it is important to identify our goal and our population. The ultimate goal is to lower the prevalence of childhood obesity in Georgia, the state with the second highest levels of childhood obesity in the US. Our main target population is children from families with a low socio- economic status (21). However, because it is difficult to create a different campaign for each target group (18), we assume that our intervention will have as recipients all groups involved in the obesity epidemic, from obese children and their families, to political actors, producers and food industries.

          The most important component of the proposed campaign are the messages adopted. The “slogans” should: have an explicit point in relation to why people may- or may not- engage in certain behaviors, be specific and give advice for actions instead of including general guidelines, provide easy to follow “how” and “when” information, encourage positive behaviors instead of discouraging bad ones and appear to the irrational part of the brain rather than the rational (18). How to frame the issue is critical. It is suggested that focusing on the benefits to gain, as well as recommending a specific solution are positive elements of such a frame (18). Moreover, research (6) has shown that people are positively predisposed to messages which do not emphasize on the word “obesity”. Again, focusing on the overall health of the body rather than the weight seems to be more effective. Taking into account these guidelines, some of the messages which could be incorporated in S4L are: “You have the power to do it, walk to school and change your life”, “Eat health, walk more, live better”, “Want to help your kids? You can! Cook more at home, exercise all together, enjoy family time more!”, “Take action! Make half of your plate fruits and vegetables”, “Want to eat healthier and cheaper? Make a small step and start using frozen vegetables”, “Add a fruit in every meal! Make a small change in your plate, make a big change in your life”, “Eat cheap, cook at home! Join the cooking classes at S4L”, “Give your child a better life! Learn what healthy eating involves S4L community cooking classes”, “Take action! You talk to your parents about 10 teaspoons of sugar in you soda can! Learn more at www.S4L.com”, “You chose what to eat for dinner! Visit www.S4L.com and help your parents make a healthier visit at the supermarket” and “Help your child have a healthier life. Join the S4L movement” (6). In order to take into account any rational disparities, and acknowledging that obesity levels among Latinos are skyrocketing, it would be a good idea to have some of the slogans in Spanish.

          Another component of the campaign is where are these messages going to be included? Young kids and more affluent and educated individuals tend to spend more time on the internet, while adults and poorer people respond better in printed material. Television is uniformly effective for all groups (18). In the present campaign exposure theory will be considered. According to this theory, “variation in exposure of a message, is more important than variation in the quality of a message” (23). Moreover, the more a person is exposed to a message the more likely it will take action, frequent exposure to a slogan increases the chances of reaching the individual in a state ready to receive it and finally, a message repeated multiple time and by various sources appears important. The intention of the present campaign would be to maximize exposure of the messages through: billboards, bus stations, public transportation, schools, playgrounds, tv adds, movie theaters, magazines, web, even public restrooms!

          In the next three sections the present analysis will go into the specifics of the intervention in order to address the issues which came up during critiques 1, 2 and 3 according to the principles of social behavior theories.

Defense #1: Combat the stigma

          “Fat” kids are definitely stigmatized for their whole life by reading with big bolded letters that they are at risk to die. Specific steps and ideas should be implemented to combat the formation of stereotypes. Firstly, as already mentioned, emphasis should be given in the overall health of the individuals. A recent study (24) suggests that obese individuals, who were metabolically healthy, had a better prognosis for mortality and morbidity compared to the metabolically unhealthy subjects. Thus the slogans of the intervention do not set as a goal losing weight but improving health and enjoying a better quality of life. After all, healthy dietary practices are beneficial for the population as a whole and not only for obese individuals.

          Secondly, in the S4L campaign pictures and testimonies of existing children are included. This could be the ultimate form of stigmatization, as you can watch the 10 year old school- kids calling themselves fat. It seems that these children have learned to live with this stereotype, and they have passively assumed the role our society has chosen for them. As an effort to change the components of the original S4L initiative, I would substitute the pictures of overweight kids, with drawings- sketches of normal weight children and adults promoting healthy attitudes.

          Another approach to stigmatization, moves responsibility from the individual to the “social justice” (25). According to this hypothesis a conductive social environment should be created, and this should eliminate disparities. All the individuals in the society should have equal access to resources to fight the obesity epidemic (ex. education, supermarkets, fresh produce). In terms of the present intervention, this could be part of a multidisciplinary approach of a general anti- obesity policy, accompanying the S4L slogans. It is only after the reallocation of resources is achieved that an individual can assume any responsibility about being overweight. Moreover, again in a more general spectrum, stigma could be combated through legislation against weigh discrimination, at school, work environment or health care (13).

Defense #2: Promote self- efficacy

            Depending of the feelings of the individual, responsible/ irresponsible, attractive/ unattractive etc, one is going to act accordingly. Thus, the messages of the intervention should focus on how the individuals can take action. Such empowering messages include phrases like:  you have the power to do it, you can!, take action! , make a small change, give your child a better life! etc. By creating an image of responsibility and capability about one’s self this will be turned into reality, and overweight children and their families will find the emotional strength to make a small change for themselves or for their loved ones (26).

            A characteristic example of how mass media campaign may result in significant weight loss of obese participants is the BBC’s “Fighting Fat, Fighting Fit” (FFFF) campaign(27). In this large scale intervention (N= 2,112 at follow up), participants were exposed to the main message of the campaign (“fight obesity with small and permanent changes to diet and exercise”) for 7 weeks through the BBC network. One of the cornerstones of the campaign was promoting self- efficacy, self- monitoring of behavior change and encouraging participants to take action, join groups, and make life- style changes by using the resources available in the community. According to the findings, 75% of the individuals experienced some weight loss and increase in their physical activity. The take home message of this study, which could apply to the present S4L campaign, is that repeated exposure to an empowering message can actually be beneficial for weight management.

            VERB was another successful intervention, managed by the Department of Human and Health Services and the Centers of Disease Control and Prevention (28). This mass media campaign was designed to empower twins and engage them in physical activity. The VERB initiative contributed significant results and provided guided for future research. One of the implications of VERB is that “persuasion should be used beyond education”. This is a component also adopted in the proposed catch phrases of the modified S4L , as many among them aim for the irrational part of the human brain (ex. Want to help your kids, change your life, live better, make a big change in your life).

            It has also been suggested (17), that high self- efficacy itself is not an adequate predictor for weight loss. Self- efficacy may promote weight control behaviors, which effectiveness is not guaranteed. As a result, the messages used to empower receptors of a campaign should be carefully chosen, and should have high specificity (ex “make half of your plate fruits and vegetable”, “exercise for 30 minutes on a daily basis”, “visit our website etc.”). In other words our modified intervention will focus not only in motivating our target groups, but will also provide guidance to engage themselves in effective practices.

Defence #3: Take into account the social milieu, and adopt a multidisciplinary approach

          Shifting our attention from the individual to the environment begins with framing the issue differently in a mass media campaign. It is the society’s role to create an environment in which it will be easier for the obese individual to make a healthy choice. This would include not only motivation to consume more fruits and vegetables, but also making them more accessible as a part of a multidisciplinary policy (29). Part of this notion could be the solutions provided to low income families (ex. “Want to eat healthier and cheaper? Make a small step and start using frozen vegetables”), and the translation of the messages in Spanish.

          Moreover, policy campaign terminology should evolve. Excess weight should be associated with the context in which the behavior occurs, in other words with the environment and the circumstances. In the specific milieu the individual should become aware of which are the healthier choices (ex. fruits and veges, cook at home), what does more active mean, etc. Additionally, using descriptive phrases such as healthful eating are considered effective (29).

          The obesity campaigns are at the point where tobacco campaigns were 30 years ago. After many years tobacco policy makers learned how to distribute the responsibility between the individual and the society. By now, it is clear that smokers should make a great effort to quit smoking, but at the same time social actors should provide a smoking-free environment (29).

          Mass media campaigns are only one tool used in public health policy. In order to reverse the obesity trends a multidisciplinary approach is necessary, which will be based on a holistic approach of the system. Moving from increasing physical activity time and modifying dietary factors to concomitant changes in agriculture, food industry, taxation and education, is considered critical (22).

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