Tuesday, May 11, 2010

Why the Soda Free Summer Campaign’s Reliance on the Health Belief Model Limits Its Efficacy in America’s Fight Against Obesity

The Added Sugar That’s Making Us Fat

Obesity in the United States has reached epidemic levels. 32.2% of adult men and 34.5% of adult women can be classified as obese (with a body mass index of 30 or more) (1) and many see sugar-sweetened beverages as a major contributor to the fattening of America. The Nurse’s Health Study II found that consumption of sugar-sweetened soft drinks was positively correlated with caloric intake, weight gain, and incidence of diabetes (2). A prospective observational study found that for each additional serving of sugar-sweetened drink consumed, body mass index and frequency of obesity both increased after adjusting for anthropometric, demographic, dietary, and lifestyle factors (3). Soda consumption in particular, has also been negatively associated with children’s nutrient intake, specifically vitamin A in all age strata, calcium in children under 12, and magnesium in children 6 years and older (4). The American Association of Pediatrics recommends that doctors suggest limiting intake of sugar-sweetened beverages to all children but those below a 5% body mass index (5).

The Soda Free Summer Campaign aims to reduce obesity and obesity-related diseases by inspiring individuals to abstain from drinking soda and other sugar-sweetened beverages for a 10-week period during the summer. The campaign, first implemented in the San Francisco Bay Area, recruits people to sign a pledge card to commit to a soda free summer and log their progress. To support the campaign they distribute informational pamphlets and promotional materials such as wrist bands, conduct Be Sugar Savvy workshops showcasing sugar content of beverages, and spread their campaign messages via local media outlets (6).

This critique of the Soda Free Summer Campaign postulates that the campaign’s reliance on the health belief model (7, 8) limits its efficacy through its focus on the individual, assumptions of rationality and unfaltering self-control, its lack of environmental and policy considerations, and its failure to provide compelling visuals or appeal to core values.

If Only Our Behavior Was Truly Individual, Rational, and Subservient to Our Long-Term Health Goals

The view that lifestyle is determined simply by the sum of behavioral choices and some intrinsic personality characteristics is antiquated at best. No consumer ever entered a restaurant demanding a bottle filled with high fructose corn syrup; consumer choices are made based on which products are produced and promoted by corporations whose goal is profit maximization (9). The idea that this consumer should be the sole target of a campaign to reduce obesity is a predictable, individualistic, and simplistic western response (10) especially given that there is little evidence that individual level interventions have had much success at the population level (11). Dietary behavioral change is not always as easy as simply deciding to make a change but is instead a complex interplay between availability and cost of alternatives, social supports, and consistent positive feedback that outweighs the barriers to making the change (12). After all, if it were as simple as deciding to make a positive change we would all stick to our New Year’s Resolutions, strictly adhere to our diets, and exercise regularly.

We humans are deeply irrational beings (13). The world in which we rationally weigh the costs and benefits of each possible choice and do only that which we intend, while remaining uninfluenced by those around us or by the environment around us, is called an economic model. In reality, we judge people’s personalities differently if we’ve been exposed to different temperatures (14), we start diets and then decide to have one more piece of chocolate cake (15), and we fail to adhere to healthy behaviors even after we’ve actually experienced a negative health outcome like cardiovascular disease, hypertension, or diabetes (16).

Rather than being isolated and independent actors, we are deeply affected by the behavior of others (17-19). Teenage girls who see other teenage girls having children are more likely to have children themselves and the GPA of a college freshman’s randomly assigned roommate can essentially predict her GPA (20). Quantitative analysis done using data from the Framingham Heart Study demonstrated that over a 32 year period individuals connected by social ties gained weight and quit smoking in concert. A person’s chance of becoming obese increased if she had a friend, spouse, or sibling who became obese in a given interval but was not affected by a neighbor becoming obese (21). In the same vein, smoking cessation of a spouse, friend, sibling, or co-worker at a small firm considerably reduced a person’s chances of smoking (22).

Consumption of sugar-sweetened beverages in particular, has been associated with other dietary patterns (23), clustered with TV viewing among teens (24), and influenced by parental consumption among Latinos (25). The focus on individual and isolated behavior ignores social influence and our current understanding of human irrationality.

Left to Our Own Devices: Why Environmental and Policy Changes Shouldn’t Be Ignored

While the 2009 Soda Free Summer Campaign gauged public support for policy changes (26), its failure to incorporate any environmental or policy nudges as part of the intervention weakened its efficacy. This decision, in keeping with the simplistic view of the health belief model, relies heavily on an individual’s self-control and fails to take advantage of the power of a small environmental nudge in the right direction.

Recent research showing the degree to which we underestimate context and overestimate our ability to behave in accordance with our good intentions has underscored the usefulness of policy and environmental interventions. It turns out that different parts of the brain are involved with planning and doing: the planner part looks out for our long-term welfare while the doer easily succumbs to temptation; a man on a diet might agree to go out with colleagues thinking that he can resist the wine and desert options but immediately orders wine once at the restaurant (27). The farther removed we are from a temptation the more self-control we have and the more self-control we believe we will have when tempted. This is why so many pregnant women say they will refuse drugs during labor but so often change their minds once actually experiencing the pain of childbirth (28) and why when given the choice of $100 in 30 days or $110 in 31 days nearly everyone chooses $110 in 31 days but when given the choice of $100 today or $110 tomorrow nearly everyone chooses the instant $100 (29).

Small environmental and policy changes can help steer us toward healthier choices without mandating or controlling our behavior. Smaller portion sizes can nudge us to eat less (30-31), musical stairs can coax us off the escalator (32), and greater access to physical activity resources encourages us to be physically active without telling us to be (33). Taxing unhealthy products is another social disincentive policy at our disposal. Cigarette taxes are seen as a useful way of reducing smoking and increasing state revenues (34) and some states have begun to implement soda taxes (35) in the same vein. Some also call for a ban on food advertising to children (36) citing studies like one published in Health Psychology showing that children consumed 45% more when exposed to food advertising (37).

In the case of sugar-sweetened beverages, a randomized, controlled pilot study almost completely eliminated sugar-sweetened beverage consumption in a diverse group of adolescents and showed a beneficial effect on body weight through delivering beverages with no added sugar to the homes of adolescents (38).

Environmental interventions and policy changes can be effectively used to incentivize healthier behaviors, discourage unhealthy behaviors, improve availability of healthy alternatives, restrict access to unhealthy foods, control marketing and advertising, and create communities that support healthy lifestyles (39). With such potential to influence behavior at the population level, they should not be ignored.

Selling Health and Statistics: No Match for the Coke & Pepsi Promise

The Soda Free Summer Campaign promises a reduction in weight gain, a reduced risk of diabetes and heart disease (40,41) and the chance at a few raffled prizes in exchange for giving up soda (42). The health promises are backed up by statistics about sugar consumption and obesity-related diseases. The campaign also created a video that reiterates the same statistics on their website and fails to provide compelling visuals or appeal to core values like independence and control.

While the Soda Free Summer Campaign sells health benefits, Coke and Pepsi make grand promises and appeal to consumers’ core values. Coke promises its consumers happiness with its “Open Happiness” advertising campaign (43) and “Share Happiness” slogan for its new 2 liter bottle and backs up its promise with images showcasing beautiful, young people looking incredibly happy (44). Pepsi makes similarly grand promises: if you drink Pepsi you will belong to a larger movement of youthful change makers (45) appealing to American values of community and positive social change. Both Coke and Pepsi have recently launched “movements”, further capitalizing on Americans’ hunger for positive change, with the Pepsi Refresh Project which awards grants to “refreshing” ideas (46) and Coke’s Live Positively Campaign which supports environmentalism, active lifestyles, and volunteerism (47).

If indeed Americans saw health as a core value, the Soda Free Summer Campaign and other health promotion campaigns who promise health would be more effective and we might see fitness facilities marketing health benefits rather than attractiveness. Time and time again, health does not motivate our behavior (48). The 5 A Day Campaign is largely considered a failure (49, 50), nutritional knowledge has been shown to have only a peripheral impact on children’s food preferences (51), and smokers who overestimate the prevalence of heart disease and cancer in smokers continue to smoke (52). This is only magnified by the fact that we have an incredibly strong optimistic bias, so that even if we know and understand the health risks and statistics related to diseases like obesity and diabetes we think our own susceptibility is below average (53, 54).

While the Soda Free Summer Campaign utilizes promotional materials, reaches out to local media, and contains a short video, it fails to be an effective social marketing campaign. An effective campaign must have a unified core position, evoke desired visual images, employ recognizable catch phrases, suggest appropriate metaphors, showcase its program as the solution, and must not attribute the problem to the individual (55). The Soda Free Summer Campaign fails to suggest any appropriate metaphors or use compelling visual images and attributes responsibility solely to the individual.

The Soda Free Summer Campaign also runs the risk of inciting reactance through its negative messaging. The campaign tells you that soda and other sugar-sweetened beverages should be completely given up, essentially a “just say no” campaign. Between the request to give up something that for many may be a daily habit and the adults in the video barraging you with facts and statistics, the campaign may elicit psychological reactance. In a study done with heavy drinkers, those exposed to “Don’t Drink” messages drank significantly more directly after exposure to messaging than those exposed to a “Drink Moderately” message (56). A video on youtube in response to New York City’s Pouring on the Pounds Campaign (57) is a concrete example of this kind of response, showcasing New Yorkers who feel angry and rebellious toward a campaign which they see as the government telling them what to do (58).

An effective social marketing campaign could go a long way in the fight to reduce American consumption of sugar-sweetened beverages but we won’t get there by putting seemingly far-off health promises up against happiness.

A Different Approach: How Using the Social Ecological Model and Advertising Theory Could Nudge People Toward Healthier Drinks And Create a Social Movement

The social ecological model with a strong social marketing component modeled on the Truth Campaign’s success has the potential to effectively reduce sugar-sweetened beverage consumption, obesity, and obesity-related diseases at the population level. The social ecological model has many advantages over other public health models as it provides an effective framework for real people living in complex environments (59). Prominent agencies like the U.S. Centers for Disease Control have used this framework to assess and coordinate school health services (60) due to its comprehensive structure that addresses the macrosystem (laws, history, culture, economic system, social conditions), exosystem (extended family, community centers, neighborhoods, mass media), and microsystem (family, peers, siblings) components that surround each individual (61).

Policy initiatives that eliminate corn subsidies, tax sugar-sweetened drinks, or even ban high fructose corn syrup, mandate 0 sugar-added drinks in schools, government buildings, and government funded community centers, and ban sugar-sweetened beverage advertising to children could significantly alter the demand and availability of sugar-sweetened beverages and nudge people to make healthier choices. A broad-based social marketing campaign modeled on the Truth Campaign’s use of advertising theory (62) could include a series of ads that promise unity and social change with desired visual images. The campaign could also harness reactance to create positive behavioral change by appealing to people’s distrust of government and corporations and inspire a Tea Party-esque outrage about corporate profit margins and institutionalized racism (63) and the government’s subsidization of the high fructose corn syrup that’s making our country fat.

Beyond Door-to-Door: How We Can Effectively Target the Population

The social ecological model and advertising theory are both group-level models. For these models we need not assume that humans make decisions in rational vacuums and we avoid the typical western trap of blaming the individual; we actually take advantage of the social influence we have on one another instead of ignoring it. Corporations like Coca-Cola and Pepsi who produce and promote sugar-sweetened beverages have always successfully aimed their promotion efforts at the population, so why should we go door-to-door?

The ecological model allows us to target the population and see population level results. Shape Up Somerville is an ecological wellness intervention that has successfully reduced body mass index of elementary-aged children at the population level (64). Its initiatives have encouraged an entire city’s children to become more active not by targeting individual children but by creating an environment that supports activity for all.

Effective social marketing like the Truth Campaign also have an essential role in modern public health promotion (65). They successfully target a wide range of groups in an array of settings (66) and address the population as a whole (67). Successful campaigns have increased demand for everything from condoms in Zambia (68) to syphilis testing among gay and bisexual men in San Francisco (69).

Nudged: How Environmental and Policy Changes Can Help Us Make Healthier Choices

Policy and environmental changes give the planner in us a chance to follow-through on our good intentions by creating an environment that supports healthier options. We have seen these interventions work to combat smoking (70) and increase healthy behavior in schools (71).

Getting rid of corn subsidies would eliminate the artificially low price of high fructose corn syrup, a base ingredient in the most popular sugar-sweetened drinks. A sugar-sweetened beverage tax would further increase the price and a ban on high fructose corn syrup might be considered given its other negative health effects (72-74). The American Public Health Association supports a soda tax citing that it is just as appropriate as a cigarette tax and could help pay for the $47.5 billion a year that the government spends on medical care related to obesity through Medicaid and Medicare (75). Economists estimate that a 58% soft drink tax would result in a small but real decrease in body mass index (a reduction of 0.16 points) (76) so just think what a broader sugar-sweetened beverage tax could do.

Mandating 0 sugar-added drinks in schools, government buildings, and government funded community centers and a ban on sugar-sweetened beverage advertising to children would improve environmental support for healthy choices and allow for mindless choosing of healthier options in schools and other public institutions. This could improve health and change social norms in much the same way as cigarette bans have (77, 78).

A New Truth: High Fructose Corn Syrup, Sugar-Sweetened Beverages and Obesity

Public Health campaigns have an enormous opportunity to learn from commercial branding and marketing strategy. We need to cultivate brand recognition, promise core values, and deliver on those promises (79). If we strategically reframe the issue of sugar-sweetened beverages we can affect population consumption by selling core values, harnessing reactance, and starting a social movement.

The VERB Campaign and the Truth Campaign were highly successful social marketing campaigns that used advertising theory to begin positive social movements and significantly increased physical activity (80, 81) and reduced smoking respectively. The VERB Campaign and associated advertisements promised community and opportunity. The campaign sent yellow balls all over the country and put kids in charge. VERB challenged kids to invent new games that could be played with the ball and then pass the ball on to someone else giving kids an opportunity to feel in control (82). The Truth Campaign appealed to adolescent values of rebellion and independence (83) and created a counter-industry movement that significantly reduced the prevalence of smoking in Florida teens (84-88).

The issues surrounding sugar-sweetened beverages, high fructose corn syrup, and obesity are rife with material that would make an excellent Truth Campaign. Instead of selling abstinence of sugar-added beverages, a social marketing campaign could sell freedom, independence, control, and rebellion. It could inspire a movement that stood for community and rebellion against the corporations and government subsidies that conspire to make Americans fat. The “product” being sold would be identity as a fit and attractive person in charge of her appearance and rebellion against the feelings of unattractiveness and lack of control over her appearance (89).

Uniting Against Obesity: Conclusion and Call to Action

The Soda Free Summer Campaign has severe limitations due to its reliance on the health belief model, its focus on isolated and rational behavior, its failure to address policy and environmental change, its weak promise backed up by statistics, and its failure to provide compelling visual imagery. The campaign could be improved by addressing any one of these failures.

Obesity is arguably the most serious health issue in America today. The public health community needs to incorporate best practices from successful public health marketing campaigns and ecological model approaches in order to target the population and stop blaming the individual, nudge us toward healthier choices with smart policy and environmental supports, and inspire us to join a movement where we stand up against government subsidies and corporate agendas and say enough is enough.


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Soda Free Summer Campaign Video:


Coca-Cola Commercials:



Coca-Cola Live Positively Project:


Pepsi Commercial:


Pepsi Refresh Project:


Sprite Commercial:


The Truth Campaign Commercials:


NYC’s Pouring on the Pounds Campaign:


ABA’s Response to NYC’s Pouring on the Pounds Campaign:


The Fun Theory:


People get fat in groups:


People quick smoking in groups:


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