"Whenever I go into a restaurant, I order both a chicken and an egg to see which comes first"

Wednesday, December 26, 2012

New Year’s Resolutions? Lose Weight? Stop Smoking? Think Again.

I worked in the field of ‘Behavior Change Communications’ – using media to improve individual health outcomes – for over 40 years and had little success.  People’s beliefs, especially about food and sex (nutrition and reproduction, the two areas in which I was most involved) are case-hardened and remarkably resistant to change.  One would think that if a person learned about a change in diet, sexual, or reproductive behavior that could improve his life – say using a condom to prevent a life-threatening illness, or taking the Pill to eliminate unwanted pregnancies – he would jump at the chance.  Nothing could be farther from the truth.  I tried everything in my long career, with little success. 

People in developing countries eventually change behavior in their own good time – i.e. when they have enough of an economic cushion to move them in from the margins, and make the risk of adopting a new and untried behavior acceptable; and when the market provides the necessary goods and services.

When I first started my career in India back in the late 1960s, I had the idea that advertising and marketing techniques could easily be applied to social change. “If you can sell soap”, I said, “You can sell green leafy vegetables”.  The principle itself was sound, and decades of American advertising successes were the proof.  Advertisements appealing to social aspirations, status, sexuality, envy, and a raft of other psycho-social determinants of consumer behavior could easily be applied to food, condoms, or diarrhea control.

My first project was to promote green leafy vegetables, a source rich in iron, a necessary element in everyone’s diet but especially in pregnant women who suffered from anemia at significantly high levels in India. I designed a multi-media program in which the good news about green leafy vegetables was presented through ten media from folk drama to Bollywood films.  I had enough money to assure good reach and frequency, and I was sure that the campaign was successful.  It was a total failure.  Although we succeeded in raising awareness about the problem and the solution, we were totally unable to change people’s attitudes (i.e. favorable towards dietary change) let alone get them to start eating spinach.

It wasn’t that the campaign was bad – our data on public awareness and appreciation of the posters, billboards, films, radio spots, comic books, etc. showed that people liked it – it was that we never considered the many other factors that enable people to change.  As suggested above, families who live on the economic margins are unlikely to take any risk at all because failure would mean liquidation, misery, and death. Second, human nutrition is a complicated matter.  Within the context of a high-carbohydrate diet, common in poor countries, a woman could eat five times her recommended daily allowances of spinach and still be anemic.  Why?  Phytate build-up.  Apparently some foods block the absorption and assimilation of nutrients, and high-phytate rice blocks iron.

As important, growing vegetables is a near impossibility in the hot, dry Indian climate.  As a result the price of spinach in the market is beyond the reach of most of anemic population.  Growing vegetables at home in kitchen gardens was just as unfeasible because of the time (opportunity cost), labor (seeding, planting, weeding, watering), and expense.

So although people heard our message, it was rejected or ignored for good, logical reasons.  The media can only do so much; and if economic, social, or cultural factors are not considered, no change will occur.  The provision of reliable, valid, attractive, and motivational  information is only the first step in the process.

The failure of most anti-smoking campaigns in the United States resulted from a similar failure to address these constraints. The first warnings of the link between smoking and lung cancer were published by the Surgeon General in 1964, and it took over 25 years to see any dent in American smoking rates.  When I joined the World Bank in 1984, all the secretaries smoked, and it was a smoke-filled environment, far from the smoke-free era of today.  Cigarettes were cheap, no no-smoking laws were in effect, no cigarette pack warnings printed, and most people ignored the health issue.

Even now there are still approximately 20 percent of all adults who continue to smoke, and even more troubling is the fact that the rate among teenagers remains high (20 percent) and shows no signs of dropping. Even with what should be considered prohibitive pricing -  a pack of cigarettes costs $12.00 in New York State – rates remain high.

Only one media-only anti-smoking success story comes to mind. Teen smoking 15 years ago was very high (over 35 percent) but this rate declined significantly until plateauing to its current resistant level.  One reason given for this decline was a Florida advertising campaign based on adolescent idealism.  “Why enrich  fat cat capitalist tobacco companies’, the ads said.  Stop buying cigarettes’.  Where millions of dollars had been wasted trying to discourage smoking by appealing to health, image (Smoking makes your clothes and breath stink), and social status, here was a campaign that didn’t even tell teenagers to stop smoking.  It said stop buying cigarettes.

Smoking is a particularly resistant behavior to change because of nicotine addiction; and it may be that the 20 percent of Americans who continue to smoke simply are so addicted that no matter what they cannot.  However, this is not the case with teenagers.  It is still acceptable if not cool to smoke; and few if any media campaigns have been developed to take up where the Florida effort left off.

Shedding pounds seems even more difficult than stopping smoking.

In an article in the Wall Street Journal (12.26.12) Shirley S. Wang writes:

Some 45 million Americans go on a diet each year, spending $33 billion on weight-loss products, according to the Boston Medical Center, but only a fraction succeed. More than half of the 45 million adult smokers in the U.S. tried to quit in 2010, but less than 10% of them managed to stop, according to the Centers for Disease Control and Prevention.

Some experts, like Dr. David Kessler, former head of the FDA, say that sugar, fat, and salt are addictive (The End of Overeating), and that are brains become conditioned to demand them and feel unsatisfied when deprived of them.  The obesity epidemic is currently at alarming levels, and the trend keeps going up.  It is not hard to see why, and although experts disagree on the reasons, most agree that a sedentary life style, poverty, and advertising are major contributing factors.  Americans don’t get around much any more.  Poor people can only afford cornmeal, fatback, fried foods, and McDonalds; and children and adults are barraged with ads for junk food.

Other critics have noted that the US agricultural subsidy program favors foods like corn, rice, and potatoes which are high in fat and calories, and not healthy foods.

The government is complicit in this phenomenon.  There are no direct subsidies for vegetables, but potatoes receive generous US dollars. Potato subsidies in Maine alone totaled $535,858 from 1995-2010.  Idaho, Washington, North Dakota, Wisconsin, Colorado, Minnesota, California, and Michigan are also recipients.  Cheap potatoes allow McDonalds and other fast-food restaurants to offer huge portions for relatively nothing. (http://www.uncleguidosfacts.com/2012/05/obesitywere-in-it-for-long-haul.html)

Finally, there is a psychological dimension to obesity; and many recent studies have concluded that depression and obesity often occur as co-variables in morbidity.  On a less toxic level, diets high in carbohydrates in poor countries are especially attractive because at least the produce a feeling, although temporary, of satiety and satisfaction.

There are also psychological dimensions which favor reducing and other salubrious changes in behavior.  Wang reports on recent studies which have shown that realism as opposed to optimism is key to behavior change.  In other words, if unrealistic goals (“the false-hope syndrome”) are set for weight reduction, then people will be discouraged when they do not meet them and will give up the effort altogether.

More successful programs have set realistic goals for dieters, and although the time necessary to lose the weight desired may be longer, the chance of achieving them is higher.  Removing obstacles to dietary change is also key:

People who prepare plans on how to reach their goals, which psychologists call "implementation intentions," are more effective at reaching goals, by spelling out in their minds what they will do if an obstacle arises, says Peter Gollwitzer, a psychology professor at New York University. If a cookie tempts you every time you walk into a cafe, come up with a plan to reach for an apple.

These rather simple and mechanistic approaches to weight loss may be exactly what some, already motivated people need to become more fit.  However, for most people, it is not so easy.  As mentioned above, poverty is perhaps the most important factor in weight, and few people can do much about it.  More well-off Americans can shop for the freshest and tastiest vegetables at Whole Foods, exercise at a private gym, and be surrounded by other trim people (important because research has shown that we tend to unconsciously mimic our peers).  Poorer people have none of these advantages.

So, it is all well and good for the professional living in Northwest Washington to devise and follow a weight-loss program based on the sound behavioral principles presented in Wang’s article, up his frequency at the gym, and try some of the latest designer greens; but most obese people are stuck in a cycle of restricted income which leads to high-calorie, low-nutrition foods; which lead in turn to addiction to fat, salt, and sugar; which, combined with the energy-sapping two-job daily routine, result in obesity.

My article Obesity – We’re In It For The Long Haul – details these any other factors relating to obesity and behavior change in general.  As the title implies, I am not very optimistic about reducing obesity levels any time soon.  There are simply too many factors which contribute to it to enable any private or public advocacy group to have any effect.  Smoking rates should come down because of the radical change in social norms and high price of cigarettes.  It is now totally unacceptable by social standard and by law to smoke.  However, because of addiction, they are likely to plateau at a high, but ‘acceptable’ level.

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