6

Advertising, Promotion, and Education: Bringing Health Equity to the Message Environment

Important Points Made by Speakers

•     The food and beverage marketing environment and messages about physical activity and nutrition need to change dramatically to accelerate movement toward healthy equity. (Wartella)

•     Obesity prevention messages can counter at least some of the unhealthy messaging to which people are exposed, but they need to be sustained given the ubiquity of food and beverage advertising and the time required to change behaviors. (Signorelli)

•     The message environment and its targeting practices need to be examined to determine the best ways of countering the advertising of unhealthy foods. (Dorfman)

Americans are surrounded by messages about food and beverages: advertising on television, billboards, and cell phones; product placements in movies and video games; product packaging; advergames on popular websites; brand ambassadors offering free products to college students; and character tie-ins on product packages. Furthermore, many of these messages are directed with special intensity at vulnerable populations that are especially susceptible to being overweight (IOM, 2012a, 2013c).

Three speakers at the workshop considered ways of reorienting the message environment to ease the marketing pressure on vulnerable populations in accordance with goal 3 of Accelerating Progress in Obesity Prevention (IOM, 2012a) (see Box 6-1). Standing committee member Ellen Wartella, Al-Thani professor of communication at Northwestern University, reviewed the strategies and actions to this end



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6 Advertising, Promotion, and Education: Bringing Health Equity to the Message Environment Important Points Made by Speakers  The food and beverage marketing environment and messages about physical activity and nutrition need to change dra- matically to accelerate movement toward healthy equity. (Wartella)  Obesity prevention messages can counter at least some of the unhealthy messaging to which people are exposed, but they need to be sustained given the ubiquity of food and beverage advertising and the time required to change behaviors. (Signorelli)  The message environment and its targeting practices need to be examined to determine the best ways of countering the advertising of unhealthy foods. (Dorfman) Americans are surrounded by messages about food and beverages: advertising on television, billboards, and cell phones; product placements in movies and video games; product packaging; advergames on popular websites; brand ambassadors offering free products to college students; and character tie-ins on product packages. Furthermore, many of these messages are directed with special intensity at vulnerable populations that are especially susceptible to being overweight (IOM, 2012a, 2013c). Three speakers at the workshop considered ways of reorienting the message environment to ease the marketing pressure on vulnerable populations in accordance with goal 3 of Accelerating Progress in Obesity Prevention (IOM, 2012a) (see Box 6-1). Standing committee member Ellen Wartella, Al-Thani professor of communication at Northwestern University, reviewed the strategies and actions to this end 61

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62 CREATING EQUAL OPPORTUNITIES FOR A HEALTHY WEIGHT BOX 6-1 Goal 3 from Accelerating Progress in Obesity Prevention Goal: Transform messages about physical activity and nutrition. Recommendation: 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. suggested in Accelerating Progress in Obesity Prevention while emphasizing the many challenges posed by health disparities. Anthony Signorelli, vice president and campaign director for the Advertising Council (commonly known as the Ad Council) described the Council’s efforts to prevent obesity and the potential of future marketing campaigns. Lori Dorfman, director of the Berkeley Media Studies Group, a project of the Public Health Institute, talked about the four Ps of marketing—product, price, place, and promotion—and how to reduce disparities in each. STRATEGIES FOR CHANGING THE MESSAGE ENVIRONMENT Summary of Remarks by Ellen Wartella As described in the recent Institute of Medicine (IOM) publication Challenges and Opportunities for Change in Food Marketing to Children and Youth: Workshop Summary, food advertising on television is associated with increased weight in children aged 2 to 18 (IOM, 2013c). The most frequently marketed foods and beverages are high in fats, sugars, and salt. At the same time, many health-related social marketing programs are underfunded, inadequately designed and tested, or not sustained long enough to have an effect (IOM, 2012a, 2013b). Consumers are confused by many of the front-of-package nutrition rating systems currently in use, which have been multiplying and are not necessarily consistent with each other (IOM, 2012b). Nor can consumers easily evaluate the healthfulness of many restaurant menus, Wartella stated. Accelerating Progress in Obesity Prevention (IOM, 2012a) presents four strategies for changing the message environment. The first is to

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ADVERTISING, PROMOTION, AND EDUCATION 63 develop and support a sustained, targeted physical activity and nutrition social marketing program. According to the report, 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. In addition, the report states that the messages conveyed in this program should be specific, culturally appropriate, and aimed at particular audiences. The program also should provide clear goals for changing behaviors and the environment. The second strategy is to implement common standards for marketing foods and beverages to children and adolescents. The food, beverage, restaurant, and media industries should take broad, shared, and urgent voluntary actions to make substantial improvements in their marketing aimed directly at children and adolescents, the report says. In particular, all the foods and beverages that are marketed to children should support a diet that accords with the Dietary Guidelines for Americans. Children and adolescents should be encouraged to avoid calories from foods they generally overconsume, such as products high in sugar, fat, and salt, and consume more whole grains, fruits, and vegetables. The standards should be widely publicized and apply to digital marketing as well as the more traditional media. Most important, said Wartella, if such marketing standards have not been adopted within 2 years by a substantial majority of food, beverage, restaurant, and media companies that market food and beverages to children and adolescents, policy makers at the local, state, and federal levels should consider setting mandatory nutritional standards for marketing to this age group. The third strategy is to ensure consistent nutrition labeling for the fronts of packages, retail store shelves, and menus and menu boards that encourages healthier food choices. In particular, the U.S. Food and Drug Administration (FDA) and the U.S. Department of Agriculture (USDA) should implement a standard system of nutrition labeling for the fronts of packages and retail store shelves that is harmonious with the Nutrition Facts panel. The fourth strategy is to adopt consistent nutrition education policies for federal programs with nutrition education components. In particular, said Wartella, USDA should update policies for the educational component of the Supplemental Nutrition Assistance Program (SNAP- Ed) to encourage the provision of advice about types of foods to reduce in the diet.

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64 CREATING EQUAL OPPORTUNITIES FOR A HEALTHY WEIGHT Meeting these challenges while reducing disparities will be difficult, said Wartella. As observed in Chapter 2, opportunities for safe and af- fordable recreation are less available in racial and ethnic minority and low-income communities than elsewhere. The lowest-cost foods and bev- erages often are the least healthy and the highest in calories, which means that people with low incomes may need to rely on these foods to a greater extent than people with higher incomes Wartella stated. Message environments in many minority and low-income communities are dominated by advertisements and other promotions of unhealthy foods and beverages to a significantly greater extent than in white and higher- income communities (IOM, 2013c). Black and Latino and low-income children rely heavily on television and electronic media as sources of entertainment and are thereby exposed disproportionately to advertise- ments for unhealthy foods and beverages (Nielsen Company, 2012; Powell et al., 2010). Television shows watched predominantly by black audiences have more fast food advertisements than shows watched primarily by white audiences, Wartella stated, and these advertisements are generally for unhealthy foods (Harris et al., 2010; Powell et al., 2010). Finally, Wartella explained that the mix of foods available in low- income communities presents a plethora of high-calorie options in quantities, at prices, and in culturally tailored avenues that are attractive to residents of these communities. The marketing and message environment needs to change dramatically to accelerate movement toward health equity, Wartella concluded. “Advertising works, and the kinds of messages that children receive are influential.” —Ellen Wartella CASE STUDY: THE ADVERTISING COUNCIL Summary of Remarks by Anthony Signorelli The Ad Council, a nonprofit organization founded during World War II, has developed communication programs around a wide range of significant public issues, including forest fires, pollution, drunk driving, seatbelts, AIDS, domestic violence, autism, texting and driving, and bullying. Currently, its campaign issues in the area of health include

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ADVERTISING, PROMOTION, AND EDUCATION 65 childhood asthma, children’s oral health, and childhood obesity. In each area, the Ad Council selects the target audience it wants to reach and constructs an integrated campaign that can involve public service announcements, public relations, websites, social media, corporate and media partnerships, cell phone communications and apps, gaming, and events. Signorelli explained that the organization works on issues on which it thinks it can make a difference and seeks to measure the resulting exposure, recognition, engagement, and impact. The Ad Council disseminates its messages, developed in partnership with advertising agencies that work pro bono, through major media outlets (broadcast, print, outdoor, the Internet) that donate time and space to run the ads. Each year it receives an estimated $1.5 billion in donated media support, which makes it among one of the top advertisers in the United States, according to Signorelli. Building on programs it had created for the U.S. Department of Health and Human Services (HHS) and USDA, the Ad Council developed a new childhood obesity prevention communication program. Its advertising partners were Burrell Communications, an agency that focuses on the African American community; Casanova Pendrill, which works primarily in the Hispanic community; and the large marketing and public relations firm Ogilvy and Mather. The objective of the campaign was to encourage parents and caregivers to promote healthy eating and physical activity habits among their children aged 0 to 7. (A separate program, known as the Greatest Action Movie Ever, which Signorelli did not describe in detail, targeted children aged 7 to 17.) Specific goals for the campaign were to teach parents and caregivers about the correct amount of food to feed their children, about how to replace empty calories with nutrient-rich foods, and about how to promote and provide opportunities for children to engage in 60 minutes of physical activity daily. Signorelli noted that the program had a special focus on minority and lower-income audiences. Messages were tested with target audiences to ensure that they were meaningful, motivating, and actionable. Signorelli stated that research already had shown that, although they are aware of the problem of childhood obesity, many mothers do not identify the problem in their own children. Signorelli explained that many mothers admit they do not always do a good job of feeding their children healthy food or of providing them with physical activity opportunities.

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66 CREATING EQUAL OPPORTUNITIES FOR A HEALTHY WEIGHT Messages and Countermessages A prominent misconception in society, said Signorelli, is that eating healthy foods and exercising more require major, unsustainable lifestyle changes—changes that are too time-consuming, too expensive, and not kid-friendly. To counter this idea, the Ad Council developed the message that “moms everywhere are discovering creative and easy ways to keep their families healthy each and every day.” The message encouraged mothers to “get ideas, get involved, and get going” at the campaign website, which provides resources such as recipes and places to play, connections with other organizations, suggestions for family activities, and other information. Among African Americans in particular, Signorelli pointed out, many mothers have more immediate and pressing concerns involving economic disparity and safety. They know that extra weight can cause problems, but when they look at their children, they see happy individuals. They do not want to spend the limited time they have with their children arguing over eating healthfully or being physically active, Signorelli said. Many in the African American community also embrace role models with full figures, he added, which can reduce concern over obesity. The message developed for this target audience was that “every day is an opportunity to make family time healthy time and guarantee your kids a better future.” Print material encouraged “let’s move Mondays,” “walk it off Wednesdays,” and “small plate Saturdays.” For Hispanics, food often is an emotional and cultural tool with which mothers demonstrate their love, Signorelli stated. They may believe their children are a little chubby, but see them as happy. According to Signorelli, most know little about body mass index (BMI), although they are open to the idea that it is a scientific measure of whether their child is healthy. The campaign took advantage of this openness by encouraging mothers to “help guarantee a better future for your children by making sure they’re as healthy as they can be,” with the tagline “know your child’s BMI,” and asking them to visit the website. According to Signorelli, the obesity prevention campaign received approximately $45 million in donated media exposure in the first year alone, with the general market accounting for about $20 million, the African American market for about the same amount, and the Spanish- language material for just under $4 million. Signorelli explained the campaign more than doubled visits to its website, and consumer tracking surveys demonstrated changes in awareness, attitudes, and behaviors.

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ADVERTISING, PROMOTION, AND EDUCATION 67 Intriguingly, he pointed out, awareness of the campaign was higher among African Americans than in the general market, perhaps reflecting the greater effectiveness of messages targeting a specific audience. Sustaining the Effort The campaign, which launched in February 2010, ran for 2 years, after which it no longer had funding for the necessary consumer research and production costs. The Ad Council is currently working with HHS on a different program with similar obesity prevention messaging, although that program also has faced funding challenges. The Ad Council will continue to work on obesity as long as organizations are supporting the effort, Signorelli observed, but sustained funding is important for this work, especially given the amount of unhealthy advertising to which people are exposed. Also, cultural change takes time—decades in some cases—which requires that pressure to change be maintained. In response to a question about when the Council’s public service advertisements tend to run, Signorelli pointed out that 70 percent appear in desirable daytime slots, with only 30 percent in the overnight period. Furthermore, Signorelli said, they run during popular shows such as American Idol and The Oprah Show, because the media community knows that the advertisements need to reach a target audience to be effective. He also pointed to the tension between media messages about physical activity and nutrition and the lack of activity involved in using those media, although media messages do encourage children and families to get away from a screen and be active. “What we want to do is make mom the hero. She is already the hero in the home to begin with, but make her a hero in the nutrition and physical activity space.” —Anthony Signorelli UNDERSTANDING THE FOUR PS Summary of Remarks by Lori Dorfman Most food and beverage marketing is taking the country in the opposite direction from that advocated in Accelerating Progress in Obesity Prevention. Marketing, which goes beyond advertising, is

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68 CREATING EQUAL OPPORTUNITIES FOR A HEALTHY WEIGHT generally understood as depending on four Ps—product, price, place, and promotion. To reach particular groups of children, marketers create products designed specifically for them; at prices they can afford; in nearby places; and promoted in terms, images, and language they can understand. Dorfman stated that almost all of this marketing is for foods and beverages children and youth should avoid. Television, although still influential, is just part of an always-on and personalized marketing environment, Dorfman emphasized. Even when children are watching television, they often have another screen in front of them. Messages are integrated into all aspects of their lives, including their online lives. Their friends become what advertisers like to call brand ambassadors, delivering what is known as content marketing, in which the line between advertising and content is blurred or nonexistent (Elliot, 2013). This marketing environment impedes health equity because research has shown that youth of color are more interested in, positive toward, and influenced by targeted marketing than are their white peers, Dorfman said. As a result, children of color get a double dose of advertising—that which is directed specifically at them, plus that directed at the general market. In addition, products are being developed and marketed specifically for children and for children of color (Kunkel et al., 2013). Compared with their white counterparts, African American and Latino children and youth see more advertisements for sugary and energy drinks, and more than 84 percent of all foods and beverages advertised to children on Spanish-language television shows are unhealthy (Harris et al., 2010; Kunkel et al., 2013). Products like Lunchables, Dorfman said, are specially designed for children, and their prices are carefully targeted so that lower-income consumers can afford them. What public health workers call low-income communities are known to the food industry as value-oriented customers, Dorfman explained. Dorfman also detailed how marketers saturate certain places with ads. Communities of color are filled with billboards, many in residential areas (Yancy et al., 2009). Sponsorships also allow marketers to expand beyond physical places to more dispersed communities, such as groups of people with shared interests; in this way, a concert, sporting event, or entertainment venue becomes a marketing place. This sort of marketing gets around some of the self-regulatory pledges companies have made, Dorfman said. If a branded Coca-Cola cup is on the counter during

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ADVERTISING, PROMOTION, AND EDUCATION 69 American Idol, that is not considered a child-focused advertisement because the overall percentage of children watching the program is less than 35 percent. Nonetheless, thousands more children will see that advertisement than see advertisements during cartoons or other programs viewed predominantly by children. Dorfman stated that many parents would rather leave their children at home than take them down the cereal aisle at a supermarket filled with characters on packaging at the children’s eye-level. Moreover, marketers are using digital technologies to establish a highly engaging, constant marketing presence wherever youth are online, including on their mobile devices. Online marketing also can be finely targeted to reach specific racial/ethnic groups, Dorfman emphasized. For example, she pointed out that the chief executive officer of McDonald’s has said that the company does not try to target people of color, but its website 365black.com indicates otherwise (Simon, 2013). Dorfman stressed that the message environment and targeted marketing need to be examined with respect to all four Ps—product, price, place, and promotion—which requires a systems approach to research. (Such an approach is discussed in Chapter 8 of this report.) Rapidly changing message environments and marketing practices need to be monitored. Parents also need to understand basic information about targeting, susceptibility, and adolescent brain development, Dorfman emphasized. The media have evolved in such a way that a stimulating environment is always available, attracting the attention of youth. Parents tend to think of advertising as annoying but not harmful, said Dorfman, and this must change for action to be taken. Parents need to know how to work together to insist that companies and government protect their children from harmful food and beverage marketing, Dorfman said some groups, such as MomsRising1 and the Food Marketing Workgroup,2 are meeting with increased success in doing so. Those who create and promulgate marketing also need to take responsibility, Dorfman noted. The industry has to strengthen its nutrition standards for self-regulation and cover all forms of marketing, such as packaging, sponsorships, marketing in and around schools, and toys or other premiums paired with meals. Media companies need to adopt nutrition standards based on established nutrition guidelines for the advertisements they carry. Dorfman stated that government policies need 1 See http://www.momsrising.org for details. 2 See http://www.foodmarketing.org for details.

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70 CREATING EQUAL OPPORTUNITIES FOR A HEALTHY WEIGHT to be directed at marketing exposures, not just expenditures, and that policies should address all four Ps, including price and place. Increasing distrust of government is a disquieting trend in America, Dorfman said, but government exists in part to help create opportunities for good health for everyone. As parents and policy makers learn more about the conse- quences of food marketing for low-income communities and communities of color, they can support policies to establish health equity, Dorfman concluded. “If we want ... kids to grow up in a healthier message environment, then we have to call on the industry to change the way it is marketing. Right now, they are taking up most of the space with the kinds of messages that are making it harder for people to be healthy.” —Lori Dorfman