Monday, May 10, 2010

Battling the Obesity Epidemic: Why the Small Steps Campaign Does Not Work – Anar Pardhan

Obesity is a serious problem in the United States and a growing concern for public health. The Merriam-Webster dictionary defines obesity as “having excess body fat,” (1) and the CDC measures obesity by the body mass index – a number based on weight and height (2). Recent data estimates that one third of all Americans are considered to be obese (3). One of the most alarming facts is that childhood obesity has tripled in the past twenty-five years (4). The problem with obesity is not the excess body fat, but what the excess body fat can do to the overall health of an individual. People who are obese have a myriad of health issues: hypertension, hyperglycemia, type 2 diabetes, heart disease, stroke, liver and gall bladder disease, sleep apnea, respiratory problems, osteoarthritis and certain types of cancers (5). With a high prevalence of obesity in the U.S. and the host of health problems that it can create, it then poses a great financial burden on the health care system (6). Economists estimated the cost of obesity in 2000 was approximately 117 billion dollars (7), and it was also estimated that 300,000 deaths per year were associated with obesity (7). Hence there have been many campaigns implemented to address this serious issue that some have called an epidemic.

In 2004, the federal government implemented the Small Steps campaign to combat obesity ( The goal of this campaign according to the Health and Human Services Secretary at that time, Tommy Thompson, “is to have people take small, achievable steps to improve their health and reverse the obesity epidemic” (8). The website has many different features; for example, it offers different health tips of day called “small step tips,” it offers the facts and consequences about obesity, gives tips on what to eat and what foods to avoid and gives recipes that even include desserts. The campaign also featured a series of television and print ads that focused on the body. In one television ad, a boy is playing outside and he discovers a body part; a fake large human belly. In another television ad, a couple of normal body weight are about to take their seats at a movie theatre, and the women ends up sitting on some fake back fat. In both ads, the message trying to be conveyed is that if you skip the extra serving or go for the small portion amount, you can lose belly fat and back fat. In several of the print ads, very close up shots of a heavy stomach, thighs and buttocks are portrayed. The ad indicates that these body parts can be slimmed down by becoming more active or eating healthier. The message of these television and print ads is very important, but making overweight bodies look disgusting and ugly can be very offensive to people who are overweight. Hence, how effective can these ads be if they portray the overweight body in a negative way?

The first flaw with these particular ads is that they perpetuate stigma against the obese. Renowned sociologist Erving Goffman defined stigma as “a process by which the reaction of others spoils normal identity” (9). It is well known that overweight or obese people are stigmatized in society, for example children that are obese have been teased and bullied by other children (10), and health professionals also treat their obese patients differently (10, 11). The role of stigma in public health is not new. The United Nations has recognized that stigma plays an important role in the HIV epidemic and has recommended providing funding to reduce HIV stigma (12). The opposite is the case for obesity campaigns. Stigma is not considered a problem in most campaigns (11, 12). In fact, some believe that stigma can be used to help control obesity (11). The perception is that stigma will motivate individuals to change their habits and engage in healthy behaviors like exercising and eating healthy. If weight stigma was able to do this, then obesity should be of no concern to the health community and obesity rates should be extremely low. Sadly, this is not the case. Instead of obesity rates declining, in the past decades they have been drastically rising (3). Also, studies have shown that individuals who have internalized obesity stigma are more likely to engage in binge eating and avoid exercising (11). In a study conducted by Puhl and Brownell, they asked over 2400 overweight or obese women on how they cope with stigma. 79% of the women said that they coped by eating, and 75% said that they also coped by refusing to diet (14).

Weight stigma can also cause decreased psychological health (11). By internalizing stigma, an individual may increase psychological stress as well. Psychological stress itself can cause compromised physical health such as: hypertension, heart disease, type 2 diabetes, and other conditions associated with obesity (15). When people are stressed they also tend to engage in unhealthy behaviors. For example, they may smoke more or start smoking again to cope with the stress. Therefore, it is not surprising that rates of smoking among obese individuals are very high (15). Smoking alone has its own host of health problems. Not only does obesity pose a wide range of health issues, one also has to take into account the impact stigma has on health, specifically stress and smoking.

Since obesity poses a negative risk to a person’s health, individuals who are obese should seek medical care on a regular basis and should be participating in preventive screening programs like cancer screening. Unfortunately, this is not the case. Obese individuals avoid seeking medical help because they feel that they are being disrespected and not treated the same as people who are considered to be thin (11, 13, 14). For these reasons, the Small Steps campaign’s use of weight stigma to educate Americans is not having a positive impact. Instead, the use of stigma engenders the opposite of what this campaign is trying to achieve.

Another flaw with this campaign is the negative image it portrays of obese individuals. It does this by addressing the labeling theory, which states that a person will behave in a particular way if they are described in that way (16). For example, if a female student is told that she will not be able to excel in calculus because she is a girl, she now believes that she will be unable to do well. This belief creates a self-fulfilling prophecy, and she will perform very poorly when she does start calculus. In the Small Steps campaign, a Health Tip is featured everyday on the website. Health tip #92 states: “Walk instead of sitting around” ( This particular tip is insinuating that obese individuals sit around all day and do nothing. Hence, this creates a negative label: that all overweight or obese people are lazy, and they sit around all day doing nothing. Society already views obese individuals as being lazy, lacking self discipline and having poor will power (17). By having this type of negative labeling, the campaign is blaming the individual for his or her weight problem, which can cause further psychological stress to the individual. Studies have indicated that obese individuals are reluctant to seek medical care, because they feel that the health care providers are blaming them for their weight problems (11, 14). According to the labeling theory then, obese people will internalize this label and view themselves as lazy and having poor will power. Therefore, the very goal of this campaign will not be met; instead of helping and encouraging a healthy lifestyle that promotes physical activity and healthy eating habits, it is contributing to the obesity epidemic.

Additionally, the negative imagery in this campaign will cause the individual’s self efficacy to be very low. Albert Bandura’s social cognitive theory and the concept of self-efficacy state that in order for a person to perform a certain behavior successfully, he or she must believe that he or she has the power to complete the behavior with the desired outcome (18, 19). In other words, the individual has to believe that he or she can succeed in a particular task in order to be successful at it. But how is this possible when the campaign does not give individuals the power that they need to be successful at weight loss? Focusing on the appearance of the obese body is not appropriate, because it only will add to the obese person’s dissatisfaction with his or her body image. All of this will cause the individual’s self-efficacy to be low and not high. The individual will not believe that they are able to do behaviors that will make them successful at losing weight so they will not even bother to try it. This campaign is creating an environment that does not promote positive thinking and it is not giving the tools that are necessary to promote self-efficacy. Therefore by having the campaign focus on imagery of body parts that are considered to be obese, is not only offensive but it is also very insensitive to overweight and obese individuals. Obese individuals have body image dissatisfaction and low self-esteem and this can cause a negative impact on their behavior, quality of life and psychological wellness (20).

A third ineffective aspect of the ads in the Small Steps campaign is that the message is delivered at the individual level. This is a weakness, because an individual’s behavior is affected by the groups that he or she belongs to. There is an increased risk of obesity when you have friends that are obese (21). A study done to examine smoking cessation showed that individuals did not stop smoking by themselves; instead, clusters of individuals stopped smoking at once (22). In the “get active” tab in the campaign’s website, it shows a very attractive slender young women stretching. Instead of having a single person stretching, the campaign can show a group of individuals stretching at an aerobics class or a group of people walking together at the beach or park. When a group of young adults were interviewed, they considered socializing more important than exercising or eating healthy (21). If the campaign can feature ads targeting young adults as a social group, this can be more effective than targeting individuals, according to social network theory. By targeting a group of people who belong to the same social circle or network, one does not have to work at the individual level because groups of individuals can be affected at the same time. Social norms theory also applies here. Social norms theory states that “much of people’s behavior is influenced by their perception of how other members of their social group behave” (23). For example, if a group of college friends party every Friday and Saturday night and get drunk each of those nights, then a new person who wants to join this group will believe that he or she also needs to behave the same way. On the other hand, if the same group of people goes for a run every Saturday or Sunday morning, the new person will believe that he or she also needs to go for a run every Saturday or Sunday morning. Therefore, if the anti-obesity campaign focuses on influencing behavior at the group level, it will be much more effective in capturing a larger number of Americans rather than trying to influence behavior one person at a time.

While there are many flaws with this campaign, there are some aspects of it that I would keep. I would keep the section on health tip of the day and make sure that the tips chosen are not negative in any way and promote overall health. For example, I would keep health tip of the day #149: “Be realistic. Make small changes over time in what you eat and the level of physical activity you do. Small steps often work better than giant leaps.” I would also keep the online recipes, because people who are unable to cook often fail to eat healthy foods. I would also keep the desserts in the recipe section, because this can teach people how to eat sweet foods in a healthier way.

In the improved campaign, I would include a section of ads featuring overweight and obese individuals that follows their progress over time. In addition to following individuals, I would also follow a family that is overweight and show their progress toward healthier behaviors. On the website, there would be an entire section devoted to these people detailing their progress. Each participant would have an online diary detailing how they feel throughout the journey to a healthier lifestyle and letting the public know about their struggles and joys. I would also, with the permission of the participants, print medical data on their cholesterol levels, blood pressure, triglyceride levels and weight; before and after they started this journey. This would show the public that by changing to a healthier lifestyle their overall health can improve through reducing the risk of obesity related diseases. In the new campaign, I would also have section on the website that is devoted to groups or clubs that want to join and make a pledge of becoming healthier. This could be something as simple as a group of stay at home moms pledging to walk thirty minutes three times a week or the math club at the local high school pledging to train and run in a five kilometer race.

By having ads that feature overweight or obese people going through their journey of getting healthy, the new campaign tells a personal story to the American public. Overweight or obese individuals can relate to this story and become inspired to pursue healthier behaviors. These will be real stories about real people and models or actors will not be used in the campaign at all. The Massachusetts Department of Public Health (MDPH) ran an anti-smoking campaign many years ago that featured young mother Pam Laffin, who was suffering from emphysema. In this campaign, they featured her story and her health struggle as a result of smoking. This ad had a profound effect on the public, and smoking rates among the youth decreased a great amount (24). By showcasing individuals, this can help to motivate others in their struggle to achieve a healthy lifestyle.

In the story of the family that is featured, I would choose a family whose children have health problems because of their weight. I would not have any statistics of obesity related health issues because the public does not relate to numbers as well as it does personal stories. Most people tend to have optimistic bias. That is, people tend to underestimate the risk that applies to them and convince themselves that this will not happen to them (24). Hence, by focusing on one family’s struggle with weight and health problems, this will motivate other parents who are in the same situation to act now before it is too late. By motivating parents to make positive changes in their health and lose weight, their children will be encouraged to lose weight as well. Studies have shown that parent’s weight is a strong indicator for childhood obesity, and studies have also shown that children do lose weight in combined parental and child weight loss programs (25). Since childhood obesity is a great concern today, it is important to address this issue in the campaign.

As mentioned earlier, The Small Steps campaign is targeting the audience at the individual level. Having groups join the campaign and make a pledge will motivate and encourage them to become healthier. If the group chooses, they can keep track of their progress on-line for the entire public to see. This way, they can inspire other groups to do the same thing. By targeting groups and changing their perception on health and weight, one can change the social norms of that group, thereby changing or influencing the behavior of others. Special attention will be made to groups that are teenagers or young adults, because trends have shown that most individuals will become obese before the age of 35 (21). Hence if the campaign can target groups before they turn 35, progress can be made in the obesity battle. One group in particular that can be targeted is young adults who attend college. People who attend college gain weight much quicker than the general population (21) and this puts them at a greater risk for obesity related diseases. Since socializing is a large part of the college experience, we aim to allow students to socialize while being physically active. This way, they are not only doing something that they enjoy (socializing), but they are also doing something that is positive for their health.

Additionally, the campaign can provide support to the colleges by helping them create a healthier environment for their students. By creating a healthier environment, it makes it easier for students to make the changes needed to become healthier. For example, they can put up posters in the dining halls or the classrooms that promote healthy eating or regular physical activity. But instead of saying how this will improve your health, the poster can say that these activities will give you more energy, reduce your stress and improve your social life. These are the core values that are important to this age group. In contrast, being healthy is not very important for this age group; preventing heart attacks or diabetes is not on their radar at this point in their life. Hence, by choosing a message that college age kids can relate to will convince them to adapt to a healthier lifestyle.

Lastly, the improved campaign will feature positive imagery of overweight or obese individuals rather than the negative ones currently portrayed. I would remove all ads that feature body parts of obese individuals, because this very insulting to them. I would also replace all pictures of slender, attractive models and replace them with photos of real people who are overweight or obese. Instead of having the picture of the slender women stretching, I would have a picture of an overweight women stretching, indicating that overweight and obese individuals are not lazy and that they do exercise. This will help to remove the negative label that obese people are lazy. A positive image also helps to create a higher level of self-esteem and belief in oneself. Once again, instead focusing on the core value of health, the ads would then focus on the core value of self-esteem. If health was an important core value, then one third of Americans would not be obese. Also by removing the label of laziness, not only will the individual’s self-esteem improve, but this will also give the individual hope and power to make positive changes in their life. Again, the core value of health does not factor in on these ads. So by improving the individual’s self-esteem and by giving them hope and power, their level of self-efficacy will increase. When their level of self-efficacy is high, then, according to Bandura, they will believe that they have the power to complete a specific task with the desired outcome (18, 19). In this case, the task is physical activity or healthy eating and the outcome is improved health.

In conclusion, obesity is not only a problem in America, but it is a problem throughout the world. Experts predict that by 2025, obesity will be the world’s number one health problem (10). A campaign that perpetuates weight stigma and negative body images and that is only implemented at the individual level will not be effective at all and it will only continue to contribute to the obesity problem. The new campaign will not focus on the individual but on groups of people. Therefore, it will change the societal attitudes and eventually the social norms. It will also feature ads with positive imagery and remove all negative labels to instill self-esteem, power and hope. Finally, the campaign will feature stories of normal Americans, including an entire family, and how they have made positive changes in their lives. It will demonstrate their improved quality of life. Taken together, these changes will result in a better, more effective campaign.

1. The Merriam-Webster Dictionary. Springfield, MA: Merriam-Webster, Incorporated, 2004.
2. Centers for Disease Control and Prevention. Overweight and Obesity. Atlanta GA: Centers for Disease Control and Prevention.
3. Flegal KM, et al. Prevalence and Trends in Obesity Among US Adults, 1999-2008. JAMA 2010; 303(3): 235-241.
4. Skelton JA, et al. Prevalence and Trends of Severe Obesity Among US Children and Adolescents. Academic Pediatrics 2009 Sept-Oct; 9(5): 33-39.
5. Roberts D. Addressing Overweight and Obesity as Health Problems. Medsurg Nurs 2010 Jan-Feb; 19(1): 9.
6. Bachman KH. Obesity, Weight Management, and Health Care Costs: A Primer. Disease Management 2007 Jun; 10(3): 129-137.
7. Office of the Surgeon General.
8. Hellmich N. Anti-Obesity Public Service Ads May be Too Much to Stomach. USA Today March 9, 2004.
9. Goffman E. Stigma: Notes on the Management of Spoiled Identity. New York, NY: Simon and Schuster, 1963.
10. Vaidya V. Psychosocial Aspects of Obesity. Advances in Psychosomatic Medicine 2006; 27: 73-85.
11. Puhl RM, Heuer CH. Obesity Stigma: Important Considerations for Public Health. American Journal of Public Health 2009: 159491.
12. Reducing HIV Stigma and Discrimination: A Critical Part of National AIDS Programmes. Geneva Switzerland: Joint United Nations Programme on HIV/AIDS; 2007.
13. Maclean L, et al. Obesity, Stigma and Public Health Planning. Health Promotion International 2009 Vol.24 No.1 88-93.
14. Puhl RM, Brownell KD. Confronting and Coping with Weight Stigma: An Investigation of Overweight and Obese Adults. Obesity (Silver Springs) 2006 Oct; 14(10): 1802-15.
15. Muennig P. The Body Politic: the Relationship between Stigma and Obesity- Associated Disease. BMC Health 2008; 8:128.
16. Wikipedia. Labeling Theory. Wikimedia Foundation Inc.
17. Puhl RM, Heuer CA. Weight Bias: a Review and Update. Obesity (Silver Springs) 2009; 17(5): 941-964.
18. Bandura A. Self-Efficacy: The Exercise of Control. New York, NY: W.H. Freeman, 1997.
19. Wikipedia. Self-efficacy. Wikimedia Foundation Inc.
20. Dalle GR, et al. The Effect of Obesity Management on Body Image in Patients Seeking Treatment at Medical Centers. Obesity (Silver Springs) 2007 Sept; 15(9): 2320-7.
21. Strong KA, et al. Weight Gain Prevention: Identifying Theory-Based Targets for Health Behavior Change in Young Adults. J Am Diet Assoc. 2008 Oct; 108(10): 1708-1715.
22. Christakis N, Fowler J.H. The Collective Dynamics of Smoking in a Large Social Network. New England Journal of Medicine 2008; 358: 2249-2258.
23. The Main Frame: Strategies for Generating Social Norms News October 2002, 1-46.
24. Siegel M. Boston University, Boston MA. 1 April 2010. Lecture.
25. Andrews KR, et al. Parents as Health Promoters: A Theory of Planned Behavior Perspective on the Prevention of Childhood Obesity. Journal of Health Communications 2010; 15:95-107.

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