A Critical Assessment Of “Fat-Shaming” In Anti-Obesity Public Health Interventions – Brian Charest

Introduction

A number of organizations whose aim is to curb obesity have been using images of overweight and obese individuals, including children, with the belief that inciting fear or shame will motivate parents and children to lose weight.  This paper identifies the key reasons why this approach is ineffective, and provides recommendations for an alternative campaign that addresses and resolves the issues inherent in the current approach.  

There are numerous instances of so-called “fat shaming” in recent public health anti-obesity campaigns.  For example, a television commercial created by Blue Cross and Blue Shield of Minnesota depicts two boys arguing about whose father can eat more food, and concludes by showing a father looking shamefully at his fast food meal (1).  Other ads depict overweight and obese children with provocative captions in an apparent attempt to incite disgust or disdain in the viewer (2,3).  In 2012, Disney World’s Epcot Center opened an exhibit called “Habit Heroes,” which depicted obese characters as villains (with names such as Leadbottom, The Snacker, and The Glutton), in contrast to the exhibit’s heroes (named Will Powers and Callie Stenics) (4).  

Taken together, these campaigns are rooted in the idea that shame will provide strong motivation for overweight and obese individuals to take action and lose weight.  This approach is fundamentally flawed, for several reasons.

Critique Argument #1:  Reactance Theory

One problem with “fat-shaming” ads is that they may cause psychological reactance in those who view them.  Brehm and Brehm first described psychological reactance theory in 1966.  In part, the theory states that if someone is told that they cannot do something, this will trigger feelings that their freedom is being curtailed and in response, the individual will find ways to re-establish that freedom (5).  In further work on the subject, reactance theory’s authors cited four basic principles (5):  

1. Reactance may not occur in an individual if he/she is not aware that they have the freedom to act in opposition (i.e., if he/she is not aware that freedom is being limited);
2. The strength of reactance is directly and positively correlated with the perceived importance of the freedom that is being threatened;
3. More reactance occurs if multiple freedoms are being threatened (e.g., being told never to do something as opposed to being told not to do it just one time); and
4. Reactance increases if the individual perceives that a threat is implied (e.g., if an individual is told not to snack, and they perceive this to imply that they are not to smoke or drink coffee either).

An important consequence of reactance theory is that when faced with social pressure to change, an individual will often react to this threat by acting in direct opposition to the message (5).  A 2008 study characterized reactance as a two-step process, whereby a message containing forceful language will cause the person to feel threatened, which in turn becomes reactance, expressed via anger and negative emotions (6).  In the context of these anti-obesity ads, the provocative wording may cause a person to feel threatened by the message, and as a result, he or she may continue to purchase/eat unhealthy foods, or consume large quantities of foods, as a way to re-establish the notion of personal freedom.

Critique Argument #2:  Socioeconomic Inequities

The “fat-shaming” approach is also ineffective because it ignores socioeconomic realities.  People who live in poorer areas have limited access to fresh foods, and also may lack the economic means with which to purchase healthier options (7).  A qualitative study was performed that identified the barriers that were most often cited by low-income individuals with regard to access to fruits and vegetables.  The key obstacles cited were cost (mentioned 4x as frequently as any other factor), transportation (e.g., proximity to locations that sell the items), quality of produce, variety, changing food environment (some individuals noted that there used to be more stores that sold fresh produce), and changing societal norms on food (e.g., less at-home cooking and more fast food) (8).  

Predominantly black and/or low-income neighborhoods have a higher number of fast food restaurants compared to neighborhoods that are higher-income and/or predominantly white (9).  Areas where residents have limited access to healthy and/or fresh foods have been described as “food deserts”; the authors of a study conducted in Portland, OR described the concept of a “food mirage” – i.e., an area where full-service grocery stores are easily found, but where the items are cost-prohibitive for many poorer residents (10).  This is a common problem in neighborhoods that are undergoing gentrification, and underscores the fact that even if healthy foods are physically available, they may be monetarily inaccessible to some people.  Other studies have noted that people living in some inner-city neighborhoods lack easy access to physical activity:  some of these residents either do not feel safe exercising outside, or do not live in areas that are conducive to walking (11).

In the 1940’s, Abraham Maslow introduced the concept of a “hierarchy of needs”, in which human needs are classified into tiers, which are (listed from most important to least important):  physiological (i.e., those needed for basic survival), safety (e.g., housing), love/belonging (e.g., family or community), esteem (e.g., a sense of self-worth), and self-actualization (12).  Inherent to Maslow’s hierarchy is the idea that people will only focus on less essential needs once the more essential needs are met.  For example, an individual will only begin to concentrate on securing safety once basic physiological needs of food and water are satisfied.  For those who are living in poverty and are not physically ill, health is a need that is not seen as a priority by the individual.  Therefore, it stands to reason that simply telling an individual that he or she should lose weight, when other more urgent priorities and needs must be met first, will be ineffective.  

The Health Belief Model should also be considered with regard to people of limited means and their access to healthy foods.  The Health Belief Model assumes that when an individual is making health decisions, he or she will conduct an internal cost-benefit analysis, weighing the perceived benefits of taking a particular action against the inherent perceived costs of doing so (13).  In this case, the key assumption would be that the individual sees the benefit of healthy eating as worth the tangible economic costs that are involved, and also that the individual perceives obesity to be a severe condition that will have adverse long-term effects.

Therefore, it seems that a “fat-shaming” approach that simply tells people that they should lose weight is overly simplistic, particularly because it does not address ways to overcome some of the obstacles faced by people in lower-income or inner-city environments.

Critique Argument #3:  Labeling Theory

The “fat-shaming” approach to solving obesity is also problematic because of the stigma that individuals will feel when the label is applied to them.  Erving Goffman made early contributions to labeling theory in the 1950’s and 1960’s.  He wrote about different types of stigma suffered by individuals, and described three major classifications:  stigma as a result of physical abnormalities or limitations; as a result of defects of character or personality; and as a result of “tribal stigma,” related to ethnicity, national origin, or religious affiliation (14).

An important implication of labeling theory is that when a person is labeled, it can affect his or her behavior (15,16).  A recent study investigating the short- and long-term effects of negative labeling on adolescent girls found that the effects of such labeling can persist into adulthood.  This was true for white females in their study more than for black females.  The study’s authors concluded that while the physical aspects of a public health campaign to combat obesity are important, it is also recommended that mental health concerns be addressed (17).  Such a recommendation is in direct opposition to an approach that uses negative labeling as a way to curb obesity.  

A 2013 study that assessed participants’ perceptions of various anti-obesity messages found that the most positive messages, and in particular those that did not expressly use the word “obesity,” were deemed to be the most motivating.  The negative messages were deemed by participants to be the least motivating (18).  In addition, a survey conducted of patients who had lost over one hundred pounds after bariatric surgery found that most of them would prefer to be blind, deaf, or lose a limb rather than return to their pre-surgery weight (19).  This underscores the fact that many obese people do not want to be that way, and that many would change if they knew how to.

Therefore, if a label itself impacts a person’s behavior, negative labeling (such as “fat-shaming”) might in fact have a negative effect on a person’s self-worth, and in turn may impact the belief in whether he/she can change the situation.  This would cause a “fat-shaming” campaign to be at best ineffective, and at worst to yield the exact opposite of the intended effect.

Recommended Alternative Intervention:

Based on the three criticisms of anti-obesity campaigns that use fat-shaming, which were described above, I recommend a public health approach that will have the following goals:

• Provide education on the topics of healthy food choices and exercise;
• Provide concrete and tangible steps that can be taken that are designed to promote weight loss; and
• Fulfill the above goals while promoting a positive message that makes the individual feel good about him- or herself, and instills confidence that these goals can be achieved.

The next sections will discuss, in detail, how the proposed approach will address each of the shortcomings of the existing “fat-shaming” campaigns.

Reducing Reactance

A 2005 study concluded in part that people would be more receptive to a message if it were positive rather than negative.  It has been shown that one way to reduce reactance is to relay the intended information using a messenger who is similar and shares common characteristics with the recipient (20).  Therefore, it is recommended that the people used in these campaigns be individuals with whom the target audience can identify – this can mean showing the real journey of an overweight or obese person as he or she works to change health habits; or perhaps using a celebrity spokesperson who has had struggles with weight in the past.  As a way to target children and provide a positive message, the use of celebrities that children look up to could be very effective.  An example might be to show a series of ads encouraging physical activity, using stars of kid-oriented television programs, such as those aired on the Disney Channel or Nickelodeon, to reinforce the positive message.  Providing positive encouragement and reinforcement will have the dual benefits of reducing reactance and reducing stigma.  

Addressing Socioeconomic Inequities

The recommended approach will have a component that directly addresses the fact that cost and availability of healthy foods can be prohibitive.  A recent study found that while many consumers hold the belief that healthy food is too expensive, that is in part a perception that is perpetuated and supported by what the individual sees in the media and in their social interactions (7).  Nutritional education and food budgeting proved helpful to lower-income individuals and families in that study, and therefore it is recommended that these concepts be included in our proposed public health intervention.  One of the drawbacks noted above about the “fat-shaming” ad campaigns is their reductive nature.  The ads tell people that they need to lose weight, but they do not provide any information about how to accomplish this.  The proposed campaign will show individuals engaged in activities such as learning how to read nutrition labels, cooking at home, or beginning to exercise.  By outlining steps that can be taken, this gives the target audience some degree of structure and guidance.

Advertising and Marketing Theory

The proposed anti-obesity campaign will utilize the theories of advertising and marketing.  The three key components of advertising theory are:

• Promise:  effective advertising makes a promise to the viewer/consumer
• Support:  it is important to provide examples and reasons for the viewer/consumer to believe in the message
• Core values:  the message must appeal to a strong and identifiable core value.

Marketing theory is based on the idea that rather than identifying the product that people want and marketing it to them, it is better to identify exactly what people want and then package and market a product in a way that seemingly fulfills an individual’s needs and/or wants.  An offshoot of traditional marketing theory is what is known as social marketing theory.  The key idea behind social marketing theory is to take the fundamental underpinnings of marketing theory and apply them to address problems in the social sciences.  While traditional marketing theory has been argued to create and perpetuate unnecessary needs and wants, social marketing theory applies the same concepts with the goal of improving the common good (21).  In the context of this proposed anti-obesity campaign, social marketing theory can be used to promote the concepts of health and well being.  The campaign will promote the promise of improved health and increased energy, in addition to weight loss.  Instead of appealing to a core value of health, the campaign will rely on a core value of family.  One ad can show a couple and their kids cooking a meal and then enjoying it together.  Another ad could show a dad and his son going on a bike ride together.  Using a positive message with a core value of family would be far more motivating, and far less stigmatizing, than the “fat-shaming” approach.

Conclusion

Based on the evidence shown above, it is clear that the “fat-shaming” approach to fighting obesity is simplistic and ineffective; and it may indeed have the unintended consequence of making overweight and obese people more entrenched in their current habits.  The proposed approach is far more comprehensive, and addresses the shortcomings of the “fat-shaming” campaigns, while using the theories of advertising and social marketing to effectively deliver the message.  Obesity in America is a complex problem, and therefore it will require a comprehensive, multi-pronged solution.  Hopefully, the campaign outlined above will resonate with the intended audience.

References

1. NPR.  New Anti-Obesity Ads Blaming Overweight Parents Spark Criticism.  Washington, DC:  National Public Radio. http://www.npr.org/blogs/thesalt/2012/09/27/161831449/new-anti-obesity-ads-blaming-overweight-parents-spark-criticism
2. About-Face.  Georgia’s Strong4Life campaign relies heavily on fat shaming.  San Francisco, CA:  About-Face.  http://www.about-face.org/georgias-strong4life-campaign-relies-heavily-on-fat-shaming/
3. The Atlantic.  Think Of The (Fat) Children:  Minnesota’s ‘Better Example’ Anti-Obesity Campaign.  http://www.theatlantic.com/health/archive/2012/09/think-of-the-fat-children-minnesotas-better-example-anti-obesity-campaign/262674/
4. Huffington Post.  Disney's Anti-Obesity 'Habit Heroes' Exhibit At Epcot Causes Controversy.  New York, NY:   http://www.huffingtonpost.com/2012/02/24/disney-habit-heroes-anti-obesity-disney-world-epcot_n_1299664.html
5. Brehm, J.; Brehm S.  Psychological Reactance: A Theory of Freedom and Control. Mahwah, NJ:  Erlbaum, 1981.
6. Quick, B.; Considine J.  Examining the use of forceful language when designing exercise persuasive messages for adults:  a test of conceptualizing reactance arousal as a two-step process.  Health Communication 2008; 23:483-491.
7. Carlson A.; Frazao E.  Food costs, diet quality and energy balance in the United States.  Physiology & Behavior 2014; http://dx.doi.org/10.1016/j.physbeh.2014.03.001.
8. Haynes-Maslow L. et al.  A qualitative study of perceived barriers to fruit and vegetable consumption among low-income populations, North Carolina, 2011.  Preventing Chronic Disease 2013; 10:E34.
9. Larson N.  Neighborhood environments:  Disparities in access to healthy foods in the U.S.  American Journal of Preventive Medicine 2009; 36(1):74-81.
10. Breyer B, Voss-Andreae A.  Food mirages: geographic and economic barriers to healthful food access in Portland, OR.  Health & Place 2013; 24:131-139.
11. Rundle A.; Neckerman K.; Freeman L.; Lovasi G.; Purceil M.; Quinn J.; Richards C.; Sircar N.; Weiss C.  Neighborhood Food Environment and Walkability Predict Obesity in New York City.  Environmental Health Perspectives 2009; 117(3):442-447.
12. Maslow AH.  A Theory Of Human Motivation.  Psychological Review (1943), 50:370-396.
13. Rosenstock I.  Historical Origins Of The Health Belief Model.  Health Education Behavior 1974; 2(4):328-335.
14. Goffman E. 1963. Stigma: Notes on the Management of Spoiled Identity. New York, NY: Touchstone.
15. Link B.; Cullen F.; Struening E.; Shrout P.; Dohrenwend B.  A Modified labeling Theory Approach To Mental Disorders:  An Empirical Assessment.  American Sociological Review 1989 54:400-423.
16. Link B.; Phelan J.  Conceptualizing Stigma.  Annual Review of Sociology (2001); 27:363-385.
17. Mustillo S.; Budd K.; Hendrix K.  Obesity, Labeling, and Psychological Distress in Late-Childhood and Adolescent Black and White Girls: The Distal Effects of Stigma.  Social Psychology Quarterly 2013 76:268.
18. Puhl R.; Peterson JL; Luedicke, J.  Fighting Obesity Or Obese Persons?  Public Perceptions of Obesity-Related Health Messages.  International Journal of Obesity (2012), 1–9.
19. Tomiyama AJ; Mann T.  If Shaming Reduced Obesity, There Would Be No Fat People. Hastings Center Report (2013), 43: 4–5.
20. Silvia P.J.  Deflecting reactance: The role of similarity in increasing compliance and reducing resistance.  Basic and Applied Social Psychology 2005;  27:277-284.
21. Hastings G.; Saren M.  The critical contribution of social marketing.  Marketing Theory 2003 3: 305.