Tuesday, May 13, 2014

A Critique of New York City’s Size Limit on Sugary Beverages - Elizabeth Reidy

            Obesity is one of the greatest public health challenges today. More than one-third (34.9%) of adults and 17% of children in the United States are obese (1). Obesity is a label for a range of weights that are greater than what is generally considered healthy for a given height. In adults and children, this is measured by calculating body mass index (BMI), which usually correlates with amount of body fat. Adults with a BMI greater than or equal to 30 are considered obese (25). In children, obesity is defined as a BMI at or above the 95th percentile for children of the same age and sex (25). Obesity is related to several of the leading causes of preventable death, including heart disease, stroke, type 2 diabetes, and certain types of cancer (2). Obesity is also costly. It is estimated that in 2008, obesity-related medical costs were $147 billion in the United States; this is almost 10% of all medical spending (3). Per capita medical spending for obese individuals is $1,429 higher, approximately 42%, per year than for someone of normal weight (3).
In September 2012, the New York City Department of Public Health voted 8-0 to approve a ban on the sale of sugary drinks, defined as having 25 kilocalories per 8 ounces, in containers of more than 16 fluid ounces at restaurants, food carts, movie theaters, and stadium concession stands to combat obesity (4-5, 14). This measure was championed by Mayor Michael Bloomberg and was the first restriction of its kind in the United States (4). In the last 40 years, the largest single cause of the rise in calories in the American diet has been attributed to an increase in sugary drink consumption (5). Studies show consumption of these beverages is linked to weight gain and obesity, as well as diabetes and heart disease (6-7). This proposal has been challenged in court and most recently in July 2013 an appeals court ruled against the ban citing that it violates “the principle of separation of powers” (8). The regulation is set to be reviewed later this year by New York City’s highest court, the Court of Appeals (9).
While the proposal is well-intentioned, even if the Court of Appeals rules in favor of the prohibition on the sale of sugary beverages in excess of 16 ounces, the policy is not an effective approach to reduce soda consumption and combat obesity.  Limiting the size of soda available will induce psychological reactance, which could result in an effect opposite of what is intended. The proposal also violates the Health Belief Model and does not take into account the social and environmental factors associated with both soda consumption and obesity.
Critique Argument 1: The ban will induce psychological reactance
            Under the proposed law, consumers would not be allowed to purchase sugary beverages in bottles or cups greater than 16 ounces; however, refills are permitted and so is the option to purchase multiple bottles or cups of 16 ounce sodas. A study suggests that the ban may result in unintended consequences where consumers purchase beverage bundles (multiple 16 ounce drinks) rather than individual beverages (10-11). In the study, 100 participants were randomized to purchase sodas from different menus as if they were at a fast food restaurant, movie theater or stadium to simulate establishments where the ban would take place. The results demonstrated that participants bought significantly more soda from the menu with bundles of 12 ounce and 16 ounce drinks than they did from the menu of individual sodas of different sizes (11). Critics of the study argue that it only measures the amount of soda purchased and not what was actually consumed by participants; however the Psychological Reactance Theory explains why NYC’s policy restricting choice of soda size could lead consumers to both purchase and drink more.
            The Psychological Reactance Theory suggests that when an individual perceives that their freedom is threatened they experience reactance, a state that drives them to restore the threatened freedom (12). In the case of the soda ban, individuals perceive that their freedom of choice over which beverage and which size beverage to consume is threatened. As a result they will rebel by purchasing and consuming refills or bundles of soda. This theory suggests that a size limit on sugary beverages will not be an effective approach in fighting obesity, particularly if it provokes increased soda consumption.
Highly aware of the effect of psychological reactance, the beverage industry, who is opposed to the policy, framed the issue about freedom, rather than obesity, even creating a coalition called New Yorkers for Beverage Choices to coordinate public relations efforts (24). This demonstrates the industry’s desire and ability to take advantage of reactance to stimulate public opposition.
Critique Argument 2: The policy fails to consider several components of the Health Belief Model
            Another major failing of the policy to restrict soda sales in excess of 16 ounces as an intervention to combat obesity is that it fails to consider important components of the Health Belief Model (HBM). The HBM states that a person’s behavior is the product of several factors: the degree to which a person feels at risk for a health problem, the degree to which a person believes the consequences of the health problem will be severe, the perceived benefits and barriers resulting from taking action, an external event that motivates a person to act, and finally a person’s belief in his or her ability to take action (13). All of these predict whether a person will engage in a given preventive or healthy behavior. The ban on sugary beverages to reduce consumption rests on aspects of this model, but will not be effective because it fails to consider other aspects.
            Prohibiting the sale of sugary beverages greater than 16 ounces is the cue to action, the impetus designed to push an individual to reduce soda consumption and engage in healthier behavior. For this intervention to be successful, an individual has to believe that he/she is at risk for obesity, though. Banning soda sales in excess of 16 ounces is not targeted to specific individuals; it affects everyone. Therefore, it is unlikely that this alone will influence an individual’s feeling of susceptibility to obesity. In addition, the intervention incorrectly assumes that individuals are aware of the links between soda consumption and obesity and obesity and more severe health issues such as heart disease and type 2 diabetes (18). It also presumes that individuals have the knowledge and ability to make healthy, alternative choices by perceiving the benefits of not consuming soda outweigh the costs. Finally, it assumes that individuals have the capability and the will in order to change their behavior and reduce their soda consumption. As indicated in the previous section, this especially may not be true if individuals experience reactance resulting from the imposition on their freedom to choose what beverages to consume. Given that the soda ban does not address many of these aspects of the HBM, it is unlikely that it will actually result in reduced soda consumption.
Critique Argument 3: The soda ban fails to address the social and environmental determinants of consumption and obesity
A person’s diet, including soft drink consumption, is largely influenced by social and environmental factors. If children and teenagers are exposed to soda in their homes and at school, it will have a major impact on their consumption habits. Studies have shown that accessibility, modeling, and attitudes are all strong determinants of soda consumption (19). In addition, parents act as role models, particularly for young children, whose health behaviors are entirely influenced by their parents’ behaviors, while older children also look to their friends, teachers, and community leaders as role models for their health behaviors (16).
People learn by observing others. Social Cognitive Theory (SCT) is used to describe the process in which a person learns and develops new behaviors and how personal factors and environmental factors influence this process (15). This theory describes the main factors that affect a person’s likelihood of changing his or her behavior. The soda ban fails to take several of these aspects into account. New York’s policy prohibits the sale of soft drinks in excess of 16 ounces only in certain environments: at restaurants, food carts, movie theaters, and stadium concession stands. Soda will still be available for purchase in grocery stores and convenience stores and in bundles of 16 ounces at other locations. The policy also does nothing to impact people’s attitudes toward soda and people, especially children, will learn or continue this behavior from witnessing parents’ and peers’ soda consumption and maintain an attitude that it is the norm. There is a persistent viewpoint within American culture that “bigger is better,” which influences individuals to purchase and consume beverages in excess of 16 ounces. In order for the soda ban to be an effective strategy to reduce consumption, it would need to incorporate a strategy for changing this outlook.
Obesity is also influenced by social factors. A person is more likely to be overweight if they have a lot of overweight friends, for instance (17). In addition, studies of adolescent social networks have recognized the degree to which clique formation, the tendency to form social ties with similar individuals, is associated with weight status and physical activity. One study found that adolescent friendships tended to cluster on the basis of weight status (16). Limiting the sales of large soft drinks as a policy to combat obesity does not take this factor into account. It is unlikely for eating and drinking patterns among social networks to change through this intervention because soda and other unhealthy foods are still accessible in a variety of locations and because attitudes surrounding soda consumption and obesity have not been altered. Children, adolescents and even adults will continue to be influenced by the consumption habits of their peers since these behaviors are considered acceptable among those groups.
Proposed Intervention
            While New York City’s proposed policy to ban soda sales in excess of 16 ounces was well-intentioned, it would not be an effective strategy to combat obesity because of its failure to account for a variety of social and behavioral factors that influence an individual’s soda consumption and weight. A modified approach to combat obesity would be to impose a tax on sugary beverages. Revenue from this tax would then be used to strengthen obesity prevention strategies in schools. The New England Journal of Medicine estimates that a tax of 1 cent per ounce on sugary beverages would raise approximately $937 million in New York in a year (18). It is beneficial to target these programs to children because early childhood eating and physical activity behaviors translate into similar behaviors in adulthood (16). Tax revenue can be used to subsidize child nutrition programs in schools, for instance. These programs are administered by state agencies with the goal of fighting hunger and obesity by reimbursing schools, child care centers, and after-school programs for providing healthy meals to children (20). Another important component is to provide funding for programs that educate both students and parents on healthy eating, physical activity, and how to engage in other healthy behaviors.
            The primary criticism of imposing a tax on sugary beverages is that it is regressive, meaning that it affects those of a lower socioeconomic status more than those of a higher socioeconomic status because purchase of these beverages constituents a higher proportion of their income. However, obesity also disproportionately affects poor people. It is most prevalent among groups with the highest poverty rates and the least education likely because diets consisting of unhealthy food tend to be more affordable (21). Additionally, soda is not necessary to survival; water is an example of an alternative that is available at little or no cost so a tax on soda that shifts consumption from sugary beverages to water would benefit the poor by improving health and by lowering expenditures on beverages (18).
This intervention would be more effective in combating obesity than the soda ban because it will not stimulate psychological reactance. It also takes into account components of the Health Belief Model as well as the social and environmental factors associated with soda consumption and obesity.
Defense of Intervention 1: Taxing soda and funding obesity prevention programs will not produce psychological reactance
Banning soda in excess of 16 ounces induces psychological reactance as individuals perceive that their freedom of choice over which beverage and which size beverage to consume is threatened. Consequently, they will revolt by purchasing and consuming refills or bundles of soda thus reducing the effectiveness that this approach has in fighting obesity. A tax, on the other hand, will not induce psychological reactance because sugary beverages in all sizes will remain available; therefore, consumers’ freedom of choice will not be put at risk. Because soda will be slightly more expensive, especially if larger portions are taxed at higher rates, it will affect behavior change by promoting consumption of smaller portions or consumption of cheaper, healthier alternatives, such as water.
This intervention would likely be popular among residents. A 2008 poll of individuals living in New York showed that 52% support a tax on soda; 72% support such a tax if the revenue is used to support obesity prevention programs (18). This is in contrast to 60% that reported they were opposed to the policy to ban soda sales in excess of 16 ounces (22). Critics of a soda tax argue that it would induce reactance similar to a soda ban because individuals feel the government is still imposing on their freedom of choice of beverage consumption by making soda more expensive. In order to limit any potential reactance to a tax, it should be framed in a way that emphasizes how revenue will be spent on obesity prevention programs (23).
Defense of Intervention 2: Important components of the Health Belief Model are taken into consideration
The Health Belief Model identifies components that contribute to an individual’s behavior. These components are addressed in the intervention to enhance obesity prevention programs in schools funded by soda tax revenue. Programs should include an educational component for students and parents on the health effects of obesity. Because young children’s behavior is largely a product of their parents’ behavior, it is important to educate parents, as well as children. Funding permitting, it would be beneficial to have a nutrition or health counselor meet individually with parents to talk about the specific degree to which their child is at risk for obesity. Tailoring the intervention to the individual/family level would increase the extent to which parents feel that they are susceptible to obesity and related health problems and the extent to which their child is susceptible. Greater perceived susceptibility increases the likelihood that parents and children will change their behavior (13).
Parents and children also need to be aware of how they can engage in healthy eating. It is important to educate them on resources available so that they can see that the perceived benefits outweigh any perceived barriers. One example would be to teach parents and children about healthy alternatives to soda and to show that these would be more cost-effective choices and that they still taste good. Having this information helps to enable healthy choices and also enhances self-efficacy, the belief in one’s ability to actually change his/her behavior.
The tax, in a way, acts as the cue to action in that if soda is more expensive families will choose to purchase healthier, cheaper alternatives. The educational component supplements this cue to action by providing information on the severity of obesity and the rationale for how and why behavior change can help prevent obesity for parents and children, especially given that family health tends to be a very important priority. It also can provide information on the link between soda consumption and obesity, information that is necessary to precipitate behavior change.
Defense of Intervention 3: Social and environmental determinants of soda consumption and obesity are addressed
Social Cognitive Theory (SCT) suggests that learning occurs in a social context and emphasizes the interaction of the person, environment, and behavior (15). It offers several strategies to create an effective program aimed to change behavior, which in this case is encouraging healthy eating and drinking and reducing obesity. These are addressed through the improved policy of taxing sugary beverages and using revenue to enhance obesity prevention strategies in schools.
The first SCT concept that the intervention addresses is reciprocal determinism, which is the interaction of the person, behavior, and the environment in which the behavior is performed. The intervention takes this into account by making adjustments to the environment and by influencing attitudes toward soda consumption (15). The tax is part of the adjustment to the environment, making it more expensive to consume soda. Using revenue to subsidize child nutrition programs in schools and therefore making healthier foods more available is also an adjustment to the environment. Providing health and nutrition education to parents and children works to influence their attitudes toward soda consumption, particularly by demonstrating the link between soda consumption and obesity and other health conditions.
Expectations and observational learning are also important SCT constructs that are addressed by the intervention. Expectations are anticipated outcomes of a behavior and observational learning is the idea that behaviors are acquired by watching the actions and outcomes of others’ behaviors (15). By including parents in the intervention and educating them on how to make healthy choices in their lives and in their children’s lives it will help parents to become positive role models for their children. If children see their parents engage in healthy behavior, such as choosing alternatives to soda or exercising, and see the positive outcomes of these behaviors then the children will be more likely to incorporate these behaviors into their lives, as well.
Obesity poses a significant public health challenge and it is unlikely to be solved by a single intervention like NYC’s policy to limit sales of soda in excess of 16 ounces. While this proposal was constructed with good intentions, it would not be effective in reducing soda consumption or obesity because of its likelihood to induce reactance and its failure to account for aspects of the Health Belief Model and social and environmental considerations. A multifaceted approach of assessing a tax on soda and using revenue to fund obesity prevention programs in schools for children and their parents that takes into account important social and behavioral concepts is a more effective strategy.


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