Background
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.
Framing
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).
Framing
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.
Conclusion
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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