American Heart Association’s Face the Fat Campaign: A Flawed Approach to Improving Heart Health—Elizabeth Jarrard

Heart disease is the number one killer of Americans every year (1). With a variety of risk factors, both controllable and uncontrollable, there are many public health initiatives that aim to reduce heart disease. Most recently, in 2007 the American Heart Association launched a “Face the Fat” campaign to increase knowledge about healthy and unhealthy fats while creating behavior change. While it was a valiant effort, the approach is flawed in several ways. There are several social and behavioral psychology principles that explain why this campaign has failed. Because program is founded on the health belief model, improperly uses marketing and branding theory, and decreases self-efficacy, it is easy to see why it has not created change in heart disease rates or dietary patterns. However, by making slight changes to this program, its reach and effectiveness could be greatly improved. By creating a multidisciplinary program that acknowledging the role of societal and environmental pressures on eating, using proper Branding and Marketing Theory, allowing for irrational behavior and using broader, real world applications of reductionist nutrition messages, rates of heart disease amongst Americans could be significantly reduced.

Heart Disease: The Public Health Problem

More than 1 in 3 (81 million) U.S. adults currently live with one or more types of cardiovascular disease(2). As the leading cause of death amongst Americans(1) , heart disease is a major public health problem. The cost of cardiovascular diseases in the United States, including health care expenditures and lost productivity from deaths and disability, is approximately 503 billion in 2010(2). As our population ages, this number is only expected to grow. One of health professionals’ roles is to prevent heart disease by controlling the risk factors. There are several risk factors for heart disease. Some factors you can not control, such as sex (males), age (older), family history, and race (African Americans, American Indians, and Mexican Americans). You can however reduce some risk factors by changing your diet, such as stopping smoking, reducing LDL cholesterol, elevating HDL cholesterol, being physically active, controlling diabetes, and controlling stress. Diet plays a very large role in prevention of heart disease, and a low-fat low sodium diet rich in whole grains, fruits, and vegetables is recommended(3). Research over the past few decades has shown that dietary fatty acids affect serum cholesterol and overall CHD risk differently. High levels of saturated fat and cholesterol have been associated with increased rates of cardiovascular disease, while a diet rich in omega-3 fatty acids, unsaturated fats, fruits vegetables, and whole grains, has been shown to have protective effects.(4) On a per-calorie basis, trans fats appear to increase the risk of CHD more than any other macronutrient(5). Trans fat is a liquid oil that has been transformed into semisolid or solid fats through the process of partial hydrogenation, which increases the shelf life and flavor stability of the oils. While beef and high-fat dairy products naturally contain small amounts of transfat, the majority of transfat in the average American’s diet is due to of highly processed food (6). Replacing saturated and trans fat with monounsaturated and polyunsaturated fats in the diet can help control cholesterol, and reduce heart disease risk (7). While scientific evidence clearly points to the optimal diet for heart health, the real challenge lies in how to make the public adopt such a diet. Numerous public health initiatives have been created to try to enforce this, but with limited success. The USDA Food Pyramid recommends liquid oils over solid fats(8) and the American Public Health Association recommends that trans fat be banned across the nation (9). Several cities and communities have already started banning transfat. Most recently, the American Heart Association launched their “Face the Fat” campaign to try to get the public to switch their consumption of fats to promote heart health. Unfortunately it has been met with only limited success.

The American Heart Association Face The Fat Campaign

As a leading source of information on heart health, and diet, American Heart Association (AHA) is in a powerful position to affect the health of the general population, especially those diagnosed with heart disease. According to Robert H. Eckel, M.D., past president of the AHA, “Consumers have heard a lot about the ‘bad’ fats lately and what not to eat. That’s why it’s important for people to know the ‘better’ fats and foods where they’re found so they can lower their risk for heart disease”(10). In 2007 AHA conducted a survey of US adults 18-65 years old that showed that while ~70% of Americans knew that saturated fats and trans fat increased the risk of heart disease, only ~40% knew that consuming polyunsaturated and monounsaturated fats decreased the risk of heart disease (10). To help increase awareness and understanding of transfats and other fats, the AHA launched the “Face the Fats” national consumer education campaign in April 2007(11). The purpose behind Face the Fats is to enhance knowledge and change behavior. A web-based campaign which lives at contains information about types of fat, and how they impact heart health. There is an interactive “Test Your Fats IQ test” as well as a personalized daily calorie and fat consumption. There is a page on picking better fats in restaurants, and healthy fat recipes. The American Heart Association introduced two cartoon characters, the Better Fats Sisters - Mon and Poly - to help consumers learn more about the benefits of monounsaturated and polyunsaturated fats alongside their Bad Fats Brothers, Sat and Trans (Figure 1). While it is important that the AHA support good dietary measures, and continue to educate the public about heart health, this approach is flawed in several ways. The fundamental reliance on the Health Belief model places too much blame on the individual without looking at the societal and environmental causes of eating behavior. It incorrectly uses marketing and branding theory while ineffectively attempting to reach the target audience. Also, by breaking down total diet into smaller, reductionist components, with heavy use of scientific names, disengages the consumer, and decreases self-efficacy.

I) Individual behavior is the focus of the Face the Fat Campaign

One of the main flaws in the Face the Fats campaign, is that like many public health campaigns it is based on the Health Belief Model. This Model proposes that intention leads to a health behavior (12). The health belief model includes six independent components of perception upon which behavior is determined: perceived susceptibility, severity, benefits, barriers, health motivations, and cues to action. It supposes that the individual will carry out the healthier action if they perceive the threat of disease, it is very susceptible and severe, there are benefits, and there are few barriers. Several reviews of the model however have concluded that these variables are only weakly correlated with behavior (13). It also supposes that each individual weighs the positives and negatives for each decision made and makes a rational choice of which action to then take. However individuals are irrational beings and act spontaneously (14). The Health Belief Model overemphasizes individual decisions and fails to address social and other environmental factors that can affect an individual’s actions. The Face the Fat campaign places all blame and responsibility on the individual, without addressing how the American food environment, societal factors, and socioeconomic factors that affect access. It fails to address the power of the food industry and how influential these companies are in the United States. The food industry is a profitable business yet ‘Face the Fats’ places all of the responsibility on the consumer and does not make recommendations for the food companies to make healthier products. Margo Wootan director of nutrition policy at the Center for Science in the Public Interest, a consumer group based in Washington, D.C. "Basic nutrition advice hasn't changed much over the 30 years that the dietary guidelines have been published, but what has changed is it is harder and harder to eat well. For Americans today, healthy eating is like swimming upstream. It's not that you can't do it, it's just it's so hard. Without changing the food environment, people don't stand a chance of following the advice in the dietary guidelines" (15). The current American food environment is loaded with heavily processed foods, that require saturated and transfats to remain shelf-stable for extended periods of time. It can be difficult for the average consumer, even when armed about information about a heart healthy diet to decipher nutrient claims and health labels. By limiting the focus of the campaign to individual perspective the Face the Fat campaign does not take into account the wide array of other influences on the individual when deciding what to eat.

II) Ineffective Branding and Promotion of the Face the Fat Campaign

One of the major flaws with this campaign is its incorrect use of Marketing and Branding theory. The entire premise of marketing theory is to tailor the campaign to the target audience, and basing it on 4 Ps of Marketing: price, promotion, product and place (16). The perceived price here is the switching of “bad” fats with “better fats” that might be more expensive, not as accessible, not as tasty to the consumer. The promotion is entirely web-based. The product they are selling is better heart health by forming a diet that uses healthier fats. The place this intervention and campaign takes place is again the internet. While they did complete formative research, the entire basis of their web-based campaign both in place and promotion, does not suit the target audience. This information is available mainly to those who have a computer and internet access as well as the motivation to visit the website. The campaign assumes that Americans are actively seeking information, and turning to the internet for that information. A 2008 survey by the American Dietetic Association found that messages that focus on cutting, rather than adding, food are undesirable. 60% are not actively seeking health and nutrition information. Of those 40% who are seeking nutrition information, 63% get it from TV, 45% from magazines, 19% from newspapers and only 4% on the internet (17). Even if you are using the internet as your main source of dietary advice, in order to find the information, you have to first reach the AHA’s website, and then subsequently find the tab that will take you to Fat section. Navigating this cluttered website (See Figure 2) could be especially hard for those that spend limited time on the world wide web. If we look at the demographics of those with heart disease, age is a huge risk factor. About 82 percent of people who die of coronary heart disease are 65 or older (7). Only 38 percent of adults 65 + use the internet regularly (18). Data also suggests that adults with chronic disease are less likely to have access to the internet when compared to healthy adults. The Pew Internet & American Life Project and the California HealthCare Foundation found that compared with the 81% of adults reporting no chronic diseases go online, only 62% of adults living with one or more chronic disease go online. Furthermore only 47% of people with heart disease go online for information (19). Because this is only a web-based campaign, it is unlikely to reach those who are at highest risk for heart disease.

If the intended consumer does navigate to the website and begins to investigate the campaign, they will find that it is poorly branded. The brand elements of the campaign are the slogan, “Face the Fat” and a set of cartoons. With the Bad Fat Brothers and Better Fat Sisters (Figure 1) AHA was trying to create a brand the market healthier fat consumption. Branding is an effective means of health promotion, but needs to be done correctly to see results. You want the consumer, in this case the intended audience, to form a positive association with the brand, which they perceived to model a socially desirable good, such as youth or independence (20). The brand needs to provide a solution to the problem the public sees. Imagery is a powerful tool to build brand recognition and should be used to create that external ideal. The imagery used in the Face the Fats campaign is not effective. While no one wants to exhibit the image of the “Bad Fat Brothers,” the “Better Fat Sisters” are no more idealistic. Poorly drawn cartoons, they do not radiate any traits one would want to model. They appear juvenile, and are difficult to take seriously. The sound recordings that accompany them in some sections are distracting and annoying at best. Without creating a brand that is easily recognized, and well-received it is difficult to market the campaign, and create behavior change.

III) Reductionist View of Nutrition Reduces Self-Efficacy

The language of the ‘Face the Fat’ Campaign is primarily in "mono unsaturated" "saturated" while only glancing over actual foods that contain these nutrients. This reductionist view of nutrition that is rampant in most of the dietetics and public health campaigns, but given the current state of obesity, diabetes and heart disease in America, it does not seem to be effective. The customer does not relate or fully understand the nutrients in the food, which is a huge barrier to them adapting the changes health professionals recommend. While there is an increased awareness of transfats, especially with the regulatory measures taken to ban it, knowledge about food sources of different fats remained low. On an unaided basis, 21% of the American public could name three food sources of trans fats in 2007. Knowledge of food sources of saturated fat remained unchanged at 30% in 2007 (22). Most Americans know that saturated and trans fats are bad for their hearts and health, but few can name the foods that contain them. ‘Face the Fat’ incorporates a couple of heart-healthy recipes and suggestions into their education, but this should be the primary focus, rather than an afterthought. Without this education on actual foods, the consumer is likely to continue reaching for highly processed foods that contain saturated and transfats, because of taste and cheap price. Glanz et al found that nutritional concerns are of less relevance to most people than taste and cost (23). Consumer research suggests that people make food choices based on what looks good, what tastes good, what is economical, and what is easily prepared. Any nutrition education message that fails to recognize these competing elements almost certainly will fail in meeting people’s aspirations, perceptions, and values (24). The focus on food groups and other abstract concepts is fundamentally flawed. Diet and health are very complex systems which are composed of many components. An overall diet is not fully reducible to its parts, and by focusing solely on reductionist parts of the diet we lose much of the real picture(25). By reducing diet to abstract concepts like saturated fat, without giving many examples of actual food, self-efficacy is reduced. The audience does not feel empowered, but rather more frustrated. The language of the campaign lowers self-efficacy, which is a major step between intention and behavior. Without self-efficacy the individual will not be motivated to act or persist through challenges because they believe they have no control over the health behavior (21). This primary disconnect between the scientific, public health message, and the overall positive action people can actually make in their lives, limits self-efficacy, creating another barrier to behavior change.

Concluding thoughts on the Face the Fats Campaign: Good Intentions; Poor Execution

While the AHA had the best intentions when creating the Face the Fat campaign it is failing. It is making only small advances in improving heart health and consumers’ behaviors and thoughts about fats, because it postulates that behavior is solely up to the individual, incorrectly applies marketing theory, is poorly branded, and, reduces self-efficacy. However, with a few changes, these things could easily be corrected to create a more effective campaign.

Proposed Solution: iHeart

A multidisciplinary approach with new methods of promotion and levels of nutrition education is necessary to improve heart health through healthy diet. iHeart will be a partnership between the American Dietetic Association, and Massachusetts General Hospital’s Heart Center to launch a community based initiative in Boston MA, which integrates advertising, nutrition education in hospitals, gyms, and schools, with free classes to those at highest risk for heart disease. To get people to switch to healthier fats in their diet, this new campaign would be a three-pronged approach which would focus more on the food environment, correctly use marketing theory, and include real world applications instead of simple, reductionist information. Although it will start locally in a community setting, upon confirmation of success, which will be evaluated annually, it will have the possibility of expanding nationwide.

Step 1: Reshape Food Environment

Unlike the Face the Fats campaign we would not base iHeart on the Health Belief Model. We understand that an individual’s food choices are shaped by many other influences than simple knowledge about the health topic, benefits and risks of certain diet. Food choices are shaped by societal pressures, food environments, and the availability of healthy foods. Because nutrition is such a complex topic, simple communication of the health risks and benefits is apt to do little to change the consumer’s behavior. Instead we need to recognize the social context in which these behaviors appear, and highlight why the positive behavior is beneficial to the consumer(20). Corporate practices of food processors need to be addressed. We need to impose more direct burdens on food makers and marketers to reformulate their products and realign their advertising to be consistent with educational messages (26). Since 2003, all food manufacturers have been required to label the amount of transfat in their products, per ruling by the Food and Drug Administration (FDA) (27). Boston has already passed legislation for a transfat ban (28), one of the first steps to creating a healthier food environment. Although transfat are banned in this community, grocery shelves are still loaded with highly processed foods that are high in saturated fats, low in whole grains, and high in sodium. By teaching community cooking classes, & culinary demonstrations, as well as working in corporate offices to improve cafeteria and dining out options, we can help to shape the environment in which people eat. Education materials will include how to read nutrition labels on processed foods. There will also be an iHeart sticker put on all foods in supermarkets that meet our nutritional specifications for a heart-healthy diet, with education material at store entrances. These modifications in the food environment will reduce individual burden in creating positive health decisions, and remove a barrier to eating a heart healthy diet.

Step 2: Rebrand Campaign and use Marketing Theory to reach those at highest risk

The correct application of marketing theory requires formative research on target audience, and then creates a product which fulfills and appeals to these human values. For those with cardiovascular disease they may live their life in fear of a heart attack or blood clot. We want to show that this healthy diet will give them freedom from this fear. We want to empower them that they can make a difference in their life, by simply changing some of the foods they eat. It is not a complex message, but it needs to be aligned with values that the target audience desires. To form a more effective social marketing campaign we need to find out what the consumer wants and then redefine, repackage, reposition and reframe the product in such a way that it satisfies an existing demand among the target audience (29). Our target audience is those at highest risk for heart disease, especially males over the age of 65, the physically inactive, and obese. Education spots should be featured in a variety of different types of media, not just the internet, to reach the target audience. The product is more energy, freedom, youth and vigor, the price is simply switching some of the foods you eat, the promotion will be through traditional media channels, in supermarkets, and through cooking classes, and the place will be throughout the Boston community.

To create a very effective marketing campaign we have to have a easily recognizable brand. A brand is a set of associations linked to a name, mark or symbol associated with the product (20). The set of associations we wish the consumer to relate with this new campaign is youth, vitality, and independence from hospitals. We won’t market healthy fats because they promote “health” but instead we will promote lustrous skin, hair, vigor and sexual power. For our target audience, health means very little, instead “health” is a proxy for other things. Like any commercial brand, this new campaign will position this positive health behavior with the lifestyle the consumer wants to embody, and establish a long-term relationship with the target audience. Eating healthy fats needs to be seen as a desirable activity and tied into freedom, beauty, and youth. This message will be streamlined throughout the campaign. The campaign will be called iHeart, because it has allusions to the youth, but still is very personable, and easy to relate to with the singular first-person pronoun. With slogans like “What’s good for your heart is good for other parts” we will emphasize benefits of healthy fats on sexual performance, eyes, skin, hair, etc. To change behavior we are going to have both emotional and rational drivers, tying core values of youth, vitality and independence, that Americans hold so dear, with the adaption of a healthier diet. Through celebrity endorsements we can feature prominent individuals whom are looked to for beauty and creativity, and highlight them eating the diet we advise. By building a relationship with our target audience, showing why this action is beneficial for specific reasons besides the illusive “health,” and using rational and emotional drivers we will build a more convincing argument for behavior change. With the iHeart Logo we will step away from the childish cartoons of Face the Fats, with a more refined, tasteful logo (see Figure 3). The red alludes to heart health without being too apparent. The font is similar to the one used commercially for Apple and iPod products, alluding to sophistication, wealth, technology, and youth, without being too distant and pretentious. Through a newly defined social marketing theory, improved slogan and brands, we will be able to more effectively reach the target audience of those at greatest risk for heart disease.

Step 3: Enhance Self-Efficacy through Real World solutions.

iHeart will be an empowering campaign that creates self-efficacy by showing the intending audience that they have the power to live a better life, that they can do this. Several empirical studies suggest that consumers with higher confidence over their own health are more likely to undertake healthy eating behavior (30). We know that people do not behave rationally, and that “health” is not a primary motive for people to choose to eat a food. We will step away from the reductionist perspective of highlight scientific terms such as saturated fats, and instead emphasize the actual foods which contain healthy fats. This concept is only briefly mentioned in the old campaign, but with iHeart it will be the driving force. First the name, iHeart implies that this campaign is about the audience, that it is personalized, that “I can do it.” The ads, website, and marketing materials will highlight delicious foods, that are “secretly” healthy for you. Enticing recipes of Salmon, Salad with almonds, and an oil dressing, and whole grains/vegetables will be featured. We will be replacing the childish cartoons with images of mouthwatering food, and showing the audience how to create such dishes. This new campaign will include a cooking program in the first communities to adapt it. A 2008 survey by the American Dietetic Association found that 52% need more practical tips to help them eat right (17). Our attention will be focused the foods and changes in a positive way, steering clear of “don’t-eat-this” lists. Glanz et al recommend nutrition education programs should attempt to design and promote nutritious diets as being tasty and inexpensive (23) which we will include. There should be less emphasis on the individual nutrients and more on taste, convenience, and affordability. Throughout supermarkets will be signs that say iHeart Salmon, iHeart Avocados, iHeart 100% whole wheat pasta, iHeart Almonds, etc, emphasizing heart healthy foods. Cooking classes will greatly increase self-efficacy and give members real world skills to improve their heart health. Through real world application and tips on how to eat the foods we recommend for a heart healthy diet, while empowering and giving motivation to high risk populations, iHeart will increase self-efficacy, leading to behavior change.

Evaluation

Like any campaign, we will re-evaluate iHeart every year to determine its effectiveness. This will be determined by surveys that reflect community attitudes about fats, and heart health. We will also keep track of illness and morbidity statistics in the communities we are targeting. By doing many focus groups and pre-formative studies, starting with a small pilot, and gradually expanding it to a larger community we will have the most success. Once we have determined that it has been effective in Boston we will be expanding it nationwide, with partnerships with other hospitals and public health organizations.

Conclusion Let’s really Face the Fat with iHeart!

iHeart will be the first multidisciplinary approach to improving heart health through simple dietary changes in Boston. By reshaping the food environment, creating a brand that the target audience can relate to an associate with, while marketing it in a variety of ways, we will be able to increase self-efficacy and make concrete changes in behavior. Stepping away from the individual-centered, web-based, reductionist campaign of Face the fats, we will help to transform the Boston community. Because iHeart Healthy Foods.™

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