Calorie Labels on Menus: Why this Public Health Approach Fails In Low-Income Neighborhoods--Alina Rossini

More than one-third of adults in the United States are obese (35.7%), meaning their Body Mass Index (BMI) exceeds 30 (1). Within the American population, non-Hispanic blacks have the highest age-adjusted rates of obesity (49.5%) compared with all Hispanics (39.1%) and non-Hispanic whites (34.4%) (1). Americans who live in the most poverty-dense counties are those who are most likely to be obese (poverty/obesity) (1). Obesity is related to other non-communicative diseases that include heart disease, stroke, type-II diabetes, and certain types of cancer, all of which are some of the leading causes of preventable death (1). Medical costs associated with obesity were estimated to be around $147 billion, and obese people pay an average of $1,429 more than their non-obese counterparts (1). The Surgeon General issued a warning of an ‘obesity epidemic’ in 2001, and years later, New York City and Philadelphia have required that fast food chains include caloric information of standard menu items (2). However, it was not until the Patient Protection and Affordable Care Act of 2010 that there were national laws enacted to target the epidemic.

As part of the Patient Protection and Affordable Care Act of 2010, all chain restaurants with 20 or more locations must include calorie information on all their menus (3). Among other policy approaches, menu labeling has been proposed to address the growing rate of obesity in the United States, and the focus has primarily been on food consumed outside of the home. Eating meals away from home comprises 30% of daily caloric intake and 50% of yearly food expenditure (3). This trend is alarming because food consumed outside of the home is more likely to be higher in calories, fat, and sodium than foods prepared in the home (3) There have also been links between high rates of obesity and frequent consumption of food outside of the home (3). However, calorie labeling is an ineffective tool in combatting obesity, especially in low-income settings. According to an analysis done by researchers from New York University in 2009, only half of the fast-food consumers from low-income communities in New York City noticed calorie labeling. Consequently, only 28% of those who noticed the labels changed their order (4). Low-income and minority communities were chosen for the study due to the higher rates of obesity and the higher presence of fast-food restaurants in these neighborhoods (4). Calorie labeling in low-income environments is unsuccessful, as demonstrated by this study and others like it. While there are various reasons why this public health approach is limited, this study will focus on three major flaws and develop solutions for each.

 Literacy rates undercut the success of calorie labeling

Health literacy is a major flaw of the calorie labeling initiative, because not all Americans can properly read nutrition facts. In order to understand labels, individuals must first know how many daily calories are recommended for adults (5). In a study done in 2010 by New York University researchers, only one-third of fast food customers in low-income areas could accurately identify the number of calories an adult should consume each day as between 1500 to 2500. (6). Without knowing the recommended daily caloric intake, calorie labeling in fast-food restaurants becomes meaningless, because consumers are unable to relate calorie labels of individual items to the number of calories needed per day. Consumers do not have a caloric reference point in order to understand if a food item is high or low in calories. The study also concluded that racial and ethnic minorities of low-income communities were most likely to overestimate the suggested number of calories needed each day (6).

In addition to being unaware of how many calories are recommended each day, many consumers are also unaware of serving size (5). The number of calories in each serving and serving size are two critical pieces of information that are essential for weight control (5). According to a health study, 33% of people do not regularly read caloric information and only 5% looked at serving size (5). This suggests that people are unable to properly read food labels, because sometimes interpreting these labels requires mathematics to determine the total caloric amount. The study also concluded that people with less healthful diets are less likely to look at calorie labels and have less interest in doing so (5).

Low health literacy poses a significant barrier to the successful adoption of calorie labeling on menus, because it lowers the perceived risk of chronic diseases associated with a poor diet, such as obesity (7). Without a basic understanding of the consequences associated with an unhealthful diet, consumers are unaware of what constitutes a healthy diet and what does not. If consumers are unable to determine what is healthy, they are also unable to determine what would be the benefit of choosing healthier fast food options. They are also less likely to use calorie-labeled menus in their decision-making process (7). By not penetrating the consumers’ decision-making process, people who frequent fast food establishments will not be encouraged to change their eating behaviors (7). Ultimately, without labeling menus in a way that is understood to all consumers, no matter their education level, calorie labeling will continually fail in low-income areas.

Food Labels: Where are they in placed in fast-food restaurants?

Calorie labeling on menus is expensive for restaurants, so the Obama administration targeted restaurants that had 20 or more locations because they could better absorb the costs (5). However, extensive calorie labels on menus is still widely unavailable (9). Many restaurants choose to put the most comprehensive calorie listings online, and many fast food restaurants offer pamphlets that are not always available at point of purchase (10). In a study that examined the availability of calorie information in McDonald’s restaurants in Washington DC, only 59% provided in-store information for the majority of items on the menu (10). In 62% of the restaurants, it was necessary to ask two or more employees in order to obtain the calorie information (10). In majority of the McDonald’s visited, the information was available on tray liners (43%), pamphlets (43%), posters (5%), or one-page charts (10%) (10). Consumers see tray liners only after they purchase food, and food items often conceal or sully the information, yielding it illegible. Pamphlets are only available at the register where people may feel pressured to order quickly, and therefore not use it (10). Also, if people want more in-depth nutrition facts, that information is only available online (9). Even at the largest fast-food chain in the country, 40% of McDonalds outlets did not provide nutrition information for the majority of the items on the menu (10).

Consumers consider asking employees or searching for online caloric menus as a burden, and the majority of fast-food consumers do not perceive a benefit in searching for the information (9). The Behavioral Economics Model can explain the inaction of consumers (11) As explained by economics, behavior is the result of benefits and costs. Benefits are interpreted as reinforcers and people who frequent fast food restaurants more often obtain more reinforcing value from food than those who do not (11) Consequently, the cost of searching for caloric information outweighs the immediate desire for fast food; the convenience and craving is more important to consumers than caloric information or health (11). The absence of point of purchase nutrition information in majority of fast-food restaurants creates barriers in accessing the calorie facts, and the burden in searching for it is too high for majority of consumers. 

Barriers to obtaining healthful foods

The final major flaw of this public health intervention can be explained with the social ecological model. The social ecological model explains that interventions that solely focus on behavior change on the individual level often neglect the social and environmental context in which those behaviors occur (12). This clarifies why calorie labeling is ineffective. The intervention fails to recognize that there are few alternative healthy options available in fast food restaurants, convenience stores, and small grocery stores since they rarely have fresh produce or low-fat dairy items (13). This is especially true in low socioeconomic neighborhoods, where smaller grocery stores, convenient stores, and fast food restaurants like KFC and McDonald’s are abundant compared to higher quality grocery stores, Starbucks and Chipotle that are commonly found in middle- to high-socioeconomic communities (13). While calorie labeling aims to help consumers choose more healthful options, the intervention fails to understand that there are few, healthy alternatives in low-income communities because of the specific fast-food environment (13). Unless the intervention addresses the barrier in accessing more healthful foods, calorie labeling will continually fail in these communities

Defining a Better Intervention

Calorie labeling on menus as a public health approach to combat obesity will fail in low-income neighborhoods across the country if low health literacy rates, availability of nutrition information, or the low access to healthier options is not addressed. These three major flaws undercut the successful adoption of calorie labeling in quick serve food locations.

This study proposes a three-pronged intervention to specifically target the three main flaws. This new design improves calorie-labeling techniques by using color to represent the level of healthfulness of menu options, allows for customization of standard menu items for fewer calorie and low-fat alternatives, and finally proposes effective measures to support community partnerships to transform the physical and social environment as demonstrated in Chelsea, Massachusetts. This strategy focuses on the three critical weaknesses of calorie labeling as a public health intervention. By adopting this innovated design, calorie labeling will find more success in low-income communities. 

Numbers or Colors?

The past failure of calorie labeling efforts highlights that the general health knowledge of a population greatly impacts the efficacy of this public health approach. While calorie labeling may sway people in choosing a more healthful option, the approach cannot be expected to change a population’s eating behaviors if the majority of consumers do not know how many calories are needed each day. For this reason, calorie labeling needs to be reformatted.

Presenting caloric information by using colors may increase menu-labeling effectiveness, according to a study by Yale University researchers (14). After calorie-labeling formats were compared, investigators found that using colors to represent healthfulness of food items led to the fewest calories ordered by participants on average (14). This suggests that using green, yellow, and red to designate healthfulness leads to more informed decisions by consumers (14).

Green, yellow, and red are universal colors that represent good, moderate, and poor (14).  When applied to menus, the colors are interpreted as an item that is healthy, moderately healthy, or not very healthy. Little outside health knowledge is needed to understand the labels, since the colors have meaningful significance across many cultures (14). Therefore, the labels’ health meanings can be interpreted without having to read words. Language barriers in non-English speaking populations, primarily in Latino communities, limit access to healthy food options. Thus, the color system will be useful in areas where there are non-English speakers or illiterate community members. Color-coordinated calorie menus will allow all consumers, regardless of language ability, to successfully interpret the healthfulness of a menu item.

It is also important to educate consumers on health issues, such as the recommended daily caloric intake. To address this issue, menus should have informative prompts that read, “The health guidelines for Americas suggest consuming about 2,000 calories per day” (6). This prompt will provide consumers with a reference point, giving them a context in which they can better interpret the number of calories in menu items. (6).

Providing this background information is essential for informative decision-making, and will help successfully implement calorie labeling in low-income communities. Also, reformatting calorie labeling into a colored-coordinated system will allow all consumers to easily interpret healthfulness without having to understand English or to know basic health knowledge.

Small Changes

As discussed previously, calorie labeling is not always readily available in fast-food restaurants. Convenience and desire for food are always preferred over health, or in this case, searching for the caloric information (9). Point of purchase information is crucial to decision making, because if the caloric information is not readily accessible, consumers will not search for it, and it will not be taken into consideration when ordering (10). Instead of making consumers find and read labels, fast food restaurants can customize standard menu items to offer healthier options at the register.

Customization can take many forms on fast-food menus. For example, consumers can have the option of grilled meat instead of fried, using less bread, adding vegetables, removing all or some cheese, ordering low-fat salad dressing, or asking for sauce on the side. By asking consumers if they would like any of these options at the register, they are informed of these healthier options without having to consult pamphlets or search online. These small changes do not tell people to choose different options all together, but they make consumers’ favorite menu items healthier.

According to the incorrect assumption of the health belief model, consumers will completely change their fast-food orders once they learn that a high calorie diet gravely threatens their health. This theory, however, does not take into the account the high value of convenience and desire of food in comparison to health. In other words, consumers will not modify their eating habits for health reasons, as that is not a reason compelling enough to prompt change. Customization, therefore, will allow consumers to order the foods they love with the additional option to decrease their overall caloric intake.

Community Partnerships

Without considering the social environment of low-income communities, calorie labeling will continually fail. Policy changes need to be implemented that make healthier fast food alternatives easier to find. As the Social Ecological Model suggests, it is unrealistic to expect people to modify their behaviors when their physical and social environments do not support the change (12). Instead, the environment needs to become a part of the transformation. To incentivize change, community partnerships can be created to encourage local food marts to carry more produce and low-fat dairy products by offering a tax credit for those who do (15).

An intervention like this was implemented in Chelsea, Massachusetts in 2010 called ‘Healthy Chelsea’ (16). Just northeast of Boston, this city has declared itself a safe-haven for undocumented immigrants and is made up of 44.1% foreign-born non-citizens (17). Moreover, 62.1% of people living in Chelsea are of Hispanic or Latino decent and 67.8% of residents speak little to no English (17). Only 14.5% of the residents have a college degree or higher (17). The health initiative includes 56 individuals representing local government, state government, community organizations, healthcare providers, and businesses (16). These organizations collect health and behavioral data in Chelsea and use that information to assess the social and environmental factors influencing Chelsea’s high obesity prevalence (16). Through this assessment, the initiative implements and supports more healthful behaviors that are conducive to the diverse cultural and ethnic background of the residents (16). The initiative has increased the volume of fresh produce sold at local markets, given tax credits to participating locations, and has provided healthy marketing materials around the city (16). There has been a close partnership between the city’s Planning and Development Department to support infrastructure changes such as park renovations and installations (16). The initiative also pioneered the passage of Chelsea’s trans fat free regulation (16).

Community partnerships and organizations are essential to changing the social and physical environment to encourage the adoption of new behaviors at the population level, as demonstrated with the ‘Healthy Chelsea’ initiative (15). A tax incentive will provide affordable, low-calorie options in low-income neighborhoods where those alternatives are scarce. This will give residents the ability to choose more healthful foods when they are food shopping or dining out with their family, ultimately encouraging people to make healthier food choices.

Conclusion

While calorie labeling was developed with meaningful intentions, it is not a universally effective approach. It fails to address low health literacy rates, the value of convenience over health, and the impact of the physical and social environment on decision-making. By neglecting these issues, calorie labeling will continually fail in low-income communities. This paper recommended a better intervention, designed to consider these three major flaws. These major critiques demonstrate how social theories were not properly applied, and the intervention uses these same social theories to strengthen calorie labeling in low-income communities. The improved approach involves reformatting calorie labeling by using colors to represent the level of healthfulness of food items, allows for customization of standard menu items for fewer calorie and low-fat options, and finally proposes effective strategies to promote community partnerships to transform the physical and social environment as demonstrated in Chelsea. This three-pronged approach focuses on the major flaws of the intervention and encourages healthier decision-making in low socioeconomic communities. Making these types of changes is essential to combat obesity, and as this paper suggests, the calorie labeling approach will not be successful unless it is tailored to the specific needs of the target population.

References

1.     "Adult Obesity Facts." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 13 Aug. 2012. Web.

2.     U.S. Department of Health and Human Services.  The Surgeon General's call to action to prevent and decrease overweight and obesity. (Rockville, MD): U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General (2001).

3.     Swartz, Jonas, Danielle Braxton, and Anthony Viera. "Calorie Menu Labeling on Quick-Service Restaurant Menus: An Updated Systematic Review of the Literature."Journal of Behavioral Nutrition and Physical Activity 8.135 (2011): 1-8.

4.     Elbel B, Kersh R, Brescoll V, Dixon B. Calorie Labeling and Food Choices: A First Look at the Effects on Low-Income People in NewYork City. Health Affairs 2009; 28:1110-1121.

5.     Krukowski, Rebecca A., Jean Harvey-Berino, Jane Kolodinsky, Rashmi T. Narsana, and Thomas DeSisto. Journal of the American Dietetic Association 106.6 (2006): 917-20.

6.     Elbel B. Consumer Estimation of Recommended and Actual Calories at Fast Food Restaurants. Obesity 2011; 19:1971-1978.

7.     Berkman N, et al. Low Health Literacy and Health Outcomes: An Updated Systematic Review. Annals of Internal Medicine 2011;155:97-W41.

8.     Hanson J, Benedict J. Use of the Health Belief Model to Examine Older Adults’ Food-Handling Behaviors. J Nutr Ed Behav 2002;34:S25-S30.

9.     "Availability of Nutrition Information on Menus at Major Chain Table-Service Restaurants." Journal of the American Dietetic Association (2006): 1012-015. 

10. Wootan, Margo G., Melissa Osborn, and Claudia J. Malloy. "Availability of Point-of-Purchase Nutrition Information at a Fast-food Restaurant." Preventive Medicine43 (2006): 458-59.

11. Baranowski, Tom, Karen W. Cullen, Deborah Thompson, and Janice Baranowski. "Are Current Health Behavioral Change Models Helpful in Guiding Prevention of Weight Gain Efforts?" Obesity Research 11 (2003): 23S-43S. 

12. Robinson, T. Applying the Socio Ecological Model to Improving Fruit and Vegetable Intake Among Low-Income African-Americans. Journal of Community Health. 2008; 33:395-406.

13. Block J, DeSalvo K, Scribner R. Fast Food, Race/Ethnicity, and Income: A Geographical Analysis. Am J Preventative Medicine2004; 27:211-217.

14. Liu, Peggy J., Christina A. Roberto, Linda J. Liu, and Kelly D. Brownell. "A Test of Different Menu Labeling Presentations." Appetite 59 (2012): 770-77

15. "Helping Grassroots Advocacy Efforts Take Root." Journal of the American Dietetic Association 111.3 (211): 356-58.

16. "Massachusetts General Hospital." Healthy Chelsea.

17. "Chelsea QuickFacts from the US Census Bureau." Chelsea QuickFacts from the US Census Bureau.

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

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 1^st, 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.   

References:

(1) Establishing Guidelines for the Nutrition of Vulnerable Groups (With Special Reference to the Poor). Available at: http://www.nns.nih.gov/ 1969/full_report/White_House_Report2_S2.pdf.

(2) Meneton P, Jeunemaitre X, de Wardener HE, MacGregor GA. Links between dietary salt intake, renal salt handling, blood pressure, and cardiovascular diseases. Physiological Reviews 2005; 85: 679–715

(3) U.S. Department of Health and Human Services, U.S. Department of Agriculture. Dietary guidelines for Americans 2010. Washington, DC: Government Publishing Office, 2010.

(4) Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Sodium Fact Sheet. Available at: http://www.cdc.gov/salt/pdfs/Sodium_Fact_Sheet.pdf. November 2009.

(5) Bernstein AM, Willett WC. Trends in 24-h urinary sodium excretion in the United States, 1957-2003: a systematic review. American Journal of Clinical Nutrition, Nov 2010; 92(5):1172-80.

(6) He J, MacGregor GA. A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. Journal of Human Hypertension (2009) 23, 363–384.

(7) New York City Department of Health and Mental Hygiene. Choose Less Sodium [advertising campaign]. New York City, NY. April 2013. Available at: http://www.nyc.gov/html/doh/html/living/cardio-sodium.shtml

(8) Edberg, Mark. Social and Behavioral Theory in Public Health, Essentials of Health Behavior. Jones and Bartlett Publishers, 2007.

(9) Brehm J. A theory of psychological reactance. New York: Academic Press

(10) Woller KMP, Buboltz WC, Loveland JM. Psychological Reactance: Examination across Age, Ethnicity, and Gender. American Journal of Psychology, 2007. 120(1), 15-24

(11) Dorfman, Lori, More Than a Message: Framing Public Health Advocacy to Change Corporate Practices, Health Education and Behavior, 2005. 32, 320-336

(12) New York City Department of Health and Mental Hygiene. Health Bulletin: Choose Less Sodium. Gotham Center, NY. April 2013

(13) Menashe CL, Siegel M. The power of a frame: An analysis of newspaper coverage of tobacco issues--United States, 1985-1996. Journal Of Health Communication, 1998. 3(4), 307.

(14) Homik, R. Effects of the National Youth Anti-Drug Media Campaign on Youths. American Journal Of Public Health, 2008. 98(12), 2229-2236.

(15) Erinosho TO, Moser RP, Oh AY, Nebeling LC, Yaroch AL. Awareness of the Fruits and Veggies—More Matters campaign, knowledge of the fruit and vegetable recommendation, and fruit and vegetable intake of adults in the 2007 Food Attitudes and Behaviors (FAB) Survey, Appetite, August 2012. 59(1): 155-160

(16) Maslow, Abraham, A Theory of Human Motivation, Psychological Review, 50, 1943, 370-396.

(17) Institute of Medicine (US) Committee on Strategies to Reduce Sodium Intake; Henney JE, Taylor CL, Boon CS, editors. Strategies to Reduce Sodium Intake in the United States. Washington (DC): National Academies Press (US); 2010. Chapter 3, Taste and Flavor Roles of Sodium in Foods: A Unique Challenge to Reducing Sodium Intake. Available from: http://www.ncbi.nlm.nih.gov/books/NBK50958/

 (18) Sly DF, Hopkins RS, Trapido E, Ray S. Influence of a Counteradvertising Media Campaign on Initiation of Smoking: The Florida “truth” Campaign. American Journal of Public Health. February 2001, Vol. 91, No. 2

(19) Hersey, James C., Jeff Niederdeppe, W. Douglas Evans, James Nonnemaker, Steven Blahut, Debra Holden, Peter Messeri, and M. Lyndon Haviland. The theory of “truth”: how counterindustry media campaigns affect smoking behavior among teens. Health Psychology 24 (2005): 22-31.

(20) H.P. Weingarten, D. Elston. The phenomenology of food cravings. Appetite, 15 (1990), pp. 231–246

(21) Zeitham VA. Consumer Perceptions of Price, Quality, and Value: A Means-End Model and Synthesis of Evidence. Journal of Marketing, July 1988. 52(3): 2-22

 (22) Cummings KM, Morley CP, Horan JK, Steger C, Leavell N-R. Marketing to America's youth: evidence from corporate documents. Tobacco Control 2002; 11 (suppl) 1: 15-17

Are BMI Report Cards The Lightest Way To Break The News?: Weighing In On This Intervention—Stephanie Smith

            For years, public health authorities have been aiming to eliminate childhood obesity without great triumph. This epidemic has continued to impact the lives of millions of children and adolescents across the country as evident by the rising rates of obesity. As of 2010, more than one third of children and adolescents are considered overweight or obese (1). The Center for Disease Control (CDC) defines overweight as having excess body weight and obesity as having excess body fat (1). As the percentage of children and adolescents has more than tripled from 1980 to 2010, interventions are constantly being created to combat this spate of obesity (1-2).

            One of the most common ways to measure if a child is overweight or obese is to determine body mass index, or BMI. BMI is a simple measurement, based solely on a person’s height and weight. The resulting value is compared to average standards to determine whether the person is underweight, “normal,” overweight, or obese. In recent years, BMI has been calculated at schools for surveillance purposes to log trends in the population. Within the last ten years or so, BMI reporting has become popular in the schools. Elementary and middle schools began notifying parents of their child’s BMI on their report card. In addition to getting grades for academics and proficiency, children are now being graded on their BMI. When a child gets a score of “overweight” or “obese” it is the equivalent to receiving a bad grade (3). There is no message accompanying the number about ways to improve health, just an arbitrary score.  

            With over 25 million children in the U.S. overweight and obese, eyebrows continue to raise when wondering where the root of the problem lies (3). In an effort to determine if it is the lack of physical activity, a diet consisting mainly of processed foods, an increase in children’s screen time, public health officials have teamed up with schools to allow for BMI report cards, in an effort to make parents aware of the issue. Proponents of this intervention believe that BMI reporting on the child’s report card will show parents and children that these numbers matter to their health and well-being. Lloyd I. Sederer, M.D. says, “when students and their parents ‘know their numbers’…they are more likely to do something about them (2).” Though receiving a report card with a stamp of physical health failure can be alarming and surprising for many, without proper understanding of what this means, this method of intervention cannot work. There is no explanation as to what the number really means and what can be done to improve it because until this point, childhood obesity has been “under-recognized” (4). Of course, a child’s health is important to consider to avoid obesity later in life, leading to heart disease, diabetes, and certain cancers; but as a child, their health is not solely determined by weight (5). A child’s BMI is not synonymous with their health.

            There are two important points of this intervention that do not allow for its success. BMI, though it is a simple and quick measurement of body mass, is an inaccurate measure of body composition. Since it only uses weight and height in its calculation, a person with a lot of lean muscle can yield a high BMI and be considered obese, when they probably do not have excess body fat. A person could also have a normal BMI, but lack muscle and have more fat, which is unhealthier than the first scenario (3). These inconsistencies can cause potential harm to a child, like the development of an eating disorder that can persist into adolescence and young adulthood, bullying from other students, and pressure from family (6). BMI is an easy way to interpret one’s health, inaccurately.

It is important to instill values of a healthy lifestyle in children, which is not portrayed with this intervention. Since children are constantly going through growth spurts, their weight is constantly fluctuating and should not solely be analyzed by BMI (6). Also, an approach like this is only focusing on the individual level. When BMI is on the report card, parents think that their child is the only one with the problem. Overall, little is known about the effectiveness of BMI reporting on a child’s behavior, attitude, and knowledge, so continuing with this intervention seems unproductive (1,6-7).

            Other than lacking to address the matters previously mentioned, BMI reporting violates several models of behavior change used to create public health interventions. This intervention violates traditional models, as well as alternative models that have transformed over time. The first theory that the intervention defies is the theory of reasoned action. BMI reporting also goes against several elements used to construct the social learning and social cognitive theory. Finally, the intervention produces psychological reactance.

Critique #1: BMI reporting counters the theory of reasoned action

            The theory of reasoned action is based on the concept of attitudes and social norms. It is a function of these two factors that determines a person’s intention to further change one’s behavior (8). The theory claims that attitudes towards a behavior and social norms can be highly predictive of final behavior (11). The theory further states that behavioral intention must precede behavior change in order to be successful. When this theory was developed, the final behavior change did not take into account the involuntary outcomes of the behavior; it simply stated that once a person begins a new behavior, they have succeeded (9). In actuality, many people that are aiming to change their behavior are aiming for a goal that cannot simply be met at the start of change. Usually, for success, follow-up must transpire. It is clear that the intervention is following the same method of this critique; it is looking to change the behavior of a person and not necessarily aid in maintaining suitable outcomes. BMI report cards do not provide parents or children with any further knowledge about how to carry out the implied intentions from this intervention. Parents are given the information that their children are overweight or obese, but are not supported in ways to improve their child’s health. Schools are focusing on improving test scores and grades and less on a child’s health and well-being (10). That is one reason that this intervention was implemented; to remove responsibility of health from the schools and give it back to the parents for their sole concern. Schools are not facilitating parents or children with adequate knowledge of nutritious eating patterns, physical activity, and living a healthy lifestyle.

            Attitudes of those children at risk are not being addressed by the intervention. By sending BMI on a child’s report card, it is likely that the number will not even reach the child. Children do not have any chance to create an attitude towards being overweight if they do not know or understand. This leads to why social norms in this intervention are ineffective. The two questions that one asks when using the theory of reasoned action, pertaining to social norms, are: “what do others around me think?” and “how much do I care what they think? (8).” Neither question is applicable to a child in elementary or middle school. More often than not, report cards are not seen by children at all, so they do not have a chance to imagine “what others think” about being overweight or obese. There is also strong apprehension from parents when they receive a report card that says that their child is overweight and admitting that they need help in creating a healthy lifestyle for their children. A study found that 84% of parents believe their child is of a healthy weight, when in actuality one third of children are overweight or obese (2). Often times, parents are wearing a pair of foggy glasses, hypothetically speaking, when their child is targeted as not being “normal.” It is common for parents to ignore any social norms around them that revolve around their child because they do not want to compare their child to others; a similar philosophy that parents preach to their children. Parents have an internal struggle between admitting that their child needs help to become healthy and ignoring the problem until it is a bigger issue to let their child be himself or herself. The biggest predictor of childhood obesity is an obese mother, so when an attack is made on a child’s weight, it is essentially undermining the rest of the family’s health (10).

            Ultimately, these things do not lead to a child believing that they can become healthy and reach a BMI in the “normal” range. Social norms are shattered by this intervention, mostly because parents become frustrated and offended by the content on the child’s report card. By stamping a child with an arbitrary number that represents their status on a scale of health, there is cause for much embarrassment on the child’s end and harassment from fellow classmates; which can cause much larger issues, like bullying, that can lead to depression or disordered eating (14). 

Critique #2: Several elements of the social learning and social cognitive theory are being ignored 

             More recently referred to as the social cognitive theory, social learning theory was its original moniker. They refer to the same ideals, with certain constructs representing social learning, or social cognition. The individual is not solely involved in this model; behavior and environment are involved in the dynamic process of behavior change. This theory emphasizes the social influence and reinforcement that leads people to make decisions (12). There are six constructs that make up social cognitive theory, three of which are abused by this intervention: reinforcements, modeling, and self-efficacy.

              Reinforcements refer to internal and external factors that affect the likelihood of continuing or discontinuing said behavior (12). Reinforcements can come from the environment or from the person changing their behavior. In this intervention, it is hard to say that there are any reinforcements of any kind. Children are just given a number on their report card. There is not any further information or explanation, just an arbitrary number.

            Modeling, or observational learning, is the social learning aspect of the theory. This construct says that people act by observing the behavior of others around them and acting in accordance with these behaviors, if they feel inclined to do so. BMI reporting does not address modeling in any form. By giving children their BMI on a report card, there is nothing to observe or anyone to learn from. As mentioned earlier, parents’ weight is often indicative of a child’s weight, which means that any prior models that a child might have gotten in the home, would be unworthy in efforts to improve the child’s health (10). Oftentimes, the only model of what children are “supposed” to look like are in fact, models. Children are reading magazines and watching television shows with stick-thin celebrities that pay hundreds of dollars to look a certain way. These kids do not understand that, which could lead to detrimental eating disorders on the other end of the spectrum. There are not any role models in the entertainment industry that truly represents what a child should believe. A child should believe that it is not about what they look like, but about how healthy they are. Children at the elementary or middle school age are very impressionable, so modeling has the potential to play a major factor in changing the behavior of a child if given proper positive reinforcements.

            The third aspect of the social cognitive theory that is not supported by this intervention is the role of self-efficacy in behavior change. Self-efficacy refers to the level of a person’s confidence that they can be successful in behavior change (12). Without adequate self-efficacy, a person is likely to lack incentive to complete a task or perform behavior, finding change too difficult (13). Since this intervention is not addressing the main part of behavior change—the concrete actions necessary to actually change one’s behavior—it is hard to determine if this intervention provides people with any sense of self-efficacy. It is likely that people do not feel confident that they can change their behavior under this intervention because they simply do not know how to change. When parents, and children, receive this report card and see a high number without any further support, they will feel let down and unsure about how to tackle the issue. This is one of the most important aspects of the intervention that needs to be changed because when it comes to losing weight and making healthy lifestyle changes, self-efficacy is the only way that a person will find success.    

Critique #3: Intervention produces psychological reactance

            Psychological reactance theory recognizes the negative response to messages that aim to control one’s freedom and autonomy (15). The actual psychological reactance is an emotional state that comes from lack of control. When a person’s freedom is threatened, it is common for the person to resolve it by completing the task that was prohibited. There are three steps towards generating psychological reactance. It starts with a person perceiving an unfair restriction on their actions, followed by an activated state of reactance, concluding with an act to remove the reactance by the person affected (16). There are several factors that influence whether a message produces psychological reactance. Explicitness, dominance, reason, and similarity determine the height of reactance. BMI report cards violate all of these aspects to instigate psychological reactance.

            Explicitness represents the degree to which the language makes the message plain and clear. Explicitness is context specific, but for the most part, if a message is straightforward, there will be an enhanced sense of reactance (16). BMI report cards teeter on being both straightforward and also quite complicated to interpret and understand. Though parents are given a number that indicates if their child is overweight or obese, which seems straightforward, this message can be complicated. If a child receives an overweight BMI it can be true that they are indeed overweight in the sense that they have too much body fat, but it could also be that they are more muscular. In order for parents to determine if their child needs to lead a healthier lifestyle, parents would have to further analyze their child’s needs.

            Dominance describes the correlation between the source and the person that the message is aimed towards, the recipient. The more dominant a source is over its recipient, the more reactance is produced. In this intervention, the source is the school or government that is mandating BMI report cards. Clearly, the school is dominant over its students and families involved in the system. This dominance makes parent’s question the school’s authority; especially in this case, when their child’s health is involved, most parents believe it is their responsibility, not the school’s.

Another aspect of psychological reactance theory is reason. If there is no reason or support that accompanies the message, it is likely that reactance will increase. With BMI report cards, there is a disconnect between support of the message and what the message is meant to convey. Parents are not given reason or support for what the BMI means for their child. Without any reason, parents become outraged, which is the psychological reactance. The final factor in determining psychological reactance is similarity. If the source of the message is similar to the recipient, reactance will be reduced (15). In the case of this intervention, there is no similarity between the school administrators that are promoting the message and the parents or children that are receiving the information, so there is great psychological reactance invoked.

            In general, psychological reactance theory revolves around the loss of control and how people react to that loss. When the school says that a child is overweight or obese, solely based on height and weight, without taking into consideration that children are growing during these years in elementary and middle school or the child’s body composition, parents become offended. There is a sense of ownership among parents; although obesity is not a healthy lifestyle to lead or to “own”, parents feel that their children are “too good” and that their weight is under their ownership and should not be controlled by the schools administration. There is strong opposition from parents towards about this issue because they believe that schools are meant to teach knowledge and it is up to the parents and family to teach everything else in between (10).     

YOLO Campaign- An alternative public health intervention to reduce childhood obesity 

            The YOLO campaign is based on improving the criticisms previously made against BMI report cards aiming to reduce the rate of childhood obesity. YOLO has become a prevalent term in popular culture after artist, Drake, rapped the lyrics “you only live once, that’s the motto—yolo” in his song The Motto (17). This motto gained much attention causing young people to connect over this term. Though this motto is usually aimed towards a rebellious audience that finds a sense of confirmation with what they are doing, our campaign will aim to use this term in a positive light. Since many children are aware of this term, the campaign will help to reconstruct their view of the motto, while promoting healthy living. YOLO will represent the idea that yes, you only live once, and so why not make it the best life you can live. To do that, you need to lead a healthy lifestyle. This campaign will be focused on a group level, rather than aiming to educate specific individuals. There will not be a focus on the inaccurate measurement of BMI. Children will be targeted, not the parents, so that they see how they can change themselves to become the strongest that they can be. The campaign will be spread throughout communities, aimed towards children, by using #YOLO throughout social media and other aspects of the community, considering that “hashtags” allow the idea to spread to whomever is interested.

            This campaign will not be related to the school day, but rather after-school. Currently, many children go home after school and snack on “junk” food while sitting in front of a screen for hours. So to avoid both of these things, which have been credited to aid in the childhood obesity epidemic, we will take the child out of that situation and keep them active, eating healthy, and learning. High school aged and undergraduate college students will volunteer to lead these groups. There will be focus on physical activity and challenges created to get kids to compete against themselves. There will be healthy snacks supplied there. There will also be cooking lessons, focusing mostly on creating healthy snacks. The kids will also learn the importance of maintaining a healthy diet and how they can eat nutritious foods at every meal. This campaign is focused on reducing childhood obesity, but there will be a similar campaign offered to parents. Parents will stay involved and learn about what their child is learning while also discovering tips to lead the whole family in a direction of healthy living. 

Combating Critique #1: YOLO is about a healthy life, not a healthy weight

            Although weight plays a major role in assessing a person’s health, for a child that is elementary or middle school age, weight fluctuations are normal and crucial. Children are going through growth spurts and puberty—processes that require enough weight to function normally. If interventions harp on the fact that all children need to be in a “normal” weight range and labeling children as being obese, potentially harmful affects are imminent. Children that are obese are often depressed, have low self-esteem, have mental or emotional distress, and can often times end up with an eating disorder (14, 18-19). Many of these conditions persist even after they reach a “normal” weight. It is for these reasons that YOLO would not harp on the child’s weight, but rather on their health. Getting children to believe that they can become strong: that they can run a mile and play sports and that eating healthy will help them accomplish these goals.

            YOLO is about having one life to live, so we want to allow children to see that the one life they get should be the best life, and for that to be possible they need to live a healthy life. One of the other criticisms of the theory of reasoned action with BMI report cards was that social norms were not being addressed. By offering an extension of this program to parents, it becomes the social norm around the house to be active and to eat healthy. By impacting a child with these ideals at a young age, they will be accustomed to living healthy lives. The whole community will be aware of the campaign from #YOLO, so these children will be in a supportive environment, surrounded by a norm of healthy living. Originally, the BMI report cards did not give any information on how to change the intention of becoming healthy into a behavior. YOLO is all about the behavior. Parents and children will not be told their child’s BMI, so there is no intention, in that regard, of participating in the YOLO campaign. They are just participating to be strong and to learn the values of healthful living. They will just be doing it—eating healthy and being active—doing the behaviors that are necessary to combat the childhood obesity epidemic.

Combating Critique #2: Improving self-efficacy and modeling    

             One of the major critiques of the BMI report cards intervention was that there was no sense of self-efficacy among children. They did not know what these numbers meant or what changes needed to be made. YOLO will focus mainly on improving self-efficacy. Not only will the campaign target overweight children, but even “normal” weight children. All of the kids will feel like they are useful and important. Most children experience a sense of low self-esteem that affects anxiety and frustration and has been linked to victimization (20). YOLO will focus on self-efficacy affecting physical activity. For the most part, overweight children feel like they cannot participate in the same physical activity as other students because “they can’t run” or they get too tired. We will instill values revolving around the idea that it does not matter if you cannot run for a long time and it does not matter if you get tired, because you can do it, maybe not right now, but YOLO will get you there. The campaign will aim to prove to kids that practice and participation will allow them to do the same things as everyone else. Self-efficacy is important for anyone that is aiming to lose weight, but since YOLO is not a campaign concentrated on losing weight, but becoming healthy, strong, and the best that the child can be, self-efficacy should be easier to garner.

            The lack of reinforcements in the BMI report cards intervention has proven their importance. The whole campaign is aimed towards children that will participate in events and challenges together. This will bring a sense of unity among the students, so that they act as each other’s reinforcements. Parents and the rest of the community have a responsibility to act as these children’s reinforcements, as well, to encourage them towards becoming healthier and stronger. 

There was also an issue that BMI report cards were not exploring the modeling aspect of social cognitive theory. Modeling is the idea that people’s behaviors are often modeled from observing another person’s behavior. YOLO is going to be lead by students that are willing to take part in all of the activities, and that are eating the healthy snacks to prove to these kids that making these healthy decisions, they too can live that same healthy life. Ideally, many, if not all of the volunteers, will have struggled with their health and weight at one time in their life. That will allow these children to see firsthand what these healthy choices will do for them in the future. Children often look up to teens that they can relate to, as long as they are not feeling inferior. Having real teens and young adults as role models is crucial to getting these children to model their own behavior in a positive and healthy way.

Combating Critique #3: Avoiding psychological reactance

            The main way to avoid psychological reactance is to avoid taking control from a person. The YOLO campaign does the complete opposite. Just by the name of the campaign, people will understand that they only have on life to live and it is their life; they are in complete control over the ability that their body has to become strong, lean, and healthy. Other than losing control, the four factors that lead to reactance will be addressed and reversed.

            As far as explicitness is concerned, there will not be much of a message to convey, as much as there will be actions to perform. The main message of the whole program is to become strong and healthy, but there will not be much more to it than that. The message is not intended to tell people what to do, but instead to tell them what they are capable of doing. To reduce dominance, students are running the campaign. This shows much less dominance than having the schools tell students what to do. Over time, the goal of YOLO is to get young children that have become healthier and stronger, through the efforts of the campaign, to lead the program with the older students. Having peers to prove to the younger students that they can improve their physical abilities and healthy food choices will reduce dominance even more, making kids feel that they can accomplish their goals.

            When there is no reason to support a message, more reactance is invoked. Again, since there is not a straightforward message that is being portrayed, reason can be avoided. That being said, the students that are running the program will share personal accounts of how they have become healthier to the children. For those parents that participate in the parent extension of the campaign, there will be statistics on how leading a healthy lifestyle can benefit a child and a family. There will not be any negative data portrayed, just facts about how making all of these improvements will help them and their family. Since there was not any similarity in the BMI report cards, there would be a great deal of similarity between the leaders and children. They are all young people that want to live healthy lives, which allows them to relate to one another and find common ground.

YOLO is the best solution to combat the criticisms made towards the BMI report cards intervention. By addressing all of the issues that BMI report cards portrayed, YOLO will see great success. YOLO is a program based on doing; not about learning or teaching, but performing to become better. There is no focus on weight, just health through YOLO. Nutrition and eating habits, physical inactivity and sedentary behavior, advertising and marketing, socioeconomic status and race, and genetics are just some of the predicted causes of the childhood obesity epidemic (21). By addressing all of the modifiable changes that children and families can make, progress will be made with the YOLO campaign.

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