Saturday, May 8, 2010

No. Effective: How Nolita’s “No Anorexia” Ads Failed In Making A Statement – Lauren Kennedy

Amongst the glitz and glamour of Milan’s fashion week in September of 2007 a revealing ad aimed at addressing the problem of eating disorders, in particular Anorexia nervosa, made its debut. The clothing company Nolita commissioned the ads, and hired the controversial Oliviero Toscani to photograph it. The series featured the Isabelle Caro naked against a black and grey background, with the slogan “No. ANOREXIA” and the brand name “No-l-ita” in hot pink. Caro is a French actress who suffers from anorexia nervosa (1-3). At the time the photograph was taken, she weighed a mere 70 pounds at 5 feet and 5 inches (1). From a clinical perspective, she is 56% of the recommended body weight for her height, and severely underweight from very advanced anorexia nervosa. Her gaze is blank and haunting, a woman clearly deeply suffering the debilitating effects of her disease. This campaign, worth only its weight in shock value, fails to deliver an appropriate public health message.
The ads caused quite a controversy in the mass media, and were banned by Italy’s Publicity Control Institute shortly following release. In a statement on the company’s website, Nolita defended the ad, stating that it [used]”this nude body [to show] the reality of this illness, which in the majority of cases is caused by stereotypes caused by the fashion world (1).” Toscani claimed that “looking at [his] ad, girls with anorexia would say to themselves that they have to stop dieting (1).” These statements reflect adherence to the Health Belief Model (5).
According to the Health Belief Model, people make decisions about health according to four constructs: perceived susceptibility, perceived severity, perceived barriers, and perceived benefits. Additional components are cues to action and self-efficacy (5). Using this model, developers of the “No Anorexia” ads hoped that the disturbing image of this emaciated, nude woman who is clearly extremely sick would educate girls about the severity of anorexia nervosa. Given that they are women interested in fashion, they will appreciate that they too are susceptible to this disease. Thus, the perceived benefit of avoiding the development of anorexia nervosa will be weighed against the perceived barriers associated with refraining from dieting. Given all this information, the woman decide that the benefits outweigh the barriers this cue to action would drive them to stop dieting, thus preventing the progression of anorexia nervosa or another eating disorder. This sequence is all contingent on self-efficacy, the person’s belief in his or her ability to take action (5).

Argument 1: The problem of the Health Belief Model

While useful for some situations, the health belief model itself has some limitations in application to public health interventions. First of all, this model assumes rationality (6). If people behave rationally, then if given all the facts they will make the decision that promotes health. The general population is questionably rational (6,7). The population of people with eating disorders is arguably even less rational. Eating disorders are classified as a psychiatric disorder. Among the symptoms of eating disorders are psychopathological symptoms which include preoccupation with weight and shape and a disturbance in the way body is experienced. There may be an intense fear of weight gain. Often, people with eating disorders deny something is wrong. They may compare their body with others’ bodies (8). A typical woman with an eating disorder would most likely not be able to rationally and objectively weigh the benefits and barriers based on the image in the campaign. Her perspective will be skewed from what the expectation is under the model. For example, a woman with anorexia nervosa may not perceive the level of extreme thinness as undesirable as a result of this distorted perception of reality. Perhaps even worse, the sight of the image may trigger a competitive drive to be a thin as her, regardless of the possible consequences. Many people with eating disorders are in denial that they have a problem. Thus, a person with an eating disorder may not even perceive him or herself as susceptible to developing the severe manifestations of the disease. Thus, the constructs of the health belief model are not appropriate for the population of people with eating disorders.
A second problem with the health belief model is that it assumes that intention to perform a healthy behavior translates to action. However, this unfortunately is often not the case (6). Especially with eating disorders, even a will to recover does not necessarily mean success (8). Tragically, for many people with eating disorders, the will to change does not mean that their behaviors will change right away. Recovery from eating disorders is a slow process that requires intensive care and a multidisciplinary approach8. A simple picture will do nothing to alleviate the symptoms of eating disorders and as mentioned earlier, may even add fuel to the fire.

Argument 2: A violation of theory

While the health belief model is going out of style so to speak, new models are emerging in public health practice that more appropriately represent and predict human behavior. Models which take into account the group level of influence and the fundamental irrationality and spontaneity of many human behaviors (6). Three examples of these models are the social ecological model, marketing theory and psychological reactance theory. The Nolita ad campaign violates the principles and constructs of all three of these important models.
The social ecological model highlights the importance of both the individual and the environment and the dynamic relationships between all individuals and all environments (9). The Nolita ad campaign fails to use this model by ignoring the internal environment of people with anorexia nervosa and other eating disorders. For people with eating disorders, the body becomes the object of obsession. This can manifest in body checking, body avoidance, or body image disturbance (8). In the “No Anorexia” ad, the very object of obsession for the person with an eating disorder is put on display in an extremely exploitative fashion. This fact only serves to reinforce the distorted internal environment in which the person with an eating disorder experiences. In this way, the Nolita ad campaign fails to associate the external environment with the internal environment. Furthermore, for those without recognized eating disorders or disordered eating behaviors, it creates a negative environment. By introducing an image that is extremely disturbing for most, it disrupts the peacefulness of their environment. It creates an atmosphere of negativity surrounding eating disorders and may reinforce the idea of a woman’s body being “disgusting”, particularly given the media’s reaction (2,3). The ad does nothing to try to explain the image or the illness. An individual’s internal environment may be shaken with grief or shock. Thus, people are met with something that they do not understand which will likely lead them to criticism rather than action. This reality is exemplified in the reaction of the media. Most media outlets and newspaper articles only talked about the shock of the campaign and the controversy surrounding it, rather than brainstorming what can be done to prevent eating disorders from occurring (1-3). Importantly, the campaign only serves to shock the environment, and does nothing to promote lasting environmental change. It does not create an environment more conducive to preventing the development of eating disorders and worse, may add to the hostility of the environment towards eating disorders.
Marketing theory is a group level model that has important implications for population level behavior change. The marketing paradigm first asks what the people want, and then works to create and package a product that meets the desires of the people. The traditional public health paradigm promotes a stark contrast to the marketing paradigm. This paradigm first asks what people should want and then sells the product based on appealing to the desire for health. However, health is a weak core value for many people. Even people in poor health can be extremely happy, hopeful, and joyful. Better core values are love, acceptance, freedom, power, purpose, security and self esteem (6). The desire and need for these core values are especially in the population of people with eating disorders or people at risk for developing eating disorders. They are more likely to have low self esteem and low self concept (10). In a special way, they are yearning for love and acceptance, and the desire for these important values contributes to the development of eating disorders in the first place. The core value that Nolita’s ad is trying to promote is health. In essence, the ad is trying to say “look at how unhealthy she is, you need to stop dieting”. However, for a population with such a strong desire for the core values of love and acceptance, they may interpret the message as “look at how much attention she’s getting”. In this way, the ad fails both in appealing to the weak core value of health and the potential for being misinterpreted in what core values it promotes. The campaign would be more effective if it directly appealed to the strong core values of the target population by packing their message in a package that met those needs.
The psychological reactance theory is based on the idea that the reaction of a person to a message, in particular being told what to do, has a great deal of influence on how they receive and enact the message. If people feel that their freedom is being compromised, they will react to the threat in an attempt to restore their freedom. The path to least resistance and reactance is to use the most reason to support the message, particularly with visual aids. In particular, similarity builds trust (6). While many people with eating disorders may identify with Isabelle Caro, this may not necessarily be a good thing. For one, Caro has extremely severe clinical anorexia nervosa (8). Perhaps a better person to identify with would have already overcome the disease, so people with eating disorders could identify with someone who had been there, but recovered from the disease and are in remission. While Caro is surely a very strong woman who is capable of recovering from anorexia nervosa, she is still very much affected by the disease herself and may not be the best person to identify with for women with anorexia nervosa. Tragically, given the psychological manifestations common in eating disorders (8), Isabelle may serve as an example of the “perfect” anorexic to some because the clinical manifestation of her disease is so advanced. This may drive inspiration toward more disordered eating behaviors. The general population will probably not be able to relate to Isabelle at all based on her shockingly underweight status and the exploitative way in which she is portrayed in the picture. The ad will only serve to betray the trust of the general population by trying to shock them into action. In these ways the campaign fails in reaching both people with and without eating disorders.

Argument 3: The ethical problem of Nolita’s ad campaign

All professionals are expected to act justly in all matters. This is especially important with regards to public health professionals, who are expected to be promoting the well being of the population. This campaign is fundamentally flawed in that it is an unethical campaign that exploits a very sick woman. Although Isabelle Caro chose to pose for the ad, it can be argued that she is not autonomous and therefore did not choose to do so freely. Caro suffers from a severe, recognized psychological disorder and is severely malnourished (8). She is not well either emotionally or physically. Thus, her ability to make decisions that promote her best well being can reasonably be questioned. Fabiola DeClercq, founder of an Italian association against anorexia, bulimia, and obesity who herself suffered from an eating disorder for many years, says it best. She states, “this girl needs to be in a hospital, not at the forefront of an advertising campaign(3).” At its core, this campaign exploits an extremely ill woman in an ad arguably designed to promote a brand.
The tagline itself also promotes a negative and insensitive message. Obviously the goal in campaigns like this is to reduce the prevalence of eating disorders, but this cannot be at the cost of alienating those who already suffer from them. With the statement: “No. Anorexia” the campaign alienates those enduring anorexia nervosa. It creates an atmosphere in which a recognized illness is treated with contempt. It oppresses a population of people who are already extremely ill and vulnerable. The message is especially inappropriate given that many people with eating disorders suffer from low self esteem. Ad developers are arguably some of the most creative minds in the world; surely they could come up with a slogan that is cleverer and less stigmatizing.
Given all these facts, one can surely conclude that the “No anorexia” campaign was a failure both theoretically and ethically. The campaign relied on a flawed model, ignored tested important theories, and was ethically impermissible. Hopefully this will campaign will serve as a learning experience to future interventions.

No. Negativity: “Love Freely” as an effective public health intervention

University females are a population at high risk of developing eating disorders (8). Thus, an intervention developed to address some of the root causes of eating disorders, low self esteem and low self concept clarity (10), would be effective in reducing the incidence of eating disorders. It could also help women who are already practicing some disordered eating behaviors to recover. The goal of the intervention is to empower women by integrating leadership and community involvement with active learning and workshops targeted to help women feel better about their bodies and have a healthy relationship with food and exercise. The setting of the intervention would be a college or university, because of the high risk of the population and availability of resources. The intervention would feature a campaign entitled “Love Freely” to reach out to the University population. It would be complimented by a women’s center to foster an environment where women are empowered to discover who they are, celebrate themselves, and build healthy relationships through active participation and leadership.
Trained interventionists would initiate the program (11), with the goal of growing through training leaders in the University. To begin, they would recruit upperclassman women and give them monetary incentive to participate in an extensive summer course on leadership with body image workshops. The curriculum would consist of activities such as discussions, art and music activities, role plays, guided mediations, yoga classes, cooking demonstrations, massage therapy, and other activities to actively engage and encourage students to become strong internally and to be prepared to lead others (12). The goal of the workshops would be both to reinforce in women the conviction that they are beautiful at any size and to empower them with a greater sense of self to prevent them from internalizing the messages of the media (13). It would also include topics related to weight such as weightism as a social justice issue (12). Then, both the original interventionists and the upperclassman women who participated in the summer course would hold similar workshops during the school year.
A media campaign would run at the school both to encourage women to resist pressures that breed unhealthy eating behaviors as well as direct women to the positive community workshops held on campus. The campaign would be entitled “Love Freely”. Media spread throughout the campus would encourage women to question society’s messages that they are not “good enough” as they are. The ads would not focus on the body or on food directly, because these things can be a focus of obsession for people with eating disorders (8). Rather, the campaign would use clever graphic designs and words to get the message across. For example, one tag line would be: “r*EVOL*ution: turn the tables; love who you are, love freely”. Another slogan could be “*EVOL*ve: change the world; love who you are, love freely”. Campaign messages would be subjected to focus groups of university women to assess acceptance and to gain ideas. Additionally, as part of the effort to engage women and help them discover their identity, the women targeted for the intervention or upperclassmen involved in leadership could take part in designing slogans and messages for the media campaign.
To assess the effectiveness of the campaign, interventionists would both hold focus groups and surveys. The incentive for completing the surveys and participating in focus groups would be monetary. Participants would either get a small sum of money or be entered in a raffle to win a gift or a greater sum of money. The information that they would gather would be information about perceptions of the message of the program, as well as information about self-esteem, self-concept clarity, internalization of societal standards of attractiveness, body image concerns, and dieting behaviors (10-13).

Argument 1: Finding freedom

The intervention “Love Freely” satisfies the principles of the Psychological Reactance Theory. Many public health campaigns fall short in that they demand that women love their bodies. According to the Psychological Reactance Theory, simply telling a person what to do is not enough, and even detrimental in some cases. It can cause a reaction in the target audience to do exactly the opposite of what the campaign suggests (6). The Love Freely campaign invites and encourages women to question society’s definitions of who they should be and gives them a means to find this out for themselves. The messages uses clever visuals and ideas to support this message, rather than relying on disturbing and exploitative images of the body. The campaign invites women to take control and be free rather than shocking or scaring them into submission. Women in college, particularly freshman are vulnerable in that they are in a new and foreign place, for many it is the first time living away from home. In this susceptible time, women are in greater need of being accepted and loved, rather than alienated by an intervention. Importantly, the intervention is designed for assessment of both student acceptance and effectiveness in changing women’s self concept and behaviors. These programs of measurement will test the messages being put forth in order to ensure that the intervention is portraying the right message. Secondly, the intervention focuses on training peer leaders. The upperclassmen women who will be involved in the intervention are experiencing or have experienced the same fears and emotions associated with college. Thus, their example and leadership will serve to develop trust in other women targeted in the intervention.

Argument 2: No (wo)man is an island

According to the Social Ecological Model, environments and individuals are dynamic, multidimensional, and interconnected (9). An area where many public health campaigns fall short is in underestimating the role of the environment in promoting health behavior. Even well planned campaigns can be unsuccessful if the environment does not foster the behavior change (6). In the Love Freely campaign, public health messages are targeted to female youths, but it does not end there. Built into the campaign is an environment where women can be nurtured and grow to accept themselves and their bodies. Furthermore, the marketing messages of the campaign are positive, reinforcing an environment that is welcoming, rather than relying on fear mongering and scare tactics. Importantly, the environment offered by the program is one of engagement. Women are encouraged to take action, to lead, to question, to talk, to participate, and to learn together. Inventions which include a variety of activities rather than just passively pass on information have proved to be effective in the primary prevention of eating disorders (11,12). The campaign offers workshops that not only teach about body image and body acceptance but also offer outlets to increase self confidence and help women explore their identity, interests and talents. The campaign gives a direction for the target audience to move toward, instead of becoming another message in an environment laden with thousands of other stimuli. In theory, the nurturing environment of the women’s community and the positive messages of the campaign will replace society’s ideals in the target audience’s internalizations. The ultimate goal of this environment is to equip women to deal with the societal pressures to be thin in future situations.

Argument 3: Inspiration from Innovators

The diffusion of innovations theory is a group level model that can predict behavior at the population level. First, “early adopters” pick up the behavior or product. Then, there is a critical point called the tipping point where a majority of the population catches on to the behavior or product. There is a time where most people are participating in the behavior. Finally, the “laggards” in the population (the last to catch on) will slowly adopt the behavior. In order to ensure that the tipping point is met, it is helpful if early adopters are influential in the population of interest. This model is useful because it takes advantage of the herding phenomenon- as a public health professional, you do not have to worry about reaching every person (6). You only need to facilitate the population reaching the tipping point, or knock over the first domino. The Love Freely intervention employs this useful model in recruiting upperclassmen to participate in the women’s community first through monetary incentive. The influence of these women on campus will hopefully initiate the knocking over of the tipping point, and consequently spread the behavior of going to the center throughout the community of interest.
Anorexia nervosa and other eating disorders are a serious public health problem (8). Disordered eating patterns and progressed eating disorders seriously affect the lives of those who suffer from them and their loves ones. An intervention aimed at one of the root causes of eating disorders would help to prevent the onset or development of this serious disease (11,12). The Love Freely campaign marries propaganda outreach with a concrete community designed to empower University women. The design of this intervention satisfies the constructs of the Psychological Reactance Model, the Social Ecological Model, and the Diffusion of Innovations model.


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