Monday, May 20, 2013

Pass the Salt: Analysis of the 2013 NYC Health Campaign for Sodium Reduction – Laura Vercammen

Excessive sodium consumption has been the topic of numerous public health policies, campaigns, and mandates. Contrary to what many people believe, sodium consumption has been a concern of public health policymakers for over 40 years, beginning with the 1969 White House Conference on Food, Nutrition, and Health. This American conference was groundbreaking in its sodium reduction policies, including recommendations for food manufacturers and the initiation of several FDA investigatory commissions (1). 
High intake of dietary sodium has been strongly linked to health problems such as hypertension (and cardiovascular disease), renal disease, osteoporosis, and stomach cancer (2). The 2010 Dietary Guidelines for Americans recommends that Americans limit their daily sodium intake to no higher than 2300mg per day, and no higher than 1500mg per day if they are over 51 years of age, African American, or have high blood pressure, diabetes, or chronic kidney disease (3).  It is concerning that, in spite of these recommendations and decades of interventions, the average American over two years old still consumes roughly 3400mg of sodium per day (4).  This is a 50% increase from the recommended amount; this excess is believed to be a risk factor in thousands of additional deaths each year (4).  In fact, a controversial study from the Harvard School of Public Health recently concluded that American salt intake is nearly the same as it was over 50 years ago (5). For this reason, federal and state policy makers continue to seek innovative ways to reduce sodium consumption at the population level. 
It is estimated that about 15% of sodium is added to food at home during the cooking process, and 5% is naturally occurring in foods. The remaining 80% is consumed through increasingly popular processed foods, over which the consumer has very little direct control (6).  In fact, 40% of an average American’s sodium intake comes from only 10 types of foods, including bread, cold cuts or cured meats, pizza, poultry, and soups (4).  The prevalence of high sodium levels in common manufactured foods makes it challenging for a consumer to reduce their personal sodium levels. Therefore, state and federal governments are continually looking for new and innovative ways to educate people, and to motivate them to make healthy choices regarding this issue. 
Intervention Description
On April 1st, 2013, the New York City Health Department revealed a new advertising campaign in a renewed attempt to fight sodium overconsumption in its citizens (7).  The purpose of the advertisement is to remind consumers that most of their daily sodium intake comes from processed foods, rather than from the often-scapegoated household saltshaker.
While the colour and the image on the ads vary, the slogan and accompanying text remains constant throughout the campaign.  The ad reminds subway patrons that “too much salt can lead to heart attack and stroke” and that in order to combat this, they should “Compare labels. Choose less sodium.”(7) The ad then goes on to explain, “Most salt you eat comes from packaged foods, not table salt.” (7) The series of colourful ads is displayed on subways cars, and is accompanied by an invitation to “Learn More” via a complimentary health bulletin (7). 
To emphasize the warning message, the ads show images of different processed foods, with a magnified Nutrition Facts label. These foods include canned soup, microwaveable “TV dinners,” and loaves of mass-produced sliced bread.   
From one perspective, the NYC Health Department succeeded in conveying a successful and potentially effective health message. The advertisement is simple and the meaning is clear, which is particularly important given that the target audience is using public transport.  There is urgency and a taste of fear when the advertisement emphasizes the dire health consequences of excess sodium intake. Finally, the campaign is instructive, and may aid confused customers who previously struggled to interpret food and nutrition labels.
However, from a social and behavioural health perspective, the NYC campaign is based on inappropriately applied theories and conflicting assumptions. The purpose of this critique is to discuss the three most significant of these shortcomings. The paper will conclude with recommendations for an alternative intervention to address the pertinent public health issue of excessive sodium consumption. 
Intervention Critique
Health Belief Model
An initial concern with the NYC Health Department sodium reduction marketing campaign is that its efficacy is firmly entrenched within the health belief model.  While this model has strong theoretical underpinnings, and has been used in an array of public interventions, all of its characteristics do not necessarily apply effectively to the issue of dietary sodium overconsumption. 
The health belief model is a psychosocial model of individual behaviour that uses a rational, stepwise explanation to explain the way people approach their health choices (8).  The model contends that individuals must believe they are susceptible to the condition, that the condition has serious consequences (in this case, hypertension and other diseases), and that taking action (reducing sodium consumption) would satisfactorily mitigate these consequences.  Individuals must also believe that the health benefits of the action outweigh the costs of making a change (having to choose lower sodium foods or potentially compromising taste), and that they are capable of successfully making this change. Finally, the model requires that the individual be exposed to factors that prompt action, such as an advertisement on a subway (8). 
The overarching concern with the use of this model is that fact that it relies on rational consumer choice. Many everyday consumer choices can be seen as rational. For example, most individuals would think carefully and reasonably about the decision to purchase a car, or a house, or even an electronic device. However, the choice to buy fast, pre-prepared food items often in the midst of post-work hunger is not necessarily rational. Individuals buying these items are thinking about the immediate consequences of instant hunger gratification rather than the long-term consequences of mitigating heart disease (9).  Therefore, an individual, even after being exposed to an educational subway stimulus, may not consider the health consequences of their actions, or weigh the benefits and costs of such actions.  In fact, they may justify a high-sodium food choice by failing to acknowledge the link between sodium and heart disease that is admittedly foggy to the everyday consumer, or by believing that the consequences may be a concern to others but not to them.  Their choices will instead depend on the marketing strategies of the food industry, packaging, perceived good taste, and availability (9). 
The health belief model is further misused when considering the target audience of the campaign.  The advertisements are placed on subway cars in New York City. Although the demographic of subway-riders is extremely diverse (especially in New York), the average subway patron is most likely younger and of a lower socioeconomic status than individuals who can afford to drive or take taxis.   This demographic group is the least likely to believe they are susceptible to the condition, since high blood pressure, heart disease, and many types of cancer are generally relegated to the older population. If this population also has a lower average socioeconomic status, they may conclude that the costs of buying fresh foods and the perceived reduction in food enjoyment outweigh the health benefits of a reduced-sodium diet.  Both of these factors suggest that the advertisements could be more effective if they were situated in a different location, or modified to suit a different target audience. 
Psychological Reactance
An additional concern with the new intervention designed by the NYC Health Department is that it has potential to generate an opposite effect on consumers, according to the theory of psychological reactance.  The theory describes how, when an individual’s personal freedoms are perceived as threatened or compromised, a motivation state arises that often results in the individual “rebelling” in the opposite direction (9, 10).
In this specific advertisement, the text reads, “Compare labels. Choose less sodium.”(7) According to the theory of psychological reactance, this mandate is a threat to the person freedoms of choice and consumption.  Consumers are being told what action to take and what foods to purchase, with very little explanation.  The paternalistic,  “because I said so” approach taken by the NYC Health Department may end with many consumers rebelling against the message and continuing to buy the foods they enjoy, regardless of their sodium content. 
Message framing is as essential in public health campaigns as it is in corporate marketing. Unfortunately, public health professionals often fall short when framing an important issue, resulting in ineffective campaign results.  The NYC Health Department’s 2013 sodium reduction campaign may be no different. 
Frames influence the way individuals conceptualize and understand messages in day-to-day life. If an issue is framed in a certain way, based on specific core values and using key tools, people receiving the message will fit the ideas, images, and concepts of that issue into an existing framework in their minds (11). These frameworks are then associated with motivation, attitude, and subsequent behaviours.  In general, a frame has five components: a core position, metaphors, catch phrases, symbols/images, and a core value (11). 
Excessive sodium consumption and its negative consequences have, in this case, been framed in a way very typical of many public health campaigns.  The core value of the issue is presented as long-term health, and the core position is that unknowingly consuming sodium over the recommended daily limit via processed foods can severely impact your health. The position is supported by health claims and further statistics, information, and suggestions accessible through the Health Bulletin (12).  However, the use of health, especially long-term health, is very rarely an effective frame to motivate people to change their behaviour (13, 14, 15).
A possible explanation for the trend of dismal outcomes for various public health campaigns is based on Maslow’s hierarchy of needs.  This pyramidal structure of human drives, based on a progression from physiological to self-actualization needs, describes how humans must fulfill their more basic needs before they can fulfill more complex desires (16). Therefore, in the case of New York’s ad campaign, the core value being promoted is the drive for long-term health. Since this drive is neither disabling nor urgent, it would most likely be categorized as a self-actualization need at the top of the hierarchy. Many people, and especially those in the younger, lower-income target population on the subway (as previously discussed) are driven to act on lower-level needs such as safety, sustenance, intimacy, and employment (16).  Motivating them to act on a higher-level drive such as long-term health awareness is then an unrealistic expectation, based on this theory. 

Alternative Intervention

With the aforementioned psychosocial models clearly in mind, an alternative intervention should be created to address the obviously important issue of sodium overconsumption through processed foods.  This proposed intervention takes into account the tenets of the Health Belief Model, the theory of Psychological Reactance, and Framing theory to motivate attitude and behaviour change in the general population. 
The central idea of this new intervention is that high sodium obscures a plethora of other enjoyable flavors in everyday foods – flavours such as garlic, cinnamon, herbs, exotic spices, fresh ingredients, and delicately balanced aromas. Food manufacturers use excess sodium in foods in order to cover up cheap ingredients, a “processed” taste, and a lack of flavor variation (17).  Therefore, the campaign calls on individuals to “Take Back Your Flavor. Join the Flavor Revolution!” Through colorful ads emblazoned with empowering and exciting text, and images of mouth-watering food with an abundance of perceived flavor, the campaign calls on consumers to put pressure on food manufactures to reduce their sodium content and allow the natural flavor and quality of food to shine through.  The campaign can be supplemented with TV ads highlighting how absurd it is that sodium is the dominant flavor in many of America’s favorite foods, and a low-sodium/high-flavor recipe book called “The Flavor Guru: Taste the Flavor Revolution.” 
Strong empirical support for this proposed intervention comes from implementation and evaluation of the counter-advertising public health campaign implemented in Florida beginning in 1998 called the “truth” campaign (18). The purpose of this campaign was two-fold: 1) To convey the message to young people that the tobacco industry was manipulating them in a profit-hungry and heartless way, in spite of the very real health consequences of smoking, and 2) To empower youth to take on the tobacco industry in order to make their generation “tobacco-free.” Evaluation of the campaign concluded that youth who were probably exposed to its advertisements (i.e. those above a certain threshold on a media effect index) were significantly less likely to initiate smoking than youth who were not exposed to the campaign (i.e. those below the threshold)(18). The success of this counter-industry campaign has not, as of yet, been replicated in similar public health campaigns, but its psychosocial theoretical underpinnings (19) and emphasis on the core values of freedom and empowerment can be translated into a strong intervention plan for the issue of sodium overconsumption.
Health Belief Model
The theoretical underpinning of the Flavor Revolution campaign involve a more appropriate use of select aspects of the Health Belief Model, while sufficiently addressing the weaknesses of the model.  The NYC Health Department ad campaign relied on the concept that consumers make rational, pre-conceived choices regarding food purchases. However, it is most likely more accurate to contend that consumers do not buy many processed foods (especially high sodium products such as chips, pizza, and microwaveable dinners) with a rational basis in mind (20). Instead, these consumers are purchasing foods based on hunger, craving, and the need for instant gratification.  The Flavor Revolution campaign plays to this impulsive purchasing behavior, by convincing consumers that foods with lower levels of sodium and higher levels of other, more flavorful ingredients will satisfy them even more. The nature and tone of the campaign also conveys a spirit of being adventurous with foods and novel tastes.  By taking advantage of this impulsive and irrational behavior rather than requiring the consumer to shop rationally, the Flavor Revolution campaign overcomes a substantial weakness of the Health Belief Model. 
The Flavor Revolution campaign is also more likely to influence consumer behaviour according to other aspects of the Health Belief Model.  This model contends that the individual must believe they are susceptible to the health consequences (8).  In the original NYC campaign, the consequences were heart attack and stroke, minor concerns for many young and/or healthy individuals (7). The new intervention emphasizes that the consequence of excess sodium consumption is missing out on good food, tastes, and adventurous culinary experiences.  This is a consequence that many people can acknowledge and want to address. 
Finally, the perceived costs of choosing less sodium in the NYC intervention were the price of buying fresh food along with a supposed decrease in food enjoyment. These costs may easily outweigh the long-term health benefits emphasized by the campaign.  Conversely, the Flavor Revolution campaign involves the same perceived costs of buying fresh food or sodium reduced food, but these costs are balanced by a perceived increase in food enjoyment (21).
Psychological Reactance Theory
The basis of the Flavor Revolution campaign is that consumers’ freedom to choose the best and most flavorful foods is compromised by excessive sodium levels in many common products, often in an attempt to cover up taste deficits or processed ingredients.  The campaign gives consumers the knowledge and ability to choose better tasting options, and to pressure the processed foods industry to make those options more readily available. The NYC campaign presents a perceived threat to an individual’s personal freedom of choice and consumption, with the simple words “Compare labels. Choose less sodium.” Instead, the Flavor Revolution campaign restores and encourages these personal freedoms and empowers people to make their own choices to eat better tasting food. 
Therefore, in terms of psychological reactance, the Flavor Revolution campaign does not make individuals want to rebel against a perceived loss of choice or personal freedom. Instead, it empowers them to become part of a movement to change the way society eats for the better (10).
The reinvented frame of this new sodium reduction campaign is one of its most important components. Traditional public health campaigns, including the NYC Health Department’s new campaign, base their message around the core value of health to convince consumers to internalize information and change their behaviour.  As seen in the past, this frame is rarely the catalyst for changes in health practices at the population level (13, 14, 15).  However, the Flavor Revolution campaign discards this traditional core value in favour of adventure, freedom, and experience.  The images used are those of delicious and exotic meals, and the symbols used are those of uprising, revolution, and banding together in a movement to improve the food we eat.  Adventure and freedom are the basis for many successful advertising campaigns in corporate marketing (22).
Additionally, an aforementioned criticism of the NYC campaign is that it focuses on long-term health, which may be considered a higher-level drive on Maslow’s hierarchy of needs. These higher-level drives are often neglected in favor of more basic drives such as food, shelter, employment, intimacy, family, safety, and security. However, in the proposed Flavor Revolution campaign, the core value of freedom suggests that the related drives are safety and security, which are much lower and more pressing in the hierarchy (16), and are therefore more likely to be addressed by the average consumer.   
Although the NYC Health Department’s 2013 “Choose Less Sodium” campaign clearly has benefits and potential for efficacy, it simultaneously reveals a number of glaring theoretical errors.  This critique has outlined several shortcomings of the NYC campaign, based on the Health Belief Model, the theory of psychological reactance, and framing theory.  Using these same criteria, a new comprehensive intervention, the Flavor Revolution, has been proposed.  This reformed intervention is designed to effectively address the urgent issue of sodium overconsumption in America – an issue causing a heavier burden on the health care system with each passing day.   
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