Monday, May 10, 2010

Drinking Life Away in New York City: A Critique of the Pouring on the Pounds Campaign

In the past 20 years the incidence of obesity has been continuously rising in the U.S. and most recently around the world (1). The prevalence of obesity is a serious public health concern because it is a major risk factor for cardiovascular disease, certain types of cancer, type 2 diabetes, and lifetime morbidity (2). According to the Centers for Disease Control and Prevention (CDC), in 2007-2008 around 33% of Americans were obese and nearly 68% were overweight, ranking the U.S. as the number one country in the world with the highest rate of obesity (1). If current trends continue, it is estimated that 75% of Americans will be overweight or obese by 2015 (3). Research has stated that the rising trend of obesity in the U.S. has been consequent to the suboptimal eating habits and sedentary lifestyles of Americans (2). This unfavorable lifestyle leads to the lack of energy balance, which is the precise cause of overweight and obesity (4). Consequently, obesity and overweight occur over time when you take in more energy or calories than you use.

To combat this trend, many intervention programs have been designed to encourage consumption of healthier foods along with heightened physical activity. In 2009, the New York City Department of Health and Mental Hygiene implemented the Pouring on the Pounds public communications campaign in order to highlight the health impact of sweetened drinks (5). The campaign was designed in lieu of the proposed, but highly debated, 18% “obesity tax” on sugary sodas and juice drinks (6). Instead, the Health Department decided to target drinking habits to combat obesity by designing a public awareness campaign. Sugary drink consumption was chosen as the area of focus for this campaign because research has shown that more than 2 million New Yorkers drink at least one sugar-sweetened beverage a day, adding as many as 250 empty calories to their diets, which puts the human body at increased risk for a multitude of diseases (5). The campaign urges people to drink lower-calorie alternatives or limit their portions.

The message of the campaign is disseminated through public ads in city subways, educational brochures, the campaign website and most recently through a viral Internet video. The main component of the ad is a poster of disgusting, unadulterated, gelatinous fat substituting for soda as it pours into a cup. The video, titled Man Drinking Fat, shows a man pouring fat out of a soda can and drinking it as it drips out of his mouth. It ends by exhorting the audience to choose healthier alternatives like water, seltzer or low-fat milk. The ads work to demonstrate that we are literally pouring on the pounds and drinking ourselves fat by consuming soda and other sugary beverages. According to the Health Department, the video was produced to playfully send out the message that sugar-sweetened beverages are fueling the obesity epidemic and disabling millions of New Yorkers (5). The goal of the campaign is to shift drinking habits even slightly by gruesomely depicting the health impact of sweetened drinks.

Although the campaign was recently launched, it has had successful exposure due to the mediums of communication used. Not only has the Health Department chosen to place their ads in highly trafficked city subways, but also set up and placed ads in social media networks such as and Together, these networks have had over half a million hits in the past few months and word-of-mouth exposure is becoming viral. However, aspects of the campaign are flawed and susceptible to scrutiny.

The Campaign Does Not Account for Behavior Influenced by Context

The goal of the Pouring on the Pounds campaign is to change human behavior by embedding nauseating images of the health impact of sugary drinks. The first assumption of the campaign is that behavior is planned and rational. It is assumed that by viewing the gruesome ads, people will be disgusted and decide to eliminate or reduce sugary drinks from their diet. This concept is partly correct. In a hot state, during exposure, people might discard their beverages or avoid drinking for a few hours (7). However, the objective of the campaign disregards the concept that human behavior is dynamic and that it is influenced by context (7). It is visceral drives, or instinctive unreasoning, that control people’s behavior (7,8). Visceral factors refers to a wide range of drive states, including hunger, thirst, and sexual desire. According to a research studying the effects of emotions on economics, visceral factors can alter desires rapidly because they are affected by changing internal bodily states and external stimuli (7). The emergence of a new situation generally alters the present course of action and alters behavior (7). For example, a person purchasing a drink at Starbucks will transition to an alternative hot state to accommodate their environmental context. Exposure to images and menu options at the store or restaurant will now influence their purchasing behavior. Their decision is based on situational awareness defined by the context of their environment. This concept further suggests that the environmental context has a greater impact on unfavorable eating habits. This could be demonstrated by the considerable gap in the prevalence of obesity found among neighborhoods or cities with differing socioeconomic levels.

East Harlem, a low-income minority community, has the highest rates of obesity in New York City (9). According to a report by the Health Department published in 2006, one third of East Harlem adults are overweight or obese (9). The demographic profile of the neighborhood consists of predominantly African-American and Hispanic residents. Over 38% of the population in the community is below the national poverty level, which is nearly twice as high as in Manhattan and NYC overall (9). Similar to other low socioeconomic communities, the built environment of the neighborhood is comprised of fast food restaurants, bodegas and affordable energy-dense food grocers (10). The area also has 18 schools with fast-food restaurants within one-tenth of a mile (10). This is not surprising since researchers in New Orleans recently discovered that fast-food restaurants are geographically associated with low income, and in particular African-American, neighborhoods (11). These neighborhoods average twice as many fast-food restaurants per capita as white neighborhoods, making fast food a more likely choice for their residents (11).

High rates of obesity in low-income neighborhoods demonstrate that a stronger correlation exists between eating habits and the neighborhood residential context (12). A recent report stated that studies have not been able to link a uniform change in perceived control of health, but instead suggest that environmental and social factors can affect one’s sense of control over one’s own health (12). Therefore, public service announcements that seek to modify human behavior will only work if risk factors are modified or reduced within the context of the built environment.

The Perceived Cost Undermines the Perceived Benefit

Motivating people to modify behavior remains a critical and unmet challenge in the U.S.(13). This is especially true with modifying eating habits and physical activity. Research suggests that there are four motivational factors that are modifiable and may be influenced by education, experience and coaching: 1) Perceived chances of success, 2) Perceived benefit of the goal, 3) Perceived cost, and 4) Inclination to keep old habit (13). The most pertinent factors for this campaign are perceived costs and perceived benefits of giving up sugary beverages. This is so because people ultimately decide whether to adopt or reject behavior based on the balance of the appraisal of these factors.

Applicable to the Pouring on the Pounds campaign, the perceived benefit of modifying behavior is losing 10 pounds a year by not drinking one can of soda a day. Although it is not mentioned in the ads, it is implied that this change will ultimately reduce the risk of obesity as well. Conversely, the perceived cost of the campaign is eliminating or reducing sugary drinks from their diets. Instead of deciding to drink sugary drinks, the ad encourages consumer to drink water, seltzer or low-fat milk. The perceived cost in this equation, however, has a high significance in the U.S. due to the embedded traditions of sugary, not healthy drink, consumption (14). Events such as happy hours, bar-b-ques, sports outings, etc., have accustomed Americans to a drinking habit that often promotes sugary drinks. These habits have given significant social value to the context around sugary drink consumption. Although the campaign aims at changing life-long habits, if fails to connect healthy habits to the rhythm of life. Stating alternative drinks as bland and boring options does not strengthen the proposal to change drinking habits. Expecting people to change lifelong sugary beverage consumption needs to be supported by a strong promise to the consumer (15). Instead, stating that only a 10 pound weight gain could be prevented weakens the perceived benefit of giving up sugary beverages and associated social norms. To a portion of the population, especially those who are overweight, a 10 pound difference might not be worth the cost of giving up their drink of choice. To these people, the perceived chance of successfully modifying habits involves more than just giving up sugary drinks. This is especially true when linking behavioral risk factors, aside from social norms, to drinking habits. Instead, perceived capability and confidence has a stronger influence on initiation and self-efficacy (16). To this effect, the campaign fails to frame the issue in a way that gives strength to a change in social norms and ultimately a rippling effect on individual behavior. The intention to modify behavior is focal and crucial, yet the content of the campaign dominates the message instead of the outcome. Moreover, the campaign also uses the unadjusted approach that one sugary beverage is consumed every day. Therefore, those who consume less sugary beverages will consider the ad irrelevant instead of incorporating the overall message.

To overcome the common obstacles of modifying behavior, framing the issue in a way that gives people control and a broad sense of choices must be used (17). If the goal of the intervention is to get a high level of reactance, a program that implies a change in social norms will be more influential than targeting individual behavior (18).

The Campaign Reinforces Negative Social Stigma Towards Unhealthy Weight

Obesity has had in increasing trend for the past two decades. Yet as Americans are becoming more overweight, the standard for attractiveness remains thin and fit while overweight people are widely stereotyped as lazy, unattractive, and lacking self-discipline (19). The constant exposure to the idea of beauty as slim and proportioned has created a negative and stigmatized perception towards the overweight and obese. Not only has this created a pool of isolation, but numerous studies have examined a variety of social stressors, including discrimination, stigma and low socioeconomic status, all of which have been linked to poor health outcomes (20).

Weight-based stigmatization is defined as “negative weight-related attitudes and beliefs that are manifested through stereotypes, bias, rejection, and prejudice towards people because they are overweight or obese” (20). Acknowledging this perception, it is assumed that most obese people would like to become more fit. However, for so many leading a healthy lifestyle is a very difficult undertaking. They may give much energy towards trying to change their personal behaviors to acquire attractiveness, but their attempts continually fail.

The message of the Pouring on the Pounds Campaign reinforces this social stigma by producing a disgusting reaction of fat, which reflects a negative view of unhealthy weight. This is opposed to a good or proactive view of healthy weight. The message only serves to further internalize negative association of unhealthy eating habits. Studies that have examined the relationship between weight-based stigmatization and psychosocial functioning, state that in addition to affecting emotional well-being and social functioning in obese people, stigmatization can also negatively impact health behaviors (20). Stigmatization or the perceived threat, as the campaign message indirectly implies, has been associated with increased weight concerns, dieting, binge eating and unhealthy weight control and bulimic behaviors (21-23). This suggests that the objective of the message could be counterproductive and ineffective to prevalent cases of obesity.

Addressing and Implementing an Obesity Intervention in New York City: A Cultural Approach

The demographic profile of New York City is unique in its level of diversity. According to the U.S. Census Bureau, in 2006 over 3 million or 36.7% of the population in New York City was foreign-born (24). A recent report by the Department of City Planning states that the Newest New Yorkers, or immigrants, tend to live in enclaves of highly dense low-income neighborhoods (25). Intertwined with socio-economic disadvantage, obesity is also largely prevalent in these neighborhoods of the city (11). These neighborhoods are mostly comprised of minority or immigrant families who have assimilated to some degree to U.S. eating habits. This is evident by contrast of the Latino Paradox which refers to the epidemiological finding that Latinos in the U.S. tend to paradoxically have substantially better health than the average population in spite of what their aggregate socio-economic indicators would predict (26). Instead, the high prevalence of obesity, especially among Black and Hispanic children, supports the concept that the health status of immigrants deteriorates after acculturation to U.S. norms (26). Although obesity is widespread, a behavior modifying intervention should be targeted towards those at higher risk. Hence, due to the demographic profile of those at risk in NYC, changing the current campaign material to a culturally appropriate awareness campaign is proposed.

In order to combat obesity, we need to recover the traditional values of immigrant people. Similar to the Pouring on the Pounds campaign, the proposed campaign This is my Neighborhood, This is my Food aims to create awareness through community mediums of eating habits among immigrant families. The proposed campaign aims to emphasize traditional customs for maintenance of protective behaviors. The program is based on the concept that prevention begins in the home and embedded as tradition to future generations. Three major components will be the focal point of the campaign:
(1) Create awareness of the built environment by informing the community about their vulnerability as target consumers of fast and energy-dense processed foods,
(2) Empower perceived benefits by encouraging traditional eating habits, and
(3) Focusing on a proactive view of healthy weight.

These methods will serve as motivators to empower the community to integrate traditional customs in food consumption and preparation.

The components of the campaign will be disseminated through prominent mediums of communication in the community. Similar to the Pouring on the Pounds campaign, the material will be posted in city subways, near bus stops and near supermarkets in low-income communities around the city. Language specific material will be designed and posted in corresponding neighborhoods. However, knowing and adjusting to the most effective mediums of communication for immigrant families will be a major component of the campaign.

Create Awareness of Behavior Induced by the Built Environment

Although obesity can have many causes, most studies agree that environmental
influences are the primary factor in the current epidemic(11). The proposed campaign is based on the fact that modifying urban development is much more challenging that modifying human behavior (27). Therefore, the campaign serves to inform residents of their risk factors and susceptibility to fast food consumption. This is based on the idea that disseminating awareness of the environmental context transfers empowerment to the communities’ purchasing power of healthier foods. In low-income communities, the built environment is usually comprised of fast food restaurants, small shop bodegas and energy-dense foods (11). Unapparent to many local residents, this urban planning makes them highly susceptible to purchasing high-fat foods instead of healthy option. Therefore, informing the community about their controlled behavior by the built environment will hopefully produce a rebellion against this force. Consequently, a plan of action will be implied in the campaign ads. Encouragement to revert to traditional methods of food consumption and preparation will lead to an overt action of healthier eating habits. This plan of action however, must imply that unfavorable health outcomes were not as prevalent when practicing traditional eating habits. Therefore, proposing an awareness campaign that implies power, freedom and the perceived benefit of reverting back to traditional protective customs will be hopefully overcome the risk factors induced by the built environment.

Empowering Perceived Benefits of Traditional Values

In contrast to the traditional lifestyle in households, immigrants have been increasingly adapting to U.S. eating habits and forgoing the rice, vegetables, and fresh fruit drinks their grandparents ate and drank (26). Dietary standards in a traditional immigrant household consist mostly of home-made food with locally grown and purchased produce. Most recently, however, assimilation to U.S. eating habits has led people to flock to U.S.-style fast food and calorie-laden dishes once reserved for special occasions. Adaptation of food tailored for the mainstream American market usually is also very different than food typically served in other countries as well. This leads to the production of convenient, frozen, packaged foods and soft drinks that are widely available in local markets. To combat this trend, the campaign will serve to remind the target population that the unfavorable health outcome has occurred because of the adaptation to U.S. eating habits further induced by the built environment.

Contrary to the Pouring on the Pounds, the perceived costs of the proposed campaign are undermined because it does not discourage habits embedded in lifelong traditions. Instead, it incorporates them back into diets. By discreetly informing women that traditional values in eating habits have changed and their children’s health is at risk, women will realize that they have the power to change the outcome. This concept of the campaign strengthens perceived benefits by promoting healthy habits through tradition sustainability. It aims at changing culturally adaptive social norms, thereby allowing less perceived threat of freedom. Ultimately, the content in the material will be framed in a way that gives people control of their purchasing and eating behavior.

Focusing on a Proactive View of Healthy Weight

The focus of the This is My Neighborhood, This is My Food campaign is to modify the perception of social norms in eating habits. This is done by pointing out and targeting the risk factors, such as the context of the built environment and assimilation, of unhealthy eating habits. The campaign avoids placing blame on individuals for their eating habits, but instead implies power and freedom of taking charge of their communities and eating habits. To some extent the campaign shifts the problem from individual responsibility to corporate responsibility. In a way, the campaign skips eating habits and links obesity to the risk factors. Similar to the concept of the causation of lung cancer, the blame should be placed on tobacco manufacturers instead of smoking (28).

Transferring the association of obesity to external factors eliminates the threat of stigmatization on individuals. Instead the campaign will induce a comparison between traditional and current norms and the change in the prevalence of obesity. To this end, disseminating risk factors, encouraging modified behavior that provides empowerment and promoting proactive methods of healthy weight will prove more effective in reducing and preventing obesity in New York City communities.

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