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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6) Ebbeling  C B, Pawlak D B, Ludwig D S; Childhood Obesity: Public Health crisis, common sense cure: The Lancet, Vol 360; (9331) August 2002, 473-482.

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8) Farooqi S I, O’Rahilly SO.  Recent Advances in the Genetics of Severe Childhood Obesity.  The Archives of Disease in Childhood 2000;83:31-34.

9) Viner RM, Cole TJ.  Adult Socioeconomic, Educational, Social and Psychological Outcomes of Childhood Obesity:  A National Birth Cohort Study.  The British Journal of Medicine 2005;330:1354-1359.

10) Selling to- and selling out- children (editorial) Lancet 2002; 360; 959

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12) Mongtgomery K C . Children’s media culture in the new millennium: Maping the digital landscape. The future of children. 2000; 10:145-167

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15)American Academy of Pediatrics (2003). Policy Statement. Prevention of pediatrics overweight and obesity. Pediatrics, 112 (2); 424-430

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2005 Dietary Guidelines (“9-A-day Campaign”): A Public Health Campaign Launched to Fail - Sandrine Batonga

 The 2005 Dietary guidelines: 9-A-Day Campaign

There is solid evidence that high fruit and vegetable consumption plays a major role in lowering risk of chronic illnesses such as heart disease and stroke, and contributes to lowering total mortality (1). Thus, in 2005, as they have been doing every 5 years since 1980, the US Department of Health and Human Services (HHS) and US Department of Agriculture (USDA) released the 2005 dietary guidelines which increased the recommended daily servings for fruits and vegetables from five to nine (based on a reference 2,000-kcal diet) (2). These dietary guidelines, also known as the “9-A- day campaign”, came after the “5-A-day campaign” which was not proven effective based on the expected outcomes and funding invested. Indeed, studies have shown that the 5-A-day campaign only increased food consumption by 30 points, well below the expected target (3). In 2007, only 40% of Americans met the former 5-A-Day guidelines, and fewer than 10% appeared to meet the 2005 guidelines and subgroup recommendations for fruits and vegetables (4).

Missing an opportunity to correct the previous campaign’s mistakes and missing the opportunity to examine in depth why only 40% of Americans were able to eat 5 servings of fruits and vegetables per day despite the generated investments, the 9-A-day campaign carries some of the same flaws of the preceding public health intervention. These flaws include incorrect assumptions on people’s access to fruits and vegetables, disregard of the influence of environmental factors, and price in particular, on Americans’ eating habits and flawed advertising approach.

Unequal access to fruits and vegetables

The 9-A-day campaign, as the 5-A-day campaign, dismissed the existence of a fruit residential distribution. Low-income, minority-dominated urban neighborhoods are often considered as food deserts, as supermarkets have vacated these communities (5). A lot of people do not consume fruit and vegetables not because they do not want to, but because they don’t have access to them and lack quality and variety of healthy products.

Research has shown that low-income and African American neighborhoods have fewer supermarkets but more liquor stores and convenience stores than higher income and White neighborhoods, respectively (6). Fewer healthy food options and lower quality foods, even after accounting for store type, in low-income and African American neighborhoods have also been documented (7). Thus, residents of African American and low-income neighborhoods tend to face more environmental barriers to healthy eating than residents of other neighborhoods.

A qualitative study by Zenk and colleagues sought to understand food acquisition behaviors and environmental factors that influence those behaviors among women in a low-income African American community with limited food resources. Women in the study described that material barriers to food acquisition included store availability, store upkeep and food availability and quality. Several women indicated that the lack of a full-service supermarket in their neighborhood was an obstacle in obtaining food. These women wanted a supermarket that was convenient and within walking distance especially women without a car (8).

The lack of availability and variety of some foods at neighborhood retailers (which include healthy foods) is evident in low-income neighborhoods. Fresh produce was commonly identified as missing from the neighborhood, among others, by the women in the study. Many felt that food options were particularly limited when compared with other types of neighborhoods, even among stores of the same type (8).

Of the foods available in the neighborhood, poor quality was another material impediment to obtaining products, especially for fresh foods, but sometimes for packaged foods as well. Women described withered fresh fruits and vegetables, rotting “green” fresh meats, and expired canned and packaged foods which definitely constitute a turn-off for visiting stores that provided them (8).

Lastly, another hindrance to healthy food access is safety. However, poor customer service or treatment, poor upkeep, crowding, and unsupportive sales practices also discourage families from seeking healthy products at available stores. The lack of safety was identified as a major social-interactional deterrent to food acquisition at local stores. Many safety concerns stemmed from problems with people hanging out in front of stores, panhandling, soliciting drugs, and harassing shoppers (8). Such issues are again prevalent in economically disadvantaged neighborhoods.

Price: a Major Environmental factor

Food price is yet another environmental factor that influences food consumption. Replacement of fats and sweets with vegetables and fruit has become a standard public health recommendation. However, little to no consideration has been given to diet costs. Whereas fats and sweets provide dietary energy at a very low cost, the energy cost of lean meats, fish, vegetables, and fruit is likely to be higher (9). Following advice to replace one with the other is far from being a simple public health application, and will most likely entail higher consumer diet costs (9).

Cassady and colleagues, in their study of 25 supermarkets in varying income-level neighborhoods in Sacramento and Los Angeles found that fruits and vegetables prices varied by neighborhood income and by store type. The cost of vegetables in the 2005 Dietary Guidelines market basket was significantly lower in supermarkets in higher-income neighborhoods than in middle-income neighborhoods. There was no significant difference between fruits and vegetables prices in stores located in very-low-income and low-income neighborhoods (10).

Fruits and vegetables from bulk stores costed 14% less than from independently owned supermarkets, and 17% less than traditional chain supermarkets. In addition, prices in very-low-income neighborhoods varied within the same city and supermarket chain by 17%, and within the same city and same bulk store chain by 52% (10).

Even when average price of fruits and vegetables were found to be surprisingly less in low-income neighborhoods, the cost of a complete market basket (i.e., one that contains breads, dairy, and meat in addition to fruits and vegetables) remains the greatest in very-low- compared to high-income neighborhoods (11). In places where on average low-income consumers would pay less for fruits and vegetables compared to their middle- and high-income neighbors, there are nevertheless several important cost barriers for the low-income consumers who wish to meet dietary guidelines (10).

First, only the careful selection of the store will guarantee that low-income shoppers pay less, because prices vary across stores in very-low-income areas, for instance by 65% in Los Angeles and 76% in Sacramento (10). Even within the same chain prices varied noticeably. Second, the cost of a 2005 Dietary Guidelines fruit and vegetable market basket will require substantial changes in the family food budget. As shown in the study by Drewnowski and colleagues (12), increasing the consumption of more healthful foods is not simply a matter of substituting grapes and broccoli for cupcakes and chips. This change also involves changing the food budget for consumers. American families spend 15% to 18% of their at-home food budget on fruits and vegetables. It seems unlikely that consumers would be able to increase their spending on fruits and vegetables by 200% to 400% without substantial changes elsewhere in the food budget, or from other household expenditures. For low-income consumers this may be especially challenging because there are few discretionary funds available in these other accounts (10).

A family of four shopping in a very-low-income neighborhood would pay on average $1,688 annually to meet the 2005 Dietary Guidelines recommendations. A family of four using food stamps in California receives on average $3,888 each year (13). Therefore, the 2005 Dietary Guidelines fruit and vegetable market basket would require 43% of the food stamp budget. According to the US Department of Labor, households in the lowest two income quintiles spend an average of $2,410 each year on food at home (14), which means lower income households would have to allocate 70% of their food-at-home budget to the 2005 Dietary Guidelines fruit and vegetable market basket (10).

Advertising techniques

Besides failing to take into account all the previous environmental factors, HHS and USDA failed to properly advertise the 2005 Dietary Guidelines. Although campaigns efforts included national mass media campaigns, activities in supermarkets, and community interventions in schools and at work sites (15), HHS and USDA invested substantially less in their campaign than what would be required to launch effective campaigns such as the ones the food industry do (15). Moreover, the advertising techniques used were defective in that they did not utilize empowering messages of control as suggested by the advertising theory.

Television has been cited as a contributing factor to higher dietary energy or fat intake (3). Exposure to food advertising, especially commercials for fast food or convenience foods, influence viewers' food choices toward higher-fat or higher-energy foods (3). The food industry also extensively uses new technologies for this purpose today. Food manufacturers, retailers, and food service spent $11 billion in 1997 on mass media advertising, second only to the automotive industry (15). In 1997, Coca Cola spent $277 million on advertising (3). In 1998, McDonald's spent $571.7 million and Burger King spent $407.5 million (3). These figure contrasts with the $29.8 million spent by the “milk mustache” and “got milk?” campaigns in 1996 and the $1 million spent in 1999 by the National Institutes of Health/National Cancer Institute to promote the “5-a-day” message (15). In 1997, the entire amount spent by the USDA on nutrition education, evaluation, and demonstration was $333.3 million, 3% of what the food industry spent in 1997 (15).

Relative to national dietary recommendations, foods that are most heavily advertised are those that are over-consumed, while those that receive less advertising are under-consumed (15). Confectionaries and snacks, prepared convenience foods, soft drinks, and alcoholic beverages are the most heavily advertised foods, whereas fruits and vegetables are among the least advertised foods (15). These data are consistent with overall food advertising expenditures, where in 1997 $792 million was spent on advertising breakfast cereals, $765 million on candy/gum, $728 million on beer, and $549 on carbonated soft drinks. By contrast, only $105 million was spent advertising fruits and vegetables (15).

Furthermore, the 9-A-day campaign does not send messages of empowerment and control to the public. This campaign is based on health benefits and promises of health instead of putting forth people’s deepest aspirations and dreams.

The HHS and USDA 9-A-day campaign is flawed in many ways as it fails to account several social and behavioral sciences theories including the advertising and marketing theories. Specific measures to address the specific flaws mentioned should be put in place in order to improve this campaign of great importance for Americans and the future of America. Ways to correct this campaign comprise making fruit and vegetables affordable for low-income populations who still struggle to meet the 5-A-Day campaign, increasing fruits and vegetables availability in neighborhoods where healthy products are scarce and not only considerably increase the advertising budget allocated to dietary guidelines but also completely reframe this issue.

The NO Limits Movement

To help the public meet dietary guidelines, a movement that promotes the absence of limits in life to fulfill dreams should be launched. This movement should rally motivated believers of freedom and justice as well as believers of the fact that dreams can come true and that anyone should have the possibilities to become who he/she wants to be.

The NO limits Movement will be about self-empowerment and justice. Its activities will include active advertising that merely refers to fruits and vegetables but with the subtle underlying message that all the roads to success pass by fruits and vegetables. Indeed, in order to freely achieve his or her goals, one must be in good physical shape as a healthy diet confers, one must have equal opportunities and equal access to promising routes as would confer a developed neighborhood where fruits, vegetables and transportation are readily available.

The NO limits movement will have a website to connect all NO limiters, and let them share their success stories as well as offer tips on various topics including job interviews and career advancement tips. The website will additionally advertise places who sell fruits and/or vegetables at affordable prices, and it will publicize creative (quick and elaborate) healthy menus in order for viewers to incorporate vegetables in daily meals. The site will also display locations and rotations of NO Limits trucks that provide free fruits donated to the organization as well as locations of where local sellers, with the help of NO Limiters, will periodically set their stands in neighborhoods with low healthy products access.

Farmers’ Markets and Free Fruits Trucks

In order to precisely address the unequal distribution of fruits and vegetables, their availability, quality, and transportation issues in low-income neighborhoods, the NO Limits movement will sponsor free fruits and vegetables distributions events as well as bring farmers’ markets to underserved communities. Although just a few well-designed studies have evaluated the influence of farmers' markets and community gardens on nutrition-related outcomes and further studies are recommended (16), these studies suggest evidence of a positive impact of bringing farmer’s market to low-resource communities.

 

Bringing fruits and vegetables to the communities in need does make a difference in their consumption. Caldwell and colleagues found that the perceived access to fruits and vegetables only - that a market or a truck for instance would procure - is associated with increased consumption (17). The average increase in fruit and vegetables consumption was 2.52 servings weekly from start to 1-year follow-up for 130 participants from nine communities participating in community-based programs emphasizing fruit and vegetable consumption in Colorado (17). Greater perceived access to fruits and vegetables was significantly associated with higher increases in fruit and vegetable consumption from program start to program end. Greater availability of produce was associated with greater increases in fruit and vegetable servings from program start to program end as measured by store assessments. Caldwell et al. recommend that interventions with the goal of increasing fruit and vegetable consumption consider focusing on increasing access to fresh fruits and vegetables in target communities (17). The latter are exactly the objectives of NO Limiters massive mobilization for the development of farmers’ markets all over the nation and expansion of distribution events.

NO Limits will strive for distributions of diverse and fresh fruits, as greater variety has been associated with increased fruits and vegetables intake (18). NO Limiters would also challenge through different types of actions including protests food chains to take their limits off, and be pioneers, bold enough to open branches in less affluent neighborhoods.

Cheaper Fruits and Vegetables

In addition to making fruits and vegetables available to communities that lack them to help them meet the dietary guidelines, the cost of these food items should also be reduced, if not free. Cost constitutes a tremendous barrier to meeting dietary guidelines. Farmers’ markets, in addition to improving access to healthy food items, have been proven to offer lower prices as foods are more expensive at small food retailers (19). Larsen and Gilliland demonstrated that the introduction of a farmers’ market in a food desert increased the availability of healthy food and lowered the overall food costs for households in the neighborhood. Although everyone in the neighborhood would not necessarily shops at the farmers’ market, a cost-saving opportunity should be made available (19).

NO Limits would actively reach out to local farmers, city/neighborhoods’ non-farmers markets sellers and local authorities to buy into this trend of open low-cost fruit markets everywhere. NO Limits will also advocate for extending existing or creating new voucher systems for fruits and vegetables to disadvantaged populations.

 The WIC (Women, Infants, and Children) Farmers' Market Nutrition Program already provides eligible individuals with vouchers redeemable for fresh fruits/vegetables at approved farmers' markets (20). It is a federal–state partnership that begun in 1992 by the USDA (20). The two primary objectives of the Farmers' Market Nutrition Program are to provide fresh produce to low-income women, infants, and children up to age 5 years; and expand awareness, use, and sales at farmers' markets. Local governments determine Farmers' Market Nutrition Program participation. USDA provides 100% of Farmers' Market Nutrition Program food costs and 70% of administrative costs; local governments are responsible for 30% of administrative costs (21). Local governments may elect not to participate in the Farmers' Market Nutrition Program because of costs or lack of farmers' markets in the area (22). NO Limits goals will then be to expand the list of approved farmers’ markets by the USDA’s program and again encourage markets implantation for increased access and actual usage of the vouchers when acquired.

Dollahite and colleagues found that the Farmers' Market Nutrition Program was associated with increased fruit/vegetable consumption among program participants (23). The average number of servings of fruit and vegetables per day, 7.5, was higher than the 4.4 servings reported among non-Hispanic African-American women in the 2000 National Health Interview Survey. In general, economic supplement for fruits and vegetables purchase whether at farmers’ markets or other types of vendors seems to improve consumption.  Herman et al. study of 454 low-income women (predominantly Hispanic) in Los Angeles confirmed this pattern. The women were provided vouchers for fresh fruit and vegetable purchase in the Special Supplemental Nutrition Program for WIC. They used the supplement provided almost fully, and purchased a wide variety of fresh fruits and vegetables for their families (24).

Additionally, it was found that participation to the Farmers' Market Nutrition Program increased the use of farmers' markets which support the previous argument of creating farmer’s market in the first place. The movement will thus organize protests in front of local governments that declined having the Farmers' Market Nutrition Program to encourage them to do so or put in place alternative vouchers systems for low-income citizens.

Powerful Advertising and Marketing

Last, but certainly not least as they will represent some of the most important components of this movement are the advertising and marketing of NO Limits. The NO Limits campaign will rely on extensive advertising and presence on the web, advertising on TV, posters on buses, transportation stops and billboards to name a few. The sentence NO Limits will appear on a picture of bright sky on posters. The meaning of NO Limits should become the new mystery in town each time the campaign is physically launched somewhere through inexplicit posters. NO Limits would be the new brand of success and the movement people who do not wish to be limited by others or circumstances identify with.

HHS and USDA as well as other public health and non-profit organizations will be solicited to generously invest in the marketing and advertising of the movement. As previously mentioned, substantial funding of high-quality, appealing and persistent marketing campaigns is key to success as shown by the food industry and illustrated by the “Truth” campaign (25).

As per the advertising theory, NO Limits’ message will include in addition to the promise that success is attainable, extensive support through bright images, catchy words, ideal music (when applicable) and the portray of different determined individuals achieving their goals in sports business, and/or school. The power of advertising and marketing through a promise and support has been proven effective many times including in the “Truth” campaign (25). NO Limit will be for NO Limiters who refuse to be limited by others and circumstances but work to attain success.

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