Georgia’s Children’s Health Alliance ‘Stop Childhood Obesity’ Campaign – Not Enough Help, Too Much Harm – Thien Nguyen

Introduction:

Obesity in America is not a new phenomenon and has been a problem for many decades. The rise of childhood obesity is especially alarming, because obese children are more likely to have high blood pressure, increase risk of impaired glucose tolerance, insulin resistance and type 2 diabetes, fatty liver disease, as well as a higher risk of social and psychological problems such as discrimination and low self-esteem (1). The Center for Disease Control (CDC) classifies overweight children as having a BMI at or above the 85^th percentile and lower than the 95^th percentile for children of the same age and sex (1). Obesity in children is defined as a BMI at or above the 95^th percentile for children of the same age and sex (1). In 2009, approximately 17% (or 12.5 million) children and adolescents ages ranging from 2-19 years are obese (1). This rate tripled from just a generation ago (1). The top threes states that have the highest rate of childhood obesity are Mississippi, Georgia, and Kentucky (2). In 2007, Georgia’s overall childhood obesity rate was 37.3% (3). Specifically, 28,000 (24%) of third grade children in Georgia were obese, 59,000 (16%) of middle school students were obese, and 50,000 (12%) of high school students were obese (3). Furthermore, Georgia did not meet the Health People 2010 national goal (5%) regardless of age, sex, race, or ethnicity (4).

These startling statistics prompted Georgia’s Children Health Alliance to roll out its “Stop Childhood Obesity” campaign in May 2011 in an attempt to stop the epidemic in Georgia. These billboard ads depicted overweight children looking dismal with a different warning signs on each of the billboards (fig. 1). Georgia’s Children Health Alliance’s approach to combat the obesity epidemic have raised eyebrows, with many applauding it for its boldness while angering many parents and professionals for using the wrong method to approach the problem. Although Georgia has good intent to decrease the childhood obesity epidemic in their state, the ineffective use of fear-based strategies, reinforcement of weight stigmas, and the unsuccessful framing of the advertisement may impede its campaign from being as successful as it could be.

Criticism 1: Ineffective Use of Fear-Based Strategies

The first thing that came to my mind when I saw these advertisements was that it reminded me of cigarette warning labels, but more climactic. At least with cigarette warning labels, the labels are small with a tiny size font. However, I believe their intent was to make a statement and as dramatic as possible. As I stare at these ads, I imagine an overweight child reading one of these warning signs, and think how terrifying it may be to think that they will not outlive their parents or how jarring it is to even be ‘chubby’. While these were mean to be used as a “wake up” call, the use of scare tactics can create more pressure in young children. This can result in malnutrition, eating disorders, hazardous weight loss, body hatred, size discrimination, and stress (5,6).

When Georgia Children’s Health Alliance was asked about the negative tone of their advertisements, their explanation was that it was “necessary to jar parents of obese kids out of a state of denial that their children had a problem” (7). They believe that this was a way to end the obesity epidemic that is affecting 2.7 million Georgia children (8). However, I believe that their fear-based strategies and negative connotation of their advertisement campaign may be working against their efforts to eliminate the epidemic. The fear-based approach, also known at the fear appeal, is a strategy that has been used in many campaigns to confront people with the negative consequences of their behaviors by capitalizing on their fears (9). Fear-based approaches usually use a personal message combined with a painful picture to convey the message (9). The message is to convey the negative consequences if people choose to participate in the targeted behavior. While it is meant to motivate the audience to change by evoking fear or concern, it is more likely to have the opposite effect (9). The fear-based approach has also been found to be ineffective in other areas of prevention; such as alcohol and other drugs and have been found to be unsuccessful in sustaining reduction of alcohol, tobacco, or other drug use among youth and may have the same effect on preventing obesity (10).

Criticism 2: Is this Reinforcing Stigma?

Taking a second look at these ads, I noticed that there are a lot of exclusions. It goes along with their negative and fear-based approach to obesity. You do not see anyone else in the photo but only the overweight child by him or herself. These billboards can create stigmas and ostracize children who are already obese. Though Georgia’s advertisement is aimed to create awareness and attention to its epidemic, it is in a direction that may perpetuate stigmas for obese children. Messages like “Warning: Fat kids become fat adults” accompanying by a picture of an overweight child looking extremely somber singles out obese children. This, in turn, makes them an easy target in society to induce further psychological harm such as depression, lower self-esteem, and body image dissatisfaction (11). Additionally, it makes it acceptable for other children to make fun the children who are overweight. Likewise, it can create an “antifat” or negative attitude towards children who are just mildly overweight. A study done by Latner and Stunkard has shown that anti-fat attitudes may begin in children as young as three years of age (11). They view drawings of chubby children as mean, possessing negative characteristics towards the drawings, and as undesirable playmates (11). These stigmas can persist into early adolescence and adulthood (11).

Although some stigmas are not so visible, it is extremely hard for overweight children to hide their stigma since it is extremely visible. It is something, even if they try, they cannot hide. Studies have indicated that about one-third of overweight girls and one-fourth of overweight boys have reported being teased by their peers at school due to their size (12). This can lead to peer victimization, such as bullying and teasing (12). Overweight children who suffered from depression due to weight-based teasing may be at a higher risk of using food as a coping mechanism, thus a plausible mediator in the relationship between obesity and depression (12). Additionally, stigmatization can lead to unhealthy eating and avoidance of physical activity (12). This is because they see physical activity as a form of social interaction with their peers. If they are afraid to be teased, they are less likely to put themselves in a situation where they may be teased. Consequently, this can lead to eating unhealthy food as a way to reduce stress and a decrease in exercise in those who are heading down the path towards obesity. Thus, advertisements like these can be stigmatizing to overweight children and would not be an effective motivator for them. Puhl says it best when she warns, “we need to make sure we are fighting obesity, and not obese people” (7).

Criticism 3: Advertisement Wrongfully Framed

Framing of a message can have an extreme impact on how the audience will perceive the message being delivered. Framing of information has been shown to influence a person’s choice, preference, attitude, and behavior (13). If the message is not properly framed, its effect on the targeted audience may not be as impactful as it should be.

The most striking message that Georgia conveys in these advertisements is the size of these children and the fact that they can barely fit in their clothes due to their size. The children being depicted in the advertisements are the “wrong” size, therefore, extremely undesirable to look at. We know that they are the wrong size due to their facial expression in conjunction with the “warning” messages attached to each picture. Consequently, framing the message by focusing on the right and wrong size may be the wrong way for Georgia to make people aware of their childhood obesity epidemic.

For many decades, media portrayals of the “right” size for women and men have created unrealistic expectations. This right and wrong size idea embedded in the minds of many women and men have promoted body dissatisfaction and fear of being fat, especially in women (14). The implication of being a right or wrong size may be a factor in the obesity epidemic. We are lead to believe that size is determined by choices; our diet and exercise choice, and our choice to choose. However, it fails to recognize genetic differences and that humans do not share the same general body shape (15). It ultimately sends the message that it was your choices that have lead you to become the wrong size and maybe there is something wrong with you. These unrealistic expectations that the media have produced for a person to become the ideal size may result in people who are already overweight to become hopeless. This is why we see so many of our friends and family members who try to diet and fail, or they would lose the weight but gain it all back and some more.

These advertisements fail to frame the problem to help their cause. Framing in terms of size may perpetuate the weight gain and introduce unhealthy eating habits in adolescents. Additionally, it reinforces media’s unrealistic expectations for many young boys and girls to be a have a certain body type. Subsequently, this can create stigmas and discrimination for people who are not the ‘right’ size and may lead to psychological harm.

Proposed Intervention:

For my proposed intervention, I would create an entirely new campaign in a more positive light. Rather than using the fear-based approach to scare the audience, Georgia Children’s Health Alliance can use the Social Network Theory to create a campaign that would create community values. Additionally, the Social Network Theory can be utilized to reduce weight stigmas and strengthen communities and their values towards better health. Finally, using the social marketing approach can help reframe the issue and promote health as a core value in the community to effectively change behavior.

The Social Network Theory, developed by Barnes (1954) and Bott (1957), can help public health practitioners to better understand the spread of obesity and the reason why certain communities, cities, or states have a higher percentage of obesity than others (16). The Social Network Theory is a group level model that explains that the spread of behavior occurs through networks or nodes (16). A network is a set of nodes interconnected to another and the relationship that links them together (17). A link between two nodes can be a behavior or a value that the two nodes share. Socially speaking, individuals are interconnected (directly or indirectly) to one another through a complex social network influencing the behaviors of all individuals in the network. The strength of the Social Network Theory is that the social structure of the network itself is mainly responsible for determining and predicting individual behaviors and attitudes by shaping the flow of resources which determines access to opportunities and constraints on behavior (16). Moreover, characteristics of a network include the range or size of network members, the density of how members are connected, boundedness, and homogeneity (16). Relating to network structure, the characteristics of the individual ties or relationships between the nodes include frequency of contacts, multiplexity (the number of types of transaction or support through a set of ties), duration, and reciprocity (16). The network size and density can potentially elicit positive or negative health outcomes depending on behavior or habits that the network share. In this case, the tie between everyone in this social network may share the same behavior, such as eating habits or exercise habits.

A study done by Kristakis and Fowler (2007) analyzing the Framingham Heart Study found that weight gain spreads from person to person along social networks (18). The weight gain in a person is also related to the weight gain of his or her friends, sibling, spouse and neighbors (18). Consequently, those in the network may adapt the same eating habits or change their tolerance of being obese (18).

Solution to Criticism 1 – Abandon Fear-Based Approach

To be able to create an effective campaign, Georgia should not resort to the fear-based approach in order raise awareness of obesity. Instead, Georgia should understand and identify the cause of the obesity epidemic. Georgia’s Health Children’s Alliance should think of obesity in terms of as a social construct and the effect of a social network has on influencing behaviors in a community.

Mulvaney-Day & Womack (2009) introduced a concept called ‘identity-constitute affiliations’ as a glue to bind and reinforce social relationships together and to reinforce social relationships and healthy behaviors in weak and strong network ties (19). It creates community values to change behaviors on a group level rather than on an individual level, to produce a greater effect of behavioral change (19). Creating community values can create intimate ties within the network to reinforce behaviors, either negative or positive health behaviors. Thus, rather than using the fear-based approach to jar the audience, Georgia’s Health Alliance should think in terms of instilling community values through the social network to create positive behavioral changes such as healthy eating habits or exercise habits. When community values are instilled in a network, people in the network tend to care for one another and can influence one another’s healthy habits.

Georgia can achieve this by creating an advertisement to appeal to community without the use of scare tactics. They can instill community values by creating a video advertisement that shows many children of all physiques and ages in the group caring for one another and performing some type of physical activity outside such as playing basketball or doing yoga with a message from the parents that says, “We care about the health of our community, especially our children’s health” or “We want our children to grow up healthy. That’s why as a community, we are taking actions”.

Solution to Criticism 2: Reducing Stigmas through the Social Network Theory

The Social Network Theory can also be used to reduce stigmas by creating a positive environment and supportive network to make changes in a community. In order to reduce stigmas, we must understand the origin of weight stigmas. Stigmas are representation of society’s negative perception about a particular outcome (20). Moreover, obesity stigma is a result of social ideology that uses negative attributions to explain negative life outcomes (20). In a sense, “people get what they deserve” and are responsible for their life situation. Rather than re-enforcing stigmas, it is imperative to find a way to provide a network of support for children in order to change their behavior. It has been shown that social interactions can help reduce discrimination and prejudice by increasing interactions between those “marked” and “unmarked” increases sentiments of “liking” (21). Consequently, tolerance increases and prejudice is lowered (21). Additionally, interventions involving a network of parents, siblings, or peers with similar weight issues could prove to be more successful than targeting individuals alone (22)

I would suggest eliminating the warning labels and the picture depicting the overweight child being alone to try and eradicate the perception that people may have of obese people. If we can show children interacting regardless of race, weight, age, etc., we can send a message that is more positive and influential than isolating overweight children and reinforcing stigmas in society.

Solution 3 to Criticism 3: Reframe the Issue using the Social Marketing Approach

A successful marketing approach can be an effective tool to frame the issue in a way that compels the audience’s attention. Social marketing is a process of applying marketing concepts and techniques to promote voluntary behavioral changes in the targeted audience (23). The features of social marketing includes exchange theory, audience segmentation, “the marketing mix”, consumer research, and continuous monitoring (23).

The current advertisement attempts to target a wide array of audiences. However, it is not possible to target such a wide audience without the message losing its effectiveness or significance. It is impossible to be “all things to all people” (23). It is best to differentiate the population into subgroups and target the message to a specific population. Segmentation and target marketing have shown to increase program effectiveness and efficiency tailoring to address the needs of a specific population (23, 24). The exchange theory attempts to elicit voluntary behavior by offering or reinforcing incentives that make the voluntary exchange inviting (23). The “marketing mix” includes product, price, place, and promotion (23). Product is the benefits associated with desired behavior (23). Price is the cost or exchanged for the promised product (or benefits) (23). Place is where the targeted audience will perform the desired behavior (23). Promotion is used to convey the promised benefits, which involves careful design activities intended to influence change (23). Consumer research can provide evidence-based implementation targeting the consumer’s needs and wants. Lastly, continuous monitoring and revision of the program will help assess its effectiveness and help sustain the recommended behavior in the target population.

The current campaign frames obesity in terms of the right and wrong size for children. However, the proposed campaign would utilize social marketing strategies to reframe the problem in a different viewpoint. First, the proposed campaign would differentiate parents, children, and educators into three different subgroups and have messages that would target those groups individually, rather than altogether (audience segmentation). Tailoring to a specific subgroup can help that specific group to bind together and respond similarly to the intervention because they have similar needs and wants. Next, consumer research would be conducted to understand the needs and wants of the targeted audience. Consumer research can give public health practitioners a better understanding of their core values that could help motivate and encourage them to adopt the recommended behavior (23). To target the younger population, the proposed campaign would promote the freedom to play in children or do anything else they want as the incentive to voluntary physical activity (exchange theory).

The current advertisement focuses on the size of these children rather than what can be done to promote healthy behaviors such as eating and exercise habits. The focal point of the picture in the proposed campaign is to include a positive message that shows health and vitality for kids of all sizes interacting with one another through a type of physical activity like playing basketball or soccer. Promoting health versus the right or wrong sizes for kids to achieve can create a long-term change in behaviors to reduce obesity. Along with the image promoting health and vitality, health should be promoted as a value that can be instilled in these children at a young age. This shows the children that they can lead a healthier lifestyle regardless of their size and that they have to avoid physical activity in fear of being made fun of by their peers. Furthermore, this campaign will provide a promise that you do not have to be isolated from your peers. It gives them a message that they can choose to be active and to interact more with their peers without fear or pressure. As a result, overweight children will feel inclusive amongst their peers, which can boost their self-esteem and give them hope. When health is introduced as a value, children, parents, and the community as a whole, may be motivated to lead an active lifestyle and support one another in the behavioral change. Additionally, Georgia can run a series of positive advertisements targeting different populations (parents, children, and educators) to effectively convey their message across a variety of population. Program evaluation and research can be done to see what is effective and ineffective in the campaign and monitor the behavioral change within the community. Changes to the campaign can be made throughout the process to meet the needs of its audience.

Conclusion:

Georgia’s Children’s Health Alliance advertisements contain some severe limitations due to its use of the fear-based approach as a “wake up” call, its isolation of obese children and inherently reinforcing weight stigmas in society, and its inefficient framing of the obesity epidemic in terms of the right and wrong body size for children to achieve. Obesity still remains one of the biggest public health challenges that this country has ever faced. Reversing the obesity epidemic requires the use of a group-level model like the social network theory to understand the connections and relationships between people in a community and how it can affect behaviors on a grander scale. By eliminating the fear-based approach, preventing the isolation of obese children and reinforcing stigmas and creating community values and support through the social network theory, we can change behavior at a group level to have a more impact. Moreover, understanding the public health implications of the social marketing method to correctly frame the problem towards a targeted community can also help perpetuate behavioral changes such as eating habits or exercise habits at a group level. We must think big and think in terms of changing a whole community to make a powerful impact on reversing the trends of obesity.

Fig. 1

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