Friday, December 17, 2010

Drinking Ourselves Fat: A Critique of Why King County’s Sugar-Loaded Beverages Education Campaign Will Not Reduce Obesity – Michelle Chung

Obesity is a pervasive public health concern in the United States. In 2007-2008, 1 out of 3 American adults were classified as being obese, having a body mass index of 30 or more (1). 17% of school-age children and adolescents between the ages of 2 and 19 were obese, a prevalence rate that is triple the rate observed in the 1980s (2). Elevated rates of obesity among children have serious and concerning consequences. Obese children often continue to be obese into adulthood, where obesity puts them at a heightened risk for a number of heath care problems that include cardiovascular disease, certain cancers, diabetes, and earlier mortality (3,4). One of the culprits identified as a major contributor to our current obesity epidemic is the consumption of sugar-sweetened beverages. Among increases in obesity rates, rates of consumption of sugar-sweetened beverages have also increased to unprecedented heights with the average American consuming approximately 50 gallons of sweetened drinks equivalent to40 pounds of sugar annually (5). A systematic review of 30 studies concluded consumption of sugar-sweetened beverages was positively associated with weight gain and obesity, identifying the consumption of these beverages as a hindrance in the pursuit of a healthy lifestyle (6). Echoing these findings, the American Academy of Pediatrics currently recommends physicians discourage the consumption of sugar-sweetened beverages among all children with the exception of underweight children (7).

To combat the obesity epidemic, many interventions and campaigns have been created with the purpose of reducing consumption of unhealthy foods and encouraging healthier alternatives. In November 2010, Seattle and King County Department of Public Health announced their latest efforts to curb obesity by introducing the Sugar-Loaded Beverages Education Campaign that focus on emphasizing the harmful health impacts of consuming sweetened drinks (8). The campaign has a two pronged approach with educating parents through a public service announcement and an educational poster. The educational poster is downloadable at their website and is featured in seven different languages: English, Chinese, Russian, Somali, Spanish, Ukrainian, and Vietnamese. The educational poster depicts sixteen sugar packets being emptied into a 20 fluid ounce soda bottle where the sugar becomes gelatinous fat as it comes in contact with the bottle. The caption in the poster reads, “Your kid just ate 16 packs of sugar. All those extra calories can bring on obesity, diabetes and heart disease” (8). Another variation of the poster includes a larger 32 fluid ounce soda container where 26 packets of sugar were emptied into. In the public service announcement, it panels in on a family of three where the mother has prepared lunch for her daughter and son. The mother reaches into the refrigerator to grab a 2 liter bottle of soda. She twists the cap off and begins to poor out the soda into a glass cup. Pure sugar comes out of the bottle until she has filled the entire cup with soda. She hands the cup to her son and he begins to drink it. The following captions are shown: “You’d never pour your kid a glass of sugar. There are 55 packs of sugar in a 2 liter bottle of soda. These extra calories can bring on obesity, diabetes, and heart disease. Choose low-fat milk or water instead (9).” There are two versions of the public service announcement available on YouTube, one in English and one in Spanish.

Although sugar-sweetened beverages is undoubtedly a major contributor to the obesity epidemic, this campaign may fail to become an effective intervention due to its heavy reliance on human rationality emphasized within the health belief model, failure to appeal to the core values of their general audience that soda industries have promised, and negative labeling of soda drinkers.

The Failure of the Health Belief Model: The Irrationality of Human Behavior

One of the critical assumptions this campaign highly relies upon is that human behavior is rational and planned. This campaign is modeled after the Health Belief Model; a theory that hypothesized that motivation to adopt healthy behaviors is a result of interplay between perceived susceptibility, perceived severity, perceived benefits, and perceived barriers of the action (10). Viewers of the poster and public service announcement are assumed to make the decision to reduce future consumption of sugar-sweetened beverages based on learning new information that there is an excessively high amount of sugar in soda, with the individual rationalizing their thought process through a cost-benefit calculation whether or not to drink soda. If individual behavior, obesity itself would not have become a health crisis that is of epidemic proportions. If we were rational beings, there would be no need for interventions to continually entice people to get up and moving to exercise. Unfortunately, human beings are predictably irrational (11). Decisions individuals make is more complex than a simple cost benefit analysis; decisions are made in the social context around us such as peers and the environment. When we see a line forming outside a restaurant, we get into line because we use other people’s behaviors as a gauge to determine if something is good or not and mimic their behaviors (11). We go to Starbucks every morning to get coffee that is significantly more expensive than Dunkin Donuts coffee mainly because of habit (11). We judge people differently on the basis on of holding different temperature beverages in our hands; we perceive strangers as being trustworthy and warm when briefly holding a cup of hot coffee in comparison to iced coffee (12).

Humans are not only irrational beings, we do not live in social isolation. We are easily nudged by others in that their presence and behaviors influence our own behaviors. Our eating behaviors change dependent upon the number of people we eat with: we eat 35% more than our normal consumption when eating with one other person and eat 75% more with a group of four people (13). A person is more likely to be obese if they have a lot of obese friends (13). Decisions that we make on a day to day basis does not exist in a vacuum. Decisions, planned and unplanned are made in conjunction of the social context that we live in. This campaign is assuming that individuals will make the rational choice each time they are thirsty, regardless of social context and scope of self control. But the reality is, choice of beverage is automatic. For an individual where soda consumption is habitual, rationalizing why they are drinking soda was never part of the process of choosing to drink it in the first place. Intention does not lead to behavior. For children and adolescents, peer pressure and the desire to conform are hard to ignore. If all of your closest friends are drinking the newest brand of soda, it will be extremely difficult for an individual to opt for water or low-fat milk regardless of the health benefits.

The ad, while aimed at educating parents does not acknowledge the social influences such poverty or price of healthier alternatives in affecting beverage choice. It is not a highly regarded belief that mothers buy soda because she thinks that it has any nutritional value that is beneficial to the growth of her children. Indicating the amount of sugar in sweetened beverages is not new knowledge. While sugar-sweetened beverages are a contributing factor to the obesity epidemic, it is not the sole cause. While the campaign assumes individuals will make the rational decision for the sake of preventing onset of poor health, it fails to take into account the interplay between the irrationality of human behavior, influence of others around us, and the social context in which decisions are made.

Selling Health vs. Intrinsic Wealth: Focusing on Impending Death instead of the American Dream

The Sugar-Loaded Beverages Education Campaign focuses on promising reducing risk of immature mortality and morbidity from cardiovascular disease, certain cancers, and diabetes (8). These promises are supported by numerous statistics that focus on the wide prevalence of obesity and increases in poor health outcomes on the main website. Despite the promise of increasing health, the campaign fails to offer an appeal to the core values that American hold dear and near to their heart: freedom, love, control, opportunity, and independence.

Soda industries such as Pepsi and Coke have successfully made this appeal by offering a large promise and capturing the essence of the core values that people desire. In the “Forever Young” advertising campaign, Pepsi sells the large promise of youth, invigoration, and being strong by drinking Pepsi (14). These promises are made to the basic needs and wants that everyone aspires to, along with supporting images of people and styles of music across generations. Similarly, in a “What Goes Around Comes Around” advertising campaign, Coke sells the large promise of love, acceptance, and respect (15). In this campaign, Coke is the tying factor that brings about love and acceptance among different people through sharing their love of coke with others. Drinking coke promotes compassion. The message is supported by showcasing a diverse group of people who are happy and a cascade of helping behavior, one individual who helps another and the one helped helps another. The core values displayed by these two soda giants touch upon something very sacred to the heat of all Americans. By appealing to the deepest universal aspirations of the population, they were able to capitalize upon the emotions people felt connected to and inspire consumption of sugar-sweetened beverages.

While it is evident that the Sugar-Loaded Beverages Education Campaign has sought to incorporate the use of advertising through creation of a commercial and its dissemination through the popular social media platform YouTube, it still fails to be an effective social marketing campaign. An effective campaign must sell without drawing attention to itself, offers a large promise with a core ideal, give visual support to your claims, and excites interest (16). In comparison, the campaign never offered a true concrete promise to the population except for reducing some risk of slaving off obesity. Statistics flourishing on negativity of disease instead of positive benefits of a drinking healthy beverages were offered in support of the claim. Selling dangers of unhealthy behaviors has not been a core value that ignites motivation among human behaviors. Abstinence only campaigns have largely been considered a failure at preventing sexually transmitted diseases (17,18). By selling abstinence, youth without safe sex education are unprepared to prevent sexually transmitted diseases in which sexual opportunities arise. Similarly to the abstinence program, this campaign instills a simple message that is telling youth to abstain from sugar-sweetened beverages and by only offering alternatives that contain zero amounts of sugar. Instead of selling positive core values of the community for the individual to uphold, the message of the campaign is to illicit behavior based on gloom and doom of negative health consequences.

What about the Fat Kid? Reinforcing Negative Labeling and Stereotypes

As obesity trends continue to increase, people with lean and thin statures have been the focus of the ideal standard of beauty and health. In contrast, individuals who are overweight and obese are largely considered to be lazy, unintelligent, having weak will-power or self discipline (19). There is a growing body of literature that indicate overweight and obese children are becoming targets of stigmatization and social isolation from their peers (20). Research has shown weight- related stigma invokes psychological stress and discrimination that exacerbates physical poor health outcomes that obese individuals’ already are plagued with (20).

The message of the educational posters where sugar turns into fat strengthen the social stigmatization of obese children as it seeks repulsion from the audience in response to unhealthy weight. This message also seeks to label consumption of sugar-loaded beverages as an unhealthy eating habit, negatively associated with obesity. If this campaign is successful in selling that label, those who drink sugar-sweetened beverages periodically will become the new target of their peers and be labeled as obese. After repeated reinforcement of this message, the child may internalize and adopt the label as the “fat kid”, promoting the initiation of other harmful health behaviors and becoming a self fulfilling prophecy. Among those with are already considered overweight and obese, experiencing weight-related bullying increases their risk of engaging in unhealthy weight control behaviors such as binge eating and bulimia (19). Engaging in eating disorders will fuel further stigmatization and lead the child down a never-ending vicious cycle of ill health. By negatively associating sugar-loaded beverages to obesity, the intervention may prove to be counterproductive to the initial intention of the campaign.

With such judgments, obesity has simmered down to being framed as an individual problem instead of a societal problem by blaming the victim. By focusing on personal responsibility, societal interventions that could be effective at reducing obesity are ignored.

An Alternative Approach to the Anti-Obesity Campaign: The Use of Advertising Theory, Psychological Reactance Theory, and Labeling Theory to Combat Obesity

The obesity epidemic is a severe public health concern that requires immediate attention. Although there has been much attention and money spent on battling against obesity, rates have continued to increase or plateau in different populations. The struggle in which we face in battling obesity reflects the complexity of the problem. King County’s Sugar-Loaded Beverages Education Campaign is one of the most current attempts to lower rates of obesity by reducing consumption of unhealthy beverages and promoting healthier alternatives. Unfortunately, the campaign fails to pay attention to social and environmental factors that highly influence obesity-related behavior, the false assumption that people make rational health choices, stigmatizing fat related to sweetened beverages, and the lack of appeal to American core values that impact motivational behaviors.

From the critique of the previous campaign, it is evident that a successful intervention against obesity will have to have a multi-faceted approach to combat the complexities in which obesity stems from. The proposed campaign against obesity is a social marketing campaign loosely modeled after the successful Truth campaign, an anti-smoking campaign that advocates youth against tobacco by shedding light on the conspiracy of the big tobacco industries (21). “Food Truth” uses advertising theory through creation of a public service announcement that promises being united through change with visual imagery of a diverse group of youth taking a stand for what they believe in (16). Everyone, no matter how young or small makes a difference. The campaign borrows from Psychological Reactance Theory by unifying youth in rebellion against authority, especially large cooperation such as soda giants (22). Lastly, labeling obesity as a societal problem in which the culprits of encouraging poor health outcomes are the greedy companies responsible for manufacturing and promoting unhealthy sugar-loaded beverages.

Focusing on the Positive: What Food Means to Me

Instead of focusing on traditional approaches in affecting health-related behaviors, some public health interventions have incorporated the use of social marketing and advertising theory to change individual motivation (21). As shown in the Truth campaign, appealing to adolescent rebellion and search for independence brought about the decline of smoking prevalence among Florida teens (23,24). Similarly, the “84” campaign, which brands teens as 84% of youth in Massachusetts who choose not to smoke is another intervention where youth are united through rebellion and independence (25). For the topic of obesity, “Food Truth” could be a highly successful campaign if it brought children and adolescents together under a brand that focuses on the image of health and vitality that won’t be influenced by the schemes of big corporate soda industries. Instead of telling kids what to eat, the campaign focuses on allowing children to take control of what goes into their body, giving them independence and freedom that they desire. In support of the promise of freedom and choice, advertisements for this campaign would focus less on statistics and more on personal stories and antidotes from children similar to the target population. Example visuals in the video would show children choosing healthier options such as their favorite fruits that give them that extra kick of energy whether out on the soccer field or at dance class. Other vignettes that the advertisement may show children choosing a reduced-sugar alternative to a highly saturated sugared drink to give them to curb their craving for sugar or junk food.

The Underlying Reasons of Obesity: Food Truth about Sugar-Sweetened Behaviors

Framing of the way obesity is viewed has a tremendous impact on interventions that are proposed and implemented to combat the growing epidemic. Framing determines how people think about a problem. In many interventions such as King County’s Sugar-Loaded Beverages Education Campaign, the focus of the problem was the individual (8). The individual was responsible for being overweight and in control of managing their diet to change risks to health outcomes. In our revised campaign, we propose that the problem with obesity is the rampant exposure our children have to sugar-sweetened beverages and the lack of alternatives within their school and living environment. By framing the problem as being societal responsibility, the recommended changes are to implement new policies which would curtail the amount of soda-machines within a given school and school district. Research shows when soda and snack machines are readily available, students opt to buy junk food from them instead of a regular lunch from the cafeteria (26). Reducing the number of junk food machines and soda machines from schools would have a direct and influential impact on the health of school children.

Another way in which framing could impact rates of obesity is through unification of government, policy makers, children, adolescents, families and communities on apply pressure on soda industries to offer healthier beverage options. It is not probable that soda industries will forgo creating sugar-sweetened drinks, but any change in the amount of sugar being used in the creation of soda is a step in the right direction. Currently, one 20 ounce soda contains 16 packets of sugar (8,9). If soda industries were able to create the same 20 ounce soda taste with 8 packs of sugar, it would already decrease an enormous amount of sugar consumption for a child, dependent on the frequency in which he consumed sugar-sweetened drinks. By transferring individual responsibility to corporate responsibility, the threat of stigmatization of children based on their weight is no longer a pressing concern.

Increasing accessibility to healthier alternatives

Among the different factors that impact obesity, studies agree that the built environment has a tremendous impact (27). Besides modifying individual behavior and corporate behavior, changes in the urban landscape is necessitated. The impact the built environment has on obesity is the ability to access healthier options of food. To change residents’ access to healthier food alternatives, an education campaign will be created to increase awareness among locals of how fast-food joints decrease their purchasing power and ability to access healthier foods. Dissemination of awareness is to create psychological reactance among the residents when they feel that the power of choosing healthy foods and lifestyles are restricted (22). Under this theory, unity among the locals will grow as psychological reactance increases. The campaign will then initiate the formation of a Healthy Access Task Force which would bring the locals into planning ways to bring in community gardens to provide fresh, assessable and affordable fruits and vegetables to local communities. Researchers have found that when the community is directly involved with the process of creating a community garden, it reinforces their intake of fruits and vegetables (28). Creation of community gardens would help improve community involvement and strengthen the unity of the community.

On the other hand, the Healthy Access Task Force could regulate their access to healthier food options by restricting their access to unhealthy junk foods. By raising media attention to the density of fast-food joints in certain geographical locations, it is possible to rally for changes in regulating the number of fast-food options that are available within one census block. Reducing the number of fatty food joints that are accessible reduces consumption of unhealthy foods.


In the past month, the Seattle and King County Department of Public Health has introduced a new campaign to halt the current Obesity Epidemic that was geared towards getting people to change the types of beverages they consumed. Specifically, it targeted reducing and eliminating the consumption of sugar-sweetened beverages. The campaign was focused on individual action instead of action of the larger community. The campaign was highly reliant on the basis of human rationality that if parents knew that soda and other beverages had high amounts of sugar that contributed increased risks of developing obesity, that consumption of sugar-sweetened beverages among children would cease. Unfortunately, the intervention failed to acknowledge the presence of social and environmental factors that were pivotal to changing individual behaviors. It also failed in capturing the essential core values that motivate individuals to take action for their behaviors and sought to reinforce negative stereotypes surrounding obesity. Due to this limitation, the campaign may not see the success in reducing obesity as previously expected.


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