Monday, May 10, 2010

A Critique of Why the "Are You Pouring on the Pounds?" Campaign Will Not Prevent Weight Gain -Kate Sullivan


Soda, Gatorade, lemonade and ice tea. Refreshing drinks or dangerous drinks? What do these drinks have in common? Tons of sugar. These non-nutritive beverages are wreaking havoc on the weight of millions of Americans. What used to be an occasional treat has turned into a basic food group.
“Gross”, “disgusting”, “I can’t look at it” were comments made by passengers on the New York City subway system late last year (3). What these people were commenting on was a new public health campaign organized by the New York City Department of Health and Mental Hygiene (NYCDHMH), called “Are You Pouring on the Pounds?” The posters placed in the subway system show a soda or other beverage being poured out of a can or bottle into a cup and as the liquid reaches the cup, it turns into yellow globs of fat riddled with blood vessels. The department wanted a shocking campaign to catch people’s attention by focusing on the hazards of sugar-sweetened beverage consumption and to increase people’s awareness of how soft drinks contribute to weight gain and eventually to obesity (1). The campaign was short and focused. It ran for three months at the end of 2009. The message accompanying this image exclaims “Don’t drink yourself fat.” (1) NYCDHMH spent three years and $277,000 researching and developing this campaign.
The New York City Department of Health and Mental Hygiene was stirred to action because of studies showing connection between health problems and sugar-sweetened beverage consumption. To understand the SSBs consumption habits of its citizens, the health department conducted a survey. The 2007 Community Health Survey found that among adult New Yorkers, two million adults drink at least one SSB each day for a caloric intake of 250 calories (1). Serving sizes have increased and with that, increased consumption of empty calories. The department is looking to raise awareness of its citizens through the “Are You Pouring on the Pounds?” campaign about the hazards of SSBs. They are recommending substituting water, seltzer or low fat milk as alternatives (1).
It may be common knowledge that too many calories consumed leads to weight gain. SSBs have played a special role in the rising obesity rates is adults and children. From 1977 to 2001 the consumption of SSBs increased by 135% (7). Besides the infiltration of sodas into the American diet, SSBs also take the form of teas, sports drinks and fruit-based juices. SSBs all contain large amount of sugar. The calories contained in SSBs are empty calories and provide little nutritional value. When people drink SSBs, rarely do they take into account the extra calories. A randomized, double-blind study was conducted by Raben et al to compare the effect of calorically sweetened beverages with that of diet beverages (8). The study showed that the calories from SSBs did not replace food calories, but were additional calories to the diet (8). Those participants who were given the caloric sweetened beverages gained weight during the study and those who drank diet beverages did not (8). This is why the New York City Department of Health and Mental Hygiene is trying to decrease SSBs consumption.
Articles about the campaign are plentiful. Journalists from The New York Times, The Daily News and the British Broadcasting Corporation discussed the effectiveness of the “shock” campaign and interviewed various people. Opinions were mixed. Some people interviewed felt that this kind of campaign would work, others thought it wouldn’t. Many websites and blogs discussed the merits of the campaign (4). Claire Prentice, writing for the BBC News, interviewed a mother and daughter who were riding on the subway. The daughter was quoted as saying “gross” and the mother claimed that she never realized the amount of sugar in SSBs (3). Prentice spoke with a NY psychologist, Jonathan Alpert. He supports the shocking advertising and claims that in makes people think about what they are putting in their bodies. On the flip side, an advertising expert, George Parker, was critical of the campaign. He warned that it might backfire because the image is so gruesome people will turn away before the whole message is absorbed (3). The New York Times interviewed Cathy Nonas, director of Physical Activity and Nutrition programs. She said that the campaign was definitely going for shock value. She also said that the campaign was tested on focus groups and the “graphic in-your-face” approach would work (2). In the Daily News, Adam Lisberg spoke with Associate Commissioner Geoff Cowley. Cowley claimed that “being ‘positive and encouraging’ is not always useful in getting people to change behavior, sometimes you have to get into people’s faces to get attention (4).”
The New York City Department of Health and Mental Hygiene is not the first health department to raise awareness of the link between SSB consumption and obesity. During the summer of 2008, the Bay Area Nutrition and Physical Activity Collaboration in the San Francisco area conducted a campaign called “Soda Free Summer.” The idea behind this campaign was to get people to pledge not to drink soda over the course of a summer. The tools of this campaign included log books, pledge cards and wrist bands which were designed to keep the participants engaged through out the summer (5). Another campaign, called the global “Dump Soft Drinks” campaign is an international effort to improve children’s health and diet around the world. The campaign has succeeded in persuading Coke and Pepsi to provide more healthy alternatives at school vending machines is the Unites States and European Union (6).
There are three flaws in the “Are You Pouring on the Pounds?” campaign. The first flaw is that the campaign relies on the Health Belief model. This traditional model puts the onus on the individual to make a change. It relies on rational thought processes and planned behavior. The second flaw is that the campaign used fear to get the message across to the target audience. The third flaw is that the campaign targeted the proximal causes of SSB consumption.

Critique 1
“Are You Pouring on the Pounds?” is a campaign geared towards the individual. The NYCDHMH is asking each citizen of New York City to reconsider his/her SSB habit and substitute water, seltzer, or low-fat milk. This campaign is modeled on the Health Belief Model which is a traditional health behavior model. It is based on the motivation of the individual to adopt healthy behaviors and is comprised of several factors: perceived susceptibility, perceived severity, perceived benefits of an action and perceived barriers to taking that action (9).
The campaign is geared towards the individual: “Don’t drink yourself fat” (1); it is based on rational thought: “I will stop drinking SSBs now”; and it is planned behavior: “Next time I choose a beverage, I will drink water or milk.” The perceived benefits are less chance of obesity. The perceived susceptibility and severity is whether or not the individual believes that drinking any amount of SSBs will cause them to gain weight and to what extent will they become over weight and suffer health consequences if they don’t follow the health advice of the campaign. The perceived barriers to reducing SSBs consumption may be price of other beverages (fruit drink and soda are cheaper than milk); convenience (most SSBs do not need to be refrigerated while milk requires refrigeration) and water may not be appealing (SSBs are tasty and enjoyable, and therefore hard to give up). People may not be willing to spend money on bottled water but also may feel that tap water in their home is not good for them. Water fountains are not well maintained, many are broken, in disrepair or they look unhygienic so people are unwilling to drink from them.
Because this campaign is based on rational and planned behavior of the individual, it fails to take into account the irrationality of the individual. The campaign has created an expectation that if a person continues to drinking SSBs, he/she will become obese and have health problems. This campaign tries to educate individuals on the hazards of drinking SSBs and gives healthy alternatives, but it does not acknowledge that individuals really like SSBs and do not want to give them up; people “own” their SSB consumption.
The campaign is asking the individual to make a decision regarding beverage choice. If the individual does not follow the recommendation, something bad will happen: the individual will gain weight. The campaign is over estimating the ability of any one person, on their own, to make a change and gives no long term support to the individual.
Self-control is also an issue in this campaign. Whenever one wants to give up something, there are always others around who are doing the behavior. It’s hard to say no to soda when your best friend is drinking it. The individual faces added pressure about beverage choice because not only is drinking SSBs socially acceptable, people have been lead to believe through incessant advertising, that SSBs will make you socially acceptable.
The developers of this campaign used the Health Belief Model when they developed this campaign but fell into the “EZ program structure illusion.”(9). The message it provides “SSBs turns to fat” and people should stop drinking it for the sake of their health seems simple enough but the campaign fails to take into account expectation, ownership, framing of core values, context and self-control.

Intervention 1
Juxtaposed to the Health Belief Model with its emphasis on the individual is the Ecological Model for Health Promotion which recognizes that behavior is complex and there are many “factors” involved. The factors involved in this model are intrapersonal factors, interpersonal factors, institutional factors, community factors and public policy (10). The Ecological Model for Health Promotion recognizes that a range of strategies are necessary in health promotion activities (10).
One can understand the desire of the New York City Department of Health and Mental Hygiene to want to reach as many people as possible throughout the city. Putting the ads in the subway system would logically reach a lot of people in a short amount of time. Although their intentions were good, they wasted their money. The ads are catchy, and have a good tag line but are soon forgotten once the individual leaves the subway.
New York City Department of Health and Mental Hygiene would have been wise to target a community in which SSBs consumption is the highest. According to a survey conducted by the NYCDHMH, the Bronx had the highest consumption rates of all the boroughs surveyed (11). The ecological model says that intervening at the individual level is not enough. The community should be part of the intervention: “the purpose of an ecological model is to focus attention on the environmental causes of behavior and to identify environmental interventions” (10).
The Soda Free Summer campaign would have been a good model for New York City to use in the Bronx. The Bay Area Nutrition and Physical Activity Collaborative used an inter-disciplinary approach to reduce SSB consumption. “The soda free summer campaign consisted of a variety of activities to reach residents in the six San Francisco Bay area counties.” (5) The campaign involved the individual by distributing pledge card and logs to track progress through out the summer. The completed pledge cards could be turned in and entered into a raffle to win a prize. Promotional material was distributed to remind people of the program. Wrist bands were distributed to the participants that helped maintain a sense of community: “you are not alone in your endeavor”. Workshops were offered to educate participants on the sugar content of beverages and the health risks associated with sugar consumption. Community factors were applied to the program: school districts, public health departments, community groups, clinics and hospitals assisted in the campaign through a variety of outreach channels. Public policy factors were employed. Political leadership was engaged in the campaign (5). By using aspects of the ecological model, the campaign was a success: 47% of the participants reported a decrease in their soda consumption as a result of the campaign (5).
Money may have been a factor but if the New York City Department of Health and Mental Hygiene had used this model to target a particular community such as the Bronx, they might have made an impact by reducing this type of beverage consumption on the community with the highest consumption level of SSBs. This could then have been used as a model for other communities throughout New York.

Critique 2
The New York City Department of Health and Mental Hygiene framed their campaign with fear. The fear in this campaign is weight gain from drinking SSBs. “Fear appeals are persuasive messages designed to scare people by describing the terrible thing that will happen to them if they do not do what the message recommends” (12). Whether a message is rejected or not depends on the level of threat as well as the level of efficacy, i.e. the ability to do something about it. (12).
Many public health campaigns have used fear to motivate individuals to change their behavior. For example, the drug-resistance campaign that used a frying egg to simulate how a person’s brain looks on drugs used fear to change people’s behavior (12). Fear models such as the Extended Parallel Process Model (EPPM) use the elements of fear appeal as the basis of their model (12). There are four important components to the fear appeal process: fear, threat, efficacy and outcome variables (12).
A fear appeal can be explained by examining the content of the fear appeal, (gory pictures of crash victims) or fear appeals can be explained by the reaction of the target audience. The target audience can give self-reported levels of fear or instruments can be used to measure the physiological state of the target audience. The fear appeal targeted to the audience in this campaign is that if you drink soda, you will gain weight and have health problems (12). Fear is a negative emotion and has been described by various researchers as anxiety, concern, worry or physiological arousal (12). In this campaign, the fear of weight gain may cause anxiety. Since the campaign does display a glob of fat riddled with blood vessels, negative emotions are aroused and the images in the campaign are labeled as ‘gross” (3). Threat is an external stimulus variable that exists whether a person knows it or not (12). Threats are categorized based on severity of threat (12). In this campaign, the threat can be categorized as the severity of the weight gain and extent of health problems. A person may gain a couple of pounds or hundreds of pounds; have few health problems or many. Efficacy is the targeted audience’s ability to perform the recommended response (12). In this campaign, efficacy is the ability of the target audience to reduce the amount of SSBs in their diet. In the fear appeal, the researcher is looking for message acceptance as an outcome. The outcome does not always lead to message acceptance. Sometimes avoidance and reactance are the outcome (12). The outcome of the campaign is the actual response of the target audience to the message. The target audience may reduce consumption of SSBs, therefore the message was accepted. There may be no change in consumption habits in which case the message was avoided. The worst outcome would be an increase of consumption in defiance of the message, indicating the message had the opposite effect.
Although the campaign fits into the EPPM and this model can explain how the target audience will react to the fear appeal, researchers don’t know how effective fear campaigns are. “Beck and Frankel (1981) noted that the parallel process model is the most broad of the fear appeal theories and although virtually untestable, offers a nice frame work in which to further theorize (12).”
If the EMMP provides a framework, other researchers have explored reinforcement in relation to fear appeal. The effective use of fear is when fear is coupled with reinforcement; this is called “response- fear offset pairing (13).” An example of the type of situation that uses “response-fear offset pairing” is the pairing of seatbelt use with an outcome. Seatbelt-use campaigns have tried to get the target audience to use seatbelts. The underlying message of wearing seatbelts is that if you don’t wear seatbelts, you could die. Even though this could happen, the likelihood of it happening is very small, so the target audience rejects the message. When seatbelt-use messages are reinforced with laws that allow police to ticket and fine non-seatbelt users, the target audience embraces the message and wears seatbelts (13).
This campaign did not use fear successfully. “The use of fear is only likely to work under particular circumstances involving the identification of specific behaviors which successfully reduce the fear aroused (13).” Although the images of fat in a glass are unsettling, the threat of weight gain and the risk of poor health are not strong enough to trigger a change in the target audience because there is no appropriate reinforcement i.e. response-fear offset pairing. A reasonable reinforcement could be a tax added to sugar-sweetened beverages. Increasing the price of SSB would impact the “wallet” of the target audience.
When changing a behavior it is also helpful to see immediate results of the change (13). The target audience may feel that they have been drinking soda for a long time and it has not caused them any harm. Even if the target audience did give up drinking soda, it may be along time before they saw any positive results (weight loss). In addition, it would be impossible to judge if in fact the target audience was able to avoid poor health outcomes from reducing SSB consumption. Researchers recognize that health promotion should not be the removal of unhealthy behaviors but of the reinforcing of healthy behaviors (13). The overall message of “Are You Pouring on the Pound?” is a fear-invoking message dictating the decrease of SSB consumption instead of a positive message encouraging consumption of water or milk.

Intervention 2
The New York City Department of Health and Mental Hygiene should take some cues on promoting healthy beverage choices from the “got milk?” campaign. The campaign used humor and what the advertisers called a milk deprivation strategy (14).
For years drinking milk was promoted as “the key to good health”. Dairy advertising, public relations efforts and the government worked together to encourage milk consumption. For a while the idea of good health from drinking milk worked. But in the 1990s due to other beverage choices made available to consumers, milk consumption declined. SSBs were fun to drink; their packaging was colorful and had innovative designs. This was in contrast to milk which was packaged in boring cardboard cartons and plastic jugs (14). In order to increase sales of milk, the California Milk Processor Board hired a San Francisco ad agency to create a new campaign. “Got milk?” campaign became one of the 1990s most popular and critically acclaimed advertising campaigns (14).”
Money aside (the advertising agency had a $23 million per year budget) the advertisements were effective because they appealed to a core value that was something other than health. Although many people surveyed thought of milk as a compliment to certain foods, the advertising team decided not to sell milk as a complement to those foods (14). Instead, the ad agency used a milk deprivation strategy mixed with humor. The television ads showed people put in silly situations where milk was not available. For example, one commercial showed a man going to heaven and there were chocolate chip cookies everywhere. As he ate the cookies, he grabbed carton after carton of milk, and they were all empty. He began to wonder if he was in heaven after all. This helped to sell milk because the commercials were humorous and people could relate to that feeling of being without milk when it was needed it most (14).
What the New York City Department of Health and Mental Hygiene could have done to “sell” water was use a deprivation strategy. The campaign could reach the target audience by portraying people performing strenuous activities and then not having the most thirst quenching beverage available: water. Posters with an image of someone in the dessert seeing a mirage of water, but not being able to reach it might have portrayed a water deprivation scenario. Making the image enjoyable and positive would have a greater impact than showing an image that is disturbing and negative.

Critique 3
“Are You Pouring on the Pounds?” addresses the proximal causes of weight gain. It maintains that if you drink soda and other soft drinks you, the individual, will gain weight. Telling the individual to cut back on SSB consumption is futile in light of marketing tactics, availability, social norms and policies. Beverage companies target children and teens in their advertising campaigns. For example, the Sprite “Obey Your Thirst” campaign featured rap artists and basketball players combined with “playful cynicism” to create a brand that became popular with urban youth (14). The availability of alternatives such as water fountains is not taken into consideration. The campaign doesn’t take into account the wide availability of SSBs. Everything is geared towards making drinking beverages easy. There are reminders every where that you too can be carrying a beverage. SSB are available everywhere: in corner stores, vending machines, grocery stores, and street vendors. The fact that people bring their drinks where ever they go is not addressed. There are very few places where it is not acceptable to carry around a beverage. Schools allow students to have drinks in class. Cars have beverage cadies as do strollers and shopping carts. SSBs are portable, inexpensive and do not spoil if not refrigerated.
SSBs are served to the youngest members of society, usually in the form of fruit juices. At an early age, children are given juice during the day are snack or meal time. They are conditioned at an early age that sweetened beverages are normal. The Federal Government endorses the consumption of sweet beverages (juices) because there is concern that young children are not getting an adequate amount of fruit in their diet. The Dietary Guidelines for Americans recommends fruit juice consumption by children (15). Since SSBs are a normal part of every day life from early on, asking people to give up SSBs is not practical.
People are taught from early on that sugar-sweetened beverages are a normal part of their diet. This is further reinforced by the wide-spread availability and social acceptance of SSBs. SSBs are ingrained in the American diet. It is unrealistic to expect people to change their behavior when even the government is encouraging people to drink SSBs.

Intervention 3
Efforts to reduce SSB might be better addressed at the distal level. From a rational point of view, the individual has control to a certain extent but people are not rational. Putting policies in place such as requiring beverage manufacturers to make some labeling changes and even levying a tax on sugar-sweetened beverages would go along way in changing people’s relationship to SSBs.
Sugar-sweetened beverages are packaged and bottled in various configurations. Some juices are packages in colorful cartoon featuring favorite cartoon characters. Each juice box represents one serving. The box is around 6-8 ounces and may have a calorie content of 100 calories. This is a reasonably sized portion and represents the small end of the scale for size. Many SSBs are available in 2 liter or ½ gallon-sized bottles. These SSBs contain numerous servings. Most people would agree that this size is not a single serving size and would adequately serve a number of people. This represents the large end of the scale. In between the juice box and the 2 liter bottle is a landscape of bottles of various sizes and shapes. Are the bottles in between single serving containers or are they multiple serving bottles? Even though the 20 ounce soda bottle claims that it contains 2.5 servings, how many people are really going to share that bottle? In actuality, the 20 ounce bottle is one serving. Even if a smaller size beverage is available, it is not priced as favorably as the larger size so one may feel a little “ripped off” buying it. Larger sizes are considered a “value” because they are cheaper per unit measure. Buying in bulk is cheaper on the wallet but drinking in bulk carries the hidden cost of weight gain.
Bottlers have been getting better about labeling their bottles. They may still consider that the 20 oz bottle provides 2.5 serving, but some bottlers are also putting the calorie content of the entire bottle on the nutrition label as well as the calories “per serving”. This type of labeling was recommended by the FDA’s Obesity Working Group “encourage manufacturers immediately to take advantage of the flexibility in current regulations on serving sizes and label as a single-serving those food packages where the entire content of the package can reasonably be consumed at a single-eating occasion. For example, a 20 oz bottle of soda that currently states 110 calories per serving and 2.5 servings per bottle could be labeled as containing 275 calories per bottle.”(16) Not all bottlers are doing this but consistent labeling of the calorie content of the bottle will help consumers make better choices.
Another way to reduce SSB consumption from a distal vantage point that has caused a lot of controversy is taxing SSBs. Public health groups advise taxing SSBs would lead to decreased consumption and subsequently reduced health problems. Many consumer groups see taxes as regressive, affecting poorer people disproportionately (17). On the other hand, poorer people have greater health problems related to a nutrient-poor diet and would benefit from reducing the consumption of sugar-sweetened beverages (17). According to Brownell and Frieden, the best way to implement the tax is to use an excise tax (17). This type of tax structure taxes a fixed cost per ounce at the manufacturing level. This cost would be passed on to the consumer and it would be seen as the true purchase price of the beverage (17). The sales tax, on the other hand, is added on to the beverage at time of purchase. At this point the consumer has already made their choice or feels obligated to pay since they are already at the cash register (17).
According to Brownell et al, taxing SSBs would reduce the amount of consumption because of “price elasticity” which is described as consumption shift caused by price (18). The price elasticity for all soft drinks is the range of -0.8 to -1.0 (18). This means a decrease in consumption from 8-10% if there was an 8-10% increase in price of the beverage. Consumers would switch to diet beverages (which would not be taxed) if their favorite SSB becomes too expensive, or perhaps to a smaller size container if available (18).
Reducing consumption of SSBs through taxation would in turn lower risks of obesity, diabetes and other diseases. The tax money raised could go to obesity prevention programs geared towards children and teens.

The New York City Department of Health and Mental Hygiene sponsored a campaign that was geared towards getting people to change their sugar-sweetened beverage habit. The campaign focused on the individual instead of looking at the larger community, it used fear instead of positive reinforcement and it targeted the proximal causes of weight gain instead of looking at distal causes. One New Yorker said it well, “They look kind of lame (the posters). We’re bombarded with so many messages and these don’t stand out (3).” Unfortunately, the message may not be heeded and New York City will likely have wasted taxpayer money.

1 New York City Department of Health and Mental Hygiene. Are You Pouring on the Pounds? Health Bulletin, 2009.
2 Chan, Sewell. “New Targets in the Fat Fight: Soda and Juice.” New York Times. 01 September 2009. Web. 02 April 2010.
3 Prentice, Claire. “Anti-obesity as shocks New Yorkers.” BBC News. 07 October 2009. Web. 31 March 2010.
4 Lisberg, Adam. “Controversial new subway billboards show human fat being poured out of soft drink bottles.” Daily News. 21 August 2009. Web. 02 April 2010.
5 Bay Area Nutrition and Physical Activity Collaborative. Getting the Soda Free Message. San Francisco, CA: Bay Area Nutrition and Physical Activity Collaborative. 2009.
6 Center for Science in the Public Interest, International Association of Consumer Food Organizations. Global Dump Soft Drinks campaign. Web. 02 April 2010.
7 Malik, Vasanti S, Schulze, Matthias B., Hu, Frank B. Intake of sugar-sweetened beverages and weight gain: a systematic review. American Journal of Clinical Nutrition 2006; 84: 274-88.
8 Bray, George A., Nielsen, Samara Joy, Popkin, Barry M. Consumption of high-fructose corn syrup in beverages may play a role in the epidemic of obesity. American Journal of Clinical Nutrition 2004; 79: 537-43.
9 Individual health behavior theories (chapter 4). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp. 35-49.
10 McLeroy, Kenneth R., Bibeau, Daniel, Steckler, Allan, Glanz, Karen. An Ecological Perspective on Health Promotion Programs. Health Education Quarterly. 1988; 15(4): 351-377.
11 New York City Department of Health and Mental Hygiene. Are You Pouring on the Pounds? Press Release # 057-09. 31 August 2009. Web. 09 April 2010.
12 Witte, Kim. Putting the fear back into fear appeals: the extended parallel process model. Communication Monographs, 1992; 59: 329-349.
13 Job, R.F. Soames. Effective and Ineffective Use of Fear in Health Promotion Campaigns. American Journal of Public Health, 1988; 78(2): 163-167.
14 Holt, Douglas B. Got milk? Advertising Educational Foundation. 2002. Web. 08 April 2010.
15 United Stated Department of Agriculture. Is Fruit Juice Dangerous for Children? Washington, DC: Center for Nutrition Policy and Promotion. March 1997.
16 Food and Drug Administration. Calories Count: Report of the Working Group on Obesity. Obesity Working Group. 2004. Web. 15 April 2010.
17 Brownell, Kelly D., Frieden, Thomas R. Ounces of Prevention-The Public Case for Taxes on Sugared Beverages. New England Journal of Medicine 2009; 360(18): 1805-1808.
18 Brownell, Kelly D. et al. The Public Health and Economic Benefits of Taxing Sugar-sweetened Beverages. New England Journal of Medicine 2009; 361(16): 1599-1605.

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