Introduction
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.
Conclusion
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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