New York City Department of Health And Mental Hygiene Is Pouring On The Negativity: A Healthy Lifestyle Campaign Gone Array – Kristina Franke
Obesity is a fast-growing epidemic in the United States. In 2003, approximately two thirds of men and women over the age of 20 were overweight or obese (1). In 2008, only one state, Colorado, had a prevalence of obesity less than 20% (2). Obesity is defined by the World Health Organization as the condition of excess body fat to the extent that health is impaired – equivalent to a body mass index of 30 or greater (1). Numerous co-morbidities are associated with being overweight and obese including hypertension, cardiovascular disease, diabetes, depression, and multiple cancers (3). One of public health’s greatest challenges today is to address this obesity epidemic in an environment that does not aid in the improvement of health. Unhealthy food is sold in grocery stores, fast food restaurants, and in cafeterias making it easy for a person to make poor food choices every day. In addition to unhealthy food, it has been found that sugar-sweetened beverages promote weight gain and obesity by increasing overall energy intake (3).
Forty-seven percent of total added sugars in an average American’s diet come from non-diet soft drinks (colas, fruit drinks, lemonade, and iced tea) and consumption of these beverages has increased 135% between 1977-2001 (3). In September 2009, the New York City Department of Health and Mental Hygiene decided to take action on this unhealthy increase in soft drink consumption by launching the “Are You Pouring On The Pounds?” campaign. For three months, the Health Department put posters up in 1,500 subway cars. The signature image of the campaign is a bottle of soda that is poured into a glass and as the soda reaches the glass, it turns into blobs of fat. Below the image is the statement “Don’t drink yourself fat. Cut back on soda and other sugary beverages. Go with water, seltzer, or low-fat milk instead” (4, 5). Although this campaign aims to remind the public about how certain drinks can lead to obesity and other health related problems, it is missing key components of a successful public health campaign. This ad alone will not make people change their habits.
Traditional Health Belief Model Excludes Self-Efficacy
The main idea behind the “Are You Pouring On The Pounds?” campaign is to get individuals to think about their actions. At first glance, this campaign is straight-up gross. Who wants to drink fat? No one. However, soft drinks do not taste like fat. The theory used for this campaign is the Health Belief Model where an individual weighs the costs and benefits of a particular behavior before deciding to act on that behavior. The four factors that motivate health behavior are the perceived susceptibility, perceived severity, perceived benefits of an action, and the perceived barriers to taking that action (6). In this campaign, there is an obvious susceptibility of getting fat from drinking soda and the severity of the behavior is based on an individual’s habits – the number of sodas consumed per week, physical activity, and other eating habits. However, the biggest barrier to drinking soda is that it does taste good and if people do not see a difference in their weight, they may not stop drinking soft drinks.
For those individuals who want to stop drinking soda, the campaign does not offer any suggestions for putting down the bottle. Self-efficacy is a person’s belief in his or her ability to take a specific action (6). The thought of not drinking soda is a good first step, but the belief in actually quitting has to be strong enough to act on the thought. There is nothing in the campaign that actually explains why the calories are bad for you and how to actually take steps to stop drinking soda. Simply stating that sugar turns to fat and that there are more calories in soda than water is not a strong enough reason to make an individual believe they can lose weight and become healthier. In addition, a person’s fear of being overweight or obese can be strong enough to make them think irrationally about decisions. When a way of handling the problem is offered, like, drinking water, the person in fear might not accept it because he or she is not able to think constructively about the situation (7). Multiple questions still linger after reading the campaign ad: What are calories? How many calories are too many calories? What are considered good calories? There needs to be more content in the campaign to properly educate the public so individuals can make rational decisions and be motivated to make a change in behavior.
Who Is The Target Audience?
There were a total of 1,500 ads put up in New York City subway cars. This bears the question: Who does the Health Department not want to drink soda? From 1977-2001, soft drink consumption increased from 3.0% to 6.9% in 2-18 year olds and from 4.1% to 9.8% in 19-39 year olds (8). The current ads target commuters, but that should not be the only audience in this campaign considering the increase in soda consumption in adolescents and young adults. NHANES data from 2004 estimates that almost 17% of adolescents aged 6-19 are overweight (1). The campaign is not targeting a vital audience in the obesity epidemic.
In addition, the campaign is not utilizing multiple forms of mass media to get the message out that drinking soda adds unnecessary calories to your diet. Social marketing uses marketing to design and implement programs to promote beneficial behavior change. One factor of social marketing is the promotion of messages and activities in an effective manner (9). The “Are You Pouring On The Pounds?” campaign uses a poster, and most recently, a video of a man drinking fat, to convey the message that sugar beverages are bad for your health. This is not enough. The Health Department must consider multiple ways to reach the target audiences to promote a healthy behavior change. One example of a successful social marketing campaign is VERB, a multiethnic media campaign with the goal to increase and maintain physical activity among tweens, children ages 9-13 (9). Campaign tactics included reaching tweens and their parents at home, in school, and in the community to give the program a visible presence in tweens’ everyday lives. Media included commercials, radio advertisements, printed ads in magazines and on the Internet, attending community events, and using sweepstakes and promotional activities to convey the importance of physical activity (9). Merely posters in subway cars will not successfully change health behavior by conveying the fact that sugar beverages are bad for your health.
Fear Only Increases Obesity Stigma
There is an emotional feeling of disgust and fear when first looking at the poster for the campaign. A threatening strategy has been used in many public health campaigns with the aim of producing specific changes in attitudes, intentions, and behaviors that is expected to motivate compliance with the message’s recommendation (10). However, it is not the level of fear but the belief that an individual can act on the behavior that is the most important component of a message (10). The campaign does not provide any assistance in self-efficacy, only the suggestion of switching the type of beverage you choose to drink.
Using threats in an obesity campaign only increases the perception of the obesity stigma. The threat emphasizes that obese persons are blamed for their weight through their actions – specifically in this campaign, drinking habits. The common belief through advertisements that weight is easily controllable and easily modifiable through the simple matter of personal effort leads to stigmatization (11). In reality, changing behaviors to lose weight and become healthier is not a simple matter. Overweight and obese individuals who look at this ad may try to stop drinking soda, but if they do not lose weight, their effort to stop drinking soda may diminish, thus leading to no behavior change. This campaign just adds to the stigma and negative labeling of overweight and obese individuals. There has to be a higher level of motivation to stop drinking unhealthy beverages that is framed in a positive way to encourage behavior change.
An Alternative Approach – The Glass Is Half Full Attitude Toward Obesity
Even though there are many flaws in the “Are You Pouring On The Pounds?” campaign, it does take a step in the right direction. There is an attempt to educate the public about the harmfulness of sugar beverages. However; there needs to be a positive spin on the campaign. People will not just put down the bottle because there is a very graphic picture on a poster. First, the message needs to address why drinking low calorie beverages is good for you. There needs to be a promise that will be fulfilled by, for example, drinking water every day. A person needs to have the fulfillment of happiness and a better and more energized lifestyle.
In addition, there needs to be more information about calories. The campaign needs to expand in terms of types of media used and the audience the message is directed towards. Simply putting a poster on a subway bus does not get the attention of youth, who consume sugar beverages as well as adults. The information presented should include how to overcome barriers of trying to lose weight and facts about how caloric intake affects weight gain along with physical activity.
Lastly, the message needs to be positive. The campaign needs to re-frame its message into the importance of consuming low calorie drinks instead of negatively addressing fat, which leads to being unhealthy. A negative message creates an environment that discourages behavior change for those that already have trouble losing weight. Adjusting the campaign to address a positive message with a promise that can be fulfilled in the future along with promoting the message in a variety of ways will improve the success of this campaign.
Advertise Something Bigger Than Consuming Less Calories
This campaign needs to provide the individual with something bigger and better than consuming fewer calories. Stating that consuming too much sugar is bad for you because it adds unwanted calories to your diet does not provide the motivation to actually change the behavior. The individual has some added knowledge about sugar and calories, but how does that change his or her life? Research shows that an individual’s concern over one’s health is not the driving force behind behavior change, but instead it is characteristics such as loss of freedom, dependence or striving for a certain identity that prompts behavior change (12). A key component of advertising health is to sell something more than health or the behavior itself. That ‘something’ needs to offer benefits that fill a desire or need among the specific audience.
To discourage the consumption of soft drinks, the Health Department should emphasize what drinking water and more healthy beverages will do for you. For example, a person drinking water can be advertized as showing freedom, happiness, and having more energy on a daily basis. A current commercial that portrays this aspect is by Nutrigrain. It compares the same woman on two different days. One day she starts her morning off by eating a Nutrigrain bar and another morning she starts with a donut. The commercial then shows the changes in attitude and energy along with better food choices due to this new outlook on life. Nutrigrain is selling a better, more fulfilling life. This same concept can be applied to drinking low calorie, healthier drinks instead of high calorie, sugar drinks.
Change The Information Environment
The public needs accurate information to make rational decisions about behavior change. Without a strong basis for change, the money, time, and effort spent on campaigns will have little impact on the community. One way to make sure the proper information is conveyed is to have multiple forms of media messages. There are two forms of influence that a campaign should cover through their messages. First, there should be an attempt to increase the amount of available information on the topic of interest. Second, the issue at hand should be framed in a way that it attracts attention and suggests a solution to resolve the problem (13). The current “Are You Pouring On The Pounds?” campaign is able to suggest a solution by drinking low calorie beverages, but it fails to answer why fewer calories are important in a diet.
The hardest challenge with sugar beverages is that they are already being promoted as a fun, delicious drink to enjoy any time of the day. The key for the campaign is to change this information environment for all target audiences. Using strategies such as newspaper and magazine ads, pamphlets, fact sheets, billboards, and promotional items will spread the message to a variety of audiences (13). The type of media message will depend on the target audience. Youth ads can show improvement sports performance or muscle growth by drinking milk and ads in a magazine geared toward women can portray a more energetic lifestyle while at work or at home. The campaign message should encourage the consumption of low calorie drinks and explain why low calorie drinks are good for your health. There should be suggestions for how to start a healthy lifestyle with a balanced diet, including physical activity options.
Put a Positive Spin on a Negative Problem
Fundamentally people make irrational decisions so framing is a very important aspect of any public health campaign. It allows an idea to be sold to the individual, whether, in reality, it is a good or bad decision. To sell the idea of consuming low calorie beverages, the Health Department needs to first consider what types of decisions people make when choosing a beverage. These decisions usually provide short-term gratification but long-term harm where a higher value is placed on present satisfaction and future consequences are heavily discounted (14). Therefore, putting a positive spin on a bad habit, drinking sugar beverages, is ideal. Discouraging the consumption of soda will not stop people from drinking it. There needs to be a positive outlook on the action of drinking low calorie drinks like water and low-fat milk to make the future consequences a crucial aspect of decision making.
Certain audiences should be targeted in addition to having a positive outlook for the campaign. Childhood and adolescence are the key times to form lifelong eating, drinking, and physical activity habits (1). Expanding the campaign throughout the community will allow for the message to get out to all audiences and affect a more long term outcome of health behavior rather than short term habits. This message needs to have the perception that barriers can be overcome and habits can change to make an individual feel free, independent and enjoy a more happy life.
Sugar beverages can cause weight gain so it is important that they stay in the public health eye. The New York City Department of Health and Mental Hygiene’s “Are You Pouring On The Pounds?” campaign is a good start to addressing this issue, but it will not succeed in changing health behaviors without re-evaluating its message. There needs to be a positive spin put on the negative problem of obesity so individuals can be encouraged to change their behavior after being educated about the issue at hand. Obesity will be an ongoing public health battle in the years to come and addressing smaller issues, like consuming healthier beverages, is a step in the right direction to tackle this epidemic.
1. Wang, Y. & Beydoun, M. The obesity epidemic in the United States – gender, age, socioeconomic, racial/ethnic, and geographic characteristics: A systematic review of meta-regression analysis. Epidemiologic Reviews 2007; 1-23.
2. Centers for Disease Control and Prevention. U.S. Obesity Trends. Retrieved April 15, 2010, from http://www.cdc.gov/obesity/data/trends.html
3. Malik, V., Schulze, M., & Hu, F. Intake of sugar-sweetened beverages and weight gain: a systematic review. American Journal of Clinical Nutrition 2006; 84, 274-288.
4. New York City Department of Health and Mental Hygiene. New Campaign Asks New Yorkers if They’re “Pouring On The Pounds.” Retrieved April 15, 2010, from http://www.nyc.gov/html/doh/html/pr2009/pr057-09.shtml
5. New York City Department of Health and Mental Hygiene. Are you pouring on the pounds? Retrieved April 15, 2010, from http://www.nyc.gov/html/doh/downloads/pdf/public/dohmhnews8-06.pdf
6. 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. 25-49.
7. Rosenstock I. Historical origins of the health belief model. Health Education Monographs 1974; 2, 328-335.
8. Nielsen, S. & Popkin, B. Changes in beverage intake between 1977 and 2001. American Journal of Preventive Medicine 2004; 3, 205-210.
9. Wong, F., Huhman, M., Heitzler, C., Asbury, L., Bretthauer-Mueller, R., McCarthy, S., & Londe, P. VERB – A social marketing campaign to increase physical activity among youth. Preventing Chronic Disease 2004; 3, 1-7.
10. Lewis, I., Watson, B., White, K. & Tay, R. Promoting public health messages: Should we move beyond fear-evoking appeals in road safety? Qualitative Health Research 2007; 1, 61-74.
11. Puhl, R. & Heuer, C. The stigma of obesity: a review and update. Obesity 2009; 17, 941-964.
12. Marketing social change: An opportunity for the public health practitioner (Chapter 3). In: Siegel M, Doner L. Marketing Public Health: Strategies to Promote Social Change (2nd Edition). Sudbury, MA: Jones and Bartlett Publishers, 2007, pp.45-71.
13. Randolph, W. & Viswanath, K. Lessons learned from public health mass media campaigns: marketing health in a crowded media world. Annual Review of Public Health 2004; 25, 419-437.
14. Brownell, K. , Farley, T., Willett, W., Popkin, B., Chaloupka, F., Thompson, J., & Ludwig, D. The public health and economic benefits of taxing sugar-sweetened beverages. The New England Journal of Medicine 2009; 16, 1599-1605.