Sunday, May 5, 2013

Why the Threats About Getting Smacked by Fat? Fatsmack’s Failure to Understand Its Teen Audience – Joyce Wang

            By 1942, the American Medical Association was already aware of the negative health effects of sugary soft drinks, and warned consumers to limit their intake of sugar (1). A recent meta-analysis of 88 studies found a clear, consistent association between soft drink consumption and body weight (2). In particular, in a longitudinal study of over 90,000 women, those who consumed at least one soft drink a day had over twice the risk of developing type 2 diabetes compared to those who consumed less than 1 serving a month (3). These findings are certainly no abstract concern. Currently, 35.7% of American adults are considered obese, with an obesity rate of 49.5% among non-Hispanic blacks (4). In adolescents ages 12-19, obesity increased from 5% to 18% from 1963-65 to 2007-08, with especially large increases among Mexican-American boys and non-Hispanic black girls (5). Given these findings, it is no surprise that the Boston Public Health Commission released a public health intervention called “Fatsmack” that focused on sugary drinks, which was aimed at minority adolescents. Unfortunately, the intervention fails to effectively utilize a group-level theory of health behavior change, stigmatizes obesity, and uses an unconvincing health frame.
In fall of 2011, a series of brightly colored poster advertisements appeared across the city of Boston, concentrated in public transportation hubs. They starred four thin, minority adolescents drinking various sugar-sweetened beverages labeled as “soda” and “sports drink.” However, these adolescents are in the midst of dodging a gelatinous orange blob about to hit them in the face, which is supposed to be a lump of fat. In some of the advertisements, the portrayed teen has already been splashed by the fat globules. All of the faces have expressions of fear, disgust, and shock. In large text, the advertisement warns “Don’t get smacked by FAT,” followed by smaller text that says “Calories from sugary drinks can cause obesity and Type 2 diabetes.” In addition, the website hosts several videos that portray adolescents getting smacked, in slow-motion, by the orange blobs. Their faces, shifting in frame to frame, reflect the horror and surprise of getting “smacked by fat.” The intervention’s aim is to educate teens about how calories from sugary drinks can result in weight gain by equating the calories from sugar with fat – both precursors to obesity (6).
The associated website,, describes the negative health effects of drinking sugar, and warns readers to “Be smart” and not buy into the marketing by beverage companies. Website sections titled “You are a Target” and “Marketing Tactics” give adolescents insight about the in-depth market research conducted by food and beverage companies, describing the audience being researched – the teens themselves –as like “a bug under a microscope.” They also provide examples of the extensive reach of food and beverage corporations, from billboards, to celebrity endorsements, to product placements in popular media. This kind of perspective echoes the “truth” tobacco cessation campaign, which was very effective in reducing percentages of youth smoking in Florida (7). These materials emphasize not the health risks of smoking or sugary drinks, but the duplicitous marketing of food corporations. The Fatsmack website even offers tips about alternative healthy beverages in a section of the website called “Do something.” In particular, water is cited as an ideal alternative.  Unfortunately, none of these promising ideas were incorporated into the actual print or video advertisements, the main focus of the intervention. Instead, they remain in the background of the website (6).
Critique #1: Focuses on Individual as Nexus of Change
            The first major violation of the campaign is that it relies on the assumption that an individual who gains knowledge of the health risks of a behavior will necessarily change that behavior. The campaign is in part based on an outdated model of human behavior: the Health Belief Model (HBM). The HBM theorizes that behavior is based on six components: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy (8). Fatsmack addresses these points by portraying teenagers as the highly at-risk target population, susceptible to the health consequences of obesity and type 2 diabetes. In a very literal fashion, adolescents are warned that they will become fat if they continue drinking sugary beverages. The desire for thinness is the perceived benefit of abstaining from sugary drinks. The advertisement also assumes that teens will have the self-efficacy to stop drinking sugary beverages by themselves, and uses the threat of getting smacked by fat (becoming obese) as a cue to action. Specific barriers to not drinking sugary beverages are not addressed. Overall, this campaign relies on the assumption that if people know the health risks of drinking sugary beverages, they will abstain, and secondly, that health is important to teenagers. This assumption is flawed because there is little evidence that increased knowledge leads to significant changes in health behavior (9). Additionally, teens may be prone to the optimism bias with regard to their health. Although they may learn that sugary drinks increase the risk of obesity and type 2 diabetes in the overall population, they are not likely to perceive these risks as applicable to themselves (10). Because the central image of the advertisement is also so incongruous and unrealistic, and greatly exaggerated for dramatic effect, it is easy for teenagers to dismiss the concern of future health problems as equally exaggerated. Moreover, the models in the ad are low-BMI individuals who in no way personify the stated health risks—thus, the concerns seem even less likely, and an even more abstract possibility of the future.
            The HBM disregards the multitude of factors that impact teens who are influenced by environmental and ecological factors, social norms, and considerable levels of advertising and marketing. In addition, the model – and advertisement – assumes it is equally easy for everyone to just say no to sugary drinks, ignoring the obesogenic environment of the targeted teens, and the inter-related factors that contribute to obesity (11). The impetus is on the individual to change his or her own behavior – they alone are responsible for their health. Unfortunately, the notion of personal responsibility aligns perfectly with food corporations’ strategy of framing obesity as an individual lifestyle problem (12). The advertising campaign furthers the message of food corporations by emphasizing the individual as the nexus of change.
Critique #2: Stigmatizes Obesity
The Fatsmack campaign also stigmatizes obesity, as its central tenet is the idea of fat as gross, disruptive, and threatening. The intervention relies on fear of obesity as its driving force. Stigmatizing conditions are associated with a perceived sense of personal responsibility; that is, conditions such as Alzheimer’s disease that are associated with random chance tend to elicit pity and altruism from others, while diseases that are associated with high levels of personal responsibility do not elicit such sympathy (13). The prevailing public opinion and media regarding obesity portray its etiology as a matter of personal responsibility and self-control, which serve to justify the negative stereotypes and stigma that surround it, despite scientific evidence about the importance of genetics, biology, and social and environmental factors (14). However, evidence indicates that weight stigma, and interventions that use weight stigma as a motivating factor, are not successful. In fact, sometimes obese individuals may react to stigma by engaging in even more negative unhealthy eating behaviors or lower levels of physical inactivity (14).
At particular risk for the negative consequence of weight stigma are overweight children. Overweight children who are victims of weight-based teasing are more likely to engage in disordered eating or other unhealthy weight control behaviors (16). Obese children are even at risk of being stigmatized by adults by being rated as less favorable compared to their normal-weight peers (17). The coping literature suggests that common coping mechanisms for weight stigma include eating more food, or taking a stance on refusing to diet, especially for those who have internalized the stigma (18). Finally, given the increasing stigma against obese children from the years 1961-2001, one would expect prevalence of childhood obesity to decrease if weight stigma were an effective deterrent (19). Of course, as alluded to in the introduction, prevalence has actually been increasing, especially among Hispanic and black populations (5).
Thus, a campaign centered on weight stigma is likely to be actively harmful to obese children. The Fatsmack campaign’s tagline “Don’t get smacked by FAT” is intended as humorous. However, who exactly is the targeted audience? If an obese teenager sees the advertisement, they can easily see themselves construed as not the thin teenager, but the enemy – the gross, fatty, blob. In fact, the tagline is so ambiguous that taken out of the context of a public health campaign, it could be the cruel echo of a schoolyard taunt. If the intended audience is a normal-BMI or underweight teenager, the advertisement merely promotes already internalized weight stigma. Neither target audience would likely have a positive reaction to such a tactless campaign.
Critique #3: Ineffective Use of a Personal Health Frame
            Framing theory suggests there are a number of facets to an effective frame. The most relevant of these components are the ideas of a core position, catch phrase, visual image, and appeal to principle (20). The Fatsmack campaign has a memorable image – getting smacked by fat – as well as the catch phrase of “Don’t get smacked by FAT!”  Its core position is that consumption of sugary drinks can lead to obesity and type 2 diabetes. Correspondingly, the appeal to principle in this campaign is an appeal to personal health. This links the core position to a widely valued ideal. Unfortunately, the idea of personal health is actually not a particularly valued ideal, and thus does not serve as a powerful, effective, or convincing frame.
Initially, the notion of personal health might seem like an obvious choice for a public health campaign. It educates and informs the audience, and offers a clear message and instructions. Yet the goal of framing an issue is not necessarily to assemble the most rational or logical argument – frames are used to encourage national debate, become part of the political process, and eventually, change policy. To do this effectively they must capture the public imagination (21). The most important part of a frame is the core value an organization’s message presents. For instance, tobacco companies have historically been very successful in deflecting attention from scientific arguments against tobacco to a debate about personal liberty and individual autonomy. Within American culture and myth, freedom is among the most powerful of core values – potentially much more important than health (21).
            Not only is the Fatsmack campaign’s core value of health potentially weak, the manner in which it is presented is also ineffective. The audience is urged to not drink sugary beverages in order to not get smacked by fat or to grow obese. The focus is on preventing a problem that doesn’t even exist yet. The ad is driven not by an aspiration towards a positive state of health, but by a fear of obesity. Any kind of alternative to sugary drinks, such as water, is not mentioned at all. Moreover, considering the target audience, a health frame is an especially ineffective focus given their relative youth.
More specifically, the intervention exemplifies many of the early failures of anti-tobacco campaigns aimed at youth. As described by Hicks in a discussion of Florida’s “truth” campaign, the focus groups with youth had one consensus regarding anti-tobacco social marketing: “… they did not want to be told what to do. … If we were to be successful, ‘truth’ could not preach. ‘Truth’ needed a message other than ‘don’t’.” (7) The Fatsmack campaign violates this value precisely and laughably – its tagline begins with the word “don’t.” The distaste teenagers feel towards being told what to do further emphasizes the importance of core values like freedom and autonomy, which, when violated, inspire distrust.
Proposed Intervention: Truth, Redux
            The Fatsmack advertising campaign’s target is fat. Hidden on its website, however, are the promising beginnings of a possible alternative intervention that focuses on a corporate target – the food and beverage industry. The parallels between Big Tobacco and Big Food have been discussed by many (12). This intervention attempts to utilize similar techniques as the “truth” campaign to inspire outrage. The intervention will consist of a series of brief videos, which target the food and beverage industry’s hypocritical practices. Although the specific targets of the Fatsmack campaign are sugary drinks, in truth many of these beverage companies are owned by corporations that oversee multiple food and snacking divisions. For example, PepsiCo, Inc. owns Aquafina, Doritos, Gatorade, and Frito Lay. Kraft owns Oreo, Nabisco, Tang, and Kool-Aid. Coca-Cola owns Dasani, Fresca, Powerade, and Sprite (22). These corporations, along with their respective trade associations and front groups, have built a carefully constructed series of scripts that shape public opinion. They focus on the role of personal responsibility, attack the government for encroaching on personal freedom, and pretend to be engaged in the public interest. This intervention aims to unveil that agenda (12).
            One clip will begin with idyllic images of children in school and on the playgrounds, then cut to dismal-looking school lunches and a vast array of sodas and sports drinks that overshadow some cartons of milk. Text will appear asking who or what would be more interested in profits than adding even the simplest of food reform controls, such as removing vending machines from elementary schools. Then, a long list of beverage company names would scroll down the screen, along with the amount of money they have spent blocking specific bills that regulate nutrition standards in schools (23).
            Another clip will focus on the restaurant industry by portraying a series of lavish chain restaurant meals with huge portions. Then, a voiceover will directly quote Steven Anderson, president of the National Restaurant Association, who stated “Just because we have electricity doesn’t mean you have to electrocute yourself,” then flash his name and affiliation on the screen (12). The clip will then ask about how the restaurant industry must feel about you, the consumer. Then cut to an image of a small child near a power outlet, with his hand hovering over the socket.
            Taken from the real-life experiences of Todd Putman, a former employee of Coca-Cola, another video would dramatize his experience in trying to expand Coca-Cola’s branch internationally. He has described the company’s marketing division’s main question as “How can we drive more ounces into more bodies more often?”  This video would have a man standing in for Todd, clearly marked as an employee of Coca-Cola, landing among the destitute favelas of Brazil, which are crowded urban slums that are the next area of expansion for Coca-Cola. He would then look around, take a deep breath, and start trying to sell 6.7-ounce bottles of Coke for 20 cents by going door to door. This process would be undercut with images of poverty and lack of food security, with a voiceover once again intoning the marketing slogan about more ounces into more bodies (24).
Finally, one video could entail a group of businessmen who appear to be visiting a school on a charity trip or volunteer organization, with images of them reading and laughing with children. Then, segue to a cafeteria scene where the camera would pan over the many snacks and drinks available for purchase from the viewpoint of the businessperson. As the businessperson’s perspective shifts to watching the schoolchildren sitting down for lunch, various dollar signs and amounts pop up in bubbles over the children’s heads. Some are not worth very much, while others – perhaps better dressed or particularly demanding – are worth much more. When the camera is focused on the children with high purchasing power, the businessman will smile with satisfaction.
These clips, brief as they are, would create a link in the public’s imagination between food and beverage corporations and their greed, duplicity, and contempt for the consumer. The first and last videos would emphasize corporations’ particular disregard for the health of young children. The second portrays the consumer as foolish and unable to control himself, and moreover, implicitly reflects the restaurant industry spokesperson’s conceptualization of calorie-laden meals as electricity with the power to electrocute someone—a genuinely dangerous product. With the third commercial, Coco-Cola’s global power and reach are emphasized, along with its narrow concern for profit margins despite humanitarian objections. The last component of these ads would be a closing tagline that cements the enemy as “Big Food.”  One example could be “Big Food: they’re your biggest fan.”  This message would emphasize both the profit-driven motivations of food corporations, as well as add an allusive nod to their authoritarian, powerful methods of dissemination.
Defense #1: Utilizes a Group-Level Theory of Behavior Change
            Because obesity is a disease with a complex etiology that incorporates not just individual biological, genetic, and lifestyle factors, but even societal and evolutionary factors, an individual-level theory of change provides an unsuitable basis for intervention (25). For example, several components of the HBM presume that human behavior is completely rational in terms of assessing health risk. The proposed intervention uses a group-level theory of behavior change to avoid discussion of the negative health risks of sugary beverages altogether. Instead, it uses an emotional appeal to focus on the negative practices of the food and beverage industry. It shifts the focus away from an individual’s personal responsibility to improve their health, to the large role food and beverage corporations have in marketing unhealthy products.
            By shedding light on the unscrupulous practices of these corporations, especially with regard to marketing sugary beverages or regulating nutrition standards in schools, this intervention can increase public awareness by using Agenda Setting Theory. This theory discusses how the media can set the agenda for public discussion by bringing specific issues to light. In particular, within the context of advertising theory, the emphasis is not on persuading consumers to think of products in a certain way, but to simply focus their attention on a set of values or brands. Thus, a link between media prominence and personal awareness emerges (26).
In recent decades, there has already been increased awareness of food industry issues (e.g., the books Fast Food Nation, The Omnivore’s Dilemma; films Super Size Me and Food, Inc.). These have raised awareness about factory farming and the environmental and health consequences of food corporations. Yet there has not been a similar level of outrage or knowledge aimed at the specific practices of food and beverage companies, especially in their marketing towards children and teens. This intervention can function like a series of advertisements that bring the hypocrisy of food and beverage corporations into the public consciousness.
 Defense #2: Reduces Weight Stigma by Blaming Food and Beverage Corporations
            The Fatsmack campaign stigmatizes obesity, which is an ineffective tactic in reducing the BMI of the target audience, and which is also associated with negative health consequences (15). The proposed intervention utilizes Weiner’s attributional theory of achievement motivation and emotion to educate the public about the multiple factors that may impact obesity, such as the marketing techniques of the food and beverage companies. This reduces the amount of personal responsibility people feel is associated with obesity, by shifting some of the responsibility onto corporate entities and environmental factors. If obesity is perceived to be more similar to other kinds of illnesses such as cancer, which are regarded as not in one’s control, this could lead to a reduction in weight stigma (13).
            In addition, because the campaign is not focused on health, obesity, or fat in any way, high-BMI adolescents and individuals would not feel as if they were being specifically targeted. This might avoid some of the possible negative health consequences that are a result of weight stigma or teasing. Instead, food and beverage companies would become the stigmatized entities, much like how tobacco companies are now viewed as malicious corporations (12). This could actually be an effective deterrent in reducing the sales of these corporations’ associated products.
Defense #3: Empowers Audience Through a Core Value of Freedom
            Like the tobacco cessation “truth” campaign, this intervention will aim to tell youth “the facts” and then leave them “to make their own educated decision” (7).  In framing theory, core values of freedom and autonomy are among the most powerful and effective values to use, especially to a young, rebellious American audience (21). By showing the audience images of food corporations as powerful, sinister, and profit-driven, and prone to manipulation of those with less agency (such as children and inhabitants of global slums), they will react with a sense of betrayal and anger.
In particular, this intervention could induce psychological reactance in the audience, when individuals feel their freedom of choice is being taken away (27). In this case, they may feel manipulated by the food and beverage industry. They may feel like the industry regards them as merely consumers to be deceived, or pockets to be plundered. Consumers will look for a way out of the corporate stranglehold on the food and beverage industry by choosing alternative products for consumption.
            The Fatsmack campaign exemplifies the various well-intentioned flaws of a typical public health campaign. It emphasizes health, encourages individuals to take on personal responsibility, yet fails in understanding its target audience. It may even result in some negative health consequences for obese individuals who feel stigmatized by its message. The proposed intervention addresses these flaws by using a group-level model that takes advantage of agenda setting theory. The intervention also shifts the frame into one that targets the food and beverage industry, and their hypocrisy towards consumers, instead of a health-focused frame. Finally, it will empower the audience by providing a sense of freedom and autonomy that allows them to escape from the omnipresent reach of the powerful food and beverage corporations. By choosing to recognize these companies as malicious and purely profit-driven, animus towards obese individuals may shift towards the environmental factors that contribute to their obesity. In viewing Big Food as the 21st-century equivalent of Big Tobacco, we can learn from the strategies and mistakes of the past to change current public opinion and policy.

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