Public health anti-obesity communication: an analysis of current campaigns for future guidance

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PUBLIC
HEALTH
ANTI-‐OBESITY
COMMUNICATION:

AN
ANALYSIS
OF
CURRENT
CAMPAIGNS
FOR
FUTURE
GUIDANCE

Maria
Raquel
Orellana

A
Thesis
Presented
to
the

FACULTY
OF
THE
USC
GRADUATE
SCHOOL

UNIVERSITY
OF
SOUTHERN
CALIFORNIA

In
Partial
Fulfillment
of
the

Requirements
for
the
Degree

MASTER
OF
ARTS

(STRATEGIC
PUBLIC
RELATIONS)

December
2013

i

Table
of
Contents

ABSTRACT
iii

CHAPTER
ONE:
Introduction
1

CHAPTER
TWO:
Theoretical
Framework
5

CHAPTER
THREE:
Case
Study
Approach
9

CHAPTER
FOUR:
New
York
City
Health
Department’s
Anti-‐Obesity
Campaign
11

Target
Audience
12

Approach
13

Nutrition
Data
Education
Campaign

15

Sugar-‐Sweetened
Beverages
Campaign
17

Sodium
Reduction
Campaign
24

Media
Tactics
25

Evaluation
26

Challenges
Encountered
and
Lessons
Learned
27

Going
Forward
29

CHAPTER
FIVE:
Los
Angeles
County
Department
of
Public
Health
30

“Salt
Shocker”
Video
Series
33

“Sugar-‐Loaded
Drinks”
Campaign
35

“Choose
Less.
Weigh
Less”
Portion
Control
Campaign
37

Going
Forward
41

CHAPTER
SIX:
United
Kingdom
-‐
Change4Life
Campaign
42

Target
Audience
43

Branding
and
Messages
44

Implementation
47

Phase
One
48

Phase
Two
52

Results
56

Analysis
57

CHAPTER
SEVEN:
Issues
and
Challenges
60

CHAPTER
EIGHT:
Key
Takeaways
and
Conclusions
79

ii
Bibliography
96

Appendix
2:
Sugar-‐Sweetened
Beverage
Campaign,
NYC
Health
Department
106

Appendix
3:
Sodium
Reduction
Campaign,
NYC
Health
Department
110

Appendix
4:
“Salt
Shocker”
Video
Series,
LA
Department
of
Public
Health
111

Appendix
5:
“Sugar-‐Loaded
Drinks”
Campaign,
LA
Department
of
Public
Health
112

Appendix
6:
Portion
Control
Campaign,
LA
Department
of
Public
Health
114

Appendix
7:
UK
-‐
Change4Life
Campaign,
Branding
and
Creative
Applications
115

Appendix
8:
Professional
Interviews
117

Caroline
Wallace
–
Health
Media
&
Marketing,
New
York
City
Department
of
Health

&
Mental
Hygiene
117

Ali
Noller
–
Communications
Manager,
Choose
Health
LA,
Department
of
Public

Health,
Division
of
Chronic
Disease
and
Injury
Prevention
124

Jana
M
Scoville
-‐
Member
of
the
Media
and
Communications
Team
at
Banyan

Communications,
Contractors
for
the
CDC.
131

Keisha
Brown,
Senior
Vice
President/Chief
Creative
&
Innovative
Officer,
Lagrant

Communications
135

Patricia
A.
Groziak,
Executive
Director,
Nutrition
&
Wellness,
GolinHarris
142

Manny
Hernandez,
Co-‐Founder,
President,
Diabetes
Hands
Foundation
147

Elyse
Resch,
Co-‐Author
of
Intuitive
Eating
150

Dr.
Marc
Weigensberg
-‐
Associate
Professor,
Clinical
Pediatrics,
Keck
School
of

Medicine,
University
of
Southern
California
154

iii

ABSTRACT

In
the
last
thirty
years,
the
incidence
of
obesity
has
grown
at
alarmingly
rapid
rates.
In
2010,
the

International
Association
for
the
Study
of
Obesity
estimated
that
about
25%
of
the
world’s
population

was
obese
or
overweight.
1
,
2

Although
obesity
is
becoming
increasingly
prevalent
throughout
the
world,

it
is
particularly
problematic
in
developed
countries
where
it
is
considered
one
of
the
greatest
health

threats.
Obesity
affects
quality
of
life,
relationships,
and
self-‐esteem.
More
important,
it
poses
serious

health
consequences
and,
therefore,
represents
significant
medical
costs.

In
response
to
the
alarming
trends,
anti-‐obesity
programs
are
being
implemented
in
cities
and

countries
around
the
world.
This
document
explores
existing
anti-‐obesity
efforts
that
lie
within
the

realm
of
public
health
communications.
It
analyses
them
from
a
theoretical
(communicational),

psychological,
and
sociological
standpoint,
and
explores
how
they
are
playing
out
in
the
modern

communication
ecology.
It
includes
in-‐depth
analyses
of
public
health
communication
campaigns
in

three
localities:
New
York
City,
Los
Angeles
County,
and
the
United
Kingdom.
Other
campaigns
were
also

examined
and
are
referenced
and
used
as
examples
throughout
the
document.
The
paper
compiles
a
list

of
issues
and
challenges
faced
by
communication
practitioners
involved
in
the
topic.
In
addition,
it

provides
a
list
of
key
takeaways
and
conclusions,
including
best
practices,
failed
strategies
to
avoid,

potential
obstacles,
and
requirements
for
success.
The
elements
outlined
in
the
last
two
chapters
are

meant
to
guide
governments
and
other
organizations
planning
future
public
health
communication

initiative
to
address
the
obesity
epidemic.

1

“About
Obesity,”
IASO,
Last
modified
September
3,
2012.
2

“2012
World
Population
Data
Sheet,”
Population
Reference
Bureau
(PRB).

1

CHAPTER
ONE:
Introduction

Since
the
1980s,
obesity
has
increased
at
worrying
rates.
This
has
been
particularly
true
in
the

developed
world,
where
more
than
half
of
the
population
is
now
overweight
or
obese.
1

Obesity
is

currently
one
of
the
greatest
health
threats
in
developed
countries,
and
developing
countries,

particularly
their
urban
populations,
are
headed
in
a
similar
direction.
2

In
2010,
the
International
Association
for
the
Study
of
Obesity
estimated
that
about
1.5
billion

adults
worldwide
were
obese
or
overweight,
with
about
one-‐third
of
them
being
obese.
The
worldwide

number
of
obese
or
overweight
children
was
estimated
to
be
about
200
million,
of
whom
about
one-‐
fourth
were
deemed
obese.
3

When
compared
to
the
total
global
population
4
,
these
numbers
indicate

that,
as
of
2010,
one
in
four
individuals
in
the
world
was
overweight
or
obese.

In
the
United
States,
it
is
estimated
that
about
69%
of
the
adult
population
is
either
obese
or

overweight,
of
whom
about
half
(or
about
36%
of
the
total
population)
are
obese.
5

In
the
combined

population
of
all
member
countries
of
the
Organization
of
Economic
Co-‐operation
and
Development

(OECD),
more
than
one
in
five
adults
are
obese.
6

Obesity
affects
quality
of
life,
relationships,
and
self-‐esteem.
Obese
and
overweight
individuals

must
deal
with
the
existing
social
stigma,
which
portrays
them
as
less
attractive,
lazy,
lacking
self-‐
control,
and
irresponsible.
They
are
often
bullied,
shamed,
and
discriminated
as
a
result
of
their
physical

1

Sassi
and
Devaux,
Obesity
Update
2012.

2

Sassi,
“How
U.S.
Compares
with
Other
Countries,”
Health,
PBS
Newshour,
April
11,
2013.
The
article
is
a

joint
effort
between
PBS
and
the
Organization
for
Economic
Co-‐operation
and
Development.

3

“About
Obesity,”
IASO,
Last
modified
September
3,
2012.
4

“2012
World
Population
Data
Sheet,”
Population
Reference
Bureau
(PRB).

5
Flegal,
et
al,
“Prevalence
of
Obesity
Among
US
Adults,
1999-‐2010,”
JAMA.
307,
no.
5
(2012):
491-‐497
6

Sassi and Devaux, Obesity Update 2012.

2
appearance.
The
discrimination
can
occur
in
all
social
systems:
among
peers,
in
school
playgrounds,
in

the
workplace
and
job
market,
in
the
dating
scene,
among
medical
professions,
and
others.
Such

rejection
can
lead
to
depression
or
similar
psychological
reactions.

Obesity
is
far
more
than
what
many
consider
an
undesirable
physical
appearance.
Serious
health

conditions,
including
heart
disease,
stroke,
diabetes,
and
certain
types
of
cancer,
are
associated
with

excessive
accumulation
of
body
fat.
As
a
result,
obesity
represents
significant
health
care
costs
to
the

individual
and
to
society.
7

In
fact,
in
most
OECD
countries,
1
to
3%
of
total
health
expenditure
can
be
attributed
to
obesity.
8

According
to
the
United
States
Center
for
Disease
Control
(CDC),
the
United
States
spends
about
$US150

billion
per
year
in
medical
costs
associated
with
the
condition.
This
represents
10%
of
total
medical

expenses.
9

It
is
no
surprise
that,
since
2004,
the
CDC
has
ranked
obesity
as
the
number
one
health
risk
in

America.

In
2012,
the
OECD
announced
a
decrease
in
the
rate
of
growth
of
obesity
in
several
countries.

Figure
1
shows
that
the
actual
percentages
of
overweight
individuals
in
particular
countries
in
2010

(solid
lines)
were
lower
than
the
OECD’s
original
forecasts
(dotted
lines).
While
the
news
might
be

encouraging,
the
truth
is
that
obesity
continues
to
grow.

7

“About
Obesity,”
IASO,
Last
modified
September
3,
2012.
8

Sassi
and
Devaux,
Obesity
Update
2012.

9

“Overweight
and
Obesity,”
CDC,
last
modified
August
13,
2012.

3

Figure
1.
Chart
by:
Sassi
and
Devaux.
Obesity
Update
2012.

The
slowing
down
could
be,
in
part,
the
result
of
anti-‐obesity
efforts
currently
underway
in
cities

and
countries
around
the
world.
However,
these
efforts
are
in
the
process
of
being
implemented,
many

of
them
are
still
in
their
initial
phase,
and
conclusive
results
will
not
be
apparent
for
a
very
long
time.

Thus,
as
The
Economist
concluded
in
a
December
2012
special
report
on
obesity,
“…for
now
politicians

will
continue
to
experiment
to
see
what
works.”
10

This
document
will
focus
on
analyzing
those
anti-‐obesity
efforts
that
lie
within
the
realm
of
public

health
communication.
From
a
theoretical
standpoint,
because
there
are
no
conclusive
results
at

present,
it
is
perhaps
not
the
ideal
time
to
analyze
and
evaluate
their
effectiveness.
However,
there
are

valid,
pragmatic,
social,
and
humane
reasons
to
start
working
on
identifying
good
practices,
obstacles,

requirements,
and
success
factors
that
can
be
used
to
guide
future
actions
and
correct
current
ones
as

needed.
The
obesity
epidemic
continues
to
grow
and,
while
some
of
the
current
undertakings
may

produce
results,
none
of
them
will
eliminate
the
problem
all
together,
nor
will
they
reach
all
the

10

“The
nanny
state’s
biggest
test,”
The
Economist,
December
15,
2012.

4
affected
populations.
Furthermore,
anti-‐obesity
communication
implies
motivating
the
permanent

adoption
of
daily
behaviors,
which
will
require
consistent
reinforcement
for
a
significant
amount
of

time.
In
other
words,
with
so
much
investment
being
made
in
anti-‐obesity
communication
campaigns

and
with
so
many
efforts
yet
to
come,
it
is
important
to
study
them
in
the
hope
that
each
subsequent

investment
will
be
more
effective
than
the
last.

Anyone
who
has
ever
attempted
to
follow
a
diet
knows
how
difficult
it
can
be
to
stay
on
track.
The

individual
is
required
to
be
vigilant
of
her
behaviors
throughout
the
day;
continuously
tempted
by

advertisements
and
social
situations;
and
needs
to
spend
more
time
and
money
obtaining
healthy
food.

It
usually
takes
a
strong
motivating
factor
(an
upcoming
high-‐school
reunion,
watching
somebody
suffer

from
a
heart
attack
caused
by
obesity,
etc.)
for
a
person
to
achieve
results.
If
this
individual
is
successful

in
losing
weight,
sustaining
the
loss
can
be
an
even
greater
challenge
as
it
requires
continuous
discipline.

For
public
health
communicators,
motivating
the
adoption
of
behaviors
that
require
constant
effort
is

not
an
easy
task.
Sparking
the
drive
is
particularly
challenging
when
the
only
reward
offered
is
a

healthier
future,
which
is
not
palpable
now
and
will
be
difficult
to
measure
in
the
future.

This
paper
studies
existing
efforts
from
a
theoretical
(communicational),
psychological,
and

sociological
standpoint,
and
explores
how
they
are
playing
out
in
the
modern
communication
ecology.
It

includes
in-‐depth
analyses
of
public
health
communication
campaigns
in
three
localities:
New
York
City,

Los
Angeles
County,
and
the
United
Kingdom.
Other
campaigns
were
also
examined
and
are
referenced

and
used
as
examples
throughout
the
document.
The
purpose
of
the
analysis
is
to
identify
best

practices,
failed
strategies
to
avoid,
potential
obstacles,
requirements
for
success,
and
other
elements

that
can
guide
governments
and
other
organizations
planning
future
public
health
communication
to

address
the
obesity
epidemic.

5

CHAPTER
TWO:
Theoretical
Framework

Personal,
one-‐on-‐one-‐support
approaches
have
been
effective
for
many
individuals
struggling

with
weight
loss.
However,
the
obesity
problem
is
so
pervasive
that
unattainable
amounts
of
resources

would
be
required
to
provide
help
on
an
individual
basis.
In
addition,
a
personal-‐support
approach

would
leave
out
those
who
are
not
obese,
but
are
at
risk
of
becoming
so.
Therefore,
there
is
a
role
to
be

played
by
mass-‐scale
programs
that
address
the
problem.
Among
such
endeavors,
public
health

communication
campaigns
can
be
used
to
promote
the
adoption
of
behaviors
that
are
conducive
to

weight
loss
and/or
prevent
weight
gain.
It
is
important
to
note,
that
this
analysis
considers
that
public

health
communication
alone
will
not
solve
the
obesity
epidemic.
Rather,
it
should
be
executed
hand
in

hand
with
other
initiatives,
programs,
or
legislations.

Rice
and
Atkins
define
public
communication
campaigns
as
those
designed
to
“inform,
persuade,

or
motivate
behavior
changes”
among
members
of
a
particular
population
in
an
attempt
to
generate

benefits
for
the
individuals
and/or
society
(generally
for
noncommercial
benefits).
1

Such
campaigns
can

be
used
in
public
health
to
educate
about
a
health
issue,
raise
awareness,
influence
behaviors,
beliefs

and
attitudes,
prompt
action,
provide
examples
of
healthy
behavior,
disprove
misconceptions,
and

promote
available
resources
and
services.
2

Public
health
communication
is
often
conducted
through
social
marketing,
which,
as
defined
by

the
CDC,
“refers
to
the
application
of
marketing
principles
to
influence
behaviors.”
3

Marketing
experts

use
the
consumer
decision
journey
to
analyze
their
audience’s
current
status
and
determine
how
to

1

Rice
and
Atkins,
“Communication
Campaigns:
Theory,
Design,
Implementation,
and
Evaluation,”
In
Media

Effects
Advances
in
Theory
and
Research,
2
nd

ed
edited
by
Bryant,
Jennings
and
Dolf
Zillman,
427.

2

Rimer
and
Glanz,
Theory
at
a
Glance.

3

“Gateway
to
Health
Communication,”
CDC,
2011

6
motivate
them
to
move
to
along
the
steps
of
the
process.
The
steps
in
the
consumer
decision
journey

include
1)
awareness
of
a
product/service,
2)
familiarity,
3)
consideration
(whether
to
buy
or
not),
4)

purchase,
and
5)
loyalty.
4

Similarly,
the
transtheoretical
model
describes
the
steps
in
the
behavior
change
process:
5

1-‐ Precontemplation
during
which
a
person
is
not
thinking
about
or
considering
making
a

behavior
change;

2-‐ Contemplation
during
which
a
person
becomes
aware
of
a
risk
and
begins
to
consider
the

need
to
make
a
behavior
change
(learns
that
obesity
can
lead
to
health
consequences
and

thinks
about
what
it
would
mean
to
eat
healthier);

3-‐ Preparation,
which
involves
seeking
more
information
about
the
risks
and
how
to
avoid

or
prevent
them
(reads
about
specific
conditions
that
can
result
from
obesity
and
learns

what
behavior
modifications
can
help
avoid
them);

4-‐ Action
refers
to
the
adoption
of
the
new
behavior
(begins
preparing
healthier
meals
and

walking
to
work);
and

5-‐ Maintenance
during
which
he
continues
to
engage
in
the
modified
behavior
(healthy

eating
and
walking
become
part
of
his
daily
routine).

It
is
important
to
remember
that
a
given
audience
can
include
individuals
in
all
stages
of
the
process,

and
that
the
path
that
each
individual
follows
is
not
necessarily
linear.
Messages
and
strategies
tailored

to
individuals
in
each
of
the
stages
should
be
considered
when
designing
anti-‐obesity
public
health

campaigns.

In
“Theory
at
a
Glance:
a
Guide
for
Health
Promotion
Practices,”
6

the
U.S.
Department
of
Health

and
Human
Services
suggests
additional
communication
theories
applicable
to
public
health
campaigns.

4

Court
et
al,
“The
consumer
decision
journey,”
McKinsey
Quarterly,
June
2009.

5

The
Habits
Lab
at
UMBC.
“The
Transtheoretical
model
of
behavior
change.”
University
of
Maryland
at

Baltimore
County
website.
Accessed
in
June
2013.

7
Most
of
these
theories
can
be
used,
and
many
are
being
used,
to
design
anti-‐obesity
communication

strategies.
The
following
are
particularly
relevant
to
anti-‐obesity
communication
and
should
be

considered
by
practitioners
involved
in
the
topic:

o Ecological
Perspective,
which
calls
attention
to
the
multiple
factors
that
influence
behaviors.

These
factors
occur
in
three
levels:
intrapersonal
(a
person’s
childhood
experience
at
the
dining

table,
people’s
knowledge
about
healthy
foods),
interpersonal
(co-‐workers,
family
members,

friends,
health
professionals),
and
community
(a
tax
on
sugary
drinks,
a
cultural
preference
for

thinness,
the
availability
of
safe
places
to
walk).

o Health
Belief
Model,
which
suggests
that
the
factors
that
motivate
people
to
act
to
prevent
or

control
a
health
condition
are:
perceived
risk
(“how
likely
am
I
to
become
diabetic?”),
perceived

severity
of
consequences
(“how
bad
will
living
with
diabetes
be?”),
perceived
benefits
of
taking

action
(“what
will
happen
when
I
start
eating
healthier?”),
belief
that
taking
action
will
bring

more
benefits
than
costs
(“is
paying
more
for
healthier
food,
worth
lowering
my
risk
of
heart

disease?”),
level
of
exposure
to
reminder
cues
(advertisements,
peers
engaging
in
healthy

behaviors,
signs
at
the
local
store),
and
belief
in
ability
to
perform
the
action
(“with
some
effort,

I
can
lose
weight”).

o Theory
of
Planned
Behavior,
which
suggests
that
behavioral
intention
is
influenced
by
a

person’s
attitudes
toward
a
behavior
(“physical
activity
can
be
fun
and
healthy,”
“eating
healthy

is
boring
and
expensive”),
by
subjective
norm
or
how
they
perceive
others
will
judge
the

behavior
(“people
will
think
I’m
athletic
if
I
start
walking
to
work,”
“people
will
think
I’m
a
nerd
if

I
only
eat
healthy
food”),
and
by
their
perceived
control
over
the
behavior
(“I
can
motivate

myself
to
go
for
a
walk
every
day,”
“it’s
impossible
to
find
healthy
food
near
the
office”).

6

Rimer
and
Glanz,
Theory
at
a
Glance.

8
o Social
Cognitive
theory,
which
considers
the
process
by
which
a
person’s
behaviors
are
affected

by
modeling,
that
is,
what
he
learns
from
the
behaviors
of
others
(a
child
watches
her
mother

eat
vegetables
every
day,
new
co-‐workers
eat
snacks
all
day
long).
The
theory
emphasizes
that
a

person’s
self-‐efficacy
to
perform
a
given
behavior
is
also
important
in
motivating
the
action.

o Social
System
Theory,
which
explores
how
organizations
in
a
community
interact
and
influence

each
other
(church
groups
start
organizing
family
walks
after
prayer
group,
healthier
snacks
are

offered
at
PTA
meeting).
This
can
be
used
to
assess
their
potential
in
driving
individuals
to
adopt

healthier
behaviors.

o Media
Effects,
which
analyzes
how
the
media
influence
the
audience’s
attitudes,
beliefs,
and

behaviors
(“I
have
to
be
skinny
like
the
girls
on
TV,”
“after
I
heard
about
the
amount
of
calories

in
some
fast
foods,
I
don’t
even
want
to
go
near
them”).

Public
health
communicators
will
find
some
of
these
theories
more
relevant
than
others.

However,
it
is
important
to
remember
that
they
are
not
mutually
exclusive.
In
fact,
in
most
cases,

campaigns
will
use
several
of
them
simultaneously.
Regardless
of
which
one
is
chosen
reviewing
all
of

them
as
the
campaign
is
being
designed
can
be
a
valuable
practice.

9

CHAPTER
THREE:
Case
Study
Approach

As
the
obesity
epidemic
continues
to
spread,
anti-‐obesity
campaigns
are
being
implemented

throughout
the
United
States
and
in
countries
around
the
world.
Governments,
foundations,
not-‐for

profit
organizations,
donors,
and
companies
are
devoting
significant
resources
to
these
undertakings.

An
in-‐depth
analysis
of
three
of
these
initiatives
was
conducted
to
discover
insights
that
can
orient

future
efforts,
as
well
as
help
correct
or
improve
current
ones.
The
three
campaigns
were
chosen

considering
the
need
for
examples
with
significant
scope
and
size
(in
terms
of
resources
and

population);
an
interest
in
geographical,
methodological,
and
target
audience
variety;
and
access
to

information
and
sources.
In
addition,
particular
characteristics
of
other
anti-‐obesity
initiatives
were

reviewed,
analyzed
and
are
mentioned
and
used
as
examples
throughout
the
paper.

The
analysis
was
conducted
during
an
eight-‐month
period,
and
was
informed
by
a
combination
of

secondary
and
primary
research.
Secondary
sources
included
an
extensive
selection
of
white
papers,

studies,
reports,
and
evaluations
published
by
implementing
organization,
funders,
third
parties,
and

media
outlets,
as
well
as
publications
covering
public
health
communication
theory
and
the
obesity

epidemic.

Primary
research
methodologies
included
content
analysis
of
campaign
material,
opinion
pieces,

and
news
articles
about
the
campaigns.
In
addition,
professional
interviews
were
conducted
and
are
a

valuable
source
of
important
details,
insights,
and
opinions
that
would
have
been
impossible
to
obtain
in

writing.
The
individuals
interviewed
include
members
of
teams
who
have
worked
or
are
working
on
anti-‐
obesity
campaigns,
officials
from
funding
institutions,
psychologists
and
medical
doctors
focusing
on

nutrition
and
diabetes,
and
public
health
communication
experts.
A
complete
list
of
those
interviewed

for
the
purpose
of
this
research,
as
well
as
the
transcript
of
the
interviews,
can
be
found
in
Appendix
8.

10
This
analysis
focuses
on
public
health
communication
and
social
marketing
efforts.
However,

health
promotion
in
general,
and
obesity
prevention
in
particular,
requires
a
combination
of

simultaneous
approaches
to
support
individuals
as
they
adopt
healthy
practices.
In
addition
to
public

health
communication
and
education,
such
activities
can
include
infrastructure
improvements,

introduction
of
new
policies,
school
programs,
and
community
support
groups,
among
others.

Accordingly,
each
of
the
communication
campaigns
analyzed
is
part
of
a
larger
strategy.
Those
strategies

are
briefly
reviewed
in
the
respective
chapters.

11

CHAPTER
FOUR:
New
York
City
Health
Department’s
Anti-‐Obesity
Campaign

In
New
York
City,
about
58%
of
adults
and
close
to
40%
of
children
are
obese
or
overweight.
Every

year,
the
city
incurs
about
$4
billion
in
Medicare
and
Medicaid
expenses
to
address
obesity-‐related

health
complications.
1

As
is
the
case
with
income
levels,
there
are
significant
disparities
in
obesity
levels

among
the
city’s
population.
Lower-‐income
families,
African
Americans,
and
Hispanics
are,
by
far,
more

likely
than
other
New
Yorkers
to
be
obese.

New
York
City’s
Mayor,
Michael
Bloomberg,
is
well
known
for
his
aggressive
approaches
and
bold

initiatives
to
address
health
issues
affecting
the
city’s
population.
Some
of
his
policies,
such
as
a
ban
on

smoking
in
restaurants
and
workplaces,
have
been
controversial.
However,
there
is
no
doubt
of
the

mayor’s
commitment
to
helping
New
Yorkers
be
healthy.
Bloomberg
has
made
obesity
one
of
his

priorities
and
is
working
diligently
to
reverse
the
current
trend.

The
New
York
City
Department
of
Health
and
Mental
Hygiene
(the
Health
Department)
is
the
body

responsible
for
addressing
the
high
incidence
of
obesity,
as
well
as
other
health
issues.
In
2010,
the

Health
Department
received
one
of
the
largest
grants
given
to
cities
as
part
of
the
federally
funded

Recovery
Act
program,
Communities
Putting
Prevention
to
Work
(CPPW).
New
York
City
received
$31.1

million,
of
which
half
was
to
be
used
to
address
obesity
during
a
two-‐year
period
(the
other
$15.5

million
was
for
smoking
cessation
programs).

The
grant
was
used
to
continue
growing
the
obesity
and
smoking
cessation
efforts
included
in
the

Health
Department’s
“Take
Care
New
York”
(TCNY)
plan,
which
was
first
launched
in
2004
and
later

revised
in
2009.
The
documents
outline
the
City’s
ten
health
priorities,
including
“Promote
Physical

1

City
of
New
York,
“Bloomberg
Highlights
Impacts
of
Obesity,”
Mike
Bloomberg,
news
release,
NYC,
June
5,

2012.

12
Activity
and
Healthy
Eating;”
the
strategies
to
address
them;
and
the
indicators
to
measure
them.
The

2009
version
maintained
the
priorities,
but
modified
strategies,
including
those
focusing
on
obesity

prevention,
to:
2

o Include
participation
of
communities,
governments,
and
businesses.

o Focus
on
children’s
health.

o Address
neighborhood
conditions.

o Emphasize
health
disparities
between
population
subgroups.

At
the
same
time,
new
targets
for
each
indicator
were
established
to
be
reached
by
2012.
Table
1

shows
the
indicators
and
targets
related
to
promoting
physical
activity
and
healthy
eating.

Table
1.
Table
by:
Summers
et
al.
Take
Care
New
York
2012,
12.

Target
Audience

The
Health
Department’s
anti-‐obesity
activities
targeted
the
segments
of
the
populations
where

obesity
is
most
prevalent.
These
included
individuals
with
low
income
and
low
levels
of
education,
and

2

Summers
et
al,
Take
Care
New
York
2012,
12-‐13.

13
are
largely
African
Americans
and
Hispanic.
3

As
a
result,
most
of
the
Health
Department’s
anti-‐obesity

initiatives
have
been
implemented
in
the
City’s
poorest
areas,
including
the
South
Bronx,
East
and

Central
Harlem,
and
North
and
Central
Brooklyn.
In
addition,
all
campaigns
have
included
applications
in

Spanish
to
address
the
non-‐English
speaking
Latino
population.

Approach

Caroline
Wallace
4
,
Health
Media
&
Marketing
executive
at
the
Health
Department,
explains
that

the
Department
views
obesity
as
primarily
an
environmental
problem.
Therefore,
the
team’s
focus
is
on

providing
information
to
help
at-‐risk
populations
be
healthy
in
their
environment,
and
on
promoting

policies
and
programs
that
encourage
healthy
behaviors.
The
goal
is
to
“make
healthy
choices,
the

easier
choices,”
she
explains.
When
it
comes
to
obesity,
the
healthy
choices
include
increasing
physical

activity
and
increasing
consumption
of
healthy
foods.

To
this
end,
the
City
follows
a
multi-‐pronged
approach,
which,
as
New
York’s
Health
Commissioner

Dr.
Thomas
A.
Farley
describes,
will
create
"…
a
healthier
environment
that
gives
people
the
freedom
to

just
go
about
their
business
without
having
to
worry
so
much
about
being
vigilant
about
their
health

behavior.”
5

The
Department’s
initiatives
fall
into
three
categories:
policies
and
legislation;
prevention,

quality,
and
access;
and
public
communication
campaigns.
The
Department
believes
that
the
three

categories
are
complementary
and
necessary
to
impact
the
City’s
obesity
rates.

Many
of
the
policies
and
legislation
that
the
Department
has
worked
on
in
recent
years
have
been

controversial
and
as
a
result
have
received
significant
public
attention.
For
instance,
the
recent
move
to

limit
the
size
of
sugary
beverages
in
certain
establishments
was
attacked
for
limiting
public
liberty,

among
other
criticism.
Policy
and
legislation
efforts
have
also
included
working
with
local
restaurants
to

promote
a
voluntary
reduction
in
sodium
use;
partnering
with
the
Department
of
Parks
and
Recreation
to

3

Summers
et
al,
Take
Care
New
York
2012,
7.

4

Caroline
Wallace,
phone
interview
with
author,
November
29,
2012.

5

Goldberg,
“New
York
City
health
commissioner,”
Reuters,
September
1,
2012.

14
make
sure
all
New
Yorkers
have
access
to
safe
places
to
engage
in
physical
activity;
and
increasing
the

availability
of
healthy
foods
in
school
cafeterias.

Prevention,
quality,
and
access
refers
to
specific
programs
designed
to
address
particular

impediments
to
a
healthy
lifestyle.
Most
of
these
actions
are
implemented
at
a
grassroots
level
in

communities
where
obesity
is
most
prevalent.
For
example,
the
City
is
working
with
corner
stores
in

certain
communities
to
encourage
them
to
place
water
more
prominently
than
sugary
drinks
on
their

shelves.
Faith-‐based
organizations
are
encouraged
to
stop
offering
sugary
drinks
in
their
social
gatherings

and
to
form
support
groups
for
people
struggling
with
obesity.
Nutrition
and
healthy
meal
preparation

orientation
is
provided
at
farmer’s
market,
and
a
coupon
system
has
been
developed
to
incentivize
the

consumption
of
fresh
produce.
According
to
Wallace,
“that’s
where
the
ground
zero
really
is
for
this

fight”
because
it
empowers
people
to
take
health
in
their
own
hands.
6

Public
communication
campaigns
are
designed
to
support
the
other
two
types
of
initiatives.

Wallace
considers
the
communication
piece
as
“air
cover
for
the
ground
troops.”
7

As
described
in
TCNY

2012,
the
campaigns
aim
to
inform,
educate,
and
engage
“New
Yorkers
to
improve
their
health
and
the

health
of
their
communities.”

Since
TCNY’s
implementation
began
in
2004,
the
overarching
messages
have
been
to
eat
healthy

by
preparing
healthy
foods
and
by
cutting
sugar,
junk
food,
and
sodium
intake;
to
shop
healthy;
and
to

increase
physical
activity
and
reduce
screen
time.
When
delivering
these
messages,
the
Department’s

communication
team
makes
sure
it
is
doing
so
in
a
way
that
acknowledges
that
staying
fit
and
eating

well
in
the
current
environment
is
challenging.
They
are
also
careful
to
avoid
stigmatizing
obese
and

overweight
individuals
and
pointing
fingers
or
blaming.
At
the
same
time
they
make
sure
they
are

choosing
the
most
appropriate
strategy
for
a
particular
topic.
For
instance,
some
campaigns
have
had
a

6

Caroline
Wallace,
phone
interview
with
author,
November
29,
2012.

7

Ibid.

15
positive
tone;
others
used
hard-‐hitting
messages;
some
elicited
disgust;
and
yet
others
set
a
gloomy

mood.
The
Department’s
approach
has
been
to
execute
temporary
campaigns
that
cover
specific
topics,

including
nutrition
data
education
(July
2008
in
response
to
new
menu
labeling
legislation),
sugary
drink

consumption
(2009
–
2011),
physical
activity
promotion
(2011
and
2012),
portion
sizes
increase

awareness
(2012),
and
sodium
intake
(2013).
The
following
analysis
of
select
campaigns
implemented
by

the
Department
in
recent
years
illustrates
such
considerations.

Nutrition
Data
Education
Campaign

8

In
the
summer
of
2008,
a
law
requiring
chain
restaurants
to
post
caloric
content
on
their
menus

took
effect
in
New
York
City.
While
this
was
an
important
step
for
the
fight
against
obesity,
it
would
only

have
a
positive
impact
if
people
understood
how
to
use
the
newly
available
information.
For
that

reason,
in
October
of
the
same
year,
the
Health
Department
launched
a
campaign
to
communicate
the

following
messages:
2,000
calories
per
day
is
all
most
adults
need,
fast-‐food
calories
can
add
up
quickly,

and
some
healthy-‐looking
foods
might
be
deceptive.
The
campaign
was
delivered
through
ads
in
the

subway
system
during
a
three-‐month
period.

Five
versions
of
the
ad
were
developed
(see
Appendix
1).
All
consistently
displayed
the
main

message,
“2,000
calories
a
day
is
all
most
adults
should
eat,”
and
a
badge
encouraging
people
to
read

labels.
Each
application
showed
a
different
meal:
hamburger
and
fries,
fried
chicken,
a
subway,
a

burrito,
or
a
muffin.

The
different
applications
allowed
the
team
to
use
several
messaging
strategies.
Two
of
the

applications,
the
hamburger
combo
and
the
subway,
compared
a
calorie-‐dense
meal
to
a
similar
but

smaller
alternative,
and
encouraged
the
viewer
to
“Choose
Less.
Weigh
Less.”
9

The
ad
sought
to

alleviate
the
audience’s
possible
fear
of
having
to
give
up
fast
foods
all
together,
and
offered
a
healthier

8

Scaperotti
and
Markt,
“Health
Department
Launches
Calorie
Education
Campaign,”
NYC
Health

Department,
October
6,
2008.

9

“Choose
Less.
Weigh
Less,”
Slogan
was
later
adopted
by
the
LA
Health
Department

16
option
that
did
not
require
significant
sacrifice.
In
addition,
the
subway
application
illustrated
that
even

restaurants
perceived
as
healthy
can
offer
high-‐calorie
options,
thus
emphasizing
the
importance
of

reading
labels.
The
burrito
and
fried
chicken
versions
sought
to
put
a
calorie-‐dense
meal
into

perspective
by
placing
it
below
the
2,000
calories
a
day
statement,
labeling
its
more
than
1,000
calorie

content,
and
asking,
“If
this
is
lunch,
is
there
room
for
dinner?”

The
tagline
was
a
key
element
in

reminding
people
that
calories
add
up,
and
that
they
need
to
be
aware
of
what
they
are
consuming

throughout
the
day.
The
ad
with
the
relatively
healthy-‐looking
apple
muffin
sought
to
raise
awareness

about
the
possibility
that
some
foods
that
look
healthy,
can
be
deceptive
in
terms
of
their
caloric

content.
The
tagline
“Healthy
snack?
Maybe
not.”
encouraged
the
audience
to
reflect
on
the
choices

they
are
making.

These
applications
might
be
considered
content-‐
and
message-‐dense
for
a
poster
or
outdoor

medium.
However,
because
they
were
displayed
inside
subway
cars,
people
had
more
time
to
read

them
and
reflect
on
the
messages.

Almost
four
years
later,
in
January
2012,
the
Department
launched
another
portion
control

campaign
on
the
subway
system
with
two
new,
yet
complementary
messages.
The
first
message
alerted

the
public
of
the
fact
that
portions
served
at
restaurants
have
grown
over
the
years.
The
posters

mentioned
this
in
writing
and
also
had
a
timeline
showing
how
portions
have
grown
over
time.
The

second
pointed
out
that
the
incidence
of
certain
health
conditions,
such
as
obesity
and
diabetes,
has

also
increased.
This
message
was
also
included
in
written
form
and
graphically
by
showing
a
dramatic,

black-‐and-‐white
image
of
a
person
suffering
from
such
conditions
(for
example,
a
diabetic
with
an

amputated
leg
and
an
overly
obese
woman
in
a
wheelchair).
According
to
Wallace
the
strategy
was
to

alert
people
of
possible
consequences
of
obesity
and
to
motivate
them
to
modify
their
behaviors.

The
two
messages
combined
implied
that
the
growth
in
portion
sizes
has
led
to
the
increased

incidence
of
obesity
and
diabetes.
Such
implication
was
reinforced
with
the
phrase
“Cut
your
portions.

17
Cut
your
risk.”
The
press
release
announcing
the
campaign
claimed
that
the
phrase
offered
a
clear

strategy
to
avoid
obesity.
10

However,
the
suggestion
to
“cut”
portions
is
vague
and
difficult
to

understand
and
adopt.
A
better
and
more
effective
option
would
have
been
a
direct
and
clear-‐cut

suggestion,
such
as
“order
the
smaller
size”
or
don’t
“supersize
your
order.”

The
campaign
was
controversial,
drawing
both
approval
and
criticism.
The
Center
for
Consumer

Freedom
stated
that,
through
the
ads,
“the
City
now
implies
that
larger
sodas
and
cheeseburgers
are

causing
amputations,
and
people
to
ride
obesity
scooters.
The
ads
ignore
decades
of
research
into
the

causes
of
obesity,
choosing
instead
to
confuse
correlation
with
causation.”
11

The
Food
and
Beverage

industry
had
a
similar
opinion.
The
Department
defended
the
campaign
saying
that
there
was
no

scientific
evidence
against
the
statements
in
the
advertisements
and
that
the
strategy
used
was
based

on
the
success
of
past
smoking-‐cessation
campaigns.
12

Sugar-‐Sweetened
Beverages
Campaign

Another
strategy
used
by
the
Health
Department
to
combat
obesity
through
public

communication
has
been
to
“flag
worst
offenders.”
13

In
2009,
the
Department
launched
a
campaign
to

raise
awareness
of
the
potential
health
consequences
of
drinking
sugar-‐sweetened
beverages,
which
are

not
the
only
products
contributing
to
obesity,
but
are
certainly
among
the
worst.

In
addition
to
being
a
worst
offender,
the
sugary
beverage
category
has
other
unique
qualities,

which
allow
for
more
effective
messaging.
Sugary
drinks
are
easy
to
identify,
simplifying
message
design

and
increasing
message
comprehension.
In
addition,
they
have
no
nutritional
value,
which
allows
the

message
to
be
clear
and
straightforward:
eliminate
them
from
your
diet
(as
opposed
to
reduce

10

Craig
and
Waldhorn,
“Health
Department
Launches
New
Ad
Campaign,”
NYC
Health
Department.

11

Young,
“NYC’s
Portion
Campaign
Continues,”
The
Portion
Teller,
February
10,
2012.

12

Ibid.

13

Caroline
Wallace,
phone
interview
with
author,
November
29,
2012.

18
consumption
or
consume
in
moderation).
Finally,
and
perhaps
most
significant,
there
is
a
free
substitute

for
sugary
drinks:
water
(as
well
as
a
non-‐free
substitute:
diet
soda).

In
contrast,
behavior
modification
campaigns
focused
on
food
categories
other
than
sugary

beverages
tend
to
require
more
complex
messaging.
For
instance,
bread
comes
in
a
variety
of
sizes,

brands,
and
fat/sugar/fiber-‐content
levels,
which
makes
it
difficult
to
explain
which
one
the
campaign
is

referring
to.
Breads
do
have
a
nutritional
value,
and
therefore
cannot
be
labeled
as
“bad”
nor
should
a

campaign
advice
to
stop
consuming
them.
Finally,
while
there
are
other
sources
of
carbohydrates,
they

are
often
more
expensive,
less
available,
and,
possibly,
less
tasty
than
bread.
In
other
words,
while
in

the
case
of
sugary
beverages
the
message
can
be
as
clear
as
“Don’t
drink
sugary
beverages,”
other

products
will
require
the
use
of
a
vague
message
such
as
“eat
less
bread”
or
“choose
healthy
breads,”

which
can
be
harder
for
the
audience
to
follow.

New
York
City
launched
the
first
sugary
beverage
campaign
in
August
2009,
and
produced

complementary
campaigns
the
following
two
years.
Each
year,
the
strategy
and
messaging
were

modified
and
new
campaign
material
was
produced.
The
purpose
was
to
build
upon
the
previous
year’s

efforts,
while
offering

something
fresh
with

new
information
that

would
capture
people’s

attention.
According
to

data
from
the
Health

Department’s
annual

telephone
health

Table 2. Table by: "Community Health Survey Trends." NYC Health
Department, 2012.
19
survey,
all
three
campaigns
were
successful.
As
shown
in
Table
2,
the
number
of
New
Yorkers
drinking

one
or
more
sugary
drinks
per
day
has
fallen
every
year
since
2008.
14

The
CDC’s
decision
to
air
one
of

New
York
City’s
YouTube
videos
on
national
television
is
another
indication
of
the
success
of
the

campaign.

“Pouring
on
the
Pounds”
-‐
In
August
2009,
the
Health
Department
launched
“Pouring
on
the
Pounds,”

the
first
campaign
of
the
series
(see
Appendix
2).
It
was
inspired
by
survey
results
indicating
that
a
large

percentage
of
New
Yorkers
were
consuming
one
or
more
sugary
beverages
per
day,
and
that
the

percentage
was
even
higher
among
low-‐income
populations.
15
,
16

The
main
message
of
the
campaign
was
that
sugary
drink
consumption
could
lead
to
weight
gain.

As
a
secondary
message,
it
suggested
substituting
such
drinks
with
water
or
other
un-‐sweetened

beverages.
The
strategy
used
was
to
elicit
a
sense
of
disgust
by
offering
a
metaphorical
scenario
in

which
a
person
was
drinking
a
bottled
beverage,
and
as
the
liquid
was
pouring,
it
turned
into
large
blobs

of
fat.
Posters
were
placed
in
New
York
City’s
subway
system
for
a
three-‐month
period
(September-‐
December),
and
in
December
a
YouTube
video
was
released.
17

Different
applications
were
made
to

include
sugary
drinks
other
than
soda,
such
as
juices,
sports
drinks,
frozen
coffee
drinks,
and
sweet
teas.

The
video
went
viral
reaching
more
than
one
million
views
(as
of
May
2013).
18

The
success
of
the

video
was
likely
a
result
of
the
combined
use
of
repulsive
imagery
and
satire
(fictional
scenario
and

14

“Community Health Survey Trends,” NYC Health Department, 2012.

15

Scaperotti
and
De
Leon,
“New
Campaign
Asks
New
Yorkers
if
They’re
‘Pouring
On
the
Pounds’,”
NYC

Health
Department,
August
31,
2009.

16

Scaperotti
and
De
Leon,
“Anti-‐Obesity
Poster
Inspires
a
Video
Sequel,”
NYC
Health
Department,
December

14,
2009.

17

NYC
Department
of
Health.
“Are
You
Pouring
on
the
Pounds?”
YouTube
Channel
video,
0:33.
Posted
2010.

18

It
is
important
to
consider
that
views
do
not
necessarily
mean
views
by
members
of
the
target
audience.

For
instance,
the
“Pouring
on
the
Pounds”
YouTube
statistics
indicate
that
the
top
audience
locations
are
the

United
States,
Canada
and
Australia.
The
public
data
does
not
provide
the
percentage
of
audience
members
per

location,
but
the
fact
that
other
countries
are
listed
is
evidence
that
not
all
viewers
were
from
New
York
City.

20
comical
background
music),
which
drove
viewers
to
share
it
and
comment
on
it.
In
addition,
the
video

captured
the
attention
of
media
and
other
influencers,
who
contributed
to
its
spreading.
Message

penetration
was
also
successful.
About
half
of
the
estimated
1.5
million
people
who
were
exposed
to

the
campaign
reported
that
they
were
drinking
less
sugary
beverages
after
seeing
the
ads.
19

“Pouring
on
the
Pounds”
Analysis
-‐
Despite
the
success
of
the
campaign,
there
is
always
room
for

improvement,
particularly
in
the
realm
of
motivating
behavior
change.
The
metaphor
offered
in
the

advertisements
may
be
too
complex
to
assimilate
considering
that,
in
reality,
the
conversion
into
fat

happens
beyond
the
viewer’s
sight
and
awareness
(the
drink
has
sugar
that
may
be
converted
into
fat

once
inside
the
body).
Similarly,
because
the
viewer
lacks
a
parameter
against
which
to
judge
the

amount
of
fat
pouring
out,
it
might
be
difficult
to
understand
how
it
would
affect
his
body.
Alternately,

the
amount
of
fat
could
be
perceived
as
an
exaggeration,
thus
affecting
the
validity
of
the
campaign
and

possibly
causing
the
viewer
to
dismiss
the
message.
Finally,
the
message
at
the
end
of
the
video
points

out
that
“one
can
of
soda
a
day
can
make
you
ten
pounds
fatter
a
year.”
Alerting
of
a
consequence
that

may
happen
in
the
long-‐term
can
be
a
risky
tactic,
as
it
allows
the
viewer
to
justify
delaying
the
adoption

of
the
behavior
(“I’ll
stop
drinking
tomorrow”
or
“just
one
won’t
do
any
harm”).

The
inclusion
of
sugary
beverages
other
than
soda,
on
the
other
hand,
was
an
important
tactic.

Even
though
such
drinks
also
contain
large
amounts
of
sugar,
they
are
usually
perceived
as
healthier
and

therefore
consumed
more
freely
than
colas.

Little
Sugar
Campaign
-‐
The
2010
campaign
depicted
the
amount
of
sugar
contained
in
sugary

beverages.
The
message
focused
on
the
content
of
the
beverage
(sugar),
rather
than
on
the
effect
that

drinking
it
can
have
on
the
body
(fat).
Otherwise,
the
graphic
design
was
similar
to
that
of
the
2009

19

Miller
and
Waldhorn,
“CDC
Launches
National
Campaign
Using
NYC
Spot,”
NYC
Health
Department,
May

1,
2012.

21
campaign:
both
showed
something
being
poured
from
top
to
bottom
and
a
striking
message
was

written
across
the
middle
of
the
image.
The
tone,
however,
was
different.
Rather
than
disgust,
the
2010

campaign
sought
to
provoke
shock
by
including
a
concrete
and
measurable
fact
that
most
people

weren’t
aware
of.
This
made
it
easier
to
grasp
and
more
likely
to
be
trusted.

20
,
21
,
22

The
sugar
packet
campaign
featured
print
advertisements
in
the
subway
system
from
August
to

October
and
a
YouTube
video,
which
was
released
in
October.
An
interesting
difference
between
the

applications
designed
for
each
medium
was
the
number
of
sugar
packets
they
referred
to:
the
print
ads

mentioned
26
packets,
while
the
video
said
16.
Neither
of
these
used
an
incorrect
statistic.
Rather,
the

print
ad
referred
to
a
32oz
serving
of
soda
(shown
in
a
restaurant
cup)
and
the
video
referred
to
a
20oz

serving
(shown
in
a
bottle).
The
variation,
which
was
probably
not
necessary,
may
have
caused

confusion
and
or
doubt
on
the
message’s
validity.

A
different
application
of
the
campaign
was
design
to
target
parents.
The
advertisement
used

what
could
be
considered
a
subtle
amount
of
shame
by
posing
the
question
“You
wouldn’t
let
your

children
eat
26
packs
of
sugar.
Why
are
you
letting
them
drink
it?”
However,
most
parents
weren’t

previously
aware
that
the
sugar
content
in
beverages
was
so
high.
Therefore,
they
could
use
ignorance

to
justify
their
allowance,
and,
rather
than
feel
shame,
take
the
message
as
a
welcomed
piece
of
advice.

Little
Sugar
Campaign
Analysis
-‐
The
sugar
packet
campaign
lacked
the
graphical
impact
of
the
former

one,
which
could
explain
the
lower
number
of
video
views
(about
315,000
by
May
2013,
or
one
third
of

the
views
on
the
2009
video).
On
the
other
hand,
while
the
actual
applications
of
the
campaign
were

20

Craig
and
Tobin,
“New
Effort
to
Wean
New
Yorkers
from
Sugary
Beverages,”
NYC
Health
Department,

August
2,
2010.

21

Miller
and
Waldhorn,
“CDC
Launches
National
Campaign
Using
NYC
Spot,”
NYC
Health
Department,
May

1,
2012.

22

Craig
and
Tobin,
“New
Anti-‐Obesity
Video
Shows
What
it
Means
to
Drink
Sugar,”
NYC
Health
Department,

October
5,
2010.

22
most
likely
not
commented
on,
the
statistic
“26
packs
of
sugar
in
one
serving
of
soda”
was
probably

repeated
more
often
and
for
a
longer
time
after
the
campaign
ended.

Big
Sugar
Campaign
-‐
In
2011,
the
Health
Department
developed
a
third
sugary
beverage
campaign,
23

which
built
on
the
previous
two
and
introduced
new
concepts.
It
shed
light
on
the
fact
that
people
drink

more
than
one
sugary
drink
per
day
and,
therefore,
consume
more
than
the
equivalent
of
26
packets
of

sugar.
The
advertisements
illustrated
a
plausible
scenario
in
which
a
person
consumed
four
or
six
sugary

drinks
in
one
day,
and
calculated
the
total
amount
of
packets
consumed.

Additionally,
the
campaign
alerted
consumers
of
the
health
consequences
that
the
extra
calories

in
sugary
drinks
can
cause.
In
the
print
application,
it
mentions
them
in
small
type,
which
could
be
easily

overlooked.
The
YouTube
video,
on
the
other
hand,
used
the
hard-‐hitting
strategy
that
had
been

effective
in
the
Department’s
2009
anti-‐smoking
campaign.
The
video
showed
daunting
and
unpleasant

images
of
people
suffering
from
health
complications
caused
by
obesity.

Finally,
for
the
first
time,
the
advertisements
offered
a
helpline
for
people
struggling
with
obesity.

This
immediate
and
easy
call-‐to-‐action
(as
opposed
to
the
more
difficult
call
to
stop
consuming
sugary

drinks),
was
a
less
intimidating
way
for
individuals
to
begin
their
behavior-‐change
journey.
24

As
did
the
previous
campaigns,
the
2011
effort
included
print
ads
on
the
subway
system
(from

January
to
March)
and
a
YouTube
video.
In
addition,
the
video
was
made
into
a
television
spot
that
aired

during
three
months.
As
of
May
2013,
the
Big
Sugar
video
had
330
million
views
on
YouTube.
25

23

Craig
and
Tobin,
“New
TV
Spot
Shows
How
a
Day’s
Worth
of
Sugary
Drinks
Adds
Up,”
NYC
Health

Department,
January
31,
2011.

24

The
2010
campaign
offered
a
URL
at
which
individuals
could
find
more
information.
However,
this

presented
two
problems:
1-‐
it
was
long
and
difficult
to
remember
and
2-‐
the
target
audience
(lower-‐income,
less-‐
educated)
was
not
likely
to
use
an
online
source
to
gather
information.

25

NYC
Health
Department,
“Do
You
Drink
93
Sugar
Packets
a
Day?”
NYC
Health
Department
YouTube

Channel,
Posted
2011.
The
number
of
views
does
not
include
views
on
Facebook,
nor
on
websites.
This
is
true
for

all
such
data
in
this
document.

23
Big
Sugar
Campaign
Analysis
-‐
Waiting
to
introduce
messages
about
health
consequences
until
the
third

campaign
of
the
series,
once
the
message
about
weight
gain
had
been
diffused
prominently,
was
a
good

strategy.
This
gave
the
audience
time
to
assimilate
the
message
about
the
weight
gain
that
these
drinks

can
lead
to,
before
taking
in
the
hard-‐hitting
messages
about
the
more
serious
health
consequences.

“Walk
off
the
Pounds”
-‐
In
October
2011,
the
Health
Department
posted
two
new
YouTube
videos.
The

first
featured
the
same
character
and
music
used
in
the
past
three
sugary
drinks
videos.
It
showed
the

man
walking
from
Union
Square
to
Brooklyn
(three
miles)
and
explained
that
it
would
take
a
walk
of
that

length
to
burn
the
amount
of
calories
in
a
20oz
soda.
Once
again,
a
little
known
and
surprising
fact
was

used
to
shock
and,
therefore,
make
the
message
memorable.
The
use
of
familiar
locations
to
illustrate

the
distance,
rather
than
a
simple
number,
was
important
to
help
New
Yorkers
better
grasp
the

message.

While
the
video
was
likely
effective
in
transmitting
the
intended
message
to
those
who
saw
it,
it

has
attracted
significantly
fewer
views
than
previous
ones.
As
of
May
2013,
it
had
been
viewed
about

50,000
times.
Possible
explanations
are
that
the
Health
Department’s
efforts
to
push
it
out
were
not
as

persistent
as
in
the
past;
that
there
was
less
budget
for
promotion;
that
it
did
not
garner
the
same

amount
of
press
coverage;
that
the
audience
was
experiencing
message
fatigue;
or
that
the
production

lacked
elements
that
encouraged
sharing.

“50
Pounds”-‐
The
second
October
2011
video,
which
targeted
parents,
used
a
combination
of
shame,

shock,
and
hard-‐hits.
The
shame
was
evoked
through
questioning
parents
for
letting
their
children
drink

so
much
sugar.
The
shock
came
from
a
new
little
known
and
surprising
fact.
The
hard-‐hitting
images
of

possible
health
consequences
of
obesity
were
reintroduced
to
reflect
the
importance
of
the
message.

This
video
was
the
first
to
use
the
term
obesity
epidemic.

24

Analysis
of
the
Three-‐Year
Sugary
Beverage
Effort
2009
to
2011-‐
The
strongest
quality
of
the
three-‐year

initiative
was
precisely
the
multi-‐campaign
approach.
The
timing
of
the
long-‐term
effort
allowed
for

each
campaign
to
build
upon
the
previous
one,
without
overwhelming
the
audience
with
too
much

information
at
once.
By
spacing
out
the
campaigns,
the
Department
allowed
the
audience
time
to

absorb
each
key
message
before
getting
bombarded
with
the
next.
At
the
same
time,
maintaining
the

overall
theme
of
the
communication,
sugar
reduction,
during
an
extended
period
of
time
provided
a

continuous
stream
of
reinforcement
and
reminders
to
those
going
through
the
behavior
modification

process.

Sodium
Reduction
Campaign

New
York
City
has
led
local
governments
across
the
country
since
2008
to
urge
the
food
industry

to
voluntarily
reduce
sodium
content
in
their
products.
In
November
2010,
the
Health
Department

launched
a
two-‐month
public
awareness
campaign
in
the
subway
system
to
complement
such
efforts.
In

the
press
release
announcing
its
launch,
Dr.
Farley
explained:

This
campaign
is
geared
toward
educating
consumers
to
pay
attention
to
the
amount
of
salt
in
the

foods
they
buy.
It
is
our
hope
that
by
increasing
the
public’s
understanding
of
how
much
salt
is
in

food,
we
can
help
consumers
become
better
equipped
to
read
labels
and
choose
wisely.

Combined
with
our
national
effort
to
get
industry
to
gradually
reduce
the
excess
salt
they
put
in

our
packaged
foods,
consumers
will
have
a
greater
choice
of
healthier
products
and
ultimately
be

able
to
succeed
in
reducing
their
risk
of
heart
disease
and
stroke.
26

The
advertisements
showed
a
packaged
food
product
(a
can
of
soup,
a
loaf
of
bread,
or
a
frozen

meal)
with
vast
amounts
of
salt
flowing
out
of
it.
Each
application
stated
that
many
packaged
food
items

contain
more
salt
than
one
would
think
and
that
too
much
salt
can
cause
heart
attacks
and
strokes.
In

smaller
print,
the
viewer
is
urged
to
compare
labels
and
choose
products
with
less
sodium.
However,

26

Craig
and
Tobin,
“New
Campaign
Urges
New
Yorkers
to
Cut
the
Salt,”
NYC
Health
Department,
November

8,
2010.

25
the
advertisements
assumed
that
the
audience
knew
how
to
read
food
labels
for
sodium
content
and

did
not
provide
guidance.

In
April
2013,
the
Department
launched
an
improved
version
of
the
sodium
reduction
campaign.

The
main
message
in
the
new
posters
was
the
suggestion
to
compare
labels
and
choose
less
sodium.
A

more
significant
improvement
was
that
the
posters
showed
the
amplified
nutrition
label
of
two
similar

packaged
food
products
and
pointed
out
where
the
sodium
content
could
be
found.
In
addition,
the

new
posters
addressed
the
common
misconception
that
the
table
saltshaker
is
the
source
of
excess
salt

consumed.
The
message
was
meant
to
alert
individuals
who
falsely
thought
they
were
watching
their

sodium
intake
by
using
the
saltshaker
less
often.
The
Health
Department
was
successful
in
reusing
the

effective
elements
of
the
first
wave
of
the
campaign,
correcting
its
shortfalls,
and
producing
an

improved
version
in
2013.

Media
Tactics

According
to
Wallace,
the
choice
of
media
channel
for
each
anti-‐obesity
campaign
is
decided
by

the
Health
Department’s
Bureau
of
Communications
based,
in
large
part,
on
the
available
budget.
In

terms
of
paid
media,
the
Bureau
usually
opts
for
posters
inside
subway
cars
because
it
is
the
medium

that
offers
the
“most
bang
for
our
buck,”
Wallace
explains.
Since
most
New
Yorkers
ride
the
train,
the

number
of
people
reached
and
the
number
of
impressions
each
poster
gets
are
high.
Other
paid
media

the
Bureau
has
used
in
past
efforts
are:
free
circulation
newspaper,
which
offer
high
circulation
for
a

moderate
price;
radio
ads,
which
are
often
complemented
with
free
promotion
by
the
DJs;
and,
in

recent
campaigns,
paid
digital
and
social
media
ads.

In
addition,
the
Department
issues
informational
materials,
conducts
media
outreach,
and
uses

social
media.
Informational
materials
are
made
available
in
print
and
published
online,
and
usually

includes
versions
in
more
than
one
language.
Media
outreach
usually
includes
issuing
a
press
release

and
holding
a
press
conference.
According
to
Wallace,
social
media
has
been
very
valuable,
particularly

26
in
campaigns
with
limited
budgets.
The
Department
has
experimented
with
Twitter,
Facebook,
YouTube,

Pinterest,
and,
most
recently,
Tumblr.
Wallace
explains
that
they
want
“to
get
to
all
the
different
places

where
people
are,
and
also
have
different
conversations.”
She
points
out
that
because
platforms
like

Facebook
let
people
talk
to
each
other,
they
can
help
her
team
take
a
temperature
of
the
audiences’

sentiment
with
regards
to
a
certain
topic
or
campaign.

Evaluation

Recent
data
indicates
signs
of
a
reversal
in
New
York
City’s
obesity
epidemic.
A
study
using
weight

and
height
data
measured
by
physical
education
elementary
teachers
indicated
a
5.5%
decline
in

childhood
obesity
in
New
York
City,
between
2007
and
2011.
27

In
addition,
a
2012
study
published
in
the

medical
journal
Lancet,
shows
that
“New
York
City
far
outpaced
the
rest
of
the
nation
in
gains
in
life

expectancy.
Some
success
is
due
to
the
city
preventing
and
controlling
AIDS,
but
more
than
60
percent

of
the
increase
in
life
expectancy
since
2000
can
be
attributed
to
reductions
in
heart
disease,
cancer,

diabetes
and
stroke,
the
report
said.”
28

While
the
reduction
in
such
conditions

results,
in
large
part,
from
a
decrease
in

smoking
rates
among
New
Yorkers,
the

adoption
of
other
healthy
behaviors

may
also
be
a
contributing
factor.

As
pointed
out
before,
general

audience
communication
campaigns

are
only
part
of
a
multi-‐pronged

approach
to
fight
the
obesity
epidemic.

27

Tavernise,
“Obesity
in
Young
Is
Seen
as
Falling
in
Several
Cities,”
The
New
York
Times,
December
12,
2012.

28

Goldberg,
“New
York
City
health
commissioner,”
Reuters,
September
1,
2012.

Table 3. Table by: Marcello et al. Take Care New York
2012: Tracking the City's Progress, 2009-2010.
27
Therefore,
“it
is
hard
to
measure
what
kind
of
actual
health
effects
can
come
from
this
piece
of
the

work.
But
the
hope
is
that
it
contributes
to
a
bigger
fight,”
Wallace
explains.
The
Health
Department

uses
several
tools
to
measure
the
impact
of
its
efforts,
including
pre
and
post
campaign
research
and

analysis
through
street
intercept
surveys,
public
opinion
polls,
retail
audits,
focus
groups,
and
campaign

evaluation
surveys.

In
2010,
the
Department
published
a
progress
report
on
TCNY
targets,
which
indicated
that
three

out
of
the
four
indicators
used
to
measure
progress
in
the
“Promote
Physical
Activity
and
Healthy

Eating”
key
area
had
moved
in
the
desired
direction.
The
findings,
shown
in
Table
3,
are
encouraging,

however,
they
must
be
read
with
caution.
The
four
indicators
use
data
from
the
annual
New
York
City

Community
Health
Survey
(CHS)
and
are
likely
to
reflect
some
degree
of
social
desirability
response
bias.

Nevertheless,
while
the
results
cannot
be
used
as
exact
measures
of
behavior
adoption,
they
can
be

assumed
to
indicate
a
positive
trend.
Within
the
group
that
makes
up
the
increased
percentage,
it
is

likely
that
some
of
the
respondents
did
adopt
healthy
behaviors
that
the
campaign
encouraged;
others

have
a
desire
to
adopt
them;
and
the
rest
at
least
know
that
they
should.
While
the
latter
two
groups

might
not
contribute
to
solving
the
obesity
epidemic
in
the
short
run,
their
answers
do
indicate
that
the

communication
messages
are
getting
through
and
that
objectives
to
raise
awareness
levels
are
being

met.

Challenges
Encountered
and
Lessons
Learned

According
to
Wallace,
the
Department’s
successes
did
not
come
without
obstacles
in
the
design

and
implementation
process.
New
York
City
is
one
of
the
most
expensive
media
markets
in
the
country.

Most
efforts
were
met
by
budgetary
constraint
and
the
Department
could
not
plan
to
use
mainstream

media
such
as
television.
This
has
challenged
the
team
to
find
the
most
cost-‐effective
media,
such
as
in-‐
train
subway
posters,
and
to
seek
collaboration
from
the
media,
such
as
radio
stations.

28
In
addition,
the
Health
Department
has
faced
resistance
from
the
food
and
beverage
industry
and

from
other
groups.
The
biggest
challenge
posed
by
the
industry
is
the
amount
of
money
that
it
spends

on
promoting
its
products
with
messages
that,
often
times,
oppose
the
ones
the
Department
is
trying
to

promote.

Other
groups
have
attacked
the
Department’s
efforts
more
directly.
For
instance,
size
acceptance

groups
condemned
the
January
2012
“Cut
your
portions.
Cut
your
risk.”
campaign
for
unsuccessfully

using
scare
tactics
and
shame.
While
outcry
from
such
groups
can
be
expected,
criticism
can
also
come

from
the
least
likely
places.
For
example,
the
obese
model
in
the
amputee
application
of
the
same

campaign
told
journalists
that
the
poster
had
shocked
him
because
he
is
not
an
amputee,
and
the
image

was
photo-‐shopped
without
his
consent.
29

His
comments
resulted
in
considerable
media
coverage
and

public
criticism,
calling
the
Department’s
credibility
into
question.
Credibility
and
reputation
are
one
of

the
most
important
assets
public
health
communicators
have.
If
people
stop
trusting
them,
no
amount

of
funding
and
messaging
will
successfully
encourage
behavior
modification.
In
the
case
of
the
amputee,

the
negative
coverage
resulted
in
negative
sentiment
among
New
Yorkers,
and
provided
a
new
angle
for

opponents
to
attack.

Another
challenge
in
implementing
the
campaigns
often
resulted
from
the
extensive
scrutiny

and
approvals
required
within
the
Department,
as
well
as
from
the
Mayor’s
office.
While
this
was

factored
into
the
planning
timelines,
the
need
to
wait
for
comments
from
various
sources
increases
the

chances
for
unexpected
bottlenecks.
In
addition,
Wallace
explains
that
because
the
Department
is
also

in
charge
of
emergency
response
communication
efforts,
these
can
take
precedence
and
delay
the

implementation
of
campaigns
that
are
less
time-‐sensitive,
as
are
anti-‐obesity
campaigns.

As
have
other
organizations
working
on
anti-‐obesity
campaigns,
the
Health
Department
has

struggled
with
finding
the
“right”
message
and
approach.
Wallace
points
out
that,
if
they
“just
tell

29

AP,
“Overweight
Man
Speaks
Out
Against
Photoshopped
Image,”
CBS
New
York,
January
30,
2012.

29
people
‘eat
more
fruits
and
vegetables,’
it’s
a
tough
sell.”
30

The
messages
that
need
to
be
delivered
tend

to
be
“bad
news…and
there’s
always
a
challenge
to
make
that
compelling
and
to
giving
people
a
reason

to
care
and
to
pay
attention.”
31

The
Department
has
found
that
campaigns
that
evoke
a
sense
of
disgust

are
more
likely
to
motivate
behavior
change
than
campaigns
with
inspirational
messages.
32

With
regards

to
models
for
advertisements,
she
explains
that
choosing
ones
who
look
like
people
the
viewers
know

can
be
distracting,
can
make
people
upset,
and
can
discourage
behavior
adoption.
Wallace
admits
that

she
doesn’t
have
the
recipe
to
find
the
ideal
messages,
however
she
stresses
on
the
importance
of

providing
accurate
information
to
maintain
credibility
among
the
public.
Going
Forward

The
timeline
for
the
CDC
grant
to
New
York
City
for
communication-‐related
anti-‐obesity
efforts

ended
in
2012.
The
City
plans
to
use
money
from
other
sources
to
continue
using
public
health

education
as
one
way
to
reduce
obesity.
In
2013,
funding
came
from
the
City’s
tax
money
and
state,

federal,
and
foundation
grants.
The
Health
Department
engages
in
ongoing
fundraising
and
plans
to

continue
with
the
programs
set
forth
in
TCNY.

30

Caroline
Wallace,
phone
interview
with
author,
November
29,
2012.

31

Ibid.

32

Ibid.

30

CHAPTER
FIVE:
Los
Angeles
County
Department
of
Public
Health

The
rate
of
obesity
in
Los

Angeles
County
is
estimated
to

be
24%
among
adults
and
20%

among
youth.
1

Even
though
the

percentage
is
lower
than
the

national
average,
the
fact
that

the
obesity
rate
has
increased

more
than
75%
in
the
last
15

years
is
alarming.
In
addition,

the
disparities
in
obesity
rates

between
communities
in
Los

Angeles
County
are
significant.
In

fact,
according
to
the
Los

Angeles
County
Department
of

Public
Health
(LACDPH),
“within

a
10-‐mile
radius
the
childhood

obesity
rate
can
be
4%
in
one

neighborhood
and
34%
in

another.”
2

At
its
current
rate,

1

“Community
Profile:
Los
Angeles
County,”
CDC,
last
modified
March
4,
2013.
2

External
Relations
and
Communications,
“Los
Angeles
County
Department
of
Public
Health
2010-‐2011

Annual
Report,”
LACDPH,
April
2012.

Figure 2. Source: 2011 Los Angeles County Health Survey in
LACDPH Flickr.com page, October 2012.

Figure 3. Source: 2011 Los Angeles County Health Survey in
LACDPH Flickr.com page, October 2012.
31
obesity
represents
an
annual
cost
to
the
county
of
$6
billion
in
health
care
cost
and
lost
productivity.
3

The
mission
of
the
LACDPH
is
“to
protect
health,
prevent
disease,
and
promote
the
health
and

well-‐being
of
all
persons
in
Los
Angeles
County,”
and
is,
therefore,
the
entity
responsible
for
addressing

the
obesity
epidemic
in
the
area.
In
March
2010,
the
county
received
a
$32.1
million
grant
from
the
CDC

to
implement
a
two-‐year
program
focused
on
obesity
reduction
(US$
15.9
million)
and
tobacco

prevention
($16.2
million).
45

The
LACDPH
used
the
money
allocated
to
obesity
prevention
to
fund
a
new

program
called
RENEW
LA
County,
which
aimed
to
improve
nutrition
and
increase
physical
activity

among
Los
Angeles
County
residents.

RENEW
included
important
social
marketing
and
public
education
campaigns,
which
will
be
the

focus
of
this
chapter.
However,
most
of
the
funding
from
the
CDC
was
allocated
to
other
RENEW

programs
including
initiatives
in
the
areas
of
policy,
infrastructure,
and
access
to
healthy
food.
With
a

limited
budget,
the
communications
team
was
tasked
with
complementing
the
rest
of
the
programs
by

reinforcing
the
need
to
adopt
healthier
behaviors.

Through
RENEW,
the
LACDPH
supported
legislation
and
policy
initiatives
that
fostered
healthy

lifestyles.
The
Department
had
successfully
engaged
in
similar
efforts
prior
to
RENEW
when
California

became
the
first
state
to
require
restaurant
chains
to
label
menus
with
caloric
information.
6

Within

RENEW
such
efforts
included:

o Supporting
the
approval
of
the
Voluntary
Artificial
Trans
Fat
Reduction
Program
for
restaurants.

o Contributing
to
the
second
phase
of
the
restaurant
menu
labeling
legislation.

o Revising
the
county’s
vending
machine
policy
to
limit
the
sodium
content
in
snacks
and
the

number
of
calories
in
beverages.

3

“L.A.
County
launches
public
health
campaign
on
portion
control,”
Los
Angeles
Times,
October
4,
2012.

4

“LACDPH
2010-‐2011
Annual
Report,”
LACDPH,
April
2012.

5

“Overweight
and
Obesity,”
CDC,
last
updated,
June
4,
2012.

6

MacVean,
“Menu
labeling
law
takes
effect,”
Los
Angeles
Times,
July
1,
2009.

32
o Working
with
the
county’s
Department
of
Health
Services
to
improve
food
and
beverage
options

offered
at
health
facilities.

o Partnering
with
the
Department
of
Regional
Planning
to
develop
a
healthy
design
model

ordinance.

RENEW’s
infrastructure
initiatives
aimed
to
facilitate
and
encourage
physical
activity.
They

included
supporting
the
expansion
of
bike
paths,
designing
pedestrian-‐friendly
initiatives,
and
adopting

the
“Complete
Streets”
7

policy,
which
aims
to
make
streets
friendlier
for
users
of
all
types
of

transportation.
In
addition,
schools
and
communities
were
encouraged
to
establish
joint-‐use
policies,

where
campus
recreational
facilities
would
be
made
available
to
community
members.

Access
to
healthy
foods
and
beverages
was
improved
by
helping
corner
storeowners,
in

communities
with
high
rates
of
obesity,
offer
more
healthy
options
and
implement
product
placement

and
marketing
strategies
to
encourage
their
sale.
In
addition,
RENEW
included
interventions
for
specific

populations
including
county
school
students,
pre-‐school
children,
and
breastfeeding
mothers.

In
September
2011,
LACDPH
received
a
new
grant
from
the
CDC
to
build
upon
the

accomplishments
of
RENEW
and
the
tobacco
prevention
program,
TRUST.
The
Department
received

$9.85
million
for
the
first
year
of
the
new
Choose
Health
LA
Program,
which
addressed
five
strategic

areas:
1)
tobacco-‐free
living,
2)
active
living
and
healthy
eating,
3)
high-‐impact
evidence-‐based
clinical

and
other
preventive
services,
4)
social
and
emotional
wellness,
and
5)
healthy
and
safe
physical

environments.
8

As
had
been
done
throughout
the
implementation
of
RENEW,
Choose
Health
LA
programs
were

complemented
with
anti-‐obesity
public
health
campaigns.
Between
2011
and
2012,
the
Department’s

anti-‐obesity
communication
initiatives
focused
on
three
aspects
of
healthy
eating:
sodium
content

7

“National
Complete
Streets
Coalition,”
Smart
Growth
America,
2010.
Accessed
May
2013.

8

Fielding,
“Community
Transformation
Grant,”
LACDPH,
October
12,
2011.

33
(March
2011),
sugary
drinks
(October
2011),
and
portion-‐control
(October
2012).
All
three
campaigns

targeted
the
Angeleno
populations
with
the
highest
incidence
of
obesity
and
used
varying
combinations

of
paid,
social,
and
earned
media.

Matthew
LeVeque,
Senior
Vice
President
of
Rogers
Finn
Partners
and
communications

consultant
for
LACDPH,
spearheaded
the
three
campaigns.
He
explains
that
the
research
his
team

conducted
to
understand
the
target
audience
was
a
crucial
part
of
their
efforts.
They
began
by
using

health
data
to
identify
their
target
population.
Then,
they
sought
out
to
learn
about
each
population

segment’s
cultures,
preferred
language,
and
perceptions
of
obesity
and
its
associated
health

complications.
The
research
provided
important
insights
and
challenges.
“For
example,
Latinos
see

diabetes
as
an
inevitable
part
of
growing
old,”
explains
Leveque.

“Salt
Shocker”
Video
Series

The
March
2011
“Salt
Shocker”
series
responded
to
data
indicating
that
the
average
county

resident
was
consuming
more
than
twice
the
recommended
sodium
consumption,
and
it
accompanied

sodium-‐reduction
efforts
in
food-‐service
venues
and
school
cafeterias.
9

The
campaign
consisted
of
a

series
of
five
videos
designed
to
raise
awareness
about
the
high
levels
of
sodium
in
certain
foods
and
to

educate
on
the
recommended
amount
the
average
American
should
consume.
The
videos
sought
to

motivate
viewers
to
monitor
and
reduce
their
personal
intake,
by
“shocking”
them
with
a
comparison
of

the
recommended
daily
consumption
and
the
unexpected
amount
of
sodium
in
certain
foods.
The

videos
also
shed
light
on
the
fact
that
the
average
American
eats
more
than
the
recommended
daily

amount
of
sodium
and
offered
advice
on
how
to
stay
on
track.

Despite
the
importance
of
the
message
it
delivered,
the
budget
for
production
and
promotion
of

the
series
was
minimal.
In
addition,
in
contrast
with
New
York
City’s
initiatives,
which
lasted
up
to
three

years,
the
sodium
reduction
series
was
scheduled
to
run
for
only
three
weeks.
Therefore,
LeVeque’s

9

Division
for
Heart
Disease
and
Stroke
Prevention,
“Reducing
Sodium
in
Los
Angeles
County,”
CDC,
Last

updated
March
25,
2011.

34
strategy
was
to
use
search
engine
optimization
tactics
to
create
the
largest
digital
footprint
possible
in

order
to
maximize
reach
and
message
repetition
over
a
longer
period
of
time.
The
five
salt-‐shocker

videos
lived
on
the
Choose
Health
LA
YouTube
Channel,
were
embedded
on
the
program’s
website,
and

were
promoted
exclusively
through
social
media,
particularly
Facebook
and
Twitter.
As
a
strategy
to

direct
more
public
attention
to
the
videos,
the
campaign
was
launched
during
World
Salt
Awareness

Week.

Despite
the
limited
channels
of
distribution,
the
salt
shocker
videos
were
very
successful.
By

January
2013,
the
number
of
views
for
each
of
the
five
videos
ranged
from
675
to
5,480.
In
addition,
the

campaign
received
five
national
awards
for
its
innovative
messaging
10

and
garnered
considerable
media

attention.

In
an
effort
to
make
the
videos
relatable,
the
foods
featured
were
chosen
based
on
their

popularity
with
target
populations.
In
addition,
the
products
chosen
were
either
peripheral
ingredients

that
consumers
might
not
even
think
about,
such
as
ketchup
and
breadcrumbs,
or
that
are
generally

though
of
as
healthy,
such
as
cottage
cheese
and
canned
vegetables.
Shedding
light
on
the
excess

amounts
of
sodium
in
these
foods
would
produce
greater
shock
than
had
the
videos
used
foods

generally
thought
of
as
unhealthy
or
as
sodium-‐rich,
such
as
potato
chips.

The
inclusion
of
easy-‐to-‐follow
tips
in
the
videos
was
encouraging
to
viewers
and
increased
the

likelihood
that
they
would,
at
least,
attempt
to
modify
their
behavior.
The
video
ended
with
a
call-‐to-‐
action
to
visit
the
Department’s
social
media
channels
to
obtain
more
information.
This
gave
the
viewer

an
easy
and
accessible
first
step
to
take,
and
provided
an
opportunity
to
reinforce
the
message.

“Salt
Shocker”
Video
Series
Analysis-‐
The
language
used
on
the
videos
was
somewhat
dry,
emulating
a

lecture
and
possibly
making
viewers
to
show
interest
in
the
message.
Another
area
for
improvement
is

10

Ibid.

35
the
video’s
length
(each
is
more
than
a
minute
long)
and
timing.
The
shock
isn’t
introduced
until
about

15
seconds
into
the
video,
thereby
risking
losing
the
viewer’s
attention.

Another
limitation
of
the
campaign
is
that
the
videos
fail
to
explain
the
possible
consequences

of
excess
sodium
consumption,
which
could
have
been
a
motivating
factor
for
viewers.
However,
the

videos
do
clearly
state
that
excessive
sodium
intake
is
unhealthy,
which,
at
least,
puts
the
topic
in
the

audience’s
mind.
To
that
end,
when
the
campaign
was
launched,
Paul
Simon,
MD,
MPH,
Director
of

Public
Health
Chronic
Disease
and
Injury
Prevention,
said,
"the
launch
of
this
video
series
is
a
first
step
in

helping
residents
of
LA
County
go
from
salt-‐shocked
to
sodium-‐smart,
empowering
them
with

knowledge
and
resources
to
take
greater
control
of
their
health."
11

Undoubtedly,
a
follow-‐up
campaign

with
appropriate
resources
and
a
longer
duration
would
be
a
valuable
next
step.

“Sugar-‐Loaded
Drinks”
Campaign

In
response
to
evidence
that
sugary
drink
consumption
was
a
major
contributor
to
the
county’s

obesity
epidemic,
particularly
among
children,
the
LACDPH
launched
a
campaign
focused
on
such

beverages
In
October
2011.
The
communications
team
began
by
conducting
research
regarding
effective

messaging.
With
the
help
of
the
CDC,
they
obtained
information
and
evaluation
results
gathered
by

teams
in
other
cities,
including
Boston,
New
York
and
Seattle,
who
had
implemented
campaigns

addressing
the
topic.
The
access
to
such
secondary
research
avoided
additional
expenses
and
was
used

to
inform
the
initial
message
design.
In
addition,
the
LACDPH
conducted
six
focus
groups
with
members

of
the
target
audience.
These
were
used
to
test
messages
and
obtain
additional
insights.

The
resulting
“Sugar-‐Loaded
Drinks”
campaign
sought
to
inform
county
residents
of
the
high

sugar
content
in
many
popular
drinks,
to
shed
light
on
the
direct
impact
that
these
drinks
can
have
on

excess
weight,
and
to
suggest
healthier
alternative
drinks.
With
this
information,
residents
would
be

11

RENEW
LA,
“LA
County
Urges
Residents
to
Shake
the
Salt
Habit,”

LACDPH,
March
21,
2011.

36
able
to
make
informed
decisions
regarding
their
personal
and
family’s
consumption
of
sodas,
sports
and

energy
drinks,
and
other
sugar-‐loaded
beverages.
12

The
campaign
included
the
launch
of
the
information
Website
ChooseHealthLA.com,
extensive

use
of
social
media
channels,
posters,
flyers,
and
paid
advertisement
on
public
transportation,
and
the

production
of
shareable
online
videos
(hosted
on
Facebook
and
on
the
Website).
In
addition,
an

interactive
sugar
calculator
was
launched
on
ChooseHealthLA.com
to
offer
residents
a
tool
to
gauge

their
personal
sugar
consumption
and
make
behavioral
changes
accordingly.

To
make
up
for
the
limited
budget
allowed
for
paid
advertisement,
LACDPH
sought
alternative

strategies
to
increase
the
reach
of
the
campaign.
All
multimedia
elements
were
designed
for
easy

sharing
through
social
media,
which
resulted
in
the
video
attracting
more
than
60,000
views
and
the

sugar
calculator
being
used
more
than
25,000
times.
13

In
addition,
grassroots
approaches
were
used
to

distribute
the
material
through
schools
and
community
groups.
14

The
campaign’s
materials
provide
a
visual
representation
of
the
amount
of
sugar
in
particular

drinks
in
a
way
that
was
shocking
and
easy
to
grasp.
A
drink
was
shown
pouring
into
a
glass
and,
as
it

poured,
the
liquid
turned
into
sugar
packets.
The
material
asks
the
viewer,
“You
wouldn’t
eat

“[number]”
packs
of
sugar.
Why
are
you
drinking
them?”

The
trivia-‐style
fact
(number
of
sugar
packs
per
drink),
followed
by
the
questioning
of
the

behavior
is
meant
to
provoke
curiosity,
shock
and
possibly
disgust.
The
curiosity
tactic
was
meant
to

motivate
viewers
to
search
for
other
elements
of
the
campaign
or
for
more
information.
The
shock
and

the
disgust
made
the
message
memorable
and
motivated
behavior
change.
Stronger
feelings
towards

the
campaign
would
also
inspire
the
viewer
to
share
the
video
or
to
mention
it
to
somebody
else.

12

RENEW
LA,
“LA
County
Launches
Sugar-‐Loaded
Drinks
Campaign,”
LACDPH,
news
release.

13

Matthew
LeVeque,
phone
interview
with
author,
October
15,
2012.
14

Center
for
Science
in
the
Public,
“Life’s
Sweeter
Today,”
FewerSugaryDrinks.org,
January
2012
Edition.

37
“Sugar-‐Loaded
Drinks”
Campaign
Analysis
-‐
The
campaign
materials
were
well
designed
and

synchronized
efficiently.
The
messages
were
simple
and
easy
to
understand
and
the
call-‐to-‐action
was

clear:
drink
less
sugar-‐loaded
beverages.
The
visuals
were
clean
and
used
few
words
while
effectively

transmitting
all
the
necessary
messages
needed
to
activate
behavioral
change
in
the
consumer.

In
addition,
the
campaign
was
preceded
and
informed
by
a
study
conducted
by
the
University
of

California,
Los
Angeles
(UCLA),
which
identified
the
populations
within
the
county
that
were
consuming

sugary
drinks
at
higher
rates.
This
information
was
important
in
the
development
of
messages,
as
well

as
in
determining
the
distribution
strategy.

The
UCLA
study
was
also
important
as
it
shed
light
on
the
impact
that
sugar
consumption
had
on

the
obesity
epidemic,
particularly
among
children
in
Los
Angeles.
It
found
that
more
than
43%
of

children
under
17-‐years
of
age
consumed
at
least
one
sugary
drink
per
day.
In
addition,
it
confirmed

that,
sugary
drinks
are
the
largest
single
source
of
sugar
consumption
in
the
population’s
diet
and
that

consumption
of
these
beverages
has
increased
in
correlation
to
the
rate
of
obesity.
15

“Choose
Less.
Weigh
Less”
Portion
Control
Campaign

In
October
2012,
LACDPH
launched
a
third
campaign:
“Choose
Less.
Weigh
Less,”
which
focused

on
portion
control.
The
initiative
responded
to
recent
data
from
the
2011
Los
Angeles
County
Health

Survey,
which
indicated
that
obesity
rates
among
the
county’s
residents
continued
to
increase.
It
also

showed
that
rates
had
increased
considerably
among
certain
groups
(younger
adults,
Latinos,
and

Asian/Pacific
Islanders),
and
that
obesity
continued
to
be
more
prevalent
among
particular
groups

(lower-‐income
individuals,
Latinos
and
African
Americans,
and
people
with
lower
levels
of
education).
16

In
addition,
LACDPH’s
initiative
was
informed
with
third-‐party
studies
showing
that,
over
the
last

30
years,
portion
sizes
in
restaurants
have
increased
significantly
and
the
average
American
is

15

Center
for
Science
in
the
Public,
“Life’s
Sweeter
Today,”
FewerSugaryDrinks.org,
January
2012
ed.

16

RENEW
LA,
“LA
County
Launches
Portion
Control
Campaign,”
LACDPH,
October
4,
2012.

38
consuming
more
calories.
17

Furthermore,
the
studies
indicated
that
the
increase
in
portion
sizes
had
led

to
a
reduced
ability
to
monitor
the
amounts
of
food
consumed.
18

Other
studies
indicated
that
even

when
previously
warned
about
the
tendency,
individuals
who
were
presented
with
larger
portions

consumed
more.
19

From
the
studies,
LACDPH
concluded
that
simply
suggesting
to
“eat
less
of
what
is
on

the
plate”
would
be
insufficient.
Rather,
the
message
needed
to
suggest
starting
out
with
a
smaller

serving.

The
LACDPH
also
conducted
two
focus
groups
and
an
online
survey
among
six
hundred

respondents
to
test
four
different
messages:
calorie
awareness,
portion
comparison,
exercise

equivalence,
and
fifty-‐years
of
portion
size
increases.
The
most
important
discovery
was
that
the
target

population
was
not
aware
of
the
recommended
amount
of
calories
they
should
consume.
Many

participants
were
alarmingly
wrong
in
either
direction
(they
estimated
that
they
were
and
should
be

consuming
too
many
or
too
few
calories
per
day).
20

LeVeque
explains
that
these
findings
indicated
the

need
to
focus
on
educating
about
recommended
calorie
consumption.

The
research
was
also
helpful
in
understanding
where
the
majority
of
the
audience
stood
in
the

behavior
modification
process.
Although
most
saw
obesity
as
something
undesirable,
few
were
able
to

identify
the
size
of
their
meals
as
one
of
the
causes.
The
county
understood
that
in
order
to
motivate

behavioral
change
in
the
long
run,
people
first
needed
to
become
aware
of
the
source
of
the
problem

and
learn
what
an
adequate
portion
looked
like.

The
“Choose
Less.
Weigh
Less.”
portion
control
campaign
was
delivered
using
outdoor
and

digital
ads,
as
well
as
social
media.
In
addition,
public
relations
efforts
were
used
to
obtain
media

coverage.
The
materials
showed
a
large
serving
of
a
particular
food
or
meal
next
to
a
smaller
serving
of

17

LACDPH,
“Portion
Control,”
ChooseHealthLA.com,
October
2012.

18

French,
Jeff,
“Why
nudging
is
not
enough,”
Journal
of
Social
Marketing
1,
no.
2
(2011):
154-‐162.

19

Ibid.

20

Matthew
LeVeque,
phone
interview
with
author,
October
15,
2012.

39
the
same
food,
each
labeled
with
its
respective
caloric
content
(the
former
about
twice
as
much
as
the

latter).
In
addition,
the
material
urged
the
audience
to
“Choose
Less”
in
order
to
“Weigh
Less,”

explained
that
portion
size
matters,
and
informed
that
most
adults
only
need
2,000
calories
per
day.
Six

applications
were
developed
using
different
foods,
including:
pizza,
hamburger-‐fries-‐soda
combo,

subway
sandwich,
pasta
with
meatballs
and
garlic
bread,
pancake-‐egg-‐bacon
breakfast,
and
salad.

“Choose
Less.
Weigh
Less.”
Portion
Control
Campaign
Analysis
-‐
The
foods
used
were
well
chosen

based
on
the
audience’s
familiarity
with
them
and
they
offered
a
variety
of
choices.
However,
the

advertisements
could
have
been
perceived
as
promoting
or,
at
best,
validating
the
consumption
of
foods

served
at
fast
food
restaurants.
Moreover,
they
offered
little
guidance
on
meals
not
consumed
at
such

restaurants.
In
fact,
the
two
versions
that
could
reflect
home-‐cooked
meals,
the
pasta
and
the
salad,
are

the
least
clear.
While
they
convey
the
message
that
smaller
portions
should
be
chosen,
they
do
little
in

terms
of
suggesting
how
much
is
appropriate.

Ali
Noller,
Communications
Manager
at
Choose
Health
LA,
explains
that
the
use
of
fast
foods

raised
flags
internally.
LACDPH
officials
were
not
initially
comfortable
with
the
ideas
of
using

“unhealthy”
foods
in
the
campaign.
However,
when
the
material
was
shown
to
focus
group
participants,

the
most
common
response
was
that
the
message
gave
them
hope
because
they
could
“still
eat
the

food
they
liked.”
LeVeque
explains
that
while
it
would
be
ideal
for
people
to
stop
eating
fast
food,
in

behavior
modification
communication,
it
is
important
to
be
realistic.
Getting
people
to
give
up
a

behavior
(eating
junk
food)
is
very
difficult,
while
asking
them
to
modify
it
(eating
smaller
portions
of
it)

is
a
lot
more
likely
to
be
adopted.
Noller
agrees
and
explains
that
the
success
of
the
campaign
had
a
lot

to
do
with
the
fact
that
"it’s
easy,
it's
a
small
step,
[and]
it’s
not
a
complete
overhaul.”
This,
however,

reinforces
the
need
to
have
a
long-‐term
plan
to
make
portion-‐control
communication
a
sustained
effort,

for
“easy,
small
steps”
will
be
insufficient
to
reduce
obesity
levels.

40
Leveque
adds
that
while
they
were
confident
in
their
decision
to
use
fast
food,
they
had
to
put
a

lot
of
thought
into
the
images
used.
The
team
considered
that
it
was
important
to
strike
a
balance

between
using
images
attractive
enough
to
be
noticed,
yet
not
too
appealing
that
they
would
cause

consumers
to
crave
the
foods
represented.

The
LACDPH
has
been
implementing
health
education
campaigns
focused
on
obesity
prevention

for
over
two
years
and
education
campaigns
focusing
on
other
health
topics
for
much
longer.
According

to
Noller,
one
of
the
factors
that
have
allowed
these
campaigns
to
be
successful
is
the
Department’s
12-‐
year,
strong
relationship
with
Rogers
Finn
Partners
(with
whom
they
had
previously
worked
in
anti-‐
tobacco
campaigns).
Rogers
Finn
Partners
offers
years
of
experience
in
public
health
communication,

behavior
change
campaigns,
and
digital,
massively
integrated
strategies.
In
addition,
after
so
many
years

working
together,
the
Rogers
Finn
team
has
learned
how
the
Department
works,
what
it
is
allowed
to

do,
and
what
it
is
open
to
doing,
making
the
design
and
implementation
process
much
more
agile.

Finally,
the
firm
is
flexible
and
able
to
adapt
to
the
limited
budgets
available
for
each
campaign.

Despite
the
support
from
Rogers
Finn
Partners,
the
LACDPH’s
trajectory
in
public
health

education
has
not
come
without
challenges.
The
budgetary
restrictions
that
come
with
public
funds
and

grant
money
allow
little
flexibility
and
room
for
on-‐the-‐go
modifications
based
on
the
public’s
response.

For
example,
the
CDC
grant
for
the
portion-‐control
campaign
stipulated
that
a
certain
amount
of
money

be
used
for
outdoor
media
(in
accordance
with
the
LACDPH
application).
However,
when
designing
the

campaign,
the
team
realized
that
other
channels
could
be
more
cost
effective.
Nonetheless,
the
budget

was
already
established
and
the
money
reserved
for
outdoor
media
could
not
be
used
for
anything
else.

While
staying
within
the
limitations,
the
LACDPH
was
able
to
make
the
most
efficient
use
of
the

resources
by
placing
advertisements
on
the
outside
of
public
buses,
where
it
was
visible
to
drivers
and

pedestrians.
On
a
similar
note,
as
has
been
pointed
out
by
LACDPH’s
Director,
Dr.
Jonathan
E.
Fielding,

41
the
growing
number
of
health
topics
that
need
to
be
addressed
is
a
challenge.
The
Department
has
to

constantly
reassess
priorities
and
evaluate
strategies
to
make
sure
resources
are
being
used
wisely.

Measuring
the
campaign’s
direct
impact
in
modifying
the
target
population’s
behaviors
is

difficult
and
can
only
be
done
years
after
implementation.
However,
media
coverage
and
social
media

analysis
can
provide
a
sense
of
the
audience’s
reaction
to
the
campaign.
A
report
completed
by
Rogers

Finn
Partners
in
December
2012
shows
that,
in
the
three
months
after
they
were
launched,
the
portion-‐
control
videos
were
viewed
about
8,000
times
on
the
YouTube
channel.
A
tracking
of
Twitter
during
the

month
of
October
2012
showed
that
mentions
of
@ChooseHealthLA
and
portion
control
campaign

spiked
on
October
4
th

and
5
th
,
the
day
of
and
the
day
after
the
press
conference
in
which
the
campaign

was
announced.
The
total
number
of
tweets
during
that
month
was
close
to
600,
resulting
in
an

estimated
1.3
million
impressions.

Going
Forward

According
to
a
September
2012
report
by
the
Robert
Wood
Johnson
Foundation,
Los
Angeles

experienced
a
3%
reduction
in
childhood
obesity
between
2007
and
2011.
While
this
is
a
positive
and

welcomed
sign
that
LACDPH’s
work
could
be
having
an
impact,
the
rates
of
obesity
in
Los
Angeles

County
are
still
high
and
the
efforts
to
abate
the
epidemic
must
continue.
According
to
LACDPH
officials,

the
county
plans
to
continue
working
on
the
existing
anti-‐obesity
initiatives
and
to
develop
new
ones.

For
instance,
the
LACDPH
is
currently
working
on
a
strategy
to
recognize
restaurants
that
offer
“portion

correct
meals,”
with
a
Choose
Health
LA
badge.
Officials
explain
that
the
plan
includes
efforts
to

communicate
the
program
to
businesses
and
to
the
public.

42

CHAPTER
SIX:
United
Kingdom
-‐
Change4Life
Campaign

While
most
European
countries
have
steered
clear
of
the
obesity
epidemic,
the
United
Kingdom
is

the
fourth
country
with
the
highest
obesity
rates
in
the
world
(after
the
United
States,
Mexico,
and
New

Zealand).
1

Obesity
has
been
growing
at
startling
rates
amongst
the
British
population
since
the
1990s,

and
by
2011,
about
25%
of
adults
were
obese
(10%
more
than
in
1993).
When
overweight
individuals

are
factored
in,
the
percentage

increases
to
about
66%.
The

percentage
among
children
under
15

years
of
age
is
lower,
yet
equally

alarming.
In
2011,
17%
of
children

were
obese
and
one-‐third
were

either
obese
or
overweight.
2
,
3

Figure

5
shows
that
since
2005,
percentages

of
obese
and
overweight
children

have
leveled
off,
particularly
among

girls.
Nonetheless,
the
rates
continue

to
be
a
cause
for
concern.
4
,
5

1

Mitchell,
Change4Life
Three
Year
Social
Marketing
Strategy,
Department
of
Health,
8.

2

Department
of
Health,
Change4Life
Marketing
Strategy,
Department
of
Health,
13-‐14.

3

Department
of
Epidemiology
and
Public
Health,
University
College
London,
Health
Survey
for
England

2012.

4

Mitchell,
Change4Life
Three
Year
Social
Marketing
Strategy,
Department
of
Health,
October
13,
2011.

5

Department
of
Epidemiology
and
Public
Health,
University
College
London,
Health
Survey
for
England

2012.

Figure 4. Chart by; Health Survey for England 2012
Department of Epidemiology and Public Health, University
College London, 19.
43
The
cost
that
obesity
represents
to
the
British
society
is
equally
worrisome.
It
is
estimated
that
the

National
Health
Service
(NHS)
inquires
costs
of
about
£4.2
billion
per
year
as
a
result
of
obesity-‐related

conditions.
The
total
cost
to
society
is
estimated
to
be
about
£16
billion
per
year.

6

In
2007,
as
data
confirming
the
spike
in
obesity
continued
to
come
in,
the
British
government

began
working
on
a
long-‐term
plan
to
reduce
obesity
among
children
under
11
years
old.
The
goal
was

to
decrease
the
percentage
of
obese
children
in
the
United
Kingdom
by
2020
to
what
it
had
been
in
the

year
2000.
The
result
was
a
plan
titled
“Healthy
Weight,
Healthy
Lives,”
which
followed
an
integrated

approach,
included
programs
across
several
government
agencies,
and
had
a
total
implementation

budget
of
£372
million.
In
addition,
£75
million
would
be
used
for
a
three-‐year
(2008
to
2010)
national

social
marketing
component,
which
would
be
implemented
by
the
NHS.
The
NHS
started
working
on
a

campaign
plan
immediately
and
launched
it
in
April
2008.

In
2010,
a
second
“Healthy
Weight,
Healthy
Lives”
document
was
drafted
and
new
targets
were

established.
Most
notably,
it
added
the
goal
of
achieving
a
downward
trend
in
the
average
excess

weight
of
British
adults
by
the
year
2020
and
the
goal
of
reducing
the
“national
energy
intake
by
5
billion

calories
a
day.”
7

This
time,
the
NHS
received
a
significantly
lower
budget
of
£14
million
for
a
four-‐year
campaign

(2011
to
2014).
Nonetheless,
during
the
second
phase,
the
agency
was
able
to
broaden
its
audience
and

exceed
targeted
results
by
leveraging
the
campaign’s
previous
accomplishments,
building
strategic

partnerships,
and
applying
lessons
learned
in
previous
years.

Target
Audience

As
mandated
by
the
federal
plan,
during
the
first
phase
of
the
program
the
NHS
targeted
families

of
children
younger
than
11
years
of
age.
Mothers
were
deemed
a
particularly
important
sub-‐target

6

Cavendish,
Healthy
Weight,
Healthy
Live,
April
8,
2008.

7

Mitchell,
Change4Life
Three
Year
Social
Marketing
Strategy,
Department
of
Health,
17-‐18.

44
under
the
assumption
that
they
usually
are
the
ones
making
decisions
regarding
their
family’s
eating

behaviors
and
activities.
The
audience
consisted
of
3.5
million
families.

While
similar
messages
could
have
been
delivered
directly
to
children
in
the
classroom,
the
NHS

considered
that
communicating
with
all
family
members
would
have
a
greater
impact.
In
its
2009

strategy,
the
NHS
mentions
the
need
to
counter
the
‘conveyor-‐belt’
effect
by
which
poor
habits
early
in

life
tend
to
stick
throughout
later
years.
In
other
words,
if
the
family
practices
poor
habits,
the
children

are
likely
to
carry
them
into
adulthood
as
they
form
their
own
families.
In
addition,
the
NHS
saw
greater

potential
in
targeting
parents
and
motivating
them
to
adopt
healthier
behaviors
that
are
better
for
their

children.
They
expected
parents
to
be
more
motivated
to
change
for
the
sake
of
their
children,
than
for

the
sake
of
improving
their
own
health.
8

Before
launching,
in
2007,
the
NHS
did
extensive
research
on
the
target
audience’s
attitudes
and

behaviors
towards
diet
and
activity
and
used
the
findings
to
inform
the
design
of
messages
and

strategies.
When
a
follow-‐up
study,
conducted
in
2010,
found
that
behaviors
and
attitudes
had
changed

(as
a
result
of
Change4Life
and
other
factors),
messages
and
strategies
were
modified
to
meet
the
new

needs
of
the
audience
during
the
second
phase
of
the
campaign.

In
addition,
the
target
audience
was
expanded
to
include
middle-‐aged
adults
for
the
2011-‐2014

phase.
Similar
studies
were
conducted,
which
identified
important
characteristics
and
illustrated
the

need
to
develop
different
messages
and
strategies
for
the
new
target
audience.
Having
less
resource
for

the
second
phase,
the
NHS
established
that
it
would
focus
on
reaching
audiences
with
the
greatest
need

for
change.

Branding
and
Messages

While
it
offered
assistance
to
individuals
who
needed
to
lose
weight,
the
campaign
was
not

focused
on
weight
loss.
Rather,
as
outlined
in
the
April
2009
Change4Life
Marketing
Strategy,
the

8

Department
of
Health,
Change4Life
Marketing
Strategy,
Department
of
Health,
13-‐14.

45
objective
was
to
motivate
families
to
“change
behaviors
and
circumstances
that
lead
to
weight
gain.”

The
objective
was
to
influence
the
behaviors
of
children,
to
prevent
them
from
becoming
obese
adults.

To
do
so,
the
NHS
set
out
to
build
a
societal
movement
branded
Change4Life.
The
brand
was

chosen
because
it
was
fun,
would
be
appealing
to
entire
families,
and
offered
long-‐term
aspirations

(“4Life”).
In
addition,
it
allowed
for
the
development
of
several
sub-‐brands
by
substituting
the
first
word

(Bike4Life,
Walk4Life,
Breakfast4Life,
etc.)

Another
important
quality
was
the
broadness
of
the
brand,

which
did
not
limit
its
application
to
obesity
or
its
audience
to
children.
This
would
prove
particularly

advantageous
when
the
scope
and
the
target
audiences
of
the
campaign
were
expanded
during
the

second
phase.

The
main
message,
“Eat
Well.
Move
More.
Live
Longer,”
was
intended
to
be
simple,

straightforward,
and
encouraging,
and
would
be
used
as
a
tagline
throughout
the
campaign.
An
NHS

spokesperson
illustrated
the
agency’s
belief
that
“simplification
was
an
innate
part
of
public

communication”
when
he
said,
“The
very
nature
of
communicating
to
the
public
on
an
issue
like
obesity

means
that
we
have
to
put
complex
information
in
a
simple,
brief
form
so
everybody
can
understand

it.”
9

The
tagline
was
also
selected
to
encompass
the
secondary
messages
the
campaign
sought
to

deliver.
The
NHS
established
eight
behavior-‐focused
secondary
messages:
1)
reduce
the
intake
of
fat,

particularly
saturated
fat;
2)
reduce
their
intake
of
added
sugar;
3)
control
portion
sizes;
4)
eat
at
least

five
portions
of
fruit
and
vegetables
per
day;
5)
establish
three
regular
mealtimes
each
day;
6)
reduce

the
number
of
snacks;
7)
do
at
least
60
minutes
of
moderate-‐intensity
activity
per
day;
and
8)
reduce

time
spent
in
sedentary
activity.
10

In
addition,
the
campaign
would
include
messages
to
alert
the

audience
that
they
and
their
families
were
at
risk
of
becoming
or
might
already
be
obese;
to
warn
them

9

Piggin
and
Lee,
“Don't
mention
obesity,”
Journal
of
Health
Psychology
16,
1155.

10

Department
of
Health,
Change4Life
Marketing
Strategy,
Department
of
Health,
28-‐29.

46
about
health
consequences
related
to
obesity;
to
offer
tips
on
how
to
achieve
healthier
lifestyles;
to

encourage
seeking
help;
and
to
guide
them
to
sources
of
help.

One
important
characteristic
of
the
campaign
was
the
absence
of
the
term
obesity
in
all

communication.
This
attracted
criticism
from
certain
sectors,
including
taxpayers
and
communication

experts.
Critics
pointed
out
that
by
not
mentioning
the
word
obesity,
the
government
was
avoiding
a

necessary
evil
11

and
thus
making
the
campaign
ineffective.
Others
said
that
the
omission
of
the
term

gets
in
the
way
of
reframing
the
issue
of
obesity
as
a
health
concern
and
makes
it
difficult
to
educate

about
it.
12

The
NHS
justified
its
decision
in
the
April
2009
Change4Life
Marketing
Strategy
by
explaining
that

using
the
term,
would
exclude
those
who
are
not
obese,
but
that
are
at
risk
of
becoming
so.

Furthermore,
because
many
parents
have
a
difficult
time
identifying
themselves
and
their
children
as

obese,
they
might
wrongfully
dismiss
a
message
that
uses
the
word
obesity
as
inapplicable
to
them
or

their
families.
The
document
also
mentions
that
research
findings
suggest
that
British
parents
perceive

the
term
as
an
insult
and
refuse
to
use
it.
These
findings
were
validated
by
a
study
published
in
the

Journal
of
Obesity
in
2012,
after
the
Change4Life
campaign
was
designed.
The
study
tested
twenty-‐nine

obesity-‐related
health
messages
and
concluded
that
the
Change4Life
messages
elicited
the
most

positive
reactions
and
the
highest
intent
to
comply
with
the
message.
13

The
decision
to
avoid
the
term
obesity
is
also
reflected
in
the
campaign’s
creative
execution
(see

Appendix
7).
The
logo,
the
advertisements,
and
all
other
creative
applications
use
characters
that
the

NHS
describes
as
“little
‘people’
whose
presence
gives
the
identity
humanity,
but
they
have
no
gender,

age,
ethnicity
or
weight
status”
and
therefore
are
inclusive.
14

Critics
have
said
that
the
graphics
are

11

Piggin
and
Lee,
“Don't
mention
obesity,”
Journal
of
Health
Psychology
16,
1157-‐1159.

12

Piggin
and
Lee,
“Don't
mention
obesity,”
Journal
of
Health
Psychology
16,
1157-‐1159.

13

Puhl,
Peterson
and
Luedicke,
“Fighting
obesity
or
obese
persons?”
International
Journal
of
Obesity,
1–9.

14

Department
of
Health,
Change4Life
Marketing
Strategy,
Department
of
Health,
44.

47
discriminatory
because
they
only
show
characters
of
“normal”
proportions.
In
addition,
they
argue
that

the
use
of
only
one
body
type
implies
that
there
is
only
one
type
of
healthy
body.
15

There
is
no
discussion
that
the
characters
are
inclusive
of
all
ages
and
ethnicities.
The
characters’

voices
and
roles
give
them
a
gender
(for
example,
a
mother
is
shown
giving
her
son
food),
but
both

genders
are
equally
represented
in
the
advertisements.
It
is
possible,
however,
that
some
of
the

applications
could
be
perceived
as
placing
more
blame
on
one
parent
(usually
the
mother)
than
the

other.
For
instance,
in
one
video
the
mother
uses
a
tractor
to
dump
a
large
amount
of
food
on
her

child’s
plate
and
then
the
child
complains
that
he
is
getting
adult-‐sized
meals.
16

In
terms
of
body
shape

and
size,
the
critics
are
correct
in
that
not
everyone
is
represented
and
that
all
the
characters
have
the

same
shape.
Yet,
they
have
a
shape
that
is
unlike
the
shape
of
any
real
person:
the
characters
are

cartoon-‐like
and
linear.
They
were
cleverly
designed
to
counter
the
normalization
of
larger,
unhealthy

bodies,
without
suggesting
preference
towards
any
particular
physical
characteristics
(such
as
extreme

thinness,
long
legs,
wide
back,
etc.)

Beyond
the
characters,
the
creative
applications
are
well
designed
to
be
informative
and,
at
the

same
time,
attractive
and
inviting.
The
use
of
bright
colors
contributes
to
the
positive
voice
of
the
entire

campaign.
The
easy-‐to-‐follow
and
fun
narratives
make
the
videos
entertaining,
while
effectively

delivering
the
message.
Finally,
the
creative
design
offers
consistency
and
allows
for
the
delivery
of

secondary
messages,
without
losing
the
main
healthy-‐lifestyle
theme.

Implementation

The
most
notable
characteristic
of
the
Change4Life
campaign
was
the
extent
of
the
research

conducted
and
the
information
gathered
by
the
NHS’s
social
marketing
team,
before,
during
and
after

each
of
the
two
phases.
Having
no
precedent
campaign
to
learn
from,
the
team
made
research
an

important
part
of
their
marketing
plans.
The
efforts
included
demographic
and
ethnographic
audience

15

Piggin
and
Lee,
“Don't
mention
obesity,”
Journal
of
Health
Psychology
16,
1156
and
1161.

16

Harding-‐Hill,
“Change4Life
'Me
Sized
Meals',”
Department
of
Health
Agency
video,
2009.

48
research,
analysis
of
past
behavior-‐change
initiatives,
and
the
use
of
effective
evaluation
tools
to
track

progress.
These
findings
were
continuously
reassessed
throughout
the
implementation
by
maintaining
a

dialogue
with
audiences.
The
outcome
was
two
successful
campaigns
that
achieved
important
results

and
which
made
significant
contributions
to
the
United
Kingdom’s
federal
initiative
to
reduce
obesity.

Phase
One

The
research
suggested
that
audiences
would
need
to
make
lifestyle
changes
in
order
to
achieve

the
results
the
campaign
intended.
Therefore,
the
team
chose
to
focus
on
nutrition
and
physical
activity

simultaneously
and
to
follow
a
“life-‐course
approach.”
They
further
concluded
that
the
adoption
of
new

behaviors
would
only
be
possible
if
certain
preconditions
were
met.
The
research
had
shown
that
even

though
most
people
saw
obesity
as
a
problem,
only
5%
of
parents
thought
their
children
were
obese
or

overweight.
17

In
order
to
feel
motivated
to
adopt
new
behaviors,
the
audience
would
need
to
be

dissatisfied
with
their
family’s
present
health
and
weight,
be
concerned
about
their
future,
and/or

recognize
that
they
were
at
risk.
They
would
also
need
to
be
willing
to
take
on
the
responsibility
of

working
on
modifying
their
family’s
behaviors
and
believe
that
such
change
was
possible
and
already

being
done
by
others.

The
social
marketing
plan
drafted
was
based
on
nudge-‐style
theory,
which
seeks
to
normalize

healthy
behaviors
and
insert
positive
environmental
stimuli.
The
team’s
objectives
were
to
“reframe

obesity
in
terms
of
behaviors
and
consequences,
rather
than
obesity
as
an
outcome
itself;”
to
present
it

as
an
issue
that
concerned
the
entire
population;
and
to
suggest
that
it
was
a
result
of
the
modern

lifestyle
and
not
the
fault
of
individuals.
The
tone
would
aim
to
educate
and
offer
support,
rather
than

give
orders.

The
campaign
would
help
people
as
they
adopted
the
new
behaviors
by
providing
products
and

materials
and
orienting
them
to
find
sources
of
help.
The
audience
would
also
be
asked
about
their

17

Department
of
Health,
Change4Life
Marketing
Strategy,
Department
of
Health,
20.

49
family’s
behaviors,
offered
personalized
information,
encouraged
to
establish
goals
for
their
family,
and

given
feedback
on
their
progress.

The
social
marketing
team
did
not
intend
to
implement
its
strategies
alone.
Rather,
the
plan

included
seeking
partnerships
with
other
government
agencies,
private
organizations,
and
companies
to

increase
the
reach
of
the
communication.
The
partnerships
would
also
augment
the
campaign’s

credibility
by
having
trusted
brands
deliver
advice,
information,
and
support.
The
ultimate
goal
was
to

make
Change4Life
a
society-‐wide
movement.

The
first
phase
of
the
Change4Life
campaign
was
implemented
from
June
2008
to
December
2010

and
consisted
of
six
steps.
The
steps
followed
the
behavior-‐change
process
and
included:
1)
preparing

the
support
system,
2)
reframing
the
issue,
3)
personalizing
the
issue,
4)
promoting
and
rooting
the

behaviors,
5)
inspiring
people
to
change,
and
6)
supporting
people
as
they
adopted
new
behaviors.

During
the
first
six
months,
the
focus
was
not
on
the
target
audience,
but
rather
on
the
target

audience’s
support
system.
Medical
personnel,
school
system
staff,
employees
from
partner
NGOs
and

companies,
local
service
providers,
and
government
workers
(NHS
and
other
related
agencies)
were

trained
so
that
they
would
be
ready
to
provide
valuable
support
to
families
once
they
started
working

on
changing
their
behaviors.

During
those
six
months,
the
team
worked
on
other
pre-‐launch
efforts
as
well.
They
aligned

communication
plans
with
other
government
agencies;
created
a
searchable
database
of
support

organization
for
families
looking
for
help;
and
established
and
cemented
partnerships.
The
team

encouraged
NGOs
to
produce
advertisements
that
endorsed
the
campaign’s
objectives
and
that
used

the
same
language
and
key
messages.
They
also
worked
with
partner
companies
and
local
governments

to
coordinate
community
services
and
programs
that
would
support
the
campaign.
Finally,
they

recruited
local
activists
and
grassroots
organizations
to
help
encourage
people
throughout
the
behavior

modification
process.

50
The
first
wave
of
public
communication
was
launched
in
January
2009
and
aimed
to
reframe
the

obesity
issue.
Information
about
the
link
between
weight
gain
and
illness
was
delivered
through
a

combination
of
paid
media
(television,
newspaper,
outdoor,
and
digital),
consumer
public
relations

(including
a
helpline
and
website),
and
distribution
of
educational
material.
The
messages
positioned

obesity
as
an
issue
that
could
affect
the
majority
of
families,
directed
the
audience
to
sources
of
help,

and
sought
to
decrease
social
stigma
against
obesity.

The
second
step
involved
developing
and
distributing
a
questionnaire
titled
“How
are
the
Kids?”
to

over
five
million
households,
either
online
or
by
mail.
The
objective
was
to
personalize
the
obesity
issue

and
help
families
recognize
that
they
were
already
obese
or
were
at
risk
of
becoming
so.
Online

respondents
received
instant
feedback
on
how
their
families
compared
to
others
and
tips
on
how
to

improve.
Print
respondents
received
similar
feedback
and
tips
via
mail.
The
objective
of
the

questionnaire
was
not
to
collect
data.
Rather
in
was
meant
to
engage
with
families,
make
them
aware
of

their
weight
status,
encourage
them
to
reconsider
their
behaviors,
and
offer
them
targeted
tips
and

advice
based
on
their
unique
needs.
The
questionnaire
was
an
effective
way
to
personalize
the
issue
in
a

tangible
manner,
while
avoiding
the
promotion
of
discrimination
or
stigma
against
overweight
and

obese
individuals
through
public
communication.
Completion
of
the
questionnaire
was
encouraged

through
tactics
such
as
offering
a
small
gift
upon
submission
and
partnering
with
celebrities
to
promote

it.

The
third
step,
rooting
the
behavior,
aimed
to
educate
families
about
the
eight
behaviors
that

had
been
identified
as
helpful
in
preventing
excess
weight
gain.
Communicating
these
practices
would

not
be
easy,
as
many
of
them
were
vague
concepts
that
involved
activities
central
to
people’s
lives.
The

campaign
team
began
by
identifying
short
and
catchy
phrase
for
each
behavior
that
used
simple

language
(for
example,
“5
a
day,”
“me-‐sized
meals,”
“up
and
about”).
In
addition,
they
developed

material
for
parents
that
included
real-‐life
and
relatable
examples
and
tips.
For
instance,
rather
than
the

51
phrase
“eat
healthy
snacks,”
the
communication
would
suggest,
“switch
to
snacks
like
fruit,

breadsticks…
instead
of
sweets.”

Tips
included
consuming
some
of
the
fruit
portions
as
juice
or
using

trips
to
the
park
as
rewards,
rather
than
candy.
At
the
same
time,
the
team
made
a
searchable
support-‐
source
database
available
and
promoted
it.
All
these
resources
were
delivered
online,
through

newspaper
advertisements
and/or
via
retail
partners.

After
working
on
behavior
awareness,
the
team
set
out
to
inspire
people
to
adopt
the
new

behaviors
by
convincing
them
that
change
was
possible
and
normal
(i.e.
others
were
doing
it).
This
was

done
through
a
combination
of
paid
media,
public
relations,
and
partnerships.
Testimonials
of
how

Change4Life
was
helping
individuals
and
of
the
impact
it
was
having
in
communities
were
shared

through
editorials
in
local
press,
radio
shows,
and
live
events.
In
addition,
commercial
partners
and

other
government
agencies
supported
the
effort
through
sub-‐brand
programs
such
as
Bike4Life.

The
final
part
of
phase
one
followed
a
costumer
relationship
management
program
(CRM)
to

support
families
as
they
adopted
the
new
behaviors.
Families
had
been
urged
to
sign
up
for
an
ongoing

CRM
program
that
would
provide
encouragement,
information,
and
support.
Participants
received

materials
and
resources,
including
tools
to
help
parents
motivate
their
children,
either
online
or
through

mail.
For
instance,
a
snack
swapper
(a
cardboard
roulette
with
healthy
snack
options),
made
choosing

healthy
snacks
fun.
At
the
same
time,
the
team
coordinated
with
local
organizations
to
established

additional
support
programs.

52

Table
4.
Table
from:
Change4Life
Marketing
Strategy
2009.
Department
of
Health,
47.

Phase
Two

Audience
response
was
high
in
the
campaign’s
first
phase
and,
as
a
result,
the
Change4Life
brand

had
grown
and
garnered
national
recognition.
Therefore,
in
2011,
the
government
decided
to
make

Change4Life
the
sole
centrally
funded
public
health
campaign,
which
would
incorporate
other
health

topics
and
would
add
middle-‐aged
adult
to
its
target
audiences.

With
an
expanded
mandate,
a
longer
time
frame,
and
a
reduced
budget
(£14
million),
the
team

needed
to
reassess
its
strategies
in
order
to
achieve
the
expected
outcomes.
They
began
by
analyzing

the
evaluation
results
from
phase
one,
exploring
novel
communication
theories,
and
researching
their

new
target
audience.
Evaluation
results
from
phase
one
indicated
that
target
families
had
changed
since

2009.
In
2011,
parents
had
a
greater
sense
of
responsibility
for
their
family’s
health
and
they
now

aspired
to
make
their
children
not
only
happy,
but
also
healthy.
Families
had
adopted
healthier
lifestyles

and
children
were
more
aware
of
the
importance
of
healthy
eating
and
physical
activity.
In
addition,
the

target
audience
had
adopted
new
technologies
and
ways
of
communicating,
which
would
demand
new

messaging
strategies.

53
Research
on
middle-‐aged
adults

found
that
this
group
had
a
low
sense
of

personal
efficacy,
tended
to
focus
on
the

short-‐term,
and
sought
convenient
and

indulgent
opportunities.
They
were
inclined

to
be
dissatisfied
with
their
health
and
feel

that
they
had
no
control
over
it.
Many

were
aware
that
they
had
gained
weight
in

recent
years,
but
saw
it
as
a
normal
part
of

aging
and
believed
that
losing
it
would

require
making
large
sacrifices.
While
the

attitudes
of
middle-‐aged
adults
were

different
than
those
of
families,
the
steps
they
would
need
to
go
through
to
adopt
new
behaviors
would

be
similar.

Looking
back,
the
team
concluded
that
the
behavior-‐change
model
used
in
phase
one
had
been

too
complicated
and
structured.
Therefore,
for
phase
two,
they
replaced
it
with
a
four-‐step
model
that

was
simpler
and
which
was
continuous.
The
first
step
was
motivation
to
adopt
the
behaviors,
which

required
self-‐awareness,
reframing
of
obesity
as
important
to
overall
health,
and
normalizing
the

adoption
of
healthy
behaviors.
The
second
step
was
activation,
which
could
be
achieved
by
encouraging

audience
members
to
commit
to
changes
and
establish
plans
to
achieve
change,
and
by
giving
them

opportunities
to
test
new
behaviors.
The
third
step
was
monitoring,
for
which
periodical
reminders
of

their
progress
would
be
offered
to
individuals
and
families.
The
final
step
was
recognizing
achievements

by
offering
frequent
rewards.
The
model
implied
that
the
behavior
changes
encouraged
by
Change4Life

required
an
ongoing
process,
particularly
because
they
involved
daily
habits
that
needed
to
be

Figure 5. Mitchell, Change4Life Three Year Social
Marketing Strategy. Department of Health, 28.

54
continuously
modified.
It
also
accepted
that
individuals
would
not
be
able
to
adopt
all
the
behaviors

promoted
at
once,
nor
at
the
same
pace.
The
idea
of
a
continuous
model
changed
the
focus
from

encouraging
major
lifestyle
changes,
to
encouraging
small
behavior
modifications
that
were
easier
and

less
intimidating
and
that
would
add
up.

18

In
designing
a
strategy
to
address
middle-‐aged
adults,
the
team
could
have
opted
to
create
a

separate
campaign
with
new
messages
and
materials
according
to
their
attitudes,
needs,
and
behaviors.

However,
the
team
recognized
that
the
two
audiences
were
not
necessarily
mutually
exclusive.
That
is,

middle-‐aged
adults
could
also
be
parents,
could
soon
become
parents,
or
could
otherwise
be
involved
in

childcare.
Rather
than
having
two
separate
sets
of
messages,
which
could
have
caused
confusion,
the

team’s
approach
was
to
plan
less
audience-‐specific
communication
and
more
universal
initiatives.

Another
important
strategy
change
adopted
in
2011
was
relative
to
the
funding
model.
In
phase

one,
most
efforts
were
centrally
funded
and
partners
were
invited
to
participate.
In
phase
two,

however,
with
a
reduced
central
budget,
the
campaign
needed
significantly
more
funding
and

implementation
from
private
partners.
Thus,
the
approach
became
to
let
“trusted
brands
and
programs

[...]
deliver
advice,
information,
and
support
on
all
topics
that
[were]
relevant
to
people
at
specific

stages
through
their
lives.”
19

To
this
end,
Change4Life
retail
and
brand
guidelines
were
modified
to

allow
for
greater
participation
from
partners.
Important
additions,
such
as
allowing
sponsorships,
were

incorporated
as
ways
to
raise
funds
and
incentivize
private
participation.
At
the
same
time,
campaign

assets,
including
logos,
figures
and
fonts,
were
publicly
posted
on
the
website
to
be
used
by
any

organization
that
ran
“activities
that
encourage
people
to
make
healthier
food
choices
and
do
more

physical
activity.”
20

18

Mitchell,
Change4Life
Three
Year
Social
Marketing
Strategy,
Department
of
Health,
26-‐30.

19

Mitchell,
Change4Life
Three
Year
Social
Marketing
Strategy,
Department
of
Health,
15.

20

Public
Health
West
Midlands,
“The
Great
Swapathon
Resources.”

55
The
phase
two
Change4Life
social
marketing
plan
called
for
a
shift
to
mostly
digital
technologies
as

a
means
to
communicate
with
the
audiences.
Such
shift
would
not
only
save
money,
but,
more

importantly,
it
responded
to
new
audience
behaviors.
The
Change4Life
website
was
improved
to
make
it

more
engaging
and
stimulating
and
efforts
were
made
to
increase
traffic
with
the
help
of
partners.
In

addition,
presence
on
social
media,
particularly
Facebook
and
Twitter,
was
increased.
Following
the

same
trend,
the
Change4Life
CRM
program
was
continued
exclusively
in
its
online
version,
and
paid

digital
media,
particularly
YouTube
Videos,
became
an
important
part
of
the
work.

The
plan
also
included
few,
but
large-‐scale,
centrally
planned
annual
initiatives.
An
important

strategy
improvement
involved
establishing
the
calendar
well
in
advance
to
facilitate
the
collaboration

and/or
participation
of
partners.
The
three
annual
initiatives
included:

o “The
Great
Swapathon”-‐
An
activity
through
which
corporate
partners
offered
coupons
for

savings
on
healthy
foods
and
activities.
The
event
gave
families
an
opportunity
to
try
new

products
and
offered
partners
a
low-‐cost
way
to
test
the
value
of
joining
Change4Life.
For
the

team,
it
was
a
chance
to
experiment
with
partner-‐funded
financial
incentives
as
a
way
to
drive

behavioral
change.

o “Summer
of
Fun”
-‐
An
initiative
to
encourage
children
and
families
to
be
more
active
during
the

summer.
It
involved
developing
tools
such
as
a
“fun
wheel”
(including
cardboard
and
digital

versions),
which
suggested
fun-‐activity
ideas,
and
a
wall
chart
for
children
to
record
their

summer
activities.
Public
relations
tactics
and
paid
television
advertisements
were
used
to

promote
the
tools.
In
addition,
partners
were
encouraged
to
participate
in
the
campaign
by

offering
opportunities
for
families
to
try
new
activities.

o “Walk4Life”
-‐
A
program
designed
to
encourage
more
walking
for
recreation,
as
well
as
for

transportation.
A
website
(and
later
a
phone
app)
was
created
on
which
visitors
could
access

56
tips,
maps,
and
tools
to
incorporate
walking
into
their
lives.
In
addition,
the
team
encouraged

schools
and
employers
to
promote
walking
among
students
and
employees
respectively.

During
phase
two,
Change4Life
partnered
with
LazyTown,
a
popular
children’s
television
show
that

promotes
healthy
eating
and
physical
activity.
Co-‐branded
material
designed
to
promote
these

behaviors
among
children
ages
two
to
five
were
distributed
in
Sure
Start
Centers
and
made
available
for

families
to
download
online.
The
partners
developed
three
games,
which
invited
children
to
contribute

to
a
goal
(save
a
hero,
reach
a
certain
place,
etc.)
by
completing
a
series
of
physical
tasks
(for
example,

jumping
jacks).

At
the
same
time,
campaigns
and
initiatives
were
implemented
under
sub-‐brands.
In
the
summer

of
2012,
the
team
developed
Games4Life,
which
leveraged
the
buzz
around
the
summer
Olympics
in

London
to
promote
physical
activity.
Another
example
was
Play4Life,
which
was
developed
in

partnership
with
other
government
agencies
that
were
investing
in
recreational
infrastructure.
Through

Play4Life,
families
and
local
supporters
received
a
toolkit
to
help
them
encourage
active
play.

Results

The
results
from
phase
one
of
the
Change4Life
campaign
were
encouraging.
According
to
an
NHS

publication,
in
2009,
about

400,000
families
signed
up
for

the
CRM
program,
doubling
the

team’s
target.
In
addition,
at

least
one-‐third
of
British

mothers
claimed
to
have

modified
behaviors
as
a
result

of
the
campaign
and
almost

Figure 6. Mitchell. Change4Life Three Year Social Marketing
Strategy. Department of Health, 14.
57
80%
said
it
had
made
them
think
about
their
children’s
long-‐term
health.
21

As
mentioned
earlier,
the

2010
ethnographic
research
of
the
target
population
showed
that
attitudes
towards
obesity,
nutrition,

and
physical
activity
had
shifted.
To
further
validate
phase
one’s
success,
a
study
that
used
grocery
store

ClubCard
records
to
compare
purchases
made
by
a
group
engaged
in
Change4Life
and
a
comparable

control
group,
found
differences
in
their
purchasing
behavior.
The
study
found
that
the
“Change4Life

families
bought
more
low-‐sugar
drinks,
more
low-‐fat
milk,
more
fruits
and
vegetables,
more
dried
pasta,

and
fewer
cakes.”
22

At
the
end
of
phase
one,
brand
awareness
was
estimated
to
have
reached
68%
and
logo

recognition
88%.
At
the
same
time,
attitudes
towards
the
brand
remained
positive.
By
June
2011,
the

campaign
had
won
15
industry
awards.
23

Partnership-‐building
efforts
gained
momentum,
particularly
in

2010.
During
phase
one,
corporate
partnerships
resulted
in
about
£7.5
million
in
media-‐equivalent

contributions
and
£12
million
raised
through
programs.
24

In
addition,
about
50,000
individuals
signed
up

to
be
Change4Life
local
supporters.
Almost
350,000
“How
are
the
Kids?”
questionnaires
were
returned

(300,000
provided
enough
information
to
be
able
to
receive
a
personalized
response),
which
was

significantly
higher
than
the
targeted
100,000.
25

(At
the
time
of
publication
of
this
report,
it
is
too
early
to
evaluate
the
impact
of
the
second
phase
of
the

Change4Life
campaign.)

Analysis

While
the
long-‐term
impact
of
the
Change4Life
campaign
will
not
be
known
for
some
time,
the

short
and
middle
term
indicators
obtained
thus
far
are
promising.
There
are
several
aspects
of
the

campaign
that
contributed
to
its
success
and
that
are
worth
noting.
First
of
all,
strong
research,

21

O’Loughlin,
Change4Life,
June
23
2009,
Power
Point
Presentation.

22

Hardy
and
Asscher,
“Recipe
for
Success
with
Change4Life,”
The
Marketing
Society.

23

Ibid.

24

Mitchell,
Change4Life
Three
Year
Social
Marketing
Strategy,
Department
of
Health,
13.

25

Department
of
Health,
Change4Life
One
Year
On,
Department
of
Health,
7
and
21

58
monitoring,
and
evaluation
efforts
were
a
central
part
of
the
overall
campaign.
This
allowed
for

continuous
assessment
of
tactic
effectiveness
and
for
modification
of
strategies
as
needed.

In
addition,
the
team
recognized
that
“the
workforce
[who
supports
the
audience]
is
a
channel
for

communicating
with
the
public
as
well
as
an
audience
in
itself.”
26

The
Change4Life
team
made
sure
that

they
were
ready
to
provide
adequate
support
when
the
audience
sought
it
by
focusing
on
educating
the

audience’s
support
system
before
launching
the
public
campaign.

Furthermore,
the
branding
approach
was
designed
to
be
adaptable:
it
was
broad
in
scope
(which

allowed
for
the
incorporation
of
new
topics)
and
it
didn’t
use
government
branding
(which
made
it
more

inviting
for
other
players
to
join).
Adaptability
proved
to
be
particularly
important
in
2011,
when
the

government
mandated
the
inclusion
of
new
topics
and
reduced
the
budget.
The
team
was
able
to
adapt

the
branding
guidelines
to
motivate
more
corporate
partners
to
join
and
invest
where
the
NHS
could
no

longer.
It
is
important
to
note,
though,
that
the
team
relaxed
the
branding
guidelines
only
after
brand

awareness
and
trust
had
been
built.

Another
element
that
contributed
to
success
was
that
Change4Life
was
positioned
as
a

movement,
rather
than
as
a
campaign.
All
sectors
of
society,
including
private
organizations,

corporations,
other
government
agencies,
and
families,
were
invited
to
join.
This
promoted
a
sense
of

joint
ownership
and
community,
which
contributed
to
high
levels
of
engagement.
Moreover,
the
idea
of

a
movement
attracted
partnerships
that
allowed
Change4Life
to
grow
beyond
what
the
campaign’s

budget
allowed.
27

Finally,
the
Change4Life
team
was
not
afraid
to
try
new
theories,
partnerships,
media,
and

strategies,
even
when
if
they
were
risky
or
controversial.
Some
of
these
included
“The
Great

26

Department
of
Health,
Change4Life
Marketing
Strategy,
Department
of
Health,
43.

27

Mitchell,
Change4Life
Three
Year
Social
Marketing
Strategy,
Department
of
Health.

59
Swapathon,”
which
was
a
financial
incentives
experiment,
and
the
adoption
of
the
newly
developed

nudge
theory.

60

CHAPTER
SEVEN:
Issues
and
Challenges

The
issue
of
obesity
incorporates
a
myriad
of
challenges,
which
complicate
efforts
to
combat
its

epidemic
growth.
Governments,
organizations,
companies,
and
academics
in
various
countries
are
trying

to
identify
the
best
strategies.
However,
the
field
is
relatively
new
and
the
impact
is
slow
in
producing

conclusive
results.

As
evidenced
in
the
cases
analyzed,
the
challenges
extend
to
communication
campaigns
that

address
the
obesity
epidemic.
Obesity
is
a
complicated
issue
and
therefore
theories
and
strategies
used

in
other
public
health
campaigns
do
not
necessarily
apply.
Below
is
a
description
of
common
hurdles

faced
by
public
health
communicators
tasked
with
addressing
the
obesity
epidemic.

Some
of
these
challenges
were
also
experienced
in
the
implementation
of
campaigns
that

addressed
other
public
health
topics.
In
such
cases,
practitioners
have
done
well
in
reaching
out
to
those

with
experience
and
learning
from
them.
Many
of
these
communication
challenges
are
new,
however,

and
others
reach
a
new
magnitude
as
they
are
exacerbated
when
they
occur
simultaneously.

Understandably,
the
level
of
complexity
in
addressing
the
obesity
issue
is
significant
in
overcoming
such

complexities.

7.1. Unclear
and
multiple
sources
of
the
problem

A
mathematical
way
to
look
at
the
problem
of
obesity
is
to
subtract
the
number
of
calories
a

person
burns,
from
the
number
of
calories
a
person
consumes.
If
the
result
is
positive,
the
person
will

gain
weight;
if
it
is
negative,
the
person
will
lose
weight.
The
reality,
however,
is
not
that
simple.
The

equation
itself
overlooks
a
myriad
of
factors
that
can
lead
to
an
excess
of
calories.

61
On
the
food
side
of
the
equation
the
quantity
as
well
as
the
quality
of
the
food
consumed
need
to

be
considered.
It
is
then
important
to
understand
why
people
are
eating
beyond
what
their
body
needs.

Do
they
eat
out
of
boredom,
stress,
or
anxiety?

Is
it
a
result
of
excessive
marketing
from
the
food

industry?
Or
is
it
because
unhealthy
portion
sizes
have
been
normalized?

Do
cultural
practices
around

food
play
a
role
in
the
amount
consumed?

Is
price
and
availability
of
healthy
foods
a
factor?

Are
people

having
a
hard
time
realizing
that
they
are
eating
too
much
or
are
they
seeking
pleasure?
Do
they
not

care
about
their
health
or
the
way
they
look?
Or
do
they
find
it
impossible
to
resist
the
temptation
in

front
of
them?
In
a
similar
way,
a
deficit
in
physical
activity
can
have
a
variety
of
explanations.

Furthermore,
the
source
of
obesity
may
be
hereditary
traits,
health
complications,
psychological

addiction,
evolution,
1

the
use
of
food
as
comfort
or
medication,
and
cultural
beliefs
and
perceptions.
All

of
these
factors
are
affecting
some
people
and
most
individuals
struggling
with
obesity
are
affected
by

several
of
them
simultaneously.

This
makes
the
job
of
public
health
communicators
extremely
complex.
It
poses
several
questions:

which
factors
to
address
first?
Which
of
them
can
be
addressed
through
communication?
Can
any
one

have
an
impact
by
itself?
Is
the
budget
enough
to
cover
more
than
one?
Are
any
of
these
conflicting?

Can
the
audience
be
segmented
by
source
of
the
problem?

7.2. Multiple
solutions:
Requires
changing
multiple
behaviors

In
the
same
way
that
there
are
multiple
roots
to
the
obesity
problem,
reversing
the
trend

demands
various
solutions.
In
order
to
achieve
significant
results,
individuals
need
to
adopt
several
new

behaviors:
better
eating
habits,
more
physical
activity,
healthier
shopping,
etc.
In
addition,
individuals

need
to
make
sure
they
stay
consistent
with
their
new
behaviors
(eating
healthy
once
a
week
will
not

solve
their
problem).
Many
of
these
behaviors
are
part
of
a
person’s
everyday
routine
and
have
been

1

Department
of
Health,
Change4Life
Marketing
Strategy,
Department
of
Health,
13-‐14.

62
practiced
since
childhood,
to
the
point
that
they
are
no
longer
conscious.
Some
unhealthy
behaviors
are

more
convenient
or
less
expensive,
and
adopting
new
ones
requires
sacrifice.
Adopting
one
behavior

change
can
be
difficult
enough.
Adopting
many
is
even
more
daunting.

For
a
communicator
this
also
means
that
significant
results
in
obesity
reduction
will
most
likely

require
multiple
messages.
The
introduction
of
multiple
messages
will
demand
greater
resources
(or
will

result
in
less
exposure
per
message).
Additionally,
multiple
messages
might
confuse
audiences,

overwhelm
them,
or
prevent
them
from
being
able
to
focus
and
succeed
in
any
particular
one.

7.3. Eating
is
a
necessary
behavior
that
must
be
done
every
day

The
simple
fact
that
eating
is
not
optional
for
anybody,
and
that
it
must
be
done
multiple
times

per
day,
every
day,
is
also
a
challenge.
It
means
that
people
have
to
work
on
modifying
their
behavior

continuously.

It
is
true
that
only
some
individuals
are
addicted
to
food
but
it
is
also
true
that
most
are

occasionally
(or
more
than
occasionally)
tempted
to
indulge
in
unhealthy
foods.
If
one
compares
food

and
eating
to
drugs
and
drug
use,
one
could
conclude
that
abstaining
and
staying
away
from
the
stimuli

(food)
would
be
the
best
way
to
deal
with
overconsumption
(in
the
same
way
that
abstinence
and

staying
away
from
temptation
is
the
best
way
to
cure
substance
addiction).
However,
this
is
obviously

not
possible.
The
facts
that
abstinence
from
food
is
neither
necessary
nor
possible
and
that
we
are

constantly
exposed
to
(often
tempting
and
unhealthy)
foods,
make
staying
consistent
with
healthy

eating
behaviors
extremely
difficult.
“Moderation
of
behavior
[as
opposed
to
abstinence]
may
be
more

difficult
and
may
require
more
continuous
reinforcement
to
be
maintained.”
2

Researcher
E.P.
Köster
from
Wageningen
University
in
The
Netherlands
points
out
that
eating
is
a

“a
seemingly
simple,
but
very
complicated
behavior”
that
is
influenced
by
“many
interacting
factors,”

2

Mitchell,
Change4Life
Three
Year
Social
Marketing
Strategy,
Department
of
Health,
27.

63
many
of
which
are
“implicit
and
unconscious
intuitive
motions.”
3

He
adds
that
people
often
make

mistakes
in
problems
because
they
rely
on
intuitive
evidence
to
find
fast
solutions,
rather
than
on

reason
(particularly
when
they
are
under
time
pressure,
are
multi-‐tasking,
or
are
in
certain
moods).
4

This

often
occurs
when
people
are
making
food
choices.
Even
though
there
are
many
factors
involved,
the

individual
makes
the
choice
of
what
to
eat
without
putting
too
much
effort.
Changing
eating
behaviors

requires
making
conscious
decisions
about
what
to
eat.
Adopting
such
practice
can
be
time-‐consuming

and
emotionally
draining.

Overcoming
a
tobacco
addiction
is
by
no
means
an
easy
task.
One
strategy
used
by
people

struggling
with
it
is
to
avoid
contact
with
the
addictive
substance
or
triggering
situations.
For
instance,

the
individual
might
decide
to
throw
away
cigarette
packs
he
has
at
home,
to
stop
going
to
the
store

where
they’re
sold,
and
to
stay
away
from
the
bar
scene.
When
it
comes
to
food,
however,
avoiding

triggers
and
contact
with
the
stimuli
is
not
an
option:
everyone
has
to
eat
and
food
is
everywhere.

7.4. Lack
of
clear
“prescription,”
solution
or
message
to
offer

For
communicators,
the
lack
of
a
single
solution
and
the
fact
that
all
solutions
are
complex
pose
a

messaging
challenge.
In
anti-‐smoking
campaigns
the
message
is
as
simple
as
“quit
smoking;”
in

vaccination
campaigns,
“get
vaccinated;”
and
in
anti-‐littering
campaigns,
“stop
littering.”
When
it
comes

to
anti-‐obesity
communication,
however,
the
message
can’t
be
“stop
eating.”

Communicators
are
left

with
very
vague
and
subjective
messaging
options.
The
definition
of
healthy
varies
from
person
to

person.
Words
such
as
balanced,
nutritious,
good
for
you,
moderation,
less,
and
adequate,
depend
on

the
audience’s
perception,
education,
experience,
and
environment.
In
addition,
individuals
have

different
nutritional
requirements,
thereby
complicating
messages
about
portion
sizes.
The
differences

3

Koster,
“Psychology
of
Food
Choice,”
(lecture,
Wageningen
University,
Netherlands,
uploaded
April
2012).

4

Ibid.

64
among
individual
requirements
means
that
communicators
need
to
be
careful
not
to
offer
messages

that
are
healthy
for
some,
but
unhealthy
for
others.
For
example,
an
advertisement
that
attempts
to

show
an
“adequate”
portion
size,
might
show
what
is
adequate
for
an
adult,
but
might
send
children

and
their
parents
the
wrong
message.

The
same
applies
to
other
behavior
changes
that
are
addressed
in
anti-‐obesity
programs.
For

example,
“be
more
active”
can
take
on
many
forms.
A
person,
who
spends
all
day
sitting,
might
think

that
walking
for
five
minutes
will
make
a
difference.
At
the
same
time,
a
person
who
is
over-‐exercising

might
think
they
need
to
do
more
and
injure
themselves
in
trying
to
comply
with
the
advice.

7.5. Audience
is
not
easy
to
identify

Another
issue
in
designing
anti-‐obesity
campaigns
is
the
fact
that
audiences,
that
is
individuals

who
are
overweight
or
obese
or
people
who
are
at
risk,
are
not
easy
to
identify.
“Unlike
other
health

promotion
categories
(smoking,
drugs,
alcohol),
in
which
a
given
individual
either
does
or
does
not

exhibit
risky
behaviors,
everyone
exhibits
the
behaviors
that
can
lead
to
weight
gain:
we
all
eat,
we
all

travel,
we
all
have
to
find
ways
to
spend
our
leisure
time.
The
difference
between
a
healthy
and
an

unhealthy
diet
or
healthy
and
unhealthy
levels
of
activity
can
be
remarkably
small,
and
marginal

imbalances
of
energy
in
versus
energy
out
will
lead
to
weight
gain,
if
maintained
for
long
periods.”
5

Thus,
it
can
be
difficult
for
communicators
to
successfully
identify
and
target
the
audience
in
need.

7.6. Lack
of
awareness
or
acceptance
of
themselves
and
their
family
members
as
obese
or
overweight

On
the
topic
of
target
audiences,
individuals
are
often
unaware
that
they
or
their
family
members

are
overweight
or
obese.
This
was
made
apparent
in
a
survey
conducted
in
Colorado,
which
found
that

while
81%
of
respondents
believed
that
there
is
an
obesity
problem
in
the
state,
88%
rated
their
health

5

Department
of
Health,
Change4Life
Marketing
Strategy,
Department
of
Health,
17.

65
as
good
or
better.
When
asked
about
exercise,
53%
said
they
were
doing
enough,
while
57%
said
their

friends
were
not
doing
enough.
6

The
United
Kingdom’s
department
of
health
found
a
similar
tendency.

While
about
a
third
of
children
in
the
United
Kingdom
are
overweight
or
obese,
only
5%
of
parents

described
their
children
as
so.
7

This
means
that,
if
the
message
does
reach
the
“correct”
individuals,

they
may
not
realize
that
they
are
overweight,
obese,
or
at
risk,
and
therefore
they
might
ignore
it.

7.7. Wide
age
range
of
affected
populations

As
in
other
campaigns,
audience
segmentation
and
targeted
messaging
can
improve
the

effectiveness
of
anti-‐obesity
communication.
However,
the
audiences
in
anti-‐obesity
campaigns
can
be

so
varied
that
targeted
messaging
becomes
highly
multifaceted.

The
need
to
segment
by
age
can
be
particularly
tricky.
Obesity
affects
people
of
all
ages
and
each

age
segment
may
need
to
be
addressed
in
a
particular
way.
With
obesity-‐related
topics,
message

variations
may
not
only
be
necessary
in
terms
of
language
and
medium,
but
also
in
terms
of
substance.

For
instance,
“2,000
calories
is
what
you
should
eat
in
a
day”
would
not
only
be
too
difficult
for
certain

young
age
groups
to
grasp,
but
it
would
also
be
misleading.

Releasing
tailored
messages
for
different
audiences,
for
example
“middle-‐aged
adults
need
2,000

calories”
and
“senior
citizens
need
1,600
calories,”
can
be
confusing.
This
is
further
complicated
when

the
goal
is
to
motivate
the
adoption
of
new
behaviors
by
both
parents
and
children.
For
a
parent,
a

message
that
directs
adults
to
consume
six
grams
of
sodium
per
day
in
conjunction
to
another
message

that
suggests
toddlers
only
need
two
grams
can
be
puzzling.

6

Weiss,
“Colorado
Attitude
and
Behavior
Study,”
LiveWell
Colorado.

7

Department
of
Health,
Change4Life
Marketing
Strategy,
Department
of
Health,
20.

66

7.8. Cultural
issues
and
differences

Similar
to
age
segmentation,
obesity
affects
people
from
different
cultural
backgrounds
and

messages
should
also
be
customized
accordingly.
Failure
to
do
so
may
result
in
messages
that
are

incomprehensible
or
un-‐relatable
to
certain
segments
of
the
target
audiences.
In
many
cases,
message

adaptation
will
require
translations
into
various
languages,
using
different
media
outlets,
and
possibly

using
alternate
imagery.
In
addition,
practitioners
will
need
to
be
cognizant
of
cultural
sensibilities
that

might
make
the
messaging
seem
insulting
to
certain
groups.

In
obesity,
there
is
another,
more
complicated
factor
to
consider
when
addressing
audiences
of

various
cultural
backgrounds.
Certain
cultures
may
have
different
views
on
preferred
body
size
and
their

eating
habits
and
traditions
may
be
different.
For
instance,
while
in
mainstream
American
culture

unhealthy
levels
of
thinness
are
often
admired,
some
cultures
consider
larger
sizes
to
be
a
sign
of

wealth,
health,
or
beauty.
Keisha
Brown,
Senior
Vice
President
of
Lagrant
Communications
and

consultant
for
the
Robert
Wood
Johnson
Foundation
on
transmitting
anti-‐obesity
messages
to
Hispanic,

African
American,
and
other
minority
audiences,
explains:

“…in
our
cultures,
often
times,
African
American
and
Hispanic,
being
obese
is
not
always
a
bad

thing…
and
so,
culturally,
we
had
to
show
[our
clients]
and
let
them
know
that
people
can
get

offended
because
people
might
say…
‘I’m
thick-‐boned’,
‘obese?
I’m
not
obese.
I’m
curvy.
It’s

society
that
put
this
obese
title
on
me.
Not
my
culture.’
And
so
understanding
that,
allowed
us
to

take
a
different
approach
as
well…
In
our
communities,
sometimes
being
big
is…
in!
You

sometimes
hear
men
say
‘I
like
my
women
with
a
little
meat
on
their
bones.’”
8

8

Keisha
Brown,
phone
interview
with
author,
March
13,
2013.

67

7.9. Increased
number
of
channel
options

Anti-‐obesity
campaigns
are
being
designed
and
implemented
at
a
time
when
the
information

environment
is
going
through
a
radical
transformation.
The
increase
in
channel
and
tool
option
to

communicate
can
be
a
positive
thing
for
campaigns,
particularly
for
those
that
seek
to
engage.
For

example,
the
United
Kingdom’s
Change4Life
campaign
used
the
Internet
to
have
families
fill
the
“How

are
the
Kids?”
survey
and
provide
personalized
material
to
help
them
be
healthier.
While
they
also
used

postal
mail
to
send
the
questionnaire
and
material
to
some
families,
this
process
cost
more
and
took

significantly
more
time.
Los
Angeles
County
and
New
York
City
were
able
to
put
out
video

advertisements,
which
they
couldn’t
afford
to
air
on
television,
and
nonetheless
achieve
substantial

viewership
by
posting
them
on
YouTube
and
promoting
them
through
social
media.

On
the
flip
side,
the
increased
number
of
media
channels
can
be
a
challenge
for
public
health
and

other
communicators.
Having
limited
budgets,
they
must
be
careful
to
identify
which
of
these
new

channels
will
be
most
effective
in
reaching
their
target
audience.
At
the
same
time,
they
need
to
take

risks
by
experimenting
with
channels
and
strategies
that
haven’t
been
tested.

The
increased
number
of
channels
has
also
resulted
in
further
audience
segmentation.
For

instance,
it
used
to
be
the
case
that
people
watched
the
news
on
television,
heard
it
on
the
radio,
or

read
it
in
the
newspaper.
Today,
the
channel
options
have
expanded
to
also
include
millions
of
websites,

social
media
sites,
and
news
aggregators.
Thus,
effective
message
targeting
requires
figuring
out
where

members
of
an
audience
can
be
reached,
what
message
will
motivate
them,
and
how
that
message
will

best
be
transmitted
in
a
particular
channel.

68
7.10. Benefits
of
promoted
behaviors
are
difficult
to
explain
and
require
time
and
persistence

Anti-‐obesity
campaigns
promote
a
change
in
behavior
that
requires
effort,
and
promise
a
result

that
will
take
time
and
consistency
to
become
apparent.
For
instance,
if
an
overweight
person
walks
two

miles
one
day,
he
will
most
likely
not
see
any
immediate,
visible
results.
In
fact,
the
person
will
most

likely
feel
pain
or
fatigue
associated
with
the
increase
in
activity.
Not
receiving
that
an
immediate

reward,
and
possibly
facing
a
negative
consequence,
makes
it
less
likely
that
the
individual
will
choose
to

take
the
same
advice
and
go
out
for
a
walk
the
following
day.

If
the
individual
is
disciplined
enough
and
continues
to
walk
daily
for
a
certain
amount
of
time,

some
results
may
become
palpable,
but
many
more
will
not.
For
example,
the
individual
may
lose

weight
and
be
able
to
walk
further
distances,
which
are
visible
and
measurable
achievements.
However,

the
non-‐visible
achievements
may
also
include
the
prevention
of
a
heart
attack
or
a
delay
in
the
onset
of

diabetes.
While
these
might
be
greater
benefits
than
the
actual
perceived
weight
loss
and
ability
to
walk

further,
they
are
vague
and
possibly
less
motivating.

For
a
communicator,
promising
and
explaining
such
abstract
benefits
in
a
way
that
moves
people

to
adopt
new
behaviors
is
challenging.
This
can
be
particularly
difficult
when
addressing
individuals
who

are
not
currently
overweight,
but
are
at
risk,
or
who
are
slightly
overweight
because
they
are
currently

not
facing
negative
consequences.

Explaining
the
possible
financial
benefits
of
engaging
in
healthy
behaviors
due
to
reduced
health

care
costs
can
be
even
more
challenging.
This
is
particularly
true
when
trying
to
explain
the
societal

benefits
that
result
from
lower
public
health
care
expenditure.

Anti-‐obesity
campaigns
are
similar
to
anti-‐smoking
efforts
in
this
regard,
albeit
to
a
lesser
extent.

The
satisfaction
that
smokers
get
from
cigarettes
is
immediate,
in
the
same
way
that
eating
something

unhealthy
with
a
delicious
taste
offers
immediate
satisfaction.
Both
efforts
also
share
the
challenge
of

communicating
the
benefits
of
quitting
and
improved
health
in
the
long
run,
which
are
often
vague
and

69
take
time
to
materialize.
To
the
advantage
of
communicators
working
on
anti-‐obesity,
the
negative,

short-‐term
consequences
of
adopting
new
nutrition
and
physical
activity
behaviors
are
less
intense
and

have
a
shorter
duration
than
is
the
case
with
tobacco
cessation.
For
instance,
the
body
adapts
quickly
to

a
new
exercise
routine
and
the
pain
or
fatigue
only
lasts
a
few
days,
while,
in
contrast,
it
takes
much

longer
to
overcome
the
headache-‐causing
addiction
to
nicotine.

7.11. Costs
of
encouraged
behavior
is
higher
(or,
at
least,
perceived
to
be
higher)
than
the
current

The
complexity
of
transmitting
the
future
financial
benefits
resulting
from
lower
health
care
costs

is
exacerbated
by
the
fact
that
engaging
in
the
encouraged
behaviors
will
likely
represent
higher
costs
in

the
present.
Whether
it
is
time
spent
going
for
a
walk
or
the
cost
of
replacing
the
potato
chips
with

more
expensive
carrot
sticks,
the
healthier
behavior
tends
to
be
more
costly.
Some
may
argue
that
the

healthy
foods
are
not
necessarily
more
expensive,
however,
the
fact
that
most
people
perceive
them
to

be
is
enough
to
make
behavior
change
less
plausible.

This
is
not
the
case
in
other
public
health
campaigns,
which
discourage
a
behavior
that
has
a
clear

and
easy
to
explain
cost
and
is
more
expensive
than
the
behavior
being
promoted.
For
example,

cigarettes
have
a
set
price
range,
which
is
posted
at
the
store
and
incurred
every
time
a
consumer

decides
to
purchase
a
new
pack.
Not
having
to
spend
that
money
could
be
an
immediate
incentive
to

quit.

7.12. Changes
in
average
portion
sizes
and
norm
of
acceptable
portion
sizes

Anti-‐obesity
strategies
need
to
counter
the
growth
in
portion
sizes
served
at
restaurants
and
sold

as
packaged
food.
In
doing
so,
the
campaign
will
mold
a
social
norm
of
what
an
average
portion
looks

like.
Brian
Wansink,
PhD
and
Koert
Van
Ittersum,
PhD
point
out
that
not
only
have
packaged
goods
and

70
restaurant
portions
grown,
but
so
have
the
average
dinnerware
and
glasses
used
in
homes,
as
well
as

the
portion
sizes
suggested
in
recipe
books.
9

The
increase
in
the
size
of
portions
wouldn’t
be
a
problem
if
it
didn’t
translate
into
larger
volumes

of
consumption.
However,
the
average
American
today
consumes
about
500
more
calories
than
the

average
American
30
years
ago.
10

In
addition,
studies
suggest
that
“people
tend
to
eat
more
from

larger-‐sized
restaurant
portions
(in
the
general
range
of
30%
to
50%
more)
and
they
tend
to
serve

themselves,
and
eat
more
from
larger-‐sized
packages
(in
the
general
range
of
20%
to
40%
more).”
11

According
to
the
authors,
this
behavior
does
not
vary
by
the
subject’s
level
of
education,
weight,
hunger,

or
preference
for
the
particular
food.
Furthermore,
they
point
out
that
even
when
educated
about
the

tendency
to
eat
more
from
larger
serving
packages,
people
still
consumed
more
in
such
circumstances.

From
a
public
communication
perspective,
these
findings
are
quite
disconcerting.
Is
there
any

role
for
communicators
in
solving
the
portion-‐size
distortion
problem?
Wansink
and
Van
Ittersum

suggest
that,
rather
than
reminding
people
that
portions
sizes
are
distorted,
they
need
to
be
motivated

to
buy
smaller
portions
and
packages.
If
they
are
correct,
the
question
then
becomes:
how
can

individuals
be
motivated
to
purchase
a
package
size
that
is
more
expensive
per
ounce?

7.13. Mixed
messages
from
media
and
industries

Another
external
factor
that
can
distort
people’s
food
choices
is
the
media.
Every
day
people
are

bombarded
with
messages
about
food
products,
miracle
diets,
and
exercise
equipment
that
will
make

them
thinner.
The
food
industry
uses
all
types
of
media
to
promote
their
products,
making
products

look
tempting
and
associating
them
with
positive
feelings
and
even
consequences
(such
as
becoming

more
popular
or
being
a
more
loving
parent).
According
to
the
Federal
Trade
Commission,
food

9

Wansink
and
Van
Ittersum,
“Portion
Size
Me,”
Journal
of
the
American
Dietetic
Association,
1103.

10

LACDPH,
“Portion
Control,”
ChooseHealthLA.com,
October
2012.

11

Wansink
and
Van
Ittersum,
“Portion
Size
Me,”
Journal
of
the
American
Dietetic
Association,
1103.

71
marketers
spend
about
$1.6
billion
a
year
on
marketing
to
children
alone,
the
majority
of
which
is
used

to
promote
unhealthy
foods.
12

At
the
same
time,
the
diet
and
weight-‐loss
industry
follows
a
similarly
aggressive
marketing

strategy
to
promote
their
products.
This
industry
often
promises
unrealistic
results
that
match
the
thin-‐
body
ideals
that
are
portrayed
by
the
mainstream
media.
Such
unattainable
body
ideals
along
with

pressure
from
weight-‐loss
advertising
make
many
feel
a
sense
of
personal
failure
and
extreme
anxiety.

The
strength
of
these
two
opposing
streams
of
messages
(food
promotion,
on
the
one
hand,
and

thinness,
on
the
other)
is
a
challenge
to
communicators
working
in
public
anti-‐obesity
campaigns
for

several
reasons.
First,
it
clutters
the
media
environment
and
takes
up
a
considerable
portion
of
the

audience’s
attention.
At
the
same
time,
if
the
anti-‐obesity
message
does
get
through,
it
will
be

competing
with
two
messages
that
are
far
more
attractive
in
the
short-‐run.
In
a
way,
public
health

messaging
says,
“No,
you
won’t
be
the
prettiest
girl
in
the
class,
and
no,
you
won’t
be
able
to
indulge
in

as
much
delicious
food
as
you
want,
but
we
promise
that
someday
you
won’t
have
to
deal
with
health

problems.”

7.14. The
message
competition
is
diffused,
difficult
to
identify,
and
extremely
powerful

The
message
battle
for
audience
attention
occurs
in
an
unlevel
playing
field.
The
gap
between
the

marketing
budget
of
the
food
and
beverage
industry
and
that
of
public
health
officials
is
usually

extremely
large.
For
instance,
in
2009,
the
annual
expenditure
by
the
food
and
beverage
industry
in
the

United
Kingdom
was
estimated
at
“£335
million
on
advertising
confectionery,
snacks,
fast
food

restaurants
and
carbonated
beverages.
This
[was]
set
against
an
anticipated
spend
of
£25
million
per

year
for
social
marketing
(including
all
media
and
costs)
to
prevent
childhood
obesity.”
13

According
to

12

Voiland
and
Haupt,
“10
Things
the
Food
Industry
Doesn't
Want
You
to
Know,”
U.S.
News,
March
30,
2012.

13

Department
of
Health,
Change4Life
Marketing
Strategy,
Department
of
Health,
40-‐41.

72
Advertising
Age,
McDonalds
spent
$1.37
billion
on
advertising
in
the
United
States
in
2011.
14

This

compares
to
the
CDC’s
annual
investment
of
about
$44
million
in
anti-‐obesity
campaigns.

The
problem
is
further
complicated
by
the
level
of
fragmentation
in
the
food
industry.
The

tobacco
industry
was
a
small
group
of
companies
that
could
be
easily
identified
by
public
health

professionals
working
in
anti-‐smoking
initiatives.
In
terms
of
communication,
it
was
clear
to
the

audiences
what
brands
and
products
were
being
referred
to
in
anti-‐smoking
advertisements.
Within
the

food
industry
however,
some
food
products
contribute
to
the
obesity
epidemic,
while
others
are

neutral,
and
still
others
are
beneficial.
In
addition,
many
members
of
the
food
industry
have
a

combination
of
both
“healthy”
and
“unhealthy”
products
in
their
portfolios.
A
fragmented
industry

makes
dialogue
and
agreement
less
likely,
and
it
complicates
educating
audiences
about
types
of
foods

and
brands
they
need
to
avoid.

This
reality
requires
that
practitioners
take
a
different
approach
when
working
with
the
industry.

They
need
to
come
to
terms
with
the
fact
that
in
the
end,
companies
have
to
respond
to
their

shareholders.
As
Patricia
Groziak,
Executive
Director
of
Nutrition
&
Wellness
at
GollinHarris,
explains,

“new
product
introductions
are
driven
by
consumer
demand.
So
if
there
is
no
consumer
demand,
it’s

not
going
to
stay
on
the
shelf
and
it
will
be
pulled.”

She
explains
that
companies
find
themselves
in
a

dilemma:
they
can’t
justify
manufacturing
products
that
won’t
interest
the
consumer.
15

Alli
Noller,
from
LACDPH,
believes
that
the
role
of
public
health
communicators
is
“to
provide

public
education
and
the
science
behind
it.”
She
goes
on
to
explain
that
they
do
“a
lot
of
research
to

make
sure
everything
[they]
talk
about
in
all
of
these
campaigns
is
thoroughly
vetted
in
the
scientific

14

Morrison,
“McD's
New
President,
Will
Marketing
Come
Under
the
Microscope?”
AdvertisingAge,

November
26,
2012.

15

Patricia
A.
Groziak,
phone
interview
with
author,
May
28,
2013.

73
literature.”
She
concludes
by
saying,
“I
think
that
is
all
we
can
do
and
what
we
must
do
as
a
public
health

[entity].”
16

Groziak
thinks
that
public
officials
and
companies
need
to
work
together
and
find
a
compromise.

She
believes
that
“...
there
is
a
certain
reality
that….
public
health
experts
live
in
and
then
the
reality
of

the
food
world…
so
those
realities
somehow
have
to
come
together
and
have
to
have
some
flexibility
on

both
sides
to
come
up
with
something
a
bit
more
meaningful…
and
over
time
too.”

The
three
departments
in
the
cases
analyzed
above
have
sought
ways
to
work
with
the
food,

beverage,
or
food
retail
industries.
However,
the
tension
continues
and
communicators
need
to
take
it

into
consideration
when
drafting
their
strategies.

7.15. Lag
in
results
time

Losing
weight
takes
time.
Even
if
the
campaign
message
convinces
an
individual
to
adopt
the

encouraged
behavior
on
day
one
of
the
campaign,
the
person
might
not
be
successful
in
his
first
attempt

or
in
sustaining
the
healthy
behavior
over
time.
If
the
individual
does
continue
performing
the
new

behavior
consistently,
it
would
still
take
time
for
weight
loss
to
become
noticeable,
and
even
more
time

for
the
weight
loss
to
result
in
improved
health.
With
positive
reinforcement
lags
being
a
significant

hurdle,
there
are
much
higher
chances
that
the
individual
will
lose
motivation.

When
it’s
placed
into
the
context
of
society,
the
lag
in
results
is
even
more
pronounced.
Even
if

some
individuals
start
losing
weight,
others
will
continue
to
gain.
On
average,
the
changes
will
mutually

exclude
and
it
will
seem
as
if
the
campaign
is
having
no
impact
at
all.
In
many
cases,
the
overall
societal

weight
gain
might
continue
to
be
larger
than
the
weight
loss,
which
would
make
it
seem
as
if
the

campaign
is
having
the
opposite
of
the
intended
effect.

16

Ali
Noller,
phone
interview
with
author,
November
7,
2012.

74
This
makes
monitoring
difficult
and
frustrating.
With
such
lags
in
results,
practitioners
have
a

difficult
time
using
monitoring
data
to
adapt
and
correct
the
course
of
the
campaign.
Moreover,
it

makes
justifying
the
expenditure,
something
that
is
expected
when
using
tax
revenues,
very
difficult.

Practitioners
use
other
tools
to
monitor
and
evaluate
the
impact
of
anti-‐obesity
campaigns
such
as

asking
people
whether
they
have
adopted
new
behaviors
upon
seeing
the
message.
However,
these

tools
can
be
flawed
(for
example,
due
to
responders’
bias)
and
they
can
be
expensive.

7.16. Stigma

Anti-‐obesity
campaigns
are
often
criticized
for
contributing
to
the
existing
social
stigma
against

overweight
and
obese
individuals.
Communication
efforts
that
intend
to
shed
light
on
the
health
risks
of

being
overweight
or
obese
might
unintentionally
harm
the
very
same
individuals
they
are
trying
to
help.

In
addition
to
being
disapproving
of
their
physical
appearance,
today’s
society
unfairly
labels

overweight
and
obese
individuals
as
lazy,
irresponsible,
and
lacking
self-‐control.
Such
labels
can
lead
to

discrimination
in
the
workplace,
rejection
in
the
dating
scene,
and
bullying
among
children.
In
her
book

“What's
Wrong
with
Fat?”
Abigail
C.
Saguy,
a
Professor
of
Sociology
at
the
University
of
California
Los

Angeles
points
out
other,
less
visible
implications
of
the
social
stigma
surrounding
obesity.
She
explains

that,
“weight-‐based
stigma
represents
a
barrier
to
health
care
access,
which,
in
turn,
leads
to
later

detection
and
increased
rates
of
cervical
cancer
among
‘obese’
women.”

In
addition,
obese
children
are

often
depicted
as
victims
of
child
abuse,
which
leads
to
their
parents
being
looked
down
upon
by
their

peers.
She
also
points
out
that
messages
regarding
the
social
economic
costs
of
obesity
could
portray

non-‐overweight
individuals
as
being
victimized
by
those
who
are
obese.
17

17

Saguy,
What's
Wrong
with
Fat?
Kindle
Location
591.

75
7.17. Shame
can
backfire

Anti-‐obesity
campaigns
that
make
individuals
feel
shame
can
backfire
and
be
counter
productive.

Georgia’s
2012
anti-‐obesity
campaign,
“Stop
Sugarcoating,”
rekindled
the
discussion
regarding
the
use

of
social
shame
to
fight
obesity.
With
messages
such
as
“Obesity
takes
the
fun
out
of
being
a
child,”
the

campaign
attracted
criticism
from
some
for
blaming
the
obese
for
their
problem,
and
praise
from
others

for
being
upfront
about
the
situation.
18

One
supporter
of
using
shame
as
a
strategy
against
obesity,
Dr.
Daniel
Callahan,
published
an

article
on
the
Hastings
Center
Report
in
support
of
it.
According
to
Callahan,
education,
food
labeling,

infrastructure,
and
all
other
strategies
have
been
attempted
and
have
failed.
Because
nothing
else
has

worked,
he
suggests
that
shame
should
be
used.
He
points
to
the
successful
anti-‐tobacco
movement,

which
fostered
negative
stigma
towards
smoking
and
shamed
smokers
into
quitting.
19

Susan
B.
Apel,
a
professor
at
Vermont
Law
School,
disagrees
and
argues
that
overweight
and
obese

individuals
have
been
discriminated
and
have
felt
shame
for
years,
and
that
that
hasn’t
motivated
them

to
change.
20

Others
have
pointed
out
that
for
some
individuals,
shame
will
trigger
and
lead
to
more

overeating.
According
to
HelpGuide.org,
many
individuals
with
binge
eating
disorders
use
food
as
a

coping
mechanism
to
deal
with
uncomfortable
feelings,
including
shame.
These
individuals
find

themselves
trapped
in
a
cycle
in
which
they
eat
for
comfort
from
the
feeling
of
shame,
feel
shame
for

having
binged,
and,
as
a
result,
binge
again.
Feeding
that
cycle
would
only
make
the
problem
worse.

7.18. Possible
unintended
message
“side
effects”

Messages
used
in
anti-‐obesity
campaigns
can
have
unintended
“side
effects.”

For
instance,
many

people
suffering
from
diabetes
feel
they
are
stigmatized
and
seen
as
having
brought
the
disease
on
to

18

Salahi,
“'Stop
Sugarcoating'
Ads
Draw
Controversy,”
ABCNews.com.

19

Callahan,
“Obesity:
Chasing
an
Elusive
Epidemic,”
The
Hastings
Center
Report,
34-‐40.

20

Apel,
Susan
B.,
“Obesity
and
Public
Health,”
Bioethics.net
(blog).

76
themselves.
As
a
member
of
TuDiabetes.org,
an
online
community
for
people
suffering
from
diabetes,

wrote
on
November
28,
2010,
“[individuals
with
Type
2
diabetes]
have
the
same
problem
as
lung
cancer

sufferers
-‐-‐
that
weird
blame
game
that
says
‘you
caused
your
own
problem
with
your
bad
habits,
so

now
you
need
to
just
live
(or
die)
with
it.’”
21

Anti-‐obesity
communication
often
contributes
to
spreading

this
type
of
stigma
by
reinforcing
the
link
between
obesity
and
diabetes.

The
stigma
is
often
extended
to
individuals
with
Type
1
Diabetes
(which
is
not
associated
with

obesity).
Not
only
is
this
a
problem
of
being
wrongfully
judged,
but
according
to
Dr.
Greenberg,
author

of
50
Diabetes
Myths
That
Can
Ruin
Your
Life:
And
the
50
Diabetes
Truths
That
Can
Save
It,

"when
the

two
types
[Diabetes
1
and
2]
are
lumped
together,
it's
hard
for
organizations
committed
to
finding
a

cure
for
Type
1
to
really
get
funded.
If
policymakers
don't
understand
the
difference
between
the
two
—

they
are
thinking
people
need
to
move
more
and
eat
less
—
it's
going
to
be
hard
to
help
cure
Type
1."
22

Another
possible
unintended
side
effect
that
communicators
need
to
avoid
is
the
over
veneration

of
lean
bodies.
A
2012
study
conducted
by
researchers
from
the
University
of
the
West
of
England

explored
the
perception
and
reaction
of
a
group
of
women
diagnosed
with
eating
disorders
towards

examples
of
anti-‐obesity
campaigns.
23

The
researchers
concluded
that
the
messages
tended
to
suggest

an
“association
between
fat
and
bad,
and
thin
and
good.”
They
also
promoted
certain
unhealthy
eating

practices
such
as
the
labeling
of
good
and
bad
foods
and
failed
to
talk
about
the
dangers
of
extreme

thinness.
The
conclusions
of
this
study
cannot
be
read
to
mean
that
anti-‐obesity
campaigns
are
causing

people
to
develop
eating
disorders.

24

However,
they
should
serve
as
caution
to
practitioners
to
make

sure
that
they
are
not
hurting
one
(albeit
smaller)
group
of
people
when
trying
to
help
another.
It
is

21

Elizabeth,
TuDiabetes.org
Discussion
Forum,
November
28,
2010.

22

Greenberg,
50
Diabetes
Myths
That
Can
Ruin
Your
Life:
And
the
50
Diabetes
Truths
That
Can
Save
It,
Da

Capo
Lifelong
Books,
July
14,
2009,
quoted
in
Deardorff,
“Diabetes’
Civil
War,”
Health,
Chicago
Tribune.

23

Catling
and
Malson,
“Feeding
a
fear
of
fatness?”
Psychology
of
Women
Section
Review,
Spring
2012.

24

Andrea,
“Interpreting
Anti-‐Obesity
Campaigns,”
ScienceofEds.org.

77
important
to
note
that,
because
these
unintended
messages
can
be
subliminal,
they
may
be
easily

overlooked
during
traditional
message
testing
exercises.

7.19. Limitations
associated
with
public
funding

Every
communications
campaign
is
restricted
by
the
size
of
its
budget,
and
it
is
the

communicator’s
job
to
allocate
it
in
the
most
efficient
way
possible.
However,
practitioners
dealing
with

public
funding
face
additional
restrictions
and
complications.
Publicly
funded
project
are
subject
to

scrutiny
by
citizens
and
require
transparency.
Therefore,
practitioners
need
to
make
sure
that

everything
they
do
can
be
justified
in
a
way
that
will
be
acceptable
to
all
segments
of
the
public.
In
other

words,
they
may
have
to
forgo
certain
strategies
they
consider
would
be
effective,
because
they
are

highly
charged
or
polarizing,
or
because
they
would
be
unacceptable
to
some
constituents.

In
addition,
budgets
for
public
projects
tend
to
be
inflexible.
The
money
allocated
for
a
certain

purpose
needs
to
be
spent
in
the
way
that
was
established
when
the
project
was
approved.
For

instance,
for
the
Los
Angeles
“Choose
Less.
Weigh
Less.”
campaign,
LeVeque
recalls
having
to
use
a

certain
amount
of
money
for
outdoor
advertising,
even
if
he
thought
it
could
be
more
efficiently
used

elsewhere.
He
also
mentions
being
unable
to
buy
social
media
advertisements,
which
he
considered

would
have
significant
reach,
because
they
didn’t
fit
into
any
of
the
projects’
budget
lines.
The
budget

rigidity
and
the
fact
that
public
procurement
processes
are
often
long
and
cumbersome,
also
makes
it

difficult
to
react
in
a
timely
manner
to
changes
in
the
audience
or
the
environment.

7.20. Limited
resources:
time
and
money

Perhaps
the
most
pressing
challenge
in
anti-‐obesity
public
communication
is
one
that
relates
to

many
of
the
issues
previously
mentioned:
the
extensive
amount
of
time
and
resources
required
to

create
an
impact.
Since
they
address
everyday
lifestyle
behaviors
that
require
constant
reinforcement

78
and
that
can
be
difficult
to
understand,
anti-‐obesity
messaging
needs
to
be
maintained
over
an

extended
period
of
time
in
order
to
produce
results.
Many
initiatives
with
a
potential
to
cause
a
dent
in

the
obesity
epidemic
have
been
fruitless
because
of
such
restrictions.
One
extreme
example
is
the

LACDPH’s
“salt
shocker”
series,
which
had
a
time
frame
of
only
three
weeks
and
an
extremely
limited

budget.
Despite
the
videos’
success
in
terms
of
viewership,
the
initiative
may
have
driven
individuals
to

the
contemplation
stage,
but
not
any
further.
In
contrast,
New
York
City’s
sugary
beverage
campaign
has

offered
constant
reinforcement
and
has
addressed
different
components
of
the
main
message
over
a

period
of
three
years.
Thus,
New
Yorkers
have
had
longer
exposure
to
the
messages
and
received

continuous
support
as
they
move
along
the
behavior
change
process.

In
addition
to
requiring
extended
periods
of
time,
anti-‐obesity
efforts
are
often
cut
back
because

they
don’t
produce
palpable
results
in
the
short
run.
Moreover,
in
some
cases
when
such
efforts
are

being
implemented
by
public
agencies,
they
can
also
be
subject
to
budget
cuts
due
to
political
or

ideological
reasons.
The
responsibility
rests
on
the
practitioners
who
need
to
work
on
managing
the

expectations
of
leaders
and
funders,
and
on
making
them
aware
of
the
time
and
money
that
these

efforts
require.

The
value
of
a
consistent,
comprehensive,
and
long-‐term
effort
is
best
exemplified
by
the
anti-‐
smoking
movement,
which
achieved
a
reduction
in
the
percentage
of
adult
smokers
in
the
United
States

from
42%
in
1965
to
19%
in
2011.
25

While
the
achievements
are
significant,
after
more
than
45
years
of

varying
degrees
of
anti-‐smoking
efforts,
tobacco
use
continues
to
be
a
significant
health
concern.

Reversing
the
obesity
epidemic
will
require
a
similarly
persistent
and
well-‐funded
effort.

25

“Trends
in
Current
Cigarette
Smoking,”
CDC,
last
modified
December
7,
2012.

79

CHAPTER
EIGHT:
Key
Takeaways
and
Conclusions

Unfortunately,
there
is
no
magic
pill
that
will
eradicate
obesity,
nor
is
there
a
magic
message,

communication
strategy,
or
channel.
In
fact,
there
is
no
conclusive
evidence
of
any
large-‐scale
effort

that
has
had
a
significant
long-‐term
impact
on
obesity
levels
or
on
the
adoption
of
healthy
behavior

conducive
to
healthy
weight
maintenance.
However,
there
are
signs
of
progress.
Some
cities
have
seen

reductions
in
childhood
obesity
levels,
there
are
more
healthy
products
in
the
market,
and
today’s

society
is
becoming
increasingly
health
conscious.

There
are
indications
that
certain
communication
undertakings
have
been
a
good
investment;
as

there
are
signs
that
mistakes
have
been
made
along
the
way.
While
there
are
no
long-‐term
results

currently
available,
it
is
possible
and
important
to
begin
learning
from
the
lessons
that
those
small

achievements
and
mistakes
from
previous
campaigns
offer.
The
following
list
compiles
the
key

takeaways
and
conclusions
that
have
resulted
from
six
months
of
academic
research,
campaign
analysis,

and
conversations
with
experienced
public
health
communicators
and
experts.
Hopefully
this
list
will

contribute
to
future
anti-‐obesity
public
communication
work
that
will
produce
long-‐lasting
results.

8.1. Identify,
segment,
and
understand
the
target
audience

Obesity
is
a
complicated
issue
that
is
influenced
by
cultural,
physical,
psychological,
and

environmental
factors.
As
such,
it
affects
populations
in
different
ways.
Public
officials
need
to

understand
the
particular
situation
that
their
target
audience
is
facing
in
order
to
provide
effective

support.
This
involves
knowing
the
population’s
cultures,
preferred
language,
and
way
of
life.
It
also

requires
studying
the
population’s
health
to
understand
which
segments
are
most
affected
by
obesity

80
and
how,
1

and
to
prioritize
resources
accordingly.
With
limited
funding,
it
might
also
be
necessary
to

prioritize
based
on
the
audience’s
likelihood
of
reversing
their
situation.
The
Change4Life
plan
clearly

states
that
the
“strategy
[would]
focus
resources
on
areas
of
greatest
need
(i.e.
those
families
whose

current
behaviors,
attitudes
and
beliefs
suggest
that
their
children
are
most
at
risk
of
becoming
obese)

and
where
marketing
can
have
the
most
impact
(i.e.
where
there
is
still
scope
for
a
less-‐intensive

lifestyle
intervention).”
Their
(most
likely
correct)
assumption
was
that
social
marketing
could
do
little
to

help
individuals
who
were
at
imminent
risk
or
already
suffering
from
an
obesity-‐related
chronic
disease.
2

Practitioners
should
evaluate
if
there
are
significant
differences
between
segments
of
a
given

population.
For
instance,
LeVeque
explains
that
LACDPH’s
research
found
that
“Latinos
see
diabetes
as

an
inevitable
part
of
growing
old,”
a
belief
that
other
segments
of
their
target
population
did
not
share.

Another
way
to
segment
a
population
is
by
the
stage
in
the
behavior-‐change
model
they
are
currently

in.
Failing
to
identify
the
correct
stage
will
result
in
either
promoting
behaviors
that
have
already
been

adopted,
or
ones
that
the
target
population
is
not
ready
to
adopt.
The
Change4Life
team
did
this

particularly
well
by
offering
families
catered
tips
and
resources
based
on
their
answers
to
the
“How
are

the
kids?”
questionnaire.
While
the
costs
of
such
an
effort
might
be
prohibitive
for
some
public
health

teams,
it
is
important
to
keep
in
mind
that
the
more
accurate
the
segmentation,
the
more
effective
the

communication
will
be
in
reaching
the
intended
audience.

The
type
and
extent
of
research
that
communication
teams
are
able
to
conduct
will
depend
on
the

budget
and
time
available.
Effective
research
methods
can
include
telephone
or
online
surveys,
focus

groups,
ethnographies,
questionnaires,
and
weight
and
health
measurements
taken
by
professionals.

1

Matthew
LeVeque,
phone
interview
with
author,
October
15,
2012.

2

Department
of
Health,
Change4Life
Marketing
Strategy,
Department
of
Health,
17-‐18.
81
8.2. The
audience
segment
that
seems
most
logical,
may
not
always
be
the
most
strategic

There
are
a
variety
of
ways
in
which
audiences
can
be
segmented,
however,
certain
categorization

approaches
are
more
common
than
others
(for
instance,
income,
age,
and
geographic
location).
At
the

same
time,
some
sorting
methodologies
are
easier
to
identify
and
target
than
others
(for
instance
age

vs.
appreciation
for
the
arts).
However,
it
is
important
to
question
whether
the
most
logical
or
the
most

intuitive
segmentation
will
be
the
most
effective.
In
addition,
it
is
important
to
take
the
time
to
reassess

if
the
initial
segmentation
strategy
remains
the
most
appropriate.

For
instance,
when
Change4Life
added
middle-‐aged
adults
as
a
target
audience
during
the

program’s
second
phase,
treating
them
as
a
separate
audience
segment
seemed
logical.
After
all,
their

nutrition
and
physical
activities
were
different
than
those
of
children.
However,
the
team
realized
that

some
middle-‐aged
adults
were
also
parents
and
therefore
part
of
the
families
who
were
already
being

targeted.

As
they
were
planning
for
stage
two,
the
Change4Life
team
also
took
the
time
to
reassess
their

strategy
for
segmenting
families.
During
phase
one,
audiences
had
been
broken
down
based
on

attitudes
and
behaviors.
The
team
soon
observed,
however,
that
the
pace
at
which
families
adopted

new
attitudes
and
behaviors
varied
and
that
such
segmentation
did
not
hold
constant.
In
response,
the

team
changed
its
strategy
to
dividing
the
audience
based
on
income,
so
that
they
could
prioritize
their

limited
funds
on
lower
income
individuals,
as
mandated
by
the
Department
of
Health’s
mission.

8.3. Understand
the
local
environment

Many
public
health
professionals
understand
the
obesity
epidemic
as
primarily
an
environmental

problem.
That
is,
there
are
particular
conditions
in
certain
localities
that
are
conducive
to
individuals

adopting
the
unhealthy
behaviors
that
result
in
weight
gain.
As
an
example,
people
who
live
in

82
neighborhoods
with
no
safe
place
to
engage
in
physical
activity,
no
access
to
fresh
produce,
and
mostly

fast
food
options,
have
a
difficult
time
engaging
in
healthy
behaviors
regardless
of
their
intentions.

It
is
important
to
understand
the
environment
in
which
a
target
audience
lives
so
as
to
avoid

suggesting
behaviors
that
are
impossible.
For
instance,
the
person
in
the
example
above
may
listen
to

and
understand
the
value
of
a
message
about
the
importance
of
eating
fruits
and
vegetables.
However,

having
no
access
to
fresh
produce,
she
will
be
unable
to
follow
the
advice.
The
message
intended
to
help

those
most
in
need
will
be
ineffective,
or
even
worse,
make
these
people
feel
ashamed
or
frustrated.

8.4. Understand
your
media
market

The
media
environment
is
different
in
each
market
and
therefore,
medium
choices
that
are

feasible
and
cost-‐effective
in
one
locality
may
not
be
in
another.
For
instance,
a
television
spot
in
New

York
City,
which
is
one
of
the
most
expensive
media
markets
in
the
country
and
a
place
where
people

lead
busy
lives,
may
not
be
a
good
choice.
On
the
other
hand,
in
a
slower-‐paced
area
where
a
spot
is
less

expensive
and
people
watch
more
television,
a
commercial
might
be
a
good
investment.

Other,
more
subtle
characteristics
are
also
important
to
consider.
For
example,
in
New
York
City,

where
large
percentages
of
the
population
use
the
subway
system,
the
Health
Department
has
found

that
posters
inside
the
trains
and
advertisements
on
free
circulation
papers
distributed
at
subway

stations,
are
the
most
cost-‐effective
channels.
In
Los
Angeles,
on
the
other
hand,
more
people
drive

their
cars
and
use
public
transportation
less.
Therefore,
LACDPH
chooses
to
buy
space
on
public

transportation,
but
opts
for
posters
on
the
outside
of
buses,
where
they
are
visible
to
car
drivers
and

pedestrians.
These
choices
not
only
affect
the
media
strategy
and
budget,
but
also
play
a
role
in
the

campaign’s
art.
For
instance,
people
usually
see
posters
inside
the
train
or
in
a
free
circulation
paper
for

a
longer
time
(a
few
more
seconds
at
least),
while
signage
on
a
bus
that
is
driving
by
is
seen
for
only
an

83
instant.
The
first
one
allows
for
smaller
and
more
text,
while
the
latter
requires
delivering
the
main

message
in
a
fast
and
impactful
way.

8.5. Test
messages

Every
professional
interviewed
for
this
research
who
has
experience
in
anti-‐obesity
public
health

campaigns
stressed
the
importance
of
message
testing
with
members
of
the
target
audience.
Caroline

Wallace,
from
the
New
York
City
Health
Department
explained,
“we
don’t
get
them
right
the
first
time;

and
that
is
why
it
is
such
a
good
idea
to
test.”
3

If
there
are
segments
with
different
cultures,
languages

and
education
levels
or
living
in
different
environments,
it
is
important
to
test
the
messages
with
each

one.
While
theory
and
examples
from
past
campaign
can
provide
valuable
guidance,
a
message’s

effectiveness
may
vary
from
one
audience
to
the
next
and
therefore
should
be
tested
with
the
audience

that
will
be
consuming
it.

8.6. Use
social
media
for
research

While
the
ever-‐changing
social
media
sphere
is
daunting,
it
can
also
be
an
inexpensive
and

effective
medium
to
reach
current
and
new
audiences.
In
addition,
social
media
can
be
used
for

audience
research
and
for
testing
applications,
strategies,
or
even
messaging.
Caroline
Wallace
explains

that
her
team
has
used
social
media
to
“take
the
temperature
of
the
audience’s
sentiment”
towards

particular
topics
and
particular
campaigns.
4

For
instance,
the
online
conversation
regarding
a
proposal

to
limit
the
size
of
sugary
drinks
sold
in
restaurants
can
provide
important
insights
for
designing
the

most
appropriate
strategy
to
support
the
initiative.
If
practitioners
are
unsure
which
of
two
image

3

Caroline
Wallace,
phone
interview
with
author,
November
29,
2012.

4

Ibid.

84
options
would
be
better
received
by
the
public,
they
could
test
them
on
social
media
before
incurring

the
costs
of
publishing
in
other
media.

8.7. Extract
the
positive
and
improve

Campaign
redesigns,
the
launching
of
a
new
phase,
a
change
in
season,
or
the
beginning
of
new

budget
cycle
should
be
used
as
opportunities
to
pause,
evaluate
previous
work,
and
improve
wherever

possible.
During
evaluation
pauses,
it
can
be
very
tempting
to
focus
on
what
has
been
achieved
and

continue
with
the
same
strategy.
However,
whenever
there
is
an
opportunity
to
make
modifications,

practitioners
should
focus
on
what
has
not
worked
and
improve
it.
For
instance,
New
York
City’s
2010

sodium
reduction
campaign
was
effective
in
raising
awareness
about
the
importance
of
limiting
sodium

consumption,
but
provided
little
guidance
on
how
to
evaluate
foods.
The
April
2013
campaign
used

similar
applications
to
those
used
in
2010,
but
included
the
necessary
explanation
of
where
to
find

sodium
content
information.

8.8. Don’t
reinvent
the
wheel,
but
do
try
to
improve
it
and
adapt
as
necessary

Anti-‐obesity
campaigns
are
being
designed
and
implemented
throughout
the
world.
It
is
very
likely

that
one
that
has
worked
well
with
one
population
can
work
well
with
similar
populations.
If
a

practitioner
sees
such
an
opportunity,
he
would
be
wise
to
use
it
thereby
saving
time
and
money
in

designing
a
new
one.
However,
it
is
important
to
take
the
time
to
consider
improvements
and
also

adaptations
required
by
the
local
audience,
environment,
and
media
market.
The
Los
Angeles
team
was

effective
in
doing
so
when,
in
2011,
it
adapted
the
2010
New
York
City
sugary
drinks
campaign
to
fit
the

local
needs.
Los
Angeles
County
launched
the
same
campaign
with
slight
modifications
such
as
adding
a

question
to
make
the
audience
contemplate
about
their
current
behavior.
The
campaign
also
reversed

the
flow
of
beverage
transformation
from
sugar
being
poured
into
the
soda
to
an
image
of
a
soda

85
turning
into
sugar.
The
modifications
made
were
small
but
significant
and
they
increase
the

advertisements’
effectiveness.

8.9.
Past
public
health
efforts
can
be
informative,
but
know
that
each
topic
has
its
own
complexities

Obesity
is
a
fairly
recent
problem
in
society,
which
means
that
today’s
social
marketing
experts
are

pioneering
strategies
to
combat
it.
With
no
preceding
anti-‐obesity
campaigns
to
learn
from,
studying

successful
campaigns
addressing
other
public
health
issues
can
be
valuable.
For
instance,
an
analysis
of

the
Mother’s
Against
Drunk
Driving
(M.A.D.D.)
campaign
suggests
that
its
success
was
a
result
of
the

group’s
push
to
make
M.A.D.D.
a
society-‐wide
movement.
This
worked
for
drunk
driving
because
it
can

affect
anyone
and
it
had
a
clear,
behavioral
solution.
It
is
unlikely
that
Change4Life
based
its
strategy
on

M.A.D.D.’s
experience.
However,
it
follows
a
similar
approach
(creating
a
society-‐wide
movement),

which
is
successful
because
obesity
can
affect
anyone
and
has
a
behavioral
solution.

On
the
other
hand,
the
fact
that
a
strategy
has
been
successful
in
modifying
behaviors
related
to

one
topic
does
not
necessarily
mean
that
it
will
work
for
obesity.
To
compare,
one
important
strategy

used
in
anti-‐tobacco
campaigns
was
targeting
children
and
teenagers
before
they
started
smoking.

Prevention
was
easier
than
promoting
cessation.
However,
the
same
strategy
would
not
be
effective
in

addressing
obesity
because
people
of
all
ages
can
be
obese
or
overweight,
and
people
of
all
ages
can
be

at
risk
and
in
need
of
prevention.
While
a
strategy
of
segmentation
by
age
group
was
effective
in
anti-‐
tobacco
messaging,
it
would
be
more
complicated
in
anti-‐
obesity
campaigns.

8.10. Plan
continuous
audience
research
and
subsequent
reassessment
of
strategy

Audience
research
can
be
expensive,
however,
it
is
far
more
expensive
to
implement
a

campaign
that
is
ineffective
because
it
is
designed
based
on
incorrect
assumptions
about
the
target

86
audience.
The
campaigns
in
New
York
City,
Los
Angeles
County,
and
the
United
Kingdom
had
strong

ongoing
research
and
evaluation
components.
In
each
case,
the
effort
proved
to
be
valuable.

An
ongoing
research
effort
is
important
because
audiences
evolve.
In
fact,
the
goal
of
public

health
campaigns
is
to
motivate
change.

However,
evaluation
for
the
sake
of
knowing
how
well
a

campaign
performed
is
not
sufficient.
Continuous
research
is
only
valuable
to
the
extent
that

practitioners
are
ready
and
open
to
use
it
to
modify
or
improve
their
strategy.

8.11. Expect
unexpected
delays

Communication
strategies
include
a
timeline
and
it’s
important
for
public
health
communicators

to
try
to
follow
it.
However,
this
is
not
always
possible
as
there
is
always
a
possibility
in
the
public
health

sphere
for
unexpected
events
that
force
departments
to
switch
their
current
focus.
For
instance,

Caroline
Wallace
explains
that
the
2013
floods
caused
by
storm
Sandy
in
New
York
City,
delayed
their

anti-‐obesity
communication
plans.
There
is
little
practitioners
can
do
to
prepare
for
such
events.

However,
delays
caused
by
factors
such
as
bureaucratic
bottlenecks
can
be
expected,
addressed
and

avoided.
When
avoiding
them
is
not
possible,
they
should
be
accounted
for
in
the
campaign’s
timeline.

8.12. Be
open
to
new
theories
and
ideas

Many
of
the
theories
and
approaches
used
in
behavior-‐modification
campaigns
were
developed

years
ago.
However,
it
is
important
to
stay
informed
and
be
open
to
new
theories
and
new
studies.

8.13. Evaluate
which
type
of
campaign
will
be
more
effective

Many
anti-‐obesity
communication
plans
are
being
implemented
along
side
other
anti-‐obesity

programs.
Yet,
most
of
them
would
also
make
sense
and
still
have
some
impact
if
they
were

implemented
alone.
It
is
still
important
to
consider
whether
communication
can
and
should
be
used
as

87
support
for
other
programs.
For
instance,
in
2012,
the
LACDPH
could
have
focused
on
physical
activity
or

any
other
topic
related
to
obesity.
However,
it
designed
its
campaign
to
support
the
new
law
that

requires
chain
restaurants
to
post
calories.
The
Department
understood
that,
at
that
point
in
time,

supporting
the
menu-‐labeling
initiative
would
have
a
greater
impact
than
any
other
stand-‐alone

campaign.

8.14. Consider
indirect
effects

The
direct
effect
that
an
anti-‐obesity
campaign
has
on
the
target
audience,
that
is,
whether
it

motivates
them
to
change
their
behaviors
or
adopt
healthier
ones,
might
not
be
the
only
tangible

achievement.
During
evaluation,
it
is
important
to
consider
whether
the
campaign
had
significant
side

effects
that
will
eventually
contribute
to
a
reduction
in
obesity
levels.
For
instance,
sugary
drinks

campaigns
have
placed
pressure
on
soda
companies
and
motivated
them
to
focus
more
marketing

dollars
on
healthy
drinks
as
opposed
to
sugary
ones.
Similarly,
quick-‐serve
restaurants
have

incorporated
more
“healthy”
options
to
their
menus,
not
necessarily
because
their
costumers
are

demanding
them,
but
rather
because
they
want
to
be
perceived
as
part
of
the
solution.
These
actions
by

the
industry
provide
positive
environmental
stimuli
for
the
target
audience
as
they
go
through
the

behavior
change
process.

Side
effects
are
not
limited
to
actions
by
the
food
and
beverage
industry.
Greater
awareness

about
healthy
behaviors
could
motivate
school
administrators
to
offer
longer
physical
education
classes,

to
impart
nutrition
lessons,
or
to
modify
the
cafeteria
menu.
At
the
same
time,
the
increase
in

awareness
could
motivate
private
organizations
to
implement
or
fund
anti-‐obesity
programs.
Measuring

such
indirect
successes
can
be
particularly
important
for
continued
support
and
funding.

88

8.15. Consider
targeting
the
public
at
risk
as
a
means
to
influence
an
alternate
audience

The
title
of
this
section
is
admittedly
confusing
and
can
be
best
explained
using
an
example.
A

practitioner
may
realize
that
a
campaign
that
suggests
eating
smaller
options
to
the
population
at
risk,

may
not
be
able
to
counter
the
overwhelming
amount
of
food
marketing
in
their
environment.

However,
practitioners
could
purposely
use
the
message
suggesting
healthier
choices
to
motivate
the

industry
to
offer
those
choices
in
anticipation
of
the
public’s
change
in
demand.

8.16. Consider
the
benefits
of
making
obesity
part
of
the
national
agenda

Even
campaigns
that
are
local
can
see
great
benefits
when
obesity
is
framed
as
a
national
concern

and
is
entered
into
the
political
agenda.
The
campaigns
in
New
York
City
and
Los
Angeles
County
were

positively
impacted
by
the
First
Lady’s,
Michelle
Obama,
“Let’s
Move”
Campaign.
Obama’s
campaign
has

been
criticized
for
various
reasons,
most
notably,
her
leniency
with
the
food
industry.
However,
one

thing
most
people
agree
on
is
that,
as
she
said,
“We’ve
really
changed
the
conversation
in
this
country.”
5

The
amount
of
attention
“Let’s
Move”
drew
to
the
topic
of
obesity
increased
the
prospects
of

obtaining
funding
for
cities
like
New
York
and
Los
Angeles.
By
framing
it
as
a
national
epidemic
and

raising
the
public’s
awareness
of
the
magnitude
of
the
problem,
people
have
become
more
approving
of

the
use
of
public
funds
for
anti-‐obesity
efforts.

8.17. Seize
political
capital,
it
can
go
a
long
way

Political
approval
and
the
public’s
perception
of
local
leadership
can
have
an
important
impact
on

anti-‐obesity
actions.
If
people
don’t
trust
their
local
leader,
they
might
not
trust
the
campaign
messaging

either.
For
instance,
according
to
Wallace,
Mayor
Bloomberg’s
political
capital
has
contributed
greatly
to

5

Shen,
“Food
Corporations
Watered
Down
Obama’s
Campaign,”
ThinkProgress.org.

89
the
Health
Department’s
efforts.
Bloomberg’s
credibility
as
a
businessman
has
earned
him
trust
from

the
public,
social
capital,
and,
often,
financial
support.
6

The
Mayor’s
personal
wealth
is
another
asset

that
he
has
not
been
shy
to
use
in
past
public
health
campaigns.
In
2012,
he
stated
“I
just
spent
roughly

$600
million
of
my
own
money
to
try
to
stop
the
scourge
of
tobacco.
I’m
looking
for
another
cause.”
7

Finally,
the
Mayor
doesn’t
face
the
same
threat
from
the
food
and
beverage
industries,
as
do
officials
in

other
cities.
Wallace
explains
that
the
Mayor
“is
lucky
because
he
is
less
beholden
to
special
interests”

and
the
industry
doesn’t
play
a
roll
in
his
campaign
money.
That
has
allowed
[the
Health
Department]
to

do
great
public
health
work.
8

In
the
same
way,
Michelle
Obama’s
political
capital
played
a
key
role
in
growing
the
“Let’s
Move”

movement.
She
attracted
media
wherever
she
went;
she
obtained
support
from
celebrities
(models,

singers,
and
athletes)
which
drew
a
variety
of
audiences;
and
she
was
heard
when
she
implored
to

public
officials
with
power
to
take
legislative
action.

8.18. Be
aware
that
while
using
celebrities
can
be
effective,
it
also
comes
with
risks

Another
reason
for
Michelle
Obama’s
power
to
influence
is
her
celebrity-‐status.
Mrs.
Obama
has

differentiated
herself
from
previous
first
ladies
by
being
more
politically
active
and
engaged
with
the

public.
As
a
result,
the
media
has
treated
her
like
a
celebrity:
discussing
her
wardrobe,
capturing
her
in

her
motherly
role,
etc.
To
many
women
across
the
country,
she
has
become
a
role
model.
Therefore,

her
voice
has
been
very
powerful,
not
only
in
the
political
arena,
but
also
among
the
public.

The
“Let’s
Move”
campaign
has
also
involved
other
celebrities
to
increase
its
reach.
Celebrities
can

be
extremely
valuable
in
reaching
out
to
particular
audiences
or
in
delivering
certain
messages.
For

6

Cardello,
“To
Win
the
War
on
Obesity,”
Forbes.

7

Grynbaum,
“Health
Panel
Approves
Restriction
on
Sale
of
Large
Sugary
Drinks,”
The
New
York
Times.

8

Caroline
Wallace,
phone
interview
with
author,
November
29,
2012.

90
example,
through
partnerships
with
“Let’s
Move,”
singer
Nelly
Furtado
encouraged
young
mothers
to

raise
healthy
children,
and
major
league
baseball
players
attracted
male
audiences.
9

Using
celebrities
in
campaigns
also
comes
with
risks.
When
a
celebrity
is
associated
with
a

campaign,
the
celebrity’s
future
behavior
or
changes
in
reputation
can
affect
the
initiative.
For
instance,

in
April
2011,
Beyoncé
became
a
public
endorser
of
the
“Let’s
Move”
campaign
when
she
produced
a

workout
video
for
children
and
later
did
other
related
activities.
Her
endorsement
brought
significant

attention
to
the
campaign.
However,
in
early
2013,
the
singer
signed
a
$50
million
deal
with
Pepsi
to

become
the
brand’s
spokesperson.
10

Her
decision
caused
a
public
uproar,
which
extended
to
Mrs.

Obama
for
not
distancing
herself
from
the
celebrity.
11

8.19. Consider
engagement
as
a
powerful
tool

Face-‐to-‐face
interventions
are
being
used
in
many
settings
to
address
obesity
and,
in
very
broad

terms,
tend
to
have
a
higher
success
rates
than
do
interventions
that
address
large
audiences.
12

At
the

same
time,
they
are
also
far
more
expensive
and
are
not
an
option
for
public
health-‐level
interventions.

However,
there
are
lessons
to
be
learned
from
these
programs
and
therefore
they
should
be
analyzed.

This
is
particularly
important
today
when
new
communication
platforms,
including
social
media,
are

making
large-‐scale
engagement
strategies
more
accessible.

The
Change4Life
team
demonstrated
this
when
they
found
a
set
of
common
characteristics
in

successful
face-‐to-‐face
interventions:
they
asked
people
about
their
current
behaviors
(listened),

provided
personalized
information
about
risk
(to
avoid
dissociation),
encouraged
the
establishment
of

personal
goals,
facilitated
comparison
of
progress
to
that
of
others,
recorded
progress,
provided

9

“Let's
Move:
Celebs
Who
Have
Joined
Michelle
Obama's
Campaign,”
BET.com.

10

Huehnergarth,
“Parents,
Don't
Let
Beyoncé,”
Parents
(blog),
The
Huffington
Post.

11

Koffler,
“‘Let’s
Move’
Bud
Beyoncé,”
White
House
Dossier.

12

Department
of
Health,
Change4Life
Marketing
Strategy,
Department
of
Health,
25-‐27.

91
feedback,
offered
frequent
reminders,
and
rewarded
success.
13

The
team
then
sought
out
to
weave

some
of
these
into
their
strategy
using
the
various
media
channels
at
their
disposal.
They
asked
families

about
their
behaviors
through
a
self-‐assessment
questionnaire,
they
provided
personalized

recommendations
based
on
the
family’s
responses,
and
they
encouraged
them
to
establish
goals.
In

addition,
the
team
used
repetition
to
remind
people
of
their
goals
and
provided
tools
for
families
to

record
progress.

8.20. Make
people
aware
of
their
condition

The
“How
are
the
Kids?”
questionnaire
became
a
very
powerful
tool
for
the
Change4Life
campaign

because
it
gave
parents
and
families
a
way
to
diagnose
themselves.
Many
individuals
have
a
difficult

time
seeing
themselves
or
their
children
as
overweight
or
obese.
The
results
of
the
questionnaire
served

as
an
eye-‐opener,
which
was
crucial
in
getting
them
to
pay
attention
to
the
campaign.
Aside
from
being

effective,
the
questionnaire
had
the
added
benefit
of
allowing
for
the
self-‐diagnosis
to
be
done
in

private,
thereby
sheltering
families
from
social
shame.

8.21. Choose
your
battles

As
previously
mentioned,
the
causes
of
the
obesity
epidemic
are
numerous
and
vary
from
one

individual
to
the
next.
While
addressing
all
of
them
would
be
ideal,
limited
budgets
force
public
health

communicators
to
“choose
their
battles.”
The
angle
or
angles
to
target
should
be
chosen
based
on
cost-‐
effectiveness,
that
is,
where
each
dollar
will
have
the
greatest
impact.

New
York
City,
Los
Angeles,
and
many
other
cities
in
the
United
States
have
opted
for
campaigns

that
focus
on
sugar-‐sweetened
beverages.
One
reason
for
this
is
the
extent
of
the
role
that
such

products
are
having
on
the
obesity
epidemic.
As
Dr.
Jonathan
E.
Fielding,
MD,
MPH,
director
and
health

13

Department
of
Health,
Change4Life
Marketing
Strategy,
Department
of
Health,
17-‐18.

92
officer
of
the
Los
Angeles
County
Department
of
Public
Health
said
in
reference
to
the
sugary
drink

industry,
"If
we're
serious
about
doing
something
about
the
disturbing
obesity
trend,
we
have
to
start

with
the
biggest
culprits."
14

The
sugary
drink
product
category
shares
some
of
the
characteristics
that

allowed
for
a
successful
battle
against
the
tobacco
industry.
Most
important
of
these
is
the
fact
that,

because
sugary
drinks
have
no
nutrition
value,
the
message
can
be
as
straightforward
as
it
was
in
anti-‐
tobacco
campaigns:
don’t
drink
them.
In
addition,
the
products
that
fall
into
the
sugary
drinks
category,

as
well
as
the
companies
that
make
up
the
industry,
can
be
easily
identified.
A
product
category
such
as

bread,
on
the
other
hand,
can
include
healthy,
unhealthy,
and
middle
ground
options.
Finally,
adopting

the
encouraged
behavior
will
represent
savings
to
individuals
(they
can
consume
water
instead,
which
is

free)
in
the
same
way
that
giving
up
smoking
did.
Switching
to
healthier
options
in
other
product

categories
often
represents
higher
costs.

8.22. Prepare
the
support
base

Before
launching
the
Change4Life
campaign,
the
team
executed
a
pre-‐phase,
which
aimed
to

prepare
the
audience’s
support
system
(health
care
professionals,
public
employees,
school
personnel,

and
members
of
partner
organizations).
The
aim
was
for
the
system
to
be
ready
to
provide
information

and
guidance
to
individuals
once
they
started
working
on
adopting
new
behaviors.
This
is
a
strategy

adopted
from
the
pharmaceutical
and
medical
device
industry,
which
often
successfully
precedes
public

promotion
of
their
product
with
a
strategy
to
introduce
it
to
the
medical
community.
The
purpose
is
to

make
sure
doctors
already
know
about
the
product
once
patients
begin
to
ask
them
about
it.
Similarly,

the
Change4Life
team
aimed
for
the
support
system
to
be
ready
to
offer
advice
and
recommendations.

14

RENEW
LA,
“LA
County
Launches
Sugar-‐Loaded
Drinks
Campaign,”
LACDPH,
news
release.

93
8.23. When
designing
messages,
there
are
several
things
to
consider

Perhaps
the
most
difficult
decision
that
public
health
communicators
addressing
obesity
face
is

which
message
to
use
in
order
to
have
the
greatest
impact.
This
is
not
because
there
is
a
lack
of

messages
to
deliver,
but
rather,
because
there
are
too
many.
However,
delivering
various
messages
can

be
costly
and,
more
importantly,
can
be
confusing
and/or
overwhelming
for
the
audience.
The
following

is
a
list
of
recommendations
and
findings
relative
to
messaging
that
were
collected
and
identified

through
the
research
conducted:

o Being
realistic
when
designing
messages
is
very
important.
LeVeque,
explains
that
the

suggestions
offered
by
a
campaign
need
to
be
perceived
as
achievable
by
the
target
audience.

For
instance,
recommending
a
diet
that
is
too
expensive
or
not
appealing
to
the
target
audience

will
not
be
effective.
He
explains
that
this
is
why
they
chose
to
use
fast
food
in
the
2012
“Choose

less.
Weigh
Less.”
campaign.

o It
is
important
to
be
aware
of
variations
in
the
subject
knowledge
and
literacy
levels
of
your

audiences.
Certain
audience
segments
might
know
more
about
nutrition
than
other
groups.
It
is

also
possible
that
a
single
group
might
have
different
levels
of
knowledge
regarding
specific

areas
of
nutrition.
For
instance,
LeVeque
explains
that
most
people
perceive
sugar
as
unhealthy

and
understand
that
twenty-‐six
packets
is
a
lot.
However,
not
everyone
is
aware
of
the
health

consequences
of
excessive
sodium
consumption,
and
very
few
understand
one
thousand

milligrams
of
sodium
in
one
meal
as
too
much.

o Finding
the
right
balance
between
messages
that
are
simple
and
that
offer
concrete
suggestions

is
key.
For
instance,
the
message
in
the
2012
NYC
portion
control
campaign,
“cut
your
portion,

cut
your
risk,”
was
simple,
yet
it
was
also
too
vague.
A
more
concrete
and
equally
simple

message
such
as
“choose
the
smaller
size”
might
be
easier
to
grasp.

94
o The
Change4Life
team
found
that
messages
that
used
“marketing
speak”
were
more
popular

with
audiences.
For
example,
“Me-‐sized
Meals”
or
“five
a
day.”
15

o The
Change4Life
2011
team
also
found
that
people
don’t
want
to
hear
instructions
(for
instance

“eat
less
sugar”).
Rather,
they
want
suggestions
on
how
to
live
healthy.
The
2011
strategy

document
points
out
that
"people
do
not
eat
fat
or
eat
sugar,
they
eat
breakfast,
and
eating

breakfast
is
itself
an
integral
part
of
a
bigger
behavior
or
practice,
that
of
getting
ready
for
the

day
ahead."
16

o It
is
necessary
to
be
patient
and
avoid
overwhelming
the
audiences.
For
example,
when
the

Change4Life
team
evaluated
their
phase
one
results,
they
noticed
that
promoting
eight

behaviors
to
children,
six
to
adults,
and
another
six
for
infants
was
daunting
to
audiences
and

was
likely
to
be
perceived
as
impossible
(it
was
also
confusing).
17

o The
importance
of
taking
action
needs
to
be
transmitted.
For
example,
parents
should
be
made

aware
that
their
children
mimic
their
behaviors
(as
long
as
the
message
doesn’t
transmit
guilt).
18

o Showing
people
that
others
are
also
working
on
modifying
their
behaviors
can
be
motivating.

For
instance,
celebrities
were
featured
on
television
shows
filling
out
the
Change4Life

questionnaire
as
a
way
to
motivate
families
to
do
so
as
well.

o The
New
York
City
Health
Department
has
found
that
campaigns
that
evoke
a
sense
of
disgust

(such
as
those
showing
blobs
of
fat
pouring
from
a
sugary
drink)
are
more
likely
to
motivate

behavior
change
than
campaigns
with
inspirational
messages.
19

o Criticism
will
happen
and
therefore
practitioners
should
always
make
sure
that
messaging
is

rooted
on
substantiated
research
and
they
should
be
ready
to
effectively
react
to
criticism.

15

Mitchell,
Change4Life
Three
Year
Social
Marketing
Strategy,
Department
of
Health,
24-‐25.

16

Ibid.,
26.

17

Ibid.,
24-‐26.

18

Ibid.,
28-‐29.

19

Caroline
Wallace,
phone
interview
with
author,
November
29,
2012.

95
Solving
the
obesity
epidemic
will
require
the
joint
effort
of
various
sectors.
Public
health
education

has
an
important
role
to
play
in
raising
awareness
of
the
problem,
changing
social
perceptions,
and

encouraging
healthier
lifestyles.
Thus
it
is
essential
to
carry
on
a
continuous
effort
of
evaluating
and

analyzing
undertakings
to
promote
a
cycle
of
ever-‐improving
strategies.
In
reading
this
document,
it
is

important
to
consider
that
it
takes
into
account
data
available
up
to
early
2013.
Therefore,
some
of
the

issues
identified
and
the
conclusions
made
will
necessarily
evolve
as
new
data
is
released,
new

strategies
are
tested,
and
new
discoveries
are
made.
However,
the
hope
is
that
it
will
inform
and

contribute
to
the
next
wave
of
anti-‐obesity
strategies,
which
will
produce
a
new
set
of
lessons
that
will

be
used
to
improve
subsequent
efforts.

96
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98
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104
Appendix
1:
Nutrition
Data
Education
Campaign,
NYC
Health
Department

Timeframe:
October-‐December
2008

Medium:
Print
ads
in
New
York
City’s

subway
system

These
two
applications
compared
a

calorie-‐dense
meal
to
a
similar
but

smaller
alternative,
and
encouraged
the

viewer
to
“Choose
Less.
Weigh
Less.”
20

The
ads
sought
to
alleviate
the

audience’s
possible
fear
of
having
to

give
up
fast
foods
all
together,
and

offered
a
less
caloric
option
that
did
not

require
significant
sacrifice.
In
addition,

the
subway
application
illustrated
that

even
restaurants
perceived
as
healthy

can
offer
high-‐calorie
options,
thus

emphasizing
the
importance
of
reading

labels.

20

“Choose
Less.
Weigh
Less,”
Slogan
was
later
adopted
by
the
LA
Health
Department

105

The
burrito
and
fried
chicken
versions
sought
to

put
a
calorie-‐dense
meal
into
perspective
by

placing
it
below
the
2,000
calories-‐a-‐day

statement,
labeling
its
more
than
1,000
calorie

content,
and
asking,
“If
this
is
lunch,
is
there
room

for
dinner?”

The
tagline
was
a
key
element
in

reminding
people
that
calories
add
up,
and
that

they
need
to
be
aware
of
what
they
are

consuming
throughout
the
day.
The
ad
with
the

relatively
healthy-‐looking
apple
muffin
sought
to

raise
awareness
about
the
possibility
that
some

foods
that
look
healthy,
can
be
deceptive
in
terms

of
their
caloric
content.
The
tagline
“Healthy

snack?
Maybe
not.”
encouraged
the
audience
to

reflect
on
the
choices
they
are
making.

106
Appendix
2:
Sugar-‐Sweetened
Beverage
Campaign,
NYC
Health
Department

“Pouring
on
the
Pounds”

Timeframe:
September-‐December

2009

Medium:
Print
ads
in
New
York
City’s

subway
system
and
YouTube
video

(launched
in
December)

The
main
message
of
the
campaign

was
that
sugary
drink
consumption

could
lead
to
weight
gain.
As
a

secondary
message,
it
suggested

substituting
such
drinks
with
water
or

other
un-‐sweetened
beverages.
The

strategy
used
was
to
elicit
a
sense
of

disgust
by
offering
a
metaphorical

scenario
in
which
a
person
was

drinking
a
bottled
beverage,
and
as

the
liquid
was
pouring,
it
turned
into

large
blobs
of
fat.

Video
available
at:

http://www.youtube
.com/watch?v=-‐
F4t8zL6F0c

107

Little
Sugar
Campaign

Timeframe:
August-‐October
2010

Medium:
Print
ads
in
New
York
City’s

subway
system
and
YouTube
video

(launched
in
October)

The
2010
campaign
focused
on
the

content
of
the
beverage
(sugar),

rather
than
on
the
effect
that

drinking
it
can
have
on
the
body
(fat).

It
sought
to
provoke
shock
by

including
a
concrete
and
measurable

fact
that
most
people
weren’t
aware

of.

Video
available
at:

http://www.youtube
.com/watch?v=62JM
fv0tf3Q&list=PL06E5
CD687A191987

108

Big
Sugar
Campaign

Timeframe:
January-‐March
2011

Medium:
Print
ads
in
New
York
City’s

subway
system,
YouTube
video,
and
a

television
spot.

The
2011
campaign
shed
light
on
the

fact
that
people
drink
more
than
one

sugary
drink
per
day
and,
therefore,

consume
more
than
the
equivalent
of

26
packets
of
sugar.
In
addition,
it

alerted
consumers
of
the
health

consequences
that
the
extra
calories

in
sugary
drinks
can
cause.
For
the

first
time,
the
advertisements
offered

a
helpline
for
people
struggling
with

obesity.

Video
available
at:

http://www.youtube.
com/watch?v=hF8Xn
U4L33U

109

“Walk
off
the
Pounds”

Launched:
October
2011

Medium:
YouTube
video

The
“Walk
off
the
Pounds”

video
showed
the
same
man

from
the
previous
videos

walking
from
Union
Square
to

Brooklyn
(three
miles),
and

explained
that
it
would
take
a

walk
of
that
length
to
burn

the
amount
of
calories
in
a

20oz
soda.
Once
again,
a
little

known
and
surprising
fact

was
used
to
shock
and,

therefore,
make
the
message
memorable.
The
use
of
familiar
locations
to

illustrate
the
distance,
rather
than
a
simple
number,
was
important
to
help
New

Yorkers
better
grasp
the
message.

Video
available
at:
http://www.youtube.com/watch?v=jxfu-‐SVK6OA

“50
Pounds”

Launched:
October
2011

Medium:
YouTube
video

The
“50
pounds”
video

targeted
parents
and
used
a

combination
of
shame,
shock,

and
hard-‐hits.
The
shame
was

evoked
through
questioning

parents
for
letting
their

children
drink
so
much
sugar,

and
the
shock
came
from
a

new
little
known
and

surprising
fact.
The
hard-‐
hitting
images
of
possible

health
consequences
of
obesity
were
reintroduced
and
this
video
was
the
first
to
use
the
term
obesity

epidemic.

Video
available
at:
http://www.youtube.com/watch?v=UUfTEH7xMFM

110
Appendix
3:
Sodium
Reduction
Campaign,
NYC
Health
Department

2011
Sodium
Reduction
Campaign

Timeframe:
November-‐December

2011

Medium:
Print
ads
in
New
York
City’s

subway
system

The
advertisements
showed
a

packaged
food
product
with
vast

amounts
of
salt
flowing
out
of
it.
Each

application
stated
that
many

packaged
food
items
contain
more

salt
than
one
would
think
and
that

too
much
salt
can
cause
heart
attacks

and
strokes.
In
smaller
print,
the

viewer
was
urged
to
compare
labels

and
choose
products
with
less

sodium.
However,
the
advertisements

assumed
that
the
audience
knew
how

to
read
food
labels
for
sodium

content
and
did
not
provide
guidance.

2013
Sodium

Reduction
Campaign

Launched:
April
2013

Medium:
Print
ads
in

New
York
City’s

subway
system

The
2013
sodium

reduction
campaign

was
an
improved

version
of
the

previous
one.
The

main
message
in
the
new
posters
was
the
suggestion
to
compare
labels
and
choose
products
with
less

sodium.
A
more
significant
improvement
was
that
the
posters
showed
the
amplified
nutrition
label
of

two
similar
packaged
food
products
and
pointed
out
where
the
sodium
content
could
be
found.
In

addition,
the
new
posters
addressed
the
common
misconception
that
the
table
saltshaker
is
the
source

of
excess
salt
consumed.

111
Appendix
4:
“Salt
Shocker”
Video
Series,
LA
Department
of
Public
Health

Launched:
March
2011

Medium:
website
and

promoted
through
social

media
(during
a
three-‐
week
period)

The
videos
sought
to

motivate
viewers
to

monitor
and
reduce
their

sodium
intake,
by

“shocking”
them
with
a

comparison
of
the

recommended
daily

consumption
and
the

unexpected
amount
of

sodium
in
certain
foods.

The
videos
also
shed
light

on
the
fact
that
the

average
American
eats

more
than
the

recommended
daily

amount
of
sodium
and

offered
advice
on
how
to

stay
on
track.
In
an
effort

to
make
the
videos
more

relatable,
the
foods

featured
were
chosen

based
on
their
popularity

with
target
populations.
In

addition,
the
products

chosen
were
either

peripheral
ingredients

that
consumers
might
not

even
think
about,
such
as

ketchup
and

breadcrumbs,
or
products

that
are
generally
though

of
as
healthy,
such
as

cottage
cheese
and

canned
vegetables.

Videos
available
at:

http://www.choosehealth
la.com/eat-‐healthy/salt/

112
Appendix
5:
“Sugar-‐Loaded
Drinks”
Campaign,
LA
Department
of
Public
Health

Launched:
October
2011

Medium:
Paid
advertisement
on
public
transportation,

posters,
social
media,
and
website

The
campaign’s
materials
provide
a
visual
representation
of

the
amount
of
sugar
in
particular
drinks
in
a
way
that
was

shocking
and
easy
to
grasp.
The
trivia-‐style
fact,
followed
by

the
questioning
of
the
behavior
is
meant
to
provoke

curiosity,
shock,
and
possibly
disgust.

Video
available
at:

http://www.chooseh
ealthla.com/eat-‐
healthy/sugar-‐
loaded-‐beverages/

113

The
campaign
also

included
an
interactive

sugar
calculator
hosted

on
the
Choose
Health

LA
website.
The

calculator
offered

residents
a
tool
to

gauge
their
personal

weekly
sugar

consumption
and
make

behavior
changes

accordingly.

Calculator
available
at:

http://www.choosehea
lthla.com/eat-‐
healthy/sugar-‐loaded-‐
beverages/

114
Appendix
6:
Portion
Control
Campaign,
LA
Department
of
Public
Health

Launched:
October
2012

Medium:
Paid
advertisement
on
local

transportation,
digital
advertisements,

and
social
media

The
materials
showed
a
large
serving
of
a

particular
food
or
meal
next
to
a
smaller

serving
of
the
same
food,
each
labeled

with
its
respective
caloric
content
(the

former
about
twice
as
much
as
the

latter).
In
addition,
the
material
urged

the
audience
to
“Choose
Less”
in
order
to

“Weigh
Less,”
explained
that
portion
size

matters,
and
informed
that
most
adults

only
need
2,000
calories
per
day.
Six

applications
were
developed
using

different
foods,
including:
pizza,

hamburger-‐fries-‐soda
combo,
subway

sandwich,
pasta
with
meatballs
and
garlic

bread,
pancake-‐egg-‐bacon
breakfast,
and

salad.

115
Appendix
7:
UK
-‐
Change4Life
Campaign,
Branding
and
Creative
Applications

Change4Life
was
designed
to
be
the

brand
for
a
societal
movement
that

sought
to
“change
behaviors
and

circumstances
that
lead
to
weight

gain.”

The
brand
was
chosen
because
it
was

fun
and
would
be
appealing
to
entire

families
and
because
it
offered
long-‐
term
aspirations
(“4Life”).
In
addition,

it
allowed
for
the
development
of

several
sub-‐brands
by
substituting

the
first
word
(Bike4Life,
Walk4Life,

Breakfast4Life,
etc.)

Another

important
quality
was
the
broadness

of
the
brand,
which
did
not
limit
its

application
to
obesity
or
its
audience

to
children.

The
tagline
used
throughout
the

campaign
was
intended
to
be
simple,

straightforward,
and
encouraging.
It

was
meant
to
encompass
the

campaign’s
eight
behavior-‐focused

secondary
messages.

The
logo,
the
advertisements,
and
all

other
creative
applications
use

characters
that
the
NHS
describes
as

“little
‘people’
whose
presence
gives

the
identity
humanity,
but
they
have

no
gender,
age,
ethnicity
or
weight

status”
and
therefore
are
inclusive
of

all.
21

They
were
designed
to
counter

the
normalization
of
larger,
unhealthy

bodies,
without
suggesting

preference
towards
any
hereditary

characteristics.

21

Department
of
Health,
Change4Life
Marketing
Strategy,
Department
of
Health,
44.

116
The
easy-‐to-‐follow
and
fun
narratives

make
the
videos
entertaining,
while

effectively
delivering
the
message.

YouTube
videos
and
other
digital

media
were
particularly
important

during
the
second
phase
of

Change4Life,
when
the
budget
was

reduced
and
the
audience
and
topics

to
cover
were
expanded.

Videos
available
at:

http://www.nhs.uk/Change4Life/Page
s/watch-‐change-‐for-‐life-‐videos.aspx

Change4Life’s
ongoing
CRM
program

included
a
variety
of
tools
for
parents

and
children.
The
tools
were
available

online,
by
mail,
or
as
mobile
apps.
For

example,
“the
fun
generator”
gave

children
ideas
of
active
ways
to
have
fun,

indoor
and
outdoor.
The
“Meal
Mixer

app”
was
designed
to
help
parents
shop

for
the
ingredients
needed
to
make

healthy
and
varied
meals.

Tools
available
at:

http://www.nhs.uk/Change4Life/Pages/chan
ge-‐for-‐life.aspx

117
Appendix
8:
Professional
Interviews

Caroline
Wallace
–
Health
Media
&
Marketing,
New
York
City
Department
of
Health
&
Mental
Hygiene

Transcript
of
phone
interview
conducted
November
29,
2012.

When
did
the
NYC
Health
Department
start
working
on
obesity
and
nutrition?

CAROLINE:
That
pre-‐dates
me.
In
terms
of
advertisement,
the
first
media
campaign
that
they
did
was

when
calorie
posting
went
into
effect
in
New
York,
in
2008.
They
created
posters.
And
actually,
some
of

what
Ali
developed
in
LA,
they
had
taken
a
look
at
those
posters
as
well
as
the
most
recent
portion

control
campaign
that
we
did.

We
did
consumer
advertising,
educating
on
how,
now
that
there
are
calorie
postings,
you
can
look
and

compare
the
meals
that
you’re
ordering.
It
was
public
education
around
the
policy
that
had
just
gone

into
effect.

Shortly
after
that,
they
started
doing
sugary
drink
awareness.
It
had
an
unusual
run
with
running
a

brand,
so
we
had
the
“pouring
on
the
pounds”
ads.
The
first
subway
campaign
probably
went
up
in
the

summer
of
2009
and
then
there
was
the
video
that
went
viral
shortly
after
that.
And
since
that
time,

especially
with
some
federal
financing
for
public
education,
we
did
3
or
4
more
waves
of
that
same

campaign,
each
building
on
the
one
before
and
that’s
ongoing.
We
will
continue
to
build
that
brand.

We
have
also
done
a
portion
size
campaign,
about
a
year
ago.
It
was
about
calling
people’s
attention

that
portion
sizes
have
grown.
So
it’s
not
‘you’re
eating
more,
it’s
you’re
being
served
more,
so
watch
it’.

And
it
overlapped
a
bit
with
LA,
where
if
you
go
to
a
restaurant
where
you
can
order
small,
medium
or

large,
order
the
small.
And
it
provided
graphic
images
of
health
effects
of
obesity.

We
also
did
physical
activity
promotion
a
year
ago,
in
the,
summer
and
then
again
this
summer.

Where
those
campaigns
run
by
you
or
by
the
Department
of
Parks
and
Recreation?

CAROLINE:
We,
the
Department
of
Public
Health,
had
the
lead
on
that,
but
we
had
input
from
the
Parks

and
Recreation
Department.

We
had
two
goals
for
that
campaign.
First,
with
active
transportation,
the
idea
of
getting
around
in

public
transportation,
which
is
quite
easy
to
do
in
NYC.
Walking
more,
getting
off
the
bus
a
stop
early.

And
two,
was
promoting
a
website
for
group
fitness
programs,
which
are
run
by
the
Department
of

Parks
and
Recreation:
health
classes,
sports
in
the
parks
and
rec
centers,
etc.
The
Department
of

Transportation
was
also
our
partner;
they
maintain
the
roads
and
bike
lanes.
So
for
that
campaign
we

did
work
with
partners,
but
most
of
our
work
is
just
within
the
Health
Department.

I
think
that
is
it
for
major
ad
campaigns,
and
then
we’ve
done
signage
for
stores,
health
bulletins,
and

other
collateral
communication.
That’s
more
or
less
what
we’ve
done
since
2008.

In
terms
of
funding,
you
received
$15
million
from
the
CDC
for
5
years,
correct?

CAROLINE:
Two
years,
for
the
CPPW.
It
was
a
two-‐year
grant.
It
was
the
health
promotion
and
disease

prevention
piece
of
the
Stimulus
Package.
It
was
CDC’s
pot
that
came
from
the
Stimulus,
the
America

Reinvestment
and
Recovery
Act.
And
that
grant
is
over.
There
is
currently
funding,
although
none
of
it
is

funding
any
education
campaigns.
But
there
is
currently
funding
also
from
CDC,
also
from
kind
of
the

118
same
funding
stream,
but
it’s
a
smaller
pot.
And
those
grants
are
called
community
transformation

grants,
where
more
of
the
focus
is
more
on
programmatic
work
and
education
in
the
actual

communities
we
serve.
So
there
is
less
of
that
work
getting
done
at
the
central
Health
Department
and

more
of
it
getting
done
on
the
ground,
in
the
neighborhoods
of
most
need
and
across
the
city
in
general,

with
community
groups.
There’s
also
a
coalition
that’s
working
with
different
community
groups
to

promote
health.

Where
is
the
funding
for
the
media
campaigns
coming
from
now?

CAROLINE:
The
health
department’s
bureaus
on
the
different
topics
will
often
fund
their
own
campaigns

either
with
city
tax
levy
or
with
different
grants.
There
are
different
sorts
of
non-‐city
money,
either

federal,
or
state,
or
grants
from
foundations.
So
depending
on
the
work,
it’s
funded
in
different
ways.

And
that’s
true
with
obesity;
it
can
really
change
from
year-‐to-‐year.
The
CPPW
was
really
the
first

opportunity
to
mount
larger
media
campaigns
and
buy
more
impressions.
We
are
now
sort
of
low
in

terms
of
funding,
but
there
is
some
city
funding
set
aside
to
continue
to
do
education
for
the
public.

So
the
budget
for
your
2004
and
2012
plans
doesn’t
have
its
funding
already
established?

CAROLINE:
No.

Does
the
CDC
get
involved
in
the
design
of
the
campaign?

CAROLINE:
No,
they
haven’t.
When
the
grant
was
submitted,
there
were
some
parameters
and
they

made
some
very
detailed
plan
of
which
topics
they
were
going
to
cover.
But,
in
the
end,
they
didn’t

review
ads
of
anything
like
that.
They
did
end
up
using
one
of
the
ads
that
we
created
here
as
an
option

for
all
the
communities
under
the
grant
to
do
some
media
placement
towards
the
end
of
the
grant

when
the
CDC
had
some
money
to
do
nation-‐wide
placement.
So
one
of
our
ads
got
picked
up
in
several

other
placements,
paid
for
by
CDC,
but
not
under
our
grant.

Have
you
done
any
networking
with
other
cities
and
other
campaigns?
Has
it
been
through
the
CDC?

CAROLINE:
Absolutely.
I
personally,
just
because
I
came
into
this
job
with
that
grant,
there
were
a
lot
of

sort
of
collaborative
calls
and
a
few
live
meetings.
They
had
a
yearly
meeting
in
Atlanta,
where
everyone

would
come;
every
community
that
was
a
beneficiary
of
the
grant
would
come
and
have
a
little

conference.
There
are
several
of
the
bigger
cities
that
have
gotten
friendly
because
we’ve
exchanged

ideas
and
we’ve
served
on
panels…have
you
met
the
folks
from
Seattle?

The
Seattle
folks
do
very
good
work.
Most
of
their
education
campaigns
have
a
slightly
different
tone

than
ours.
New
York
tends
to
be
hard-‐hitting,
or
funny,
or
gross
with
our
obesity
work,
and
Seattle
has

done
more
of
a
positive,
community-‐rallying
approach.
And
I
think
that
they
feel
really
good
about

having
done
that
and
have
had
some
success.
Their
stuff
looks
great
too.

So
we
all
know
each
other,
because
the
grant
brings
us
together.
But
I
also
think
the
world
of
this
work

is
so
small.
We
also
get
requests
from
other
jurisdictions
to
use
our
advertising,
which
we
obviously

allow
them
to
use
freely.
They
just
need
to
pay
for
the
placing
in
their
own
market.
So
I’ve
gotten
to

know
counterparts
in
other
places
that
way.

119

Going
more
into
the
obesity
messaging,
what
would
you
say
is
the
Department’s
overall
approach
to

obesity
(in
terms
of
how
to
tackle
it)?

CAROLINE:
I
think
the
perspective
of
certainly
this
agency,
this
Health
Department,
as
well
as
our
mayor,

is
that
the
problem
is
primarily
environmental.
I
mean,
it’s
not
because
people
have
no
control
and

they’re
overeating,
it’s
because
their
environment
is
pointing
them
towards
more
caloric,
less
healthy,

more
sugar-‐laden
and
fat-‐laden
foods.
You
know
marketing
has
something
to
do
with
that,
and
then

placement
and
availability
and
pricing.
So,
as
the
Health
Department,
we
want
to
give
consumers

information
to,
sort
of,
guard
themselves
against
the
toxic
environment,
while
also,
hopefully,
trying
to

promote
programs
and
policies
that
encourage
healthy
behaviors.
And
then
to
make
those
choices
the

easier
choices.
So
if
you
go
to
the
bodega
and
the
impulse
buy
is
the
basket
of
banana,
instead
of
candy

or
things
like
that,
then
your
environment
is
a
little
healthier
and
you’re
likely
to
choose
something

healthier.
So
I
think,
in
general,
the
city’s
policy
on
obesity
is:
one
way
to
fight
it
is
to
create
a
healthier

environment
that
is
ultimately
wanted
by
the
people.
Sometimes
people
can
go
kicking
and
screaming

because
they
are
unaware
of
how
much
they
are
influenced
by
the
outside
environment
that
is
already

around
them,
and
that
they
have
less
free
will
that
they
think
they
do.
So
the
goal
is
to
make
it
easier
to

make
the
healthy
choices.

How
much
of
the
Department’s
efforts
go
to
education
and
how
much
goes
to
programmatic

changes?

CAROLINE:
I
think
that,
in
terms,
of
effort,
the
Communications
Bureau,
including
our
marketing
group

of
about
five
people
and
then
editing
and
digital
communications
and
our
information
line.
That
whole

group
and
our
press
office
is
only
like
thirty
people.
The
agency
has
seven
thousand.

So
communications
is…
there
are
a
lot
more
people
doing
work
around
research
and
policy

implementation
and
then
health
care
access
and
things
of
that
nature.
But
communications
can
be
more

pricy,
so
resource
wise
more
money
is
often
spent
on
the
communications
piece,
when
we
want
to
do

broad,
consumer
advertising,
per
se.
When
we
want
to
be
in
an
advertising
market
that’s
as
expensive

as
New
York,
it
takes
a
lot
of
money
to
even
mount
a
modest
education
campaign.
So
this
work
has
an

important
place,
and
because
it’s
costly
to
do,
we
take
a
lot
of
care
in
developing
messages
that
we

think
are
actually
useful
to
people,
that
don’t
alienate
people,
that
don’t
blame
people
for
their
own

health
problems,
that
give
them
the
information
they
can
use
and
possibly
change
their
mindset.

Hopefully,
to
change
the
needle
in
social
norms
around
healthy
and
unhealthy
foods.

When
you
set
out
to
develop
a
new
communication
effort,
what
process
do
you
follow?
Where
do

you
start?

CAROLINE:
There’s
definitely
a
lot
of
cooks
in
the
kitchen.
But
the
process
goes
a
little
like
this:
I’m
in

the
communications
bureau.
The
chronic
disease
prevention
and
tobacco
control
bureau
is
the
bureau

that
handles
obesity
issues,
so
they
are
the
content
experts.
So
they
will
come
to
us,
communications,

and
say
we
have
some
money,
we
want
to
do
a
campaign
around
obesity,
here’s
the
reason,
here’s
the

problem
in
New
York,
here’s
something
more
specific.
For
example,
with
obesity,
we
broke
it
down
into

portion
control,
sugary
drinks
or
physical
activity.
So
they
will
give
us
something
more
specific
than
just

obesity.
With
their
collaboration,
we
create
a
creative
brief,
which
is
basically
a
one-‐pager
that
explains

to
ad
agencies
what
the
project
is,
what
the
background
is,
what
we
anticipate
the
campaign
should
be.

120
We
sort
of
know,
based
on
our
budget,
if
we’re
just
going
to
do
print,
or
a
TV
spot,
or
if
we
want
to
do

internet
advertisement,
and
then
if
there’s
a
target
other
than
just
the
general
adult
population,
that

would
be
on
there
too.

We
have
four
agencies
under
contract
that
we
work
with,
so
we
don’t
do
any
of
this
design
in
house,

although
we
do
weigh-‐in
creatively
a
lot.
So
the
four
agencies
will
put
proposals
together
and
then
they

basically
compete
for
the
job,
but
not
in
a
financial
sense,
but
rather
in
a
creative
sense.
There
are

several
people
who
will
work
out
on
these
proposals:
two
of
us
in
communication,
then
someone
in
the

chronic
disease
group.
If
it’s
important
enough,
we’ll
elevate
it
to
people
who
run
our
division
or
even
to

the
commissioner’s
office,
just
to
make
sure
we
are
on
the
same
page
in
terms
of
where
we
want
to
go.

Once
that’s
done,
we
award
the
job
to
one
of
the
agencies.
Then
we
refine
the
concept.
Usually,
they

came
close,
but
there
are
things
we
already
know
we
want
to
change
before
we
do
focus
groups.
With

our
ads,
we
feel
very
strongly
that
it’s
not
worth
doing
a
campaign
if
we
can’t
do
some
sort
of
pre-‐
testing,
just
some
kind
of
research
to
see
what
an
actual
audience
will
think
of
the
concept,
and
we
do

this
fairly
early
on.
On
average
we’ll
do
four
or
six
groups
and
there
are
usually
about
eight
people
per

group.
So
it’s
not
a
giant
research
project,
where
you
have
interviews
of
25,000.
It’s
more
simplified,
yet

it’s
really
great.
It’s
qualitative
research;
we
get
really
good
feedback
and
sound
bites,
and
people

reacting
to
actual
work.
We
try
to
do
one
or
two
groups
in
Spanish
and
we
try
to
oversample
in
those

groups
for
our
communities
of
most
concern.
So,
even
though,
we
serve
the
whole
city
of
New
York,

there
are
health
disparities
and
some
populations
are
more
apt
to
suffer
from
the
chronic
diseases
that

we’re
worried
about.
With
obesity,
we
can
also
oversample
for
people
who
are
overweight,
sometimes

that’s
relevant,
although
not
always.
So
we
know
we
are
getting
reactions
from
people
we
would
most

hope
to
reach
with
the
messages.
At
this
point
we’re
maybe
two
or
three
months
into
the
process,

we’ve
created
a
brief,
we’ve
given
time
to
respond,
a
couple
of
weeks
to
decide,
then
to
refine
and
then

we
test.
And
it
can
certainly
move
faster
if
needed
or
it
can
move
slower,
but
that’s
the
average.

After
the
focus
groups,
we’ll
take
the
feedback
and
then
we
refine
the
concept
some
more.
And
then,

depending
on
the
group
we’re
servicing,
approvals
can
be
up
to
fifty
people
who
have
to
weigh-‐in
on

something,
or
sometimes
it
will
be
a
lot
less
than
that.
With
ad
campaigns,
they
have
a
little
more

scrutiny
than
other
communication
that
doesn’t
go
to
the
public,
so
everyone
up
to
our
commissioner

will
have
to
approve
and
they
also
need
to
be
approved
by
the
mayor’s
office.
And
we’re
often
on
the

same
page,
but
sometimes
we’re
not,
so
there’s
a
lot
of
back
and
forth.
But
we
eventually
get
to

something
that
everyone
is
happy
with.
And
then
we
launch.
We
can
and
we
have
developed
ad

campaigns
in
as
few
as
three
to
four
months,
two
or
three
even.
It’s
usually
more
like
six
months,
and
it

can
be
up
to
a
year
or
two
depending
on
what
comes
up
in
between.
With
hurricane
Sandy,
a
lot
of
the

work
that
should’ve
been
done
in
November,
was
placed
on
hold
for
a
couple
of
weeks.

When
you
are
evaluating
proposals
from
the
agencies,
what
are
some
of
the
issues
you
have
to
think

about
that
are
particular
to
obesity?

CAROLINE:
This
is
true
to
other
diseases
as
well,
it’s
really
important
not
to
stigmatize
people
who
have

a
condition
we’re
talking
about,
and
especially
with
obesity
because
it
has
the
visual
aspect
to
it,
you

look
different.
Bigger
kids
can
be
picked-‐on
at
schools,
and
adults
can
get
dirty
looks
on
the
subway.
So

the
intension
is
to
always
educate,
without
pointing
fingers
to
people.
And
we
acknowledge
that
it’s
a

very
difficult
environment
to
eat
well
and
to
stay
fit.

At
the
same
time,
we’ve
found,
especially
with
the
tobacco
advertisement
that
we’ve
been
doing
for

years,
that
harder-‐hitting
campaigns,
that
can
be
a
little
disturbing
and
have
emotional
messages,
tend

to
get
more
response.
Ad
campaigns
tend
to
be
more
memorable
to
people
when
they
freak
them
out

or
upset
them,
so,
to
some
degree,
we
don’t
shy
away
from
the
hard-‐hitting
concepts.
And
when
we
do

121
that,
we
do
sort
of
walk
the
line,
because
you
want
them
to
be
arresting,
but
you
don’t
want
people
to

feel
accused
of
something.
And
that’s
very
hard
to
do.
And
even
though
two
of
our
agencies
that
we

work
with
have
been
with
us
for
many
years,
they
don’t
always
get
it
right
the
first
time,
we
don’t
get
it

right
the
first
time.
This
is
why
we
test
them
on
focus
group.
Sometimes,
something
we
think
is
very

innocuous
can
be
very
upsetting
to
people,
or
things
that
we
think
are
very
hard-‐hitting
can
go
over

people’s
heads,
or
they
don’t
get
it,
or
they
don’t
connect
to
it.
We’ve
found
that
with
obesity,
showing

big
people,
and
showing
the
faces,
and
having
them
be
actual
human
beings,
where
someone
can
look

at
that
person
and
say
‘that
looks
like
my
brother,’
it’s
generally
too
distracting
and
people
tend
to
get

too
upset
by
that.
In
the
way
that’s
not
the
kind
of
upset
that
would
spur
them
to
take
action.
We
learn

all
these
things
as
we
go,
but
our
hope
is
we
can
do
something
impactful.
There
are
sometimes

opportunities
to
have
positive
messages,
and
we
certainly
do
that
when
we
promote
something,
like

physical
activity.
But
when
we
are
essentially
countering
other
advertising,
such
as
sugary
drinks,
the

inspirational
messages
don’t
tend
to
really
be
effective.
But
the
messages
that
are
‘ew
this
is
disgusting,

it’s
full
of
sugar’
tend
to
have
more
impact.
And
as
long
as
we
are
one
hundred
percent
accurate
with

the
information
we
are
giving,
which
we
are
very
careful
to
do,
those
are
the
kind
of
messages
we
go

with.
The
sugary
drink
messages
have
certainly
been
that
way
and
the
tobacco
stuff.
Our
portion
control

campaign
was
gloomy
and
showing
people
struggling
with
disability
due
to
obesity,
juxtaposed
with
a

growing
portions
graphic.

How
do
you
address
the
fact
that
obesity
doesn’t
have
a
clear-‐cut
solution?

CAROLINE:
It’s
difficult.
It’s
certainly
a
tricky
topic,
because
you
can’t
tell
people
to
stop
eating
and

because
so
much
of
the
food
that
is
affordable
and
accessible
and
widely
available
is
the
least
healthy

foods.
If
you
tell
people
‘just
eat
more
fruits
and
vegetables’,
that’s
a
tough
sell.
I
think
to
continue
to

raise
awareness
and
to
flag
the
worst
offenders,
which
is
why
we,
and
so
many
other
jurisdictions,
have

focused
on
sugary
drinks.
Because,
even
though
they
aren’t
the
only
part
of
the
problem,
they
are
one

identifiable
product
that
has
no
nutritional
value
and
has
a
free
substitute,
water.
I
think,
in
general,
this

city
is
looking
at
a
multi-‐pronged
approach
to
the
problem.
The
communication
is
only
one
piece
of
a

bigger
puzzle,
and
I
hope
that
the
kind
of
work
that
I
do…
if
we
had
a
major
effort
of
posters
on
the

subways,
for
example,
our
most
recent
campaign
had
maps
showing
how
far
you’d
have
to
walk
to
burn

the
calories
in
a
sugary
drink.
So
things
like
that,
I
consider
them
sort
of
like
air
cover
for
the
ground

troops.

So
if
we
have
community
groups
that
are
trying
to
take
out
the
sugary
sodas
out
of
church
socials,
or

walking
groups
in
community-‐based
organizations,
or
bodegas
that
are
trying
to
place
water
more

prominently
than
Sprite,
whatever
it
is.
If
all
that
programmatic
and
policy
work
is
happening,
or
even

this
rule
that
just
passed
in
NYC
that
limits
the
size
of
cups
of
sugary
drinks,
we
have
these
education

campaigns
up
so
that
we
can
hope
to
affect
people’s
thoughts
about
these
things
and
change
the
norm

so
that
people
don’t
think
‘oh,
they’re
taking
away
our
soda’,
but
they
feel
like
it’s
a
good
thing
to
have

less
soda.

So
our
approach
is
that
the
whole
thing
is
comprehensive
and
that
no
piece
of
it,
nor
will
any
one

message,
will
solve
the
problem
completely.
I
think
the
best
we
can
hope
for
with
this
is
that
people

recognize
and
remember
them
and
our
evaluation
efforts
show
that
most
of
our
ad
campaigns
are

getting
enough
attention
that
people
can
recall
them
when
they
are
asked
later
on.
So
that’s
our

baseline,
we
want
people
to
remember
them
and
then
we
ask
questions
about
the
campaign,
whether

they’re
drinking
less
soda,
and
often
people
will
say
that
they
are.
And
that
is
self-‐report,
and
is
hard
to

measure
what
actual
health
effects
come
from
our
piece
of
the
work,
but
the
hope
is
that
it
contributes

to
the
bigger
fight.

122
Regarding
sugary
drink
companies,
and
other
food
companies,
how
have
you
dealt
with
their

reactions
to
your
campaign?

CAROLINE:
I
think
they
have
a
responsibility
to
their
shareholders
and
the
kind
of
products
that
are
least

healthy,
tend
to
be
the
most
profitable.
So
they’re
doing
what
they
have
to
do,
and
we
are
doing
what

we
have
to
do
and
our
objectives
are
not
exactly
aligned.
We
are
very
care
to
be
truthful,
which
is

something
that
companies
don’t
have
to
be
as
careful
about.
We
don’t
overpromise,
we
don’t
attack
the

industry
directly,
because
it’s
not
like
it’s
Coca-‐Cola’s
fault.
It’s
more
the
kind
of
society
we
are
living
in

has
led
to
this
situation
where
there
is
a
lot
of
stuff
in
the
food
environment
that
surrounds
us.

Particularly
the
sugary
beverage
stuff,
can
be
seen
and
is
seen
by
the
industry,
as
a
direct
front
to
them,

but
really
they
are
spending
billions
of
dollars
on
advertising
and
we
are
lucky
is
we
have
a
million
in
any

one
year
or
two.
It’s
such
a
different
scale
what
they
do
versus
what
we
do.
And
they
push
back

sometimes,
they
certainly
pushed
back
on
the
policy
that
got
passed
this
summer,
but,
in
the
end,
the

companies
will
come
along,
because
they
have
people
who
work
for
them
too
and
they
have
families

and
they
are
also
living
in
the
same
environment
that
we
all
are.
I
don’t
sit
in
a
spot
where
we
handle
a

lot
of
that
stuff
we
have
a
press
department
that
does.

This
mayor
has
been
bold
about
instituting
policies
that
he
things
are
for
the
public
good,
even
when

they
are
not
popular
with
the
industry.
And
he
is
lucky
enough
not
to
be
in
the
pocket
of
industry,
so
he

can
do
that
and
it
doesn’t
affect
his
campaign
coffers.
It
has
been
really
nice
to
work
under
a
mayor
who

is
less
beholden
to
special
industries
for
that
reason.
And
I
think
that’s
why
we
have
been
able
to
do

some
great
public
health
work,
in
general,
because
it
allows
us
to
push
things
that
maybe
the
industry

would
push
back
on,
but
are
best
in
the
end.

How
do
you
deal
with
the
fact
that
the
number
of
channel
options
is
continuously
increasing?
How

has
social
media
helped
or
not?

CAROLINE:
If
we
have
a
decent
sized
budget,
we
will
always
start
with
subway
posters
because
New

York
City
has
a
super-‐duper
transit
system
where
almost
everybody
rides
the
train,
so
the
subways
gets

the
most
bang
for
our
buck.
It’s
a
lot
of
exposure,
for
relatively
low
cost
apiece.
Our
regular
buy
will
be
a

thousand
pieces
equally
distributed
throughout
the
system,
which
is
about
20%
of
the
total
system.
So

that
buy,
for
a
month,
gets
a
lot
of
exposure,
about
50
million
impressions.
We
know
a
lot
of
eyeballs

are
on
them.
So
that’s
our
main
channel.

Television
costs
a
lot
more
money,
the
space
and
the
production.
And
New
York
City
is
one
of
the
most

expensive
media
markets
in
the
country,
if
not
in
the
world.
So,
TV
is
usually
limited.
We
do
other
kinds

of
print
media
and
then,
increasingly,
we
are
doing
online.
We
are
doing
paid
digital
ads.
We
are
doing
a

lot
of
social
media,
when
we
want
to
add
channels
and
don’t
have
more
budget.
We
are
working
really

hard
to
grow
our
Twitter
following,
including
one
account
on
healthy
eating.
We
are
working
on

YouTube,
Tumblr...
little
by
little
we
are
trying
to
get
to
the
places
were
people
are
and
have
different

conversations.
Facebook
has
been
really
nice
for
me,
because
it’s
not
only
about
talking
to
people,
but

you’re
providing
a
forum
to
talk
to
each
other.
So
even
though
we
do
post
content,
a
lot
of
what

happens
is
the
way
that
people
react
to
that
content
or
post
to
their
content
or
react
to
each
other.
And

you
can
get
a
temperature
of
what
New
Yorkers
who
are
interested
in
the
topic
are
talking
about
and

what
they
respond
to.
We
do
newspaper
ads,
usually
in
free
commuter
papers
which
I
think
are
both

national
and
New
York,
they
distribute
for
free
outside
of
major
transit
hubs.
That
tends
to
be
cost

effective
and
have
good
circulation.
We
do
radio
advertising
sometimes,
but
we
usually
get
some
value

added,
so
the
DJs
will
promote
our
topic,
or
will
do
events,
or
add
will
any
number
of
extra
bits,
so
it’s

more
of
a
comprehensive
buy.

123

Moving
on,
did
you
work
on
the
anti-‐smoking
campaigns?

CAROLINE:
I
have
not
up
to
this
point.
I
mostly
cover
obesity,
although
I
have
worked
on
other

campaigns,
opium
awareness,
etc.

Have
you
encountered
difficulties
in
designing
obesity
campaigns
that
you
haven’t
seen
in
campaigns

on
other
topics?

CAROLINE:
No,
I
think
that
every
topic
has
its
sensitive
spots,
but
the
challenges
of
these
kind
of
work
is

that,
with
a
public
health
message,
often
the
news
is
bad.
We
often
are
not
promoting
something,
we’re

telling
people
to
be
aware
of
something
or
to
take
care
of
themselves
And
there’s
always
a
challenge
to

make
that
compelling
and
to
giving
people
a
reason
to
care
and
to
pay
attention
to
the
messages.
It’s

much
easier
when
you’re
selling
a
lifestyle.
Coca-‐Cola
can
sell
happiness
and
they
don’t
have
to
talk

about
the
product
that
much.
We
need
to
sort
of
wag
a
finger
and
give
people
information.
We
try,
with

all
of
our
topics,
to
make
the
message
compelling
in
a
way
that
doesn’t
make
you
feel
like
your
teacher

is
scolding
you
or
something
like
that.
And
that’s
just
throughout
the
spectrum.
I
think
that
the
specific

bits
for
each
topic
are
different,
but
the
overarching
theme
is
to
make
these
get
attention
as
much
as

possible.

What’s
next
for
New
York?

TCNY
is
coming
to
an
end
this
year,
are
you
extending
it?

CAROLINE:
My
understanding
is
that
there
is
talk
about
expanding
it
and
refining
what
the
goals
are,
but

I’m
not
actually
involved
in
that
work.
Everything
that
I
do
supports
that
work,
but
I’m
not
the
one
who’s

putting
the
framework
together.

How
does
the
department
decide
between
working
on
regulation,
getting
the
industry
to
self-‐
regulate,
or
educating
the
public?

CAROLINE:
That
depends
on
the
topic.
Each
department
makes
those
decisions.

How
are
the
grassroots
programs
(such
as
the
farmer’s
market
initiatives)
working
out?

CAROLINE:
Those
are
great.
To
me,
those
are
the
most
important
kind
of
work
we
do.
It’s
on
the
ground,

it
empowers
people
to
take
their
own
health
in
their
hands,
it
gives
them
the
tools
to
do
it…
All
of
that

work
is
incredibly
crucial.
And
if
the
work
I’m
doing
can
support
that
work,
then
I’ve
done
my
job.
But
I

think
that’s
where
the
ground
zero
really
is
for
this
fight.

Thank
you.

124
Ali
Noller
–
Communications
Manager,
Choose
Health
LA,
Department
of
Public
Health,
Division
of

Chronic
Disease
and
Injury
Prevention

Transcript
of
interview
conducted
November
7,
2012
in
Los
Angeles,
California.

To
start,
could
you
tell
me
a
bit
about
what
you
do
at
the
Los
Angeles
Department
of
Health?

ALI:
I
can
tell
you
a
little
bit
about
the
process
and
how
we
started
the
Choose
Health
LA
Program,
I

think
is
useful
background.

I
started
with
the
Department
of
public
health
a
little
over
a
year
ago.
The
Department
received
a

federal
funded
grant
called
Communities
Putting
Prevention
to
Work,
CPPW,
and
that
was
in
March
of

2010.
With
this
funding
they
were
able
to
bring
on
a
new
staff,
there
were
25
of
us
who
were
hired
to

work
on
this
three-‐step
grant.
All
of
our
topic
areas
ranged
from
bike
lanes,
to
promoting
breast-‐
feeding,
to
basic
health
and
nutrition,
promoting
healthy
activity…

And
one
of
our
objectives
was
to
create
this
online
platform
for
all
of
these
resources
and
topics
that
we

were
working.
The
LACDPH
has
been
working
on
obesity
prevention
for
a
very
long
time,
so
this
grant

allowed
us
to
create
a
portal
were
all
the
obesity
work
that
was
happening
would
be
brought
together

under
one
umbrella
that
was
easier
to
navigate
than
the
DPH
website,
because
there’s
a
lot
of
fantastic

information.
And
really
connect
with
the
end
user
in
an
upbeat,
aspirational
way
by
taking
small
steps
to

make
big
improvements
to
your
health.

And
so
there
were
two
goals:
one,
to
provide
information
about
healthy
living
and
also
the
second
part

was
to
support
these
grant-‐funded
partners
that
we
were
working
with.
There
were
about
25
funded

partners,
one
of
which
was
Rogers-‐Ruder.

This
was
a
countywide
challenge.
And
this
was
both
an
opportunity
and
a
challenge.
If
we
break
the

grant
down
it
comes
down
to
one
dollar
per
capita.

From
a
communication
point,
there
is
a
lot
of
information
on
health
that’s
out
there.
But
that’s
were
we

have
an
opportunity,
because
we
are
the
health
department
and
people
trust
us,
we
are
the
authority,

which
we
use
to
cut
through
some
of
the
other
messages
out
there.

I
started
as
the
communications
manager
for
that
grant.
We
started
from
scratch.
We
had
ideas
of
what

would
work
and
we
had
the
Roger
Finn
team
on
board,
and
they
obviously
have
a
very
long-‐standing

successful
relationship
with
our
tobacco
program.
So
we
brought
them
on
board
to
help
us
launch
the

Choose
Health
LA
brand
and
then
some
of
the
other
campaigns
that
you’ve
seen:
the
sodium,
the
sugar,

and
the
portion-‐size
stuff.

What
about
before?
Did
you
work
on
the
anti–smoking
campaign?

ALI:
No,
I
didn’t.
But
health
has
always
been
in
my
interest
area
and
obesity
in
particular
and
general

wellness.

Was
this
the
first
initiative
from
the
Department
focused
specifically
on
obesity?

ALI:
Yeah,
we
have
an
existing
nutrition
program
that
has
a
big
staff
and
they
are
funded
by
the
Network

for
a
Healthy
California,
which
is
another
big
anti-‐obesity
campaign
within
the
Department
and
they
are

funded
through
the
USDA.
They
focus
primarily
on
nutrition
education
and
they
have
a
Latino
campaign,

a
worksite
wellness
program,
and
an
African
American
program.
A
lot
of
community-‐based
programs,

that’s
at
health
fairs,
nutritional
information,
cooking
demonstrations,
things
like
that.
And
then
the

125
Department
also
has
the
“Ask
the
Dietitian
Program,”
which
is
at
farmer’s
markets
and
grocery
stores

where
our
registered
dietitians
on
staff
will
go
out
and
do
cooking
demonstrations
and
nutrition

education
in
the
community.
So
that
has
been
going
on
for
a
while.
But
the
new
opportunity
with
this

CPPW,
is
that
it
allows
the
department
to
do
more
policy
related
and
strategic
planning,
as
it
relates
to

obesity
prevention.
So
instead
of
just
focusing
on
the
consumer
and
the
end
user,
we
were
able
to
think

bigger
about
how
are
we
going
to
make
our
environment
healthier
for
people;
how
can
we
increase

access
to
fruits
and
vegetables
at
the
system
level?

When
the
CDC
gave
you
the
grant,
did
they
give
you
guidelines?

ALI:
Absolutely.
We
had
and
continue
to
have
a
very
rigorous
reporting
schedule
with
them,
we
have
a

clearly
defined
scope
of
work
with
all
our
objectives,
that
we
have
to
give
them
monthly
or
more
often

updates
of
how
we
are
progressive.
And
they
also
provide
technical
assistance
as
needed.
And
also
they

compare
us
with
our
peers,
with
what
is
happening
in
the
rest
of
the
country.
Because
we
were
one
of

50
funded
communities
to
do
anything
related
to
obesity
prevention
or
tobacco
control.

Once
you
had
the
funding,
how
did
you
start
tackling
the
issue?

ALI:
Well,
since
we
had
the
scope
of
work
that
had
been
written
for
the
proposal,
we
already
had
a

framework.
But
I
remember
sitting
down
with
Matthew
[Rogers
Finn]
and
brainstorming
about
all
the

different
topics
that
we
had
and
decided
that
it
would
be
easy
to
categorize
them
into
one
of
three

subject
areas:
eat
healthy,
move
healthy,
and
live
healthy.
So
that
each
of
our
topics,
whether
it
was

about
creating
open
spaces
for
people
or
nutrition
education
at
schools,
they
would
all
fit
into
one
of

those
three
pockets.
And
all
the
campaigns
we
were
doing
with
Choose
Health
LA
were
supporting
the

other
community
work,
the
programmatic
work.
So
the
sugary
drink
campaign
that
we
were
able
to

launch
a
little
over
a
year
ago,
that
was
in
support
of
some
of
the
work
we
were
doing
in
cities
to
help

them
improve
their
food
and
beverage
environment,
so
there
were
more
healthier
options,
especially
in

venues
that
serve
children.

I
know
that
the
Department
had
a
lot
to
do
with
the
menu
and
calorie
labeling
in
chain
restaurants.

Was
that
part
of
Choose
Health
LA?

ALI:
Not
directly,
but
that’s
very
similar
to
the
work
we
did
under
RENEW.
RENEW
is
actually
winding

down
at
the
end
of
this
year
and
there
is
a
new
grant
funding
the
community
transformation
grant

programs.
And
not
directly
continuation
of
the
programs
done
with
the
original
funding
stream,
but

similar.
If
you
did
a
good
job
in
the
first
phase
and
you
showed
that
you
had
made
progress
and
were

evaluating,
you
were
more
likely
to
be
funded
in
the
second
phase.

When
you
say
“these
grants,”
are
you
talking
about
those
25
organizations
you
mentioned
earlier?

ALI:
We
are
funded
by
the
CDC,
and
we
are
able
to
take
that
funding
and
take
at
least
half
of
it
to
the

community
to
do
work.

126
Was
other
half
of
the
money
for
the
communication
programs?

ALI:
Well,
for
staffing.
We
have
a
large
staff.
So
internal
management.

So
the
campaigns
were
one
of
the
grants?

ALI:
The
grants
were
more
like
with
the
LA
Unified
School
District…
working
with
the
LA
Bike
Coalition.

And
Matthew’s
[Roger’s
Finn]
was
and
is
one
of
funded
partners.
And
then
with
them
we
figure
out

which
direction
to
go
with
our
media
communication.

Do
you
then
have
both
private
and
public
partners?

ALI:
Yeah,
and
Matthew
[Roger’s
Finn]
is
kind
of
an
outlier.
All
the
rest
are
either
community
based

organizations,
or
school
or
non-‐profits
for
the
most
part.

I’d
like
to
hear
about
your
perspective
towards
obesity
communication.
When
you
are
starting
to
plan

a
campaign,
what
are
some
of
the
issues
you
face?
What
are
some
of
the
things
you
consider?

ALI:
We
had
the
opportunity
from
the
beginning
to
do
some
focus
groups,
to
really
test
what
else
was

out
there.
I
think
that
was
one
of
the
most
important
lessons
from
of
all
this,
just
assessing
the

environment
of
what
other
campaigns
had
been
done
across
the
country.
We
have
a
very
strong

partnership
with
the
New
York
City
Department
of
Public
Health,
and
they
shared
resources
of
things

they
had
done.
And
we
did
look
at
both
the
positive
messages
and
more
of
the
shaming
and
negative

ones,
and
that
just
didn’t
resonate
with
our
audience.
And
we
wanted
to
make
sure
that
everything
we

were
doing
was
something
that
was
connecting
with
the
people
we
were
trying
to
reach.
And
I
think

that’s
really
important
because
as
a
public
health
community
we
have
an
opportunity
to
connect
with

each
other
about
the
work
we
are
doing
and
share
resources
because
there
are
never
enough.
But
also

test
what
works
in
your
own
community.

How
was
your
relationship
with
the
partners?
Did
you
give
them
a
leeway
in
terms
of
what
they
could

do
with
the
sub-‐grants?

ALI:
Within
the
Department
we
were
the
only
ones
doing
a
campaign,
none
of
our
other
partners
were

doing
a
campaign.
They
had
their
own
scope
of
work
and
they
laid
all
that
out
in
their
written
proposal.

Our
campaigns
supported
what
they
were
doing,
it
was
building
the
public
support
for
these

programmatic.
With
portions,
the
overall
health
promotion
message,
I
think
this
is
something
our

director.
Dr.
Fielding
has
been
wanting
to
do
for
a
long
time
and
it
supports
a
lot
of
the
other
work
that

we
are
doing
in
the
community.
We
are
working
with
county
departments
to
help
create
healthier
food

and
beverage
options
in
those
venues
and
the
same
with
restaurants.
And
all
of
this
is
providing
the

public
education
necessary
to
build
support
for
these
programmatic
objectives.

Nutrition
education
is
our
primary
goal,
with
any
of
this.
Even
within
the
policy
development
process,

we
don’t
do
policy,
we
just
provide
the
information,
the
scientific
background,
expert
testimonial
on
the

health
effects
of
some
of
some
of
these
things.

127
I
would
like
to
hear
your
perspective
regarding
the
calorie
and
portion
campaign.
Why
did
you
focus

on
calories
and
why
not
on
weight
or
obesity?

ALI:
Obesity
is
kind
of
a
complicated
message.
You
don’t
think
about
approaching
your
day-‐to-‐day
life
to

avoid
obesity.
You
think
about
a
approaching
your
day
to
day
life
maybe
to
make
you
feel
better,
to

make
decisions
that
are
good
for
you…

So,
our
goal
in
the
campaign
was
to
make
it
more
consumer
friendly
and
less
public
health
speak.
With

the
portion
control
campaign,
the
process
was
similar
to
others.
If
you
look
at
New
York’s
2008
portion-‐
control
campaign
had
a
lot
of
the
same
messages.
We
took
messages
that
were
out
there
already
and

adapted
them
to
see
if
they
would
work
with
our
audience.
We
also
found
from
some
health
surveys

that
the
LA
County
does
and
also
some
street-‐intercept
surveys
that
we
had
done
and
focus
groups,
that

knowledge
about
calories
was
very
low.
And
we
felt
that
this
[calories
focus]
was
necessary
in
order
to

give
context
to
this
comparison
of
a
larger
vs.
smaller
portion.
If
you
don’t
know
that
2,000
calories
is
all

a
person
needs,
the
number
alone
doesn’t
speak
to
you.

Why
did
you
choose
the
food
approach
and
not
physical
activity?

ALI:
This
is
only
one
of
our
campaigns.
Some
of
our
physical
activity
programs
are
supported
by
the

activity
that
they
provide.
We
thought
that
a
wide-‐scale
campaign
focused
on
nutrition
was
really

important
to
some
of
the
other
programs
we
were
doing.
And
it’s
easy...
it’s
a
small
step.
It’s
not
a

complete
lifestyle
overhaul.
And
I
think
this
is
the
underlining
strategy
in
all
of
these
communications,

we
are
not
asking
people
to
completely
change
their
lives,
but
rather
to
make
a
few
decisions
a
little

differently
throughout
the
course
of
their
day.
And
that’s
what
makes
it
attainable
it’s
not
something

that’s
completely
overwhelming.
We
are
not
going
to
ask
to
trade
your
burger
and
fries
for
chicken
and

quinoa.
That
would
be
the
ideal
public
message,
but
it’s
not
realistic.

We
looked
at
a
lot
of
things.
We
looked
at
how
often
people
eat
out,
almost
half
of
their
meals
are

consumed
out
of
the
home.
We
know
that’s
not
going
to
change.
We
wanted
to
meet
people
where

they
went,
and
where
they
are,
it’s
out,
eating
fast
food
or
fast
casual.
And
we
realized
that
this
gave

people
a
little
bit
of
hope
because
“I
can
still
eat
what
I
want,
I
just
need
to
eat
less
of
it.”
So
instead
of

telling
people
that
there
was
good
foods
and
bad
foods,
it
was
more
about
the
positive
messages.

Have
you
received
any
criticism
for
using
fast
food?

ALI:
Absolutely,
and
that
was
one
of
challenges
internally.
As
public
health
we
like
to
promote
the

healthiest
options.
So
we
had
to
discuss
all
the
way
up
the
chain
of
command
to
get
clearance
from
our

leadership
to
get
approval
for
this
non-‐typical
public
health
campaign.

What
about
the
idea
that
it’s
such
a
small
step
that
it’s
not
going
to
make
enough
of
an
impact?

ALI:
I
think
that
is
the
million-‐dollar
question
in
obesity
prevention,
because
the
solution
to
this

epidemic
isn’t
one
fix.
It’s
a
million
different
little
fixes
that
all
add
up
to
this
turning
of
the
tide.
And

that’s
why
it’s
important
to
have
these
programmatic
preventions.
It’s
important
for
elected
officials
to

have
these
policy
interventions.
All
of
these
things
have
to
snowball
together
in
order
to
make
a

difference.

128
If
we
were
able
to
mandate
what
everyone
eats,
that
would
be
a
lot
easier.
But
this
is
just
one
of
many

steps,
and
hopefully
that
they
are
getting
these
positive
messages
through
some
of
our
other
programs.

Maybe
they
are
able
to
get
healthier
drinks
at
work,
because
the
vending
machine
at
work
offers

healthier
options.
Or
they
can
walk
more
because
they
have
access
to
the
school
track.
And
it’s

challenging
for
all
of
us
to
work
together,
because
it
is
going
to
take
a
lot
of
efforts
together,
and
a
lot
of

time,
and
the
help
of
health
practitioners.

And,
it
is
a
personal
choice,
but
you
can
only
make
those
healthy
choices
if
you
can.
If
you’re
in
a

neighborhood
where
you
don’t
have
access
to
healthy
foods
or
to
places
where
you
can
exercise
safely,

you’re
not
going
to
make
those
decisions.

What
about
the
industry?
How
have
they
reacted?

ALI:
Cautiously.
With
the
sugar
stuff
we
are
not
the
only
ones
that
are
drawing
attention
to
the
less-‐
than-‐stellar
nutritional
qualities
of
some
of
these
drinks.
So
with
the
sugary
drink
campaigns,
because
it

was
focusing
on
one
product,
we
can
see
success
in
that
the
companies
are
shifting
product
options.
You

can
still
get
a
64-‐ounce
soda,
but
you
can
also
get
an
8-‐ounce.
When
you
walk
down
a
grocery
isle,
the

shift
of
products
available
has
changed
a
lot
in
the
last
couple
of
years.

They
are
a
business,
and
they
will
always
be
looking
out
for
their
bottom
line,
but
they
look
for
ways
to

partner
with
us
as
well.
But
right
now,
there
are
so
many
of
these
“fires”
happening,
soda
taxes,
or

restricting
access
to
school,
it’s
all
happening.
And
we
our
only
one
piece
of
that.
And
our
goal
is
to

provide
the
public
education
and
the
science
behind
all
of
this.
Why
you
shouldn’t
be
drinking
them.

That’s
were
we
are.
We
did
a
lot
of
research
to
make
sure
everything
that
we
talked
about
in
all
of
these

campaigns
is
thoroughly
vetted
in
the
scientific
literature.
And
I
think
that’s
all
we
can
do,
and
all
we

must
do
as
public
health.

Have
there
been
any
direct
attacks
from
the
industry?

ALI:
Yeah,
I
mean,
they
have
all
of
our
creative
developments
that
we’ve
done.
We
have
a
FOIA
with

them
and
we
know
a
lot
of
the
other
cities
that
have
worked
on
sugary
drinks
have
done
it
too.
But
we

are
a
government
agency,
so
everything
that
we
do
is
public,
so
they
can
request
it.

Did
you
tried
to
communicate
with
the
industry
before
launching?

ALI:
Yeah,
absolutely.
They
met
with
our
director’s
office.
And
they’ve
met
with
some
of
the
members
of

our
board
of
supervisors,
which
is
the
governing
body
for
LA
County.
They
have
a
strategy
for
combating

all
of
this
public
health
education
that
is
happening.
We
aren’t
the
only
ones;
there
are
lots
of
other

cities
around
the
country
doing
something
similar.

How
has
the
public
reacted
to
these
campaigns?

ALI:
I
think
that’s
a
really
important
part
of
this.
Evaluation
and
assessment
of
all
this
work
is
extremely

important.
For
our
reporting
of
what
our
funding
is
doing,
and
for
finding
what
works
and
what
doesn’t

work.
We
evaluate
all
sorts
of
programmatic
successes
and
failures
and
we
do
the
same
with
our

campaigns.
We
do
street-‐intercept
surveys,
focus
groups,
on-‐line
research…
just
to
see
if
it’s
resonating.

129
So
far,
positive
feedback
for
the
portion-‐control
stuff.
Very
positive.
I
know
some
of
the
first
information

that
Roger’s
Finn
pulled
out
after
the
launch
was
overwhelmingly
positive,
the
same
thing
with
the

online
surveys
conducted.

How
has
the
CDC
been
involved
with
your
campaign?
And
how
have
you
collaborated
with
other
cities

working
on
campaigns?

ALI:
There
are
a
lot
of
big
cities
working
on
this.
I
was
in
San
Francisco
last
weekend
in
a
big
public
health

conference
that
happens
every
year.
I
was
on
a
panel
with
3
other
CDC-‐funded
grantees:
from
New
York

City,
Seattle
and
Wisconsin.
The
CDC
has
provided
technical
assistance
for
these
campaigns
and
health

promotion
in
generals.
We
have
calls
every
other
week
just
to
give
updates
of
what’s
happening
across

the
country
around
this
topic,
with
the
CDC
and
people
from
other
cities.
We
are
very
connected.

Has
the
collaboration
been
helpful?

ALI:
It
took
time
to
start
collaborating
because
obesity
campaigns
are
confusing
and
nobody
has
the

answer,
and
by
time
we
has
gotten
our
efforts
started…

Has
there
been
any
competition
among
cities?

ALI:
Friendly
competition.
It’s
more
so,
we
are
kind
of
in
awe
of
each
other.
How
we
are
able
to
pull

some
of
the
stuff
off
because
resources
are
limited.
Even
though
we
had
much
bigger
budgets
than

we’ve
had
in
the
past,
it’s
still
such
a
small
amount
when
we
talk
about
obesity-‐prevention
efforts.
If
we

pull
all
the
obesity
prevention
campaigns,
we
have
spent
all
of
our
money
by
the
January
3rd,
so
we’ve

expended
all
of
our
funds
in
a
very
short
period
of
time.

Is
there
any
“I
won’t
tell
you
what
I’ve
been
doing”?

ALI:
No,
not
at
all.
Actually
it’s
been
very
open
communication.
Our
sugar
stuff
has
been
adapted
up
and

down
the
state;
it
has
been
used
in
some
northern
California
counties.
And
we’re
happy
to
share

resources.
They
take
it
and
adapted
and
go
from
there.
And
we’ve
gotten
resources
from
other

communities,
because
we
don’t
have
resources
to
do
research
over
and
over.

Are
there
any
campaigns
that
you’ve
seen
that
are
really
good?

ALI:
Yeah,
absolutely.
I
know
that
New
York
City’s
“Make
NYC
your
gym”
recently,
which
was
fantastic.

Positive
messaging
along
the
lines
of
why
not
get
off
the
subway
station
a
stop
early
and
similar

messages
to
make
your
day
a
little
bit
more
active.
And
they
supported
it
with
all
these
programs
that

were
happening
throughout
the
community.
And
it
also
promoted
pride
in
your
place
[New
York
City].
It

was
very
successful.
Austin,
Texas
has
also
done
great
things.
Philadelphia
has
some
strong
obesity

campaigns,
and
they
used
a
more
serious
tone
with
some
of
their
messaging,
about
protecting
your

children
from
obesity.
Seattle
has
done
more
focused
on
environmental
changes
and
their
campaign
is

130
“Help
make
this
real,”
and
has
a
little
girls
going
around
the
town
in
TV
commercials
asking
for
healthy

choices.

Have
you
worked
with
the
“Let’s
Move
Campaign”?

ALI:
Yes.
The
“Let’s
Move”
Campaign
is
from
the
same
funding
that
the
CPPW
is
funded.
That
has
really

been
a
humongous
reason
why
all
these
other
campaigns
have
taken
off.
There’s
just
so
much
broad

community
awareness.
This
is
no
longer
just
a
public
health
issue,
it’s
an
issue
that
everyone
knows

about
and
cares
about.
And
I
think
the
“Let’s
Move”
Campaign
had
a
lot
to
do
with
it
by
raising

awareness
about
it.

Thank
you
for
your
time.

131
Jana
M
Scoville
-‐
Member
of
the
Media
and
Communications
Team
at
Banyan
Communications,

Contractors
for
the
CDC.

Transcript
of
phone
interview
conducted
November
19,
2012

I
know
you’ve
been
working
on
obesity
with
the
CDC
for
a
while,
correct?

JANA:
Yeah

What
is
your
role
at
the
CDC
right
now?

JANA:
I
am
a
contractor
with
Banyan
Communications
and
I
serve
full-‐time
on
the
Division
Community

Health
Media
Communication
team.
My
primary
roles
are
providing
technical
assistance
and
training
to

awardees.

I
was
looking
at
the
CDC
website
and
noticed
that
there
are
two
separate
divisions:
the
community

health
division
and
the
division
of
nutrition.
Do
they
work
together?

JANA:
Yes,
we
do
coordinate.

Are
you
the
division
that
funds
the
states
as
well,
or
is
it
mostly
communities?

JANA:
It’s
mostly
communities,
but
there
are
some
states
too
and
some
organizations.
But
I’m
not
on

the
funding
side
of
the
CDC,
so
I’m
not
going
to
have
clear
answers
on
that,
unfortunately.
I’m
sorry

about
that.

Ok,
lets
focus
on
the
communication
strategy
side
then.
What
is
the
CDC’s
overall
philosophy
towards

the
obesity
problem?
How
is
the
CDC
hoping
to
target
it?

JANA:
The
Division
of
Community
Health
is
basically
aligned
with
the
national
prevention
strategy
and

there
are
about
five
or
six
key
messages
around
that
strategy
that
really
highlight
were
the
Division
of

Community
Health’s
focus
is
at
this
time.

Are
you
talking
about
the
key
messages:
more
activity,
healthier
food…

JANA:
Yes,
those
are
some
of
the
focuses.
Lowering
obesity
and
the
risk
of
obesity
through
physical

activity
and
better
nutrition.
And
then
also
separate
initiatives
around
smoking
cessation.

Are
you
working
with
Michelle
Obama’s
“Let’s
Move”
campaign?

JANA:
No.

132

How
do
you
work
with
communities
in
designing
their
strategies?
Do
you
give
them
leeway
in
terms

of
design,
or
do
you
give
them
guidelines?
What
is
the
approach
with
them?

JANA:
The
CDC
uses
just
the
traditional
communication
planning
and
we
provide
technical
assistance

and
training
around
traditional
communication
planning:
doing
informative
research,
doing
audience

research,
setting
your
communication
goals
and
objectives,
developing
messages,
doing
your
message

testing,
and
just
following
the
communication
plan
that
we’ve
all
learned
in
school.
That
is
how
we

provide
technical
assistance
and
training
to
awardees
around
their
communication
efforts.

But
essentially,
they
design
their
own
projects?

JANA:
Oh,
absolutely.

Do
you
have
to
approve
them?

JANA:
No,
we
don’t
have
to
approve
them.
We
are
happy
to
look
through
them,
but
it
is
not
required

that
we
approve
them.

Do
they
have
to
report
back?

JANA:
Yes,
if
it’s
something
that’s
written
into
their
objectives,
then
yes,
they
have
to
report
back
to

their
project
officers
on
those
objectives.

Most
of
the
efforts
that
I’ve
been
studying
have
a
community
programs
component
and
then
the

social
marketing
initiatives.
In
your
opinion,
how
important
is
the
social
marketing
part
to
the
overall

strategy?

JANA:
It’s
critically
important,
that’s
my
personal
opinion.

Do
you
have
an
example
with
evidence
of
a
campaign
that
has
had
a
significant
impact?

JANA:
We’re
still
getting
information
back
from
Communities
Putting
Prevention
to
Work,
CPPW,
that

are
going
on,
so
I’m
not
sure
that
we
have
any
one
right
now,
and
it
takes
many
years
for
the
tide
to

turn,
especially
around
obesity.
And
a
lot
of
the
campaigns
are
currently
being
evaluated
right
now,
and

we
just
don’t
have
the
data
back.
So
I
don’t
know
that
I
can
point
to
any
one
and
say
the
numbers
are

good.

What
is
your
perspective
of
the
different
tactics
that
are
being
used
for
anti-‐obesity
campaigns
(for

example,
scare
tactics,
blame,
etc.)?

133
JANA:
Providing
technical
assistance
to
awardees
across
the
nation,
you’ll
find
that,
from
the
CDC’s

perspective,
we
find
that
the
technical
assistance
and
training
that
we
provide
has
to
be
extremely

tailored
for
each
community
because
each
community
has
a
different
set
of
unique
circumstances,
a

different
environment,
a
different
target
audience,
even
a
different
setup
of
how
the
health
department

or
the
organization
that’s
funded
is
set
up
and
how
they
have
to
get
things
approved.
And
so
there
really

is
not
one
strategy
that
works
best
across
the
country
is
what
I’m
saying.
It’s
required
for
us
to
really

understand
all
communication
strategies
and
help
awardees
find
the
one
that
will
work
best
for
them.

For
instance,
social
media
works
great
in
some
areas,
but
not
so
great
in
more
rural
areas.
It
really

differs
across
the
US.

I
know
that
the
New
York
amputee
campaign
received
a
lot
of
criticism
on
the
media,
and
I
was

wondering
how
the
CDC
viewed
that.
Was
it
viewed
as
a
good
campaign,
a
bad
campaign?

JANA:
I
don’t
know
that
I
can
have
the
views
of
the
CDC
on
that
campaign.
I
think
that
the
CDC
really

doesn’t
make
a
determination,
this
is
a
good
campaign,
this
is
a
bad
campaign
until
evaluation
data

comes
back
and
it’s
determined
whether
or
not
the
objectives
were
met.
So
CDC
doesn’t
necessarily

comments
until
the
information
comes
back
to
know
if
it
was
successful.

I’d
like
to
hear
about
some
of
the
challenges
that
the
communities
are
facing
when
implementing

anti-‐obesity
campaigns?

JANA:
Well,
the
list
of
communities
is
long,
and
it
really
varies
by
community.
But
starting
with
some
of

the
internal
challenges
they
face
are
as
simple
as
making
sure
they
have
communication
staff
on
board

who
understand
how
to
run
communication
work.
And
then,
making
sure
that
the
leadership
of
their

organization
is
in
a
place
where
they
can
back
the
work
once
it’s
put
in
place.
And
then
just
the

environment
the
organization
is
living
in
within
the
larger
community.
So
it
really
does
differ
in
how
the

public
views
this
issue.
All
of
those
things
can
impact
the
success
of
a
communication
plan.

What
about
trying
to
identify
or
provide
a
solution
to
offer
in
a
campaign?
How
do
communities
or

people
who
are
designing
a
campaign
go
about
choosing
which
message
to
offer
or
which
suggestion

to
give?

JANA:
The
large
majority
of
communication
plans
out
there
involve
audience
testing
of
the
messages

that
are
chosen.
So
their
target
audience
has
said
this
message
resonates
with
me,
which
is
why

ultimately
it
was
chosen
for
the
campaign.

From
what
I
understand,
you
have
worked
on
other
social
marketing
campaigns,
correct?
How
is

obesity
different
from
other
campaigns?

JANA:
I
think
that
being
funded
through
the
CDC
provides
strengths
and
challenges
in
terms
of
what
can

be
done.
I
think
that
obesity…
it
really
depends
how
the
public
in
that
community
views
the
issue.
But

that’s
really
the
case
on
all
campaigns
that
I’ve
ever
worked
on,
in
any
case.
So
it’s
really
important
to

build
your
coalitions
and
your
partnerships
early
on,
to
get
solid
backing
of
the
issue.
It’s
a
very

widespread
and
large
challenge;
so
it’s
also
important
to
make
sure
you
are
able
to
focus
on
specific

134
target
audience
groups
that
can
best
move
the
needle
on
the
issue
in
the
specific
community.
But
again,

I
don’t
know
that
that
is
unique
to
obesity
either.

One
big
issue
in
obesity
communication
is
that
it
affects
a
person’s
everyday
life:
a
person
can’t
simply

stop
eating.
How
do
you
deal
with
the
fact
that
you
are
trying
to
affect
a
behavior
that
is
such
a
big

part
of
a
person’s
everyday
life?
What
are
some
of
the
ways
that
communities
are
approaching
this?

How
do
you
educate
people
about
something
that
they
do
every
day
and
that
they
probably
think

they
are
already
knowledgeable
about?

JANA:
Again,
it
goes
back
to
the
tried
and
true
need
for
audience
testing
and
research.
That’s
one
of
the

very
first
steps
needed
for
any
communication
plan.
And
we
see
that
across
the
board
no
matter
what

community
is
implementing
a
communication
initiative
around
obesity.
Making
sure
that
the
people

running
that
initiative
fully
understand
their
target
audience
and
that
their
perspective
is
just
critically

important.

Has
that
been
a
challenge
for
you?
Making
sure
grantees
understand
the
importance
of
research?

JANA:
I
think
in
some
cases,
where
say
a
health
department
was
funded
but
never
really
had
a

communication
department
or
a
person
with
a
communication
background,
the
person
running
it
didn’t

necessarily
understand
the
importance
of
doing
that
in
the
beginning.
So,
yeah,
that
was
a
challenge
in

some
cases.

Thank
you
very
much
for
your
time.

135
Keisha
Brown,
Senior
Vice
President/Chief
Creative
&
Innovative
Officer,
Lagrant
Communications

Transcript
of
interview
conducted
March
27,
2013
in
Los
Angeles,
California.

Can
you
tell
me
more
about
Lagrant’s
experience
with
the
Robert
Wood
Johnson
Foundation
(RWJF)?

KEISHA:
I’ll
tell
you
a
little
bit
about
how
we
started
working
with
RWJF.
When
they
first
came
to
us,
it

was
to
build
a
multicultural
newsroom
for
them.
A
place
where
African
American
and
Hispanic
media

could
go,
when
they
were
looking
for
anything
regarding
health
care
resources.
So
we
were
trying
to

position
the
Robert
Wood
Johnson
Foundation
(RWJF)
as
a
health
care
expert,
when
it
came
to
obesity

and
other
health
topics.

That
was
our
first
project.
From
there
it
grew
and
we
eventually
became
consultants
to
the
RWJF
for

communication
strategies
and
tactics.
With
that,
we
had
a
person
who
was
dedicated
to
the
African

American
market
and
a
person
who
was
dedicated
to
the
Hispanic
market
to
specifically
reach
out
to

those
markets
about
the
programs
and
the
grantees
that
the
RWJF
worked
on.

Was
RWJF
trying
to
raise
money?

KEISHA:
The
RWJF
doesn’t
raise
money,
they
give
out
money.
They
are
tied
to
the
Johnson
&
Johnson

foundation
and
it
was
set
up
through
a
trust.
So
their
role
is
to
give
money
to
local
grantees
and

community
based
organization
who
can
really
be
a
champion
for
those
key
areas
that
the
RWJF
focuses

on,
on
a
national
level.

What
work
did
you
do
on
childhood
obesity?

KEISHA:
We
worked
with
the
RWJF
in
several
topics,
but
childhood
obesity
was
a
really
big
focus.
So

there
were
a
lot
of
things
that
we
focused
on.
One
was
“F
As
in
Fat,”
which
was
a
report
that
came
out

every
year
about
obesity.
Our
goal
was
to
pitch
media
stories
about
how
unhealthy
people
were
living
in

a
lot
of
the
cities.
And
it
looked
at
the
cities
or
areas
where
there
was
the
most
obesity,
those
areas

crossed
over
with
areas
where
you
had
a
lot
of
African
Americans
and
Hispanics
residing
in
those
cities,

and
often
times,
of
course,
they
were
larger
cities.

Another
one
we
did
was
about
sugary
drinks
and
how
they
contribute
to
childhood
obesity.
We
also

talked
about
a
program
called
Play
Works,
which
is
in
different
schools
and
they
provide
opportunities

for
children
to
go
out
and
play
and
be
active,
so
that
way
they
can
decrease
the
chances
of
them
getting

childhood
obesity.

Other
things
we
did
with
them
was
that
we
partnered
with
a
lot
of
their
grantees
in
different
areas
and

we
talked
to
the
community
about
what
these
organizations
were
doing
in
the
individual
communities.

So
it
was
not
about,
not
just
saying
‘your
kids
are
fat,
you’re
fat,
it’s
just
a
fat
world.’
It
was
about
saying

‘these
are
some
of
the
solutions
that
local
organization
are
implementing
and
some
of
the
things
that

you
can
do
with
your
family
to
become
healthier.’
For
example,
we
had
a
partnership
with
the

association
of
Hispanic
journalists.
And
with
this
partnership,
the
RWJF
and
the
association
would
go

around
the
country
and
hold
luncheons
with
Hispanic
journalists,
and
we
brought
in
local
grantees
who

talked
about
different
topics,
childhood
obesity,
what
a
relationship
looks
like
between
teens,
and
other

issues
that
were
relevant
to
journalists
in
those
particular
communities.
One
in
particular
that
we
did

here
[in
Los
Angeles]
was
about
obesity.
And
there
were
several
non-‐profit
organizations
that
they

funded
out
here
and
they
talked
to
journalists
about
what
these
organizations
were
doing
in
cities
like

136
east
LA.
And
what
was
interesting
was
how
these
organizations
were
taking
very
localized
approaches

based
on
the
neighborhoods
in
which
they
lived.
So
say,
for
instance,
if
you
are
an
immigrant
mother,

you
might
not
always
go
to
the
store
to
pick
the
healthiest
food.
You
might
go
and
pick
the
cheapest
and

the
one
that
can
feed
the
family
the
most.
Or
you
don’t
necessarily
understand
really
all
the
benefits
of

buying
an
apple
vs.
buying
the
canned
apples
would
do
for
you.
So
there
was
an
organization
who

partnered
with
grocery
stores
in
the
community
and
they
went
around
and
put
stickers
on
items
that

were
healthy,
to
help
parents
identify
different
healthy
foods
for
their
families.
It
was
a
very
localized

approach
to
help
parents
understand
how
to
look
at
food
differently,
but
speaking
to
them
in
a

culturally
relevant
way
and
understanding
the
culture
of
the
community.

The
goal
of
RWJF
is
to
reduce
childhood
obesity;
they
have
established
a
goal
to
reduce
it
by
a
certain

time.
So
it
was
really
about