The workshop’s third session presented four perspectives on best practices for developing effective strategies and messages for communicating obesity solutions to key audiences. The session was moderated by Carol Byrd-Bredbenner, distinguished professor of nutrition and program director of the nutritional sciences graduate program at Rutgers University.
EFFECTIVE TREATMENT MESSAGING: STAYING IN TOUCH WITH PEOPLE AFFECTED BY OBESITY
Gary Foster, chief science officer at WW International, Inc., focused on messaging for people who are engaged in a weight-loss journey. He began with an abbreviated historical overview of cultural trends in the public’s goals and approaches to weight loss, noting that consumer response to and engagement in a weight management intervention are critical for efficacy. Foster began with the “thinner is better” outlook—even if the price was excessive calorie deprivation or other unhealthy behaviors—that characterized the landscape in the early 2000s and before. By 2015, he continued, WW found that people had shifted to a broader, more holistic approach that included more emphasis on physical activity and on a focused and positive mindset, as well as an emerging consideration of food quality. People still viewed weight loss as an essential part of improving overall health, he recalled, but were less weight-focused than they previously had been and had more realistic expectations for an achievable healthy weight. Since then, Foster said, approaches have increasingly broadened to include the pursuit of more energy; increased confidence; and connection to an individual’s values, such as positive role modeling or improved well-being.
Even the most carefully designed weight-loss strategies will not be effective, Foster asserted, if they fail to meet people where they are. People
want to lose weight, he elaborated, but they also want to achieve wellness in the physical, mental, and social senses. Foster remarked on a global survey indicating that nearly 70 percent of respondents assigned weight loss primary importance when given a list of outcomes they could pursue to improve wellness. To achieve intertwined goals of weight loss and wellness, he continued, people want credible scientific principles and commonsense strategies that translate to practical techniques for applying realistic, sustainable habits to their lifestyles. As an example, he observed that most people do not buy into claims that a person can eat whatever he or she wants and still lose weight, nor are they attracted to marketing that shows only salads. Furthermore, Foster emphasized that descriptions of the problem and prescriptions for “what” to do are neither helpful nor necessary—people want to know “how” to do it. He added that seeking strategies that fit one’s lifestyle is part of the cultural trend of personalization.
Foster described WW’s programmatic approach as one that translates science into behaviors and habits that meet consumer goals and values of improved health and overall well-being. He shared excerpts from WW’s “voice of brand” document, urging language that is warm, accepting, and encouraging in tone instead of restricting, judgmental, and academic. Foster provided specific examples of verbiage that the brand carefully avoids, including “overweight” and “obesity,” along with preferred alternatives. For example, such terms as “weight (or wellness) journey” or “way of living” are favored over those that imply temporary, short-term solutions, such as “before/after” and “diet” or “diet plan.” Foster added that WW also insists on avoiding moral language, such as the terms “cheat,” “excuse-proof,” or “good/bad.” Although many people may use such language to describe lapses in health behaviors or to characterize eating plans or individual foods, he stressed that WW refuses to endorse language that contributes to stereotypes and reinforces weight-based stigma.
Self-criticism derails a weight-loss journey, Foster declared, adding that relapse prevention begins with a fundamental belief in one’s self-worth, along with self-compassion and realistic expectations about imperfection. He urged identification of proven techniques for enhancing self-compassion and of literature that supports body positivity as a bridge to an improved weight or wellness journey. Focusing on what one’s body can do rather than how it looks, he observed, can improve body image and lead to a more positive and successful weight-loss experience (Carraca et al., 2011; Palmeira et al., 2010). “It’s not like hating your body is helpful; it’s actually harmful,” he explained. He added that the company strives for diversity in the body shapes, genders, and racial/ethnic backgrounds of people in its marketing materials.
Foster ended his presentation by highlighting WW’s popular hashtag “#NSV” (nonscale victories) as an example of celebrating nonweight
outcomes related to improvements in body image and self-worth and small steps toward success. As an example, he shared a woman’s story about gaining the confidence to put on a swimsuit and play in the pool with her daughter, despite weighing more than 300 pounds. He proposed that these important nonweight outcomes are of primary importance, and will also help drive weight-loss success and improve health and comorbidity.
MARKETVISION: A HISPANIC PERSPECTIVE ON OBESITY SOLUTIONS
Luis Garcia, president and lead strategist of the culture-inspired marketing firm MarketVision, shared lessons from the VERB™ youth media campaign’s efforts to reach Hispanic audiences through purposeful communications. Understanding a group’s culture helps communicators appreciate how values influence that group’s beliefs and behaviors, he began, and he emphasized a shift from pushing messages into the market to engaging people in a collective, co-designed experience. According to Garcia, this process involves focused definitions of the target audience and the desired behavior; empathy with the target audience; and constant iteration of designing, testing, and refining messages. The Hispanic culture is built on collective experience, Garcia explained, underscoring the importance of engaging the audience to understand its needs and then designing and evolving messages.
To achieve VERB™’s goal of increasing physical activity among tweens (ages 9–13), Garcia continued, the Centers for Disease Control and Prevention (CDC) wisely enlisted various specialists to develop strategic communications that were adapted for different segments of the target audience. His team at MarketVision discovered that Hispanic audiences place value on providing a good future for the next generation, so the team developed parent-directed messages that generated awareness of physical activity as a health indicator and thus a means of providing for one’s children.
As descried by Garcia, the campaign’s VERB™ brand was based on its tangible goals of encouraging kids to choose an activity and play for 1 hour each day. Physical activity was the brand’s product, he elaborated, and it was promoted with the same strategic branding principles used by competitors. Messages that emphasized fun and belonging to a movement that portrayed physical activity as play were delivered in media, schools, and communities where local programs could promote their activity offerings for youth to sample. If programs were not available, the campaign promoted its homegrown yellow ball program. Garcia explained that thousands of yellow balls were distributed nationwide, and kids could enter their ball’s code online to describe how they played with it. As yellow balls were swapped and followed across the country, he said, they connected users to the physical activity movement.
A parallel campaign existed for parents, focused on moms, Garcia continued, to educate them about active kids and encourage continued support of their children’s physical activity. Parents gravitated toward signing a national pledge of support to keep their kids active, he noted, which reinforced the idea of joining a movement. Partnerships and media integration were cultivated to help sustain the messages after the campaign’s funding was exhausted, efforts that Garcia said created ripple effects.
Garcia reported that the campaign generated 74 percent brand awareness in its first year, which he said was “pretty remarkable,” especially given its competition with established brands boasting large marketing budgets (Huhman et al., 2005). The campaign also demonstrated increases in physical activity among target audiences.
Garcia’s lessons learned include the importance of focusing on a specific goal for a specific audience with high potential for impact, incorporating culture-inspired stories, employing an iterative strategic marketing approach, and sustaining impact through partnerships. Today’s world is much different than it was when VERB™ was implemented, Garcia argued, pointing to greater health consciousness and advances in digital technologies that have enabled immediate delivery of products. He added that digital innovation has also led to disruption and decentralization, which Garcia framed as an opportunity for various players across networks to deliver and personalize messages.
Moving forward, Garcia observed that framing physical activity as a gain can help Hispanics overcome barriers that hinder their motivation to be active. Because spending time with family is an important cultural value, he suggested promoting physical activity as an opportunity to connect with family, for example, while taking a walk. He also mentioned that using technology to nudge and gamify desired behaviors can help break long-term goals down into small, salient steps. Lastly, he noted that technology’s exponential growth has given way to a largely decentralized world, creating an unprecedented opportunity for engaging new collaborators to be part of “swarm intelligence,” that is, cross-functional collaboration that uses design thinking to create and iterate solutions across a networked system.
MESSAGING TO LOCAL, STATE, AND NATIONAL POLICY MAKERS
Marla Hollander, national partnerships manager for Voices for Healthy Kids, a joint initiative of the American Heart Association and the Robert Wood Johnson Foundation, discussed messaging to government officials as it relates to the initiative’s efforts to advance public policy changes that create healthier community settings where kids live, learn, and play. Hollander listed the initiative’s four focus areas for engaging, organizing,
and mobilizing communities to help all children grow up at a healthy weight: funding communities to mount issue advocacy campaigns, supporting those campaigns with technical assistance, engaging in collaboration and partnerships to leverage coalitions and build capacity, and conducting campaign research and development to build tools and resources that help advocates deliver messages.
Hollander shared lessons learned from the initiative’s 6-year existence and nearly 200 public policy campaign wins amassed during that time. She explained that messages for policy change may be directed to one person or an entire committee, depending on the entity responsible for passing the legislation of interest. She emphasized that, when communicating with political decision makers (and the people who influence them) about public policy change, effective messages start with values and use the right words. The initiative’s message research, she reported, revealed a values-based perspective that resonates with people across political and geographic lines: that every child deserves the right to be healthy. She encouraged framing messages to reflect shared values, drawing a contrast between a message that focuses on the problem of childhood obesity and one that invites conversation about ways of jointly achieving opportunities for every child to be healthy.
Hollander next shared a chart of language to emphasize and corresponding language to avoid (see Figure 4-1). For example, describing the environment that makes it challenging for community members to eat healthfully and be active is favored over describing personal behavior; likewise, invoking a sense of cooperation and partnership to address obesity is preferred over language that describes the problem as a “war” and uses such words as “bombard” that trigger trauma. Hollander went on to illustrate inclusive language, such as preferring “people living in the United States” over “Americans” or “citizens.” She added that describing the goal of helping children grow up at a healthy weight and in healthy communities is more effective than talking about preventing childhood obesity, as is using a gain-based frame instead of focusing on what is at risk of being lost.
Turning to ways for advocates to deliver messages to policy makers, Hollander stated that a good technique is to identify issues and solutions together as a community, then customize the messages accordingly. She emphasized that the messengers matter as well, particularly in local policy, because local issues tend to be more personal, and people tend to trust local lawmakers more than those at the state or federal level. She urged showing how everyone in the community can benefit from the proposed solution, recognizing that what is beneficial for one group is often beneficial for all. Compelling messengers can tell stories to illustrate the gaps in the community, Hollander continued, elaborating that residents most affected by an issue are often the best sources of insight into the problems and solutions.
SOURCES: Presented by Marla Hollander, September 16, 2019. Voices for Healthy Kids, n.d. With permission. Copyright Voices for Healthy Kids, American Heart Association. Reprinted with permission.
Moreover, she argued, rather than saying “the problem is…,” it is better to lead with the solution and the benefits it is expected to confer, emphasizing effectiveness (keeping the focus on the intended impact) instead of cost-efficiency (which can lead to short-term or scarcity thinking). In closing, Hollander referred participants to the initiative’s health equity messaging guide for policy advocates, which she said helps ensure that underresourced communities benefit from policy language that supports their needs (Voices for Healthy Kids, 2017).
ASSESSING STATE-LEVEL DECISION MAKERS’ SUPPORT FOR EVIDENCE-BASED APPROACHES TO CHRONIC DISEASE PREVENTION
Paula Clayton, public health consultant to the National Association of Chronic Disease Directors (NACDD), described an assessment of state-level decision makers’ support for evidence-based approaches to chronic disease prevention. The goal was to understand state decision makers’ views related to policy approaches for healthy eating and active living that resonate with them in their current environments, she explained, to better understand the forces at play when communicating with them about related policies. Clayton listed the assessment’s three focus areas: promotion of healthy food service guidelines and healthy food retail practices; new or improved pedestrian, bicycle, or transportation systems; and improved physical activity and nutrition standards in early care and education settings.
The assessment was multipronged and qualitative, she continued, and included a literature review to assess how evidence is used by policy makers and identify the messages and values that have been used to drive policy decisions; interviews with key informants, such as state health department leaders, public health advocates, and legislators; and focus groups of local leaders in public health, political administration, and business. All groups included participants from states that have enacted legislation or other policies in support of healthy eating and active living, as well as from states that have not.
Clayton reviewed the assessment’s findings, starting with the literature review. Its takeaway points were to use targeted, tailored messages presented in a concise and engaging manner; incorporate data (including cost data) and stories; and provide well-cited, unbiased information that is timely and relevant to constituents. She moved on to share lessons learned from the broader assessment, beginning with the context that legislators have numerous issues to understand and want information at the time decisions are made. They are concerned about a proposed policy’s economic impact on business and agriculture, she reported, and look for ways to attract new businesses and help existing businesses grow.
At the same time, Clayton stated that legislators recognize that issues of local control (i.e., planning, land use, transportation, recreation, infrastructure, and zoning) may limit statewide implementation of policies. State leaders appraise a policy’s success at the local level when deciding whether to support it at the state level, she explained, adding that they also consider whether it is their responsibility to do so. Therefore, she elucidated, legislators’ views on whether obesity, healthy eating, and active living are systemic societal issues or individual responsibilities affect their support for these policies. Clayton confirmed that state legislators look to data, but they place greater value on state, regional, and local data than on national data. State health departments are considered credible conveners of diverse partners and sources of expertise for implementing healthy-eating and active-living initiatives, she continued, but obesity prevention is a lower priority than other pressing legislative issues that compete for funding, and declining state revenues compound funding challenges.
With respect to translating the assessment’s findings to communications strategies, Clayton reported that clear and consistent messages, media coverage, and influential messengers, such as local champions and business leaders, are effective. She noted that according to one key informant, strong constituent voices often outweigh the evidence, while others suggested that the governor’s position and level of support are also influential. Decision makers want to know what a proposed policy can achieve in the short term (1–2 years), Clayton observed, which differs from the public health sector’s usual focus on longer-term, population-level outcomes. She urged that health advocates focus on realistic outcomes over shorter time horizons and frame them as precursors to achieving longer-term outcomes. Moreover, she added, it is important to emphasize the expected impacts of a policy change on the economy and on high-priority populations in the community, such as children and older adults. As an example, Clayton suggested highlighting the appeal of walkable destinations and other active-living environments for prospective residents. She noted that it is helpful to summarize all of this information in educational materials, although Clayton reminded participants that policy makers are not likely to consult such materials until the time comes to make a decision.
Finally, Clayton highlighted the assessment’s findings related to the critical role of the state health department, which she reported was seen as a convener and collaborative partner, an expert and authoritative resource for providing data and implementing healthy eating and active-living strategies, and a bridge to other state agencies (such as departments of agriculture, wildlife and parks, and commerce) that can help support policies. She also referenced topic-specific guides for healthy eating, active living, and early care and education that summarize the assessment’s complete findings and practice applications (NACDD, 2019).
DISCUSSION PART ONE
Byrd-Bredbenner began the discussion period with Clayton and Hollander, who answered questions about communicating with policy makers and collaboration between state health departments and local entities.
Communicating Effectively with Policy Makers
Byrd-Bredbenner asked for suggestions about effective messages for obesity solutions at the local level. Clayton reiterated her assessment’s finding that it is critical to forecast a policy’s impact on community businesses. She shared examples of policies that increased walkability to local businesses and provided avenues (e.g., farmers’ markets) for selling agricultural products. Hollander proposed framing messages in terms of social determinants of health. She pointed out that many policy solutions for healthy eating and active living involve nonhealth sectors, such as transportation, and encouraged confidence to lead with sector-specific messages and share health benefits as secondary messages.
Recognizing that advocates may feel apprehensive about talking to decision makers, Byrd-Bredbenner asked for examples of intermediary audiences for advocates to address in preparation. Hollander described influencers surrounding decision makers, such as family members, friends, and fellow members of their policy-making committees, and emphasized the importance of identifying those influencers and targeting messages accordingly. She also encouraged boldness in talking to legislators, underscoring that they are elected to represent constituents and want to hear from them. Clayton reminded participants that legislators typically do not look to data until they need to make a decision, and urged state health departments to anticipate when information will be requested.
A participant explained that many scientific experts employed by state and federal institutions are advised by their employers to avoid communication with elected officials, or are required to navigate lengthy, cumbersome approval processes to get permission to do so. She asked the speakers how to empower experts in academia and government to present elected officials with the best evidence while avoiding allegations of lobbying. Clayton validated this challenge and relayed advice from public health advocates who do not work in state government. These informants pointed out that they can obtain data from the state health department and then convey the messages that health department employees cannot, she explained, because of the limitations on a state health agency. Hollander added that employees can wear multiple hats, and can speak as individual community citizens to alert legislators to an issue of concern and direct them to data sources.
State Health Department Collaboration with Local Entities
Byrd-Bredbenner asked Clayton for examples of state health departments convening and collaborating with local health departments and coalitions. Clayton described interaction between state health departments and local health agencies in cases in which the local government would be responsible for a proposed policy. Local authorities valued the state health department’s participation, she reported, explaining that its presence manifested in such outcomes as increased attendance at local coalition meetings and the availability of data and expertise for helping to design and evaluate the impact of local healthy-eating and active-living policies. The latter is particularly helpful in states with large rural areas, Clayton noted, where expertise and data are often lacking at the local level. Consistent messages from local- and state-level public health advocates are important, she added, as are tangible examples of local success with policies that are under consideration at the state level.
DISCUSSION PART TWO
Suzi Gates joined Byrd-Bredbenner to co-facilitate the second part of the discussion, during which the session’s four panelists responded to questions about blind spots and opportunities in communicating obesity solutions, the future of messaging about obesity solutions, the role of the Roundtable on Obesity Solutions, and messaging to diverse audiences.
Blind Spots and Opportunities in Communicating Obesity Solutions
Gates asked panelists for examples of blind spots as well as opportunities with regard to communicating obesity solutions. Foster identified the risk that stakeholders are talking only to themselves and not considering the perspective of their messages’ recipients. He also called for clarifying the goals of obesity communications, including the intended audiences and outcomes, so that clear evaluation plans can be developed. Clayton stressed the importance of describing how a proposed policy will affect the economy of a city or state and create an environment that will attract talented, well-educated young people who can help boost its bottom line. Garcia observed that because communicators are focused on their target audiences and messages, they often miss the unintended consequences of their efforts. He appealed for greater attention to recognizing when such consequences occur.
Garcia also pointed out the obstacles of working in siloes, although he asserted that this compartmentalization creates the opportunity to design a system that enables cross-functional collaboration and applies swarm
intelligence to identify and implement solutions collectively. Hollander agreed that focusing solely within one’s sector is a potential blind spot, and espoused the value of cross-sector collaboration. She referenced her initiative’s work with the transportation community to integrate health into the broader transit discussion, noting that the relationship with transportation has been cultivated over time by many other public health stakeholders. Clayton mentioned the success of an NACDD model that supports state health agency staff in convening diverse stakeholders from the health, business, nonprofit, and government sectors to develop goals, objectives, and measures for chronic disease issues.
The Future of Messaging About Obesity Solutions
In response to Byrd-Bredbenner’s question about the next phase of communications about obesity solutions, Garcia promoted the framing of target health behaviors as positive and life enhancing so they are not perceived as obligations that will negatively disrupt current habits. Clayton called for consistent, science-backed messages delivered by partners who can advocate from various angles that relate to a proposed policy. Foster echoed the importance of driving behaviors that have empirical support, warning against promoting unproven or ineffective strategies. He referred back to WW’s strategy of working at the intersection of science and consumer insights, calling this the optimal space for meeting people where they are. This approach gets people interested, he maintained, and they stay engaged if the process is personally meaningful to them.
Role of the Roundtable on Obesity Solutions
A participant asked panelists how the Roundtable on Obesity Solutions can use its potential to influence members’ networks by disseminating messages that reframe obesity and address stigma. Hollander suggested connecting current policies and environments with the historical contexts that have influenced them, so that stakeholders understand that the status quo has not come about by chance. Foster suggested that targeting bias and stigma could pay dividends, because doing so influences people’s lives independently of the effects of obesity treatment or outcomes of policy campaigns. The next step, he submitted, is to identify effective messages and apply them as opportunities arise. Garcia added that cultural adaptation of messages would be a likely further step. A participant proposed that roundtable members indirectly target bias and stigma by offering positive, debiasing images when depicting people with overweight and obesity.
Messaging to Broad, Diverse Audiences
Messages about obesity solutions are received by a broad population that is affected by overweight and obesity, a participant observed, asking Foster how to reach various audiences within that population (such as stakeholders from an eating disorder community, a fat acceptance community, an obesity advocate community, and the core WW community) simultaneously. Foster affirmed the diversity of the WW community, and reported that the brand routinely assesses how messages resonate with different people and strives to include visual representation of its diverse follower groups in marketing materials. The brand also seeks to lead with science and identify global principles for messages based on cross-cutting consumer insights, he observed, and then entrusts local teams with shaping messages to be culturally relevant. He recalled Nece’s observation that diverse stakeholder and advocate groups have coalesced around the principle of treating people with overweight and obesity with respect and dignity.
Another participant contrasted WW’s focus on an individual’s journey with the guidance to focus on community impact and societal factors when communicating with policy makers, and asked how that difference affects the framing and consistency of messaging approaches. Hollander expressed support for both approaches, elaborating that personal stories shared in broader message frames draw attention to societal and community issues. She also pointed out that people look to WW for individual help, which entails different considerations for messaging. Foster contended that the two message frames are not mutually exclusive, explaining that WW leads with the positive and inspiring while acknowledging that behavior change occurs in environmental contexts. Leading with messages about the challenges of weight loss is not inspiring or engaging, he maintained, but once people are engaged in the program, there are opportunities to acknowledge and address barriers in the environments where behavior change occurs.
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