7

Message Environments

Message Environments:
Goal, Recommendation, Strategies, and Actions for
Implementation

Goal: Transform messages about physical activity and nutrition.

Recommendation 3: Industry, educators, and governments should act quickly, aggressively, and in a sustained manner on many levels to transform the environment that surrounds Americans with messages about physical activity, food, and nutrition.

Strategy 3-1: Develop and support a sustained, targeted physical activity and nutrition social marketing program. Congress, the Administration, other federal policy makers, and foundations should dedicate substantial funding and support to the development and implementation of a robust and sustained social marketing program on physical activity and nutrition. This program should encompass carefully targeted, culturally appropriate messages aimed at specific audiences (e.g., tweens, new parents, mothers); clear behavior-change goals (e.g., take a daily walk, reduce consumption of sugar-sweetened beverages among adolescents, introduce infants to vegetables, make use of the new front-of-package nutrition labels); and related environmental change goals (e.g., improve physical environments, offer better food choices in public places, increase the availability of healthy food retailing).



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7 Message Environments Message Environments: Goal, Recommendation, Strategies, and Actions for Implementation Goal: Transform messages about physical activity and nutrition. Recommendation 3: Industry, educators, and governments should act quickly, aggressively, and in a sustained manner on many levels to transform the environment that sur­ rounds Americans with messages about physical activity, food, and nutrition. Strategy 3-1: Develop and support a sustained, targeted physical activity and nutrition social marketing program. Congress, the Administration, other federal policy makers, and foundations should dedicate substantial funding and support to the development and implementation of a robust and sustained social marketing program on physical activity and nutrition. This program should encompass carefully targeted, culturally appropriate messages aimed at specific audiences (e.g., tweens, new parents, mothers); clear behavior-change goals (e.g., take a daily walk, reduce consumption of sugar-sweetened bever- ages among adolescents, introduce infants to vegetables, make use of the new front-of-package nutrition labels); and related environmental change goals (e.g., improve physical environments, offer better food choices in public places, increase the availability of healthy food retailing). 235

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For Congress, the Administration, and other federal policy makers, work- ing with entertainment media, potential actions include • providing a sustained source of funding for a major national social market- ing program on physical activity and nutrition; and • designating a lead agency to guide and oversee the federal program and appointing a small advisory group of physical activity, nutrition, and market- ing experts to recommend message and audience priorities for the program; ensuring that the program includes a balance of messages on physical activity and nutrition, and on both individual behavior change and related environmental change goals; and exploring all forms of marketing, including message placement in popular entertainment, viral and social marketing, and multiplatform advertising—including online, outdoor, radio, television, and print. For foundations, working with state, local, and national organizations and the news media, potential actions include • enhancing the social marketing program by encouraging and supporting the news media’s coverage of obesity prevention policies through the develop- ment of local and national media programs that engage individuals in the civic debate about local, state, and national-level environmental and policy changes, including such steps as providing resources to enable journalists to cover these issues and enhancing the expertise of local, state, and national organizations in engaging the news media on these issues. Strategy 3-2: Implement common standards for marketing foods and beverages to children and adolescents. The food, beverage, restaurant, and media industries should take broad, common, and urgent voluntary action to make substantial improvements in their marketing aimed directly at children and adolescents aged 2-17. All foods and beverages marketed to this age group should support a diet that accords with the Dietary Guidelines for Americans in order to prevent obesity and risk factors associated with chronic disease risk. Children and adolescents should be encouraged to avoid calories from foods that they generally overconsume (e.g., products high in sugar, fat, and sodium) Accelerating Progress in Obesity Prevention 236

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and to replace them with foods they generally underconsume (e.g., fruits, veg- etables, and whole grains). The standards set for foods and beverages marketed to children and adoles- cents should be widely publicized and easily available to parents and other consumers. They should cover foods and beverages marketed to children and adolescents aged 2-17 and should apply to a broad range of marketing and advertising practices, including digital marketing and the use of licensed char- acters and toy premiums. If such marketing standards have not been adopted within 2 years by a substantial majority of food, beverage, restaurant, and media companies that market foods and beverages to children and adolescents, policy makers at the local, state, and federal levels should consider setting man- datory nutritional standards for marketing to this age group to ensure that such standards are implemented. Potential actions include • all food and beverage companies, including chain and quick-service restaurants, adopting and implementing voluntary nutrition standards for foods and beverages marketed to children and adolescents; • the Children’s Food and Beverage Advertising Initiative and National Restaurant Association Initiative, as major self-regulatory marketing efforts, adopting common marketing standards for all member companies, and actively recruiting additional members to increase the impact of improved food marketing to children and adolescents; • media companies adopting nutrition standards for all foods they market to young people; and • the Federal Trade Commission regularly tracking the marketing standards adopted by food and beverage companies, restaurants, and media companies. Strategy 3-3: Ensure consistent nutrition labeling for the front of pack- ages, retail store shelves, and menus and menu boards that encourages healthier food choices. The Food and Drug Administration (FDA) and the U.S. 237 Message Environments

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Department of Agriculture (USDA) should implement a standard system of nutri- tion labeling for the front of packages and retail store shelves that is harmonious with the Nutrition Facts panel, and restaurants should provide calorie labeling on all menus and menu boards. Potential actions include • the FDA and USDA adopting a single standard nutrition labeling system for all fronts of packages and retail store shelves, the FDA and USDA con- sidering making this system mandatory to enable consumers to compare products on a standard nutrition profile, and the guidelines provided by the Institute of Medicine (2011a) being used for implementation; and • restaurants implementing the FDA regulations that require restaurants with 20 or more locations to provide calorie labeling on their menus and menu boards, and the FDA/USDA monitoring industry for compliance with this policy. Strategy 3-4: Adopt consistent nutrition education policies for federal programs with nutrition education components. USDA should update the policies for Special Supplemental Nutrition Assistance Program Education (SNAP-Ed) and the policies for other federal programs with nutrition education components to explicitly encourage the provision of advice about types of foods to reduce in the diet, consistent with the Dietary Guidelines for Americans. Potential actions include • removing the restrictions on the types of information that can be included in SNAP-Ed programs and encouraging advice about types of foods to reduce; • disseminating, immediately and effectively, notification of the revised regu- lations, along with authoritative guidance on how to align federally funded nutrition education programs with the Dietary Guidelines; and Accelerating Progress in Obesity Prevention 238

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• ensuring that such full alignment of nutrition education with the Dietary Guidelines applies to all federal programs with a nutrition education com- ponent, particularly programs that target primary food shoppers in low- income families (e.g., the Expanded Food and Nutrition Education Program and the Special Supplemental Nutrition Program for Women, Infants, and Children [WIC]). NOTE: Instruction in food and nutrition for children and adolescents in schools is covered in Chapter 9, on school environments. E ach day, Americans of all ages are surrounded by an environment replete with messages about physical activity and food: advertising on television, bill- boards, and cell phones; product placements in movies and video games; product packaging at grocery stores and on the kitchen table; public service campaigns; and nutrition and physical activity classes provided through schools and govern- ment programs. Some messages are explicit, making direct appeals (e.g., soft drink ads or public service messages), and some are implicit, operating more on a sub- conscious level (e.g., when people pass a familiar fast-food chain every day on the way to school or come to expect the local sports team to be sponsored by a chain restaurant). Indeed, the food and beverage and restaurant industries have invested heavily in extensive research into understanding complex, deep-seated motivation. As discussed in the preceding chapters, what is available in people’s daily environment circumscribes their choices: for example, whether there are safe play- grounds within walking distance or which drinks are in the vending machine. But what is promoted in people’s daily environment influences their choices as well. It is the message environments in which people live (highlighted in Figure 7-1) that help create the expectation that a “treat” involves a fast-food outlet or that drink- ing a particular soda is a sign of a hip or active lifestyle. This chapter addresses these message environments, including marketing and the provision of nutri- tion education within federal programs with nutrition education components; Chapter 9 covers instruction in food and nutrition for children and adolescents in schools. 239 Message Environments

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Message Environments School Environments Physical Food and Activity Beverage Environments Environments Health Care and Work Environments FIGURE 7-1 Five areas of focus of the Committee on Accelerating Progress in Obesity Prevention. NOTE: The area addressed in this chapter is highlighted. RECOMMENDATION 3 Industry, educators, and governments should act quickly, aggressively, and in a sustained manner on many levels to transform the environment that surrounds Americans with messages about physical activity, food, and nutrition. 7-1 While changing the physical environment is critical to accelerating progress in preventing obesity—whether by expanding bike paths or building more grocery stores—equally important is changing the message environments in which people function every day. These environments take many forms: advergames on popular children’s websites; brand ambassadors sent to offer free products to students on Accelerating Progress in Obesity Prevention 240

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their first day of college; public service campaigns on billboards and bus shelters; product placements in video games or reality television shows; health messages embedded in children’s educational television shows; nutrition labeling on food packages and menu boards; physical activity and eating behaviors modeled on popular sitcoms; the products that are placed at children’s eye level in grocery stores; the brand icons, celebrity endorsements, and character tie-ins featured on product packages; the mobile ads texted to teenagers; the information provided in school health classes or in education programs for those receiving public assis- tance; and what a doctor does or does not say about physical activity and diet during an annual checkup. Many different actors influence these message environments. Exerting this influence on a large scale costs money, and most of those who make that invest- ment do so not because they care about the health outcomes they may be influenc- ing but because they have a financial stake in the choices people make: whether a young boy chooses to play a video game with friends online instead of a softball game with his neighbors, or whether a young mother decides that the best reward for her daughter’s good grades at school is a meal at her favorite fast-food restau- rant instead of a home-cooked dinner. The committee therefore recommends that actors at all levels—the food and beverage industry, the entertainment and sports industries, educators, and government at all levels—do their part to contribute to the transformation of the message environments that is needed to accelerate progress in obesity preven- tion. Four strategies and potential actions for implementing this recommendation are provided. These strategies and actions are detailed in the remainder of this chapter. (As noted above, the strategy of providing food literacy in schools, along with potential actions for implementing this strategy, is included in Chapter 9.) Indicators for measuring progress toward the implementation of each strategy, organized according to the scheme presented in Chapter 4 (primary, process, foun- dational) are presented in a box following the discussion of that strategy. STRATEGIES AND ACTIONS FOR IMPLEMENTATION Strategy 3-1: Develop and Support a Sustained, Targeted Physical Activity and Nutrition Social Marketing Program Congress, the Administration, other federal policy makers, and founda- tions should dedicate substantial funding and support to the development and implementation of a robust and sustained social marketing program on physical 241 Message Environments

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activity and nutrition. This program should encompass carefully targeted, cultur- ally appropriate messages aimed at specific audiences (e.g., tweens, new parents, mothers); clear behavior-change goals (e.g., take a daily walk, reduce consumption of sugar-sweetened beverages among adolescents, introduce infants to vegetables, make use of the new front-of-package nutrition labels); and related environmental change goals (e.g., improve physical environments, offer better food choices in public places, increase the availability of healthy food retailing). For Congress, the Administration, and other federal policy makers, working with entertainment media, potential actions include • providing a sustained source of funding for a major national social market- ing program on physical activity and nutrition; and • designating a lead agency to guide and oversee the federal program and appointing a small advisory group of physical activity, nutrition, and marketing experts to recommend message and audience priorities for the program; ensuring that the program includes a balance of messages on physical activity and nutrition, and on both individual behavior change and related environmental change goals; and exploring all forms of marketing, including message placement in popular entertainment, viral and social marketing, and multiplatform advertising—including online, outdoor, radio, television, and print. For foundations, working with state, local, and national organizations and the news media, potential actions include • enhancing the social marketing program by encouraging and supporting the news media’s coverage of obesity prevention policies through the develop- ment of local and national media programs that engage individuals in the civic debate about local, state, and national-level environmental and policy changes, including such steps as providing resources to enable journalists to cover these issues and enhancing the expertise of local, state, and national organizations in engaging the news media on these issues. Context Americans of all ages, including children and adolescents, are exposed to a tremendous amount of well-financed and expertly crafted marketing and advertis- Accelerating Progress in Obesity Prevention 242

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ing messages designed to encourage food and beverage consumption (Cheyne et al., 2011; FTC, 2008; Harris et al., 2009, 2010). The most frequently marketed foods and beverages are often of lower nutritional value and tend to be from the food groups Americans are already overconsuming (Cheyne et al., 2011; Grotto and Zied, 2010; Harris et al., 2010; Harrison and Marske, 2005; IOM, 2006). For example, a 2009 study found that approximately 87 percent of the 7.9 food and beverage ads seen by children aged 6-11 on television each day were for products high in saturated fat, sugar, or sodium (Powell et al., 2011). Moreover, many of these advertisements include incentives such as premiums, sweepstakes, and contests to induce purchases and consumption. One study, for example, found that 14 percent of fast-food ads and 17 percent of dine-in and delivery restaurant messages targeting children included at least one premium offer (Gantz et al., 2007). In addition, American consumers are exposed to a vast amount of market- ing that promotes sedentary activities (such as television viewing). For example, Gantz and colleagues (2007) found that children aged 8-12 viewed approximately 8,400 promotions for upcoming television shows and approximately 5,000 ads for entertainment media products each year. The news media also are a key part of the message environments that sur- round Americans. A recent survey found that 83 percent of Americans watch local or national television news, read a newspaper, listen to news radio, or visit an online news site daily (Pew Research Center for the People and the Press, 2010). The national broadcast network evening news programs together attract approxi- mately 21.6 million viewers per night (Guskin et al., 2011). News media continue to play an essential role in highlighting the issues that are seen as legitimate or important for public consideration and in informing citizens on those topics. In describing the potential role of the news media in public health issues, a previous Institute of Medicine (IOM) committee concluded that “the more coverage a topic receives in the news, the more likely it is to be a concern of the public. Conversely, issues not mentioned by the media are likely to be ignored or to receive little attention” (IOM, 2002, p. 308). Too often, however, news coverage of physical activity and nutrition focuses on strategies for individuals to eat better and move more. This focus on the individual can obscure the importance of broader envi- ronment or policy changes (Lawrence, 2004; Woodruff et al., 2003). Foods, beverages, and entertainment media are marketed to children, adoles- cents, and adults because for-profit entities stand to benefit financially from the investment in advertising. No similar investments are made in marketing messages about fitness and nutrition, in part because there are no entities with a similarly 243 Message Environments

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clear financial stake in promoting those messages (Gantz et al., 2007). For exam- ple, in 2005 children aged 8-12 saw an average of 158 public service announce- ments (PSAs) on fitness or nutrition in that one year compared with 7,609 ads for foods and beverages, or about 1 hour and 15 minutes of messages about fitness or nutrition compared with more than 50 hours of messages promoting food and beverage consumption (Gantz et al., 2007). Across the television landscape, a total of just 17 seconds per hour is donated to PSAs on all topics combined—the equiv- alent of less than one-half of 1 percent of air time—compared with the 21 percent of air time that is devoted to paid commercial advertising (Gantz et al., 2008). Evidence Social marketing is broadly defined as the application of commercial market- ing principles to benefit society and the intended audience rather than the marketer. Social marketing applies the techniques of commercial advertising and marketing to the marketing of healthful or prosocial behaviors. Instead of simply providing the consumer with information about public health issues, social marketing often focuses on behavior change, sometimes includes broader environmental and policy goals, and generally uses the insights and avenues of modern product marketing (Grier and Bryant, 2005). For example, the well-regarded “truth” antitobacco youth campaign did not focus on imparting factual information about the health risks of smoking; instead, it focused on fostering a sense of rebellion against cor- porate tobacco companies, using popular youth media outlets and an edgy youth- oriented visual style to convey its messages and empower the targeted youth. A campaign evaluation concluded that from 1999 to 2002, the “truth” campaign resulted in 300,000 fewer youth smokers (Farrelly et al., 2005). Because many health-based social marketing campaigns are insufficiently funded, assessing their effectiveness accurately is difficult. However, evidence from carefully designed studies indicates that media campaigns can have a positive impact on health behaviors if they are carefully crafted, well tested, fully funded, highly targeted (in terms of audience and behavior), and sustained over a long period of time (Wakefield et al., 2010). Social marketing has been used to impact a variety of health and risk behaviors among children, adolescents, and adults. A comprehensive review of mass media campaigns and effects on behavior published by Wakefield et al. (2010) found “strong evidence for benefit” from the majority of antismoking campaigns, and moderate evidence for campaigns to promote physical activity (especially among motivated individuals who received prompts at decision-making moments) and Accelerating Progress in Obesity Prevention 244

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nutrition (when specific healthy food choices were promoted) (Stead et al., 2007; Wakefield et al., 2010). On the other hand, campaigns to combat drug abuse have had mixed results, and those to reduce alcohol consumption have had little success (Wakefield et al., 2010). Many health-based social marketing campaigns target parents, who can address the home health environment and talk to their children about specific health behaviors. To initiate health behavior change, many of these campaigns take a multifaceted approach, utilizing community outreach as well as mass media (Evans et al., 2010). One example of a social marketing campaign targeting parents was the Centers for Disease Control and Prevention’s (CDC’s) VERB™ campaign, a well-funded, carefully planned, and highly focused campaign aimed at promoting physical activity among 9- to 13-year-olds (tweens) (Wong et al., 2004). The multi- ethnic campaign was notable for its use of tailored messages aimed at specific audi- ence segments, which included white, black, Hispanic, American Indian, and Asian American tweens (Berkowitz et al., 2008; Huhman et al., 2008; Wong et al., 2004). An evaluation revealed increases in physical activity among important subgroups of youth exposed to the campaign (e.g., 9- to 10-year-olds, girls, children living in urban areas of high density, children from households with annual incomes between $25,000 and $50,000, and children who were low-active at baseline), and also indicated that as tween exposure to the campaign messages increased, more physical activity sessions were reported (a dose-response relationship) (Huhman et al., 2005, 2010). The VERB™ campaign provided evidence that the development of a national media campaign with social marketing messages for young people can help address a significant public health issue such as physical activity (Asbury et al., 2008; Banspach, 2008; Huhman et al., 2010). In addition to the “truth” campaign referenced above, other youth anti- smoking campaigns have had an impact on behaviors (Bauer et al., 1999; Biglan et al., 2000; Flynn et al., 1994, 1997; Wakefield et al., 2003). Some of these successful campaigns have included engaging teens and parents in supporting community-level social changes to help prevent adolescent tobacco use (Biglan et al., 2000; Wakefield et al., 2003). Social marketing also has been found effective in promoting safer sexual behaviors (Zimmerman et al., 2007). One such experiment used extensive forma- tive research to select high-performing ads, targeted a well-defined audience (high- sensation-seeking youth, who were most at risk of unprotected sex), and purchased an extensive inventory of well-targeted air time (Zimmerman et al., 2007). Previous safe sex campaigns not using such techniques generally had yielded modest results. 245 Message Environments

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