Chapter 10

Over the last few decades, while obesity rates in the United States have increased dramatically in both adults and children, there has been a rapid expansion in access to and use of electronic media, for all ages. These trends in media use are frequently blamed for the trends of increasing obesity—at least in part. Media, which here refers to newspapers, magazines, radio, television, movies and videos, electronic video games, and the Internet, have the power to influence both what we know and what we do. Without question these media influence pathways that lead to obesity, in several important ways. Media help to form and to communicate cultural norms and images, provide avenues for health education information, and create channels for food and beverage adver- tising and product promotion. Most media are used when sitting; hence media use also tends to encourage sedentary behavior. Mechanisms related to the media that contribute to overweight also include commercial marketing and advertising of high-calorie foods and beverages, portrayals of eating, drinking, and body image in both advertising and program or story content, consumption of excess calories during television viewing, and reduced levels of calorie expenditure during periods of inactivity associated with media use.

Recognizing that media are important aspects of the social structure, consideration of how to prevent and control obesity in society at large must include the potential influences of the media on the determinants of and atti- tudes about obesity and on the ability to mount effective strategies to stabilize and then reduce population weight levels. The purpose of this chapter is to consider both the beneficial and deleterious effects of media on eating and physical activity. We provide a brief overview of the different types of media, demographics of media use, and mass media trends and impacts. We also include information on media regulation and media influence on nutrition, physical activity, and body image. The chapter concludes by describing oppor- tunities for progress in promoting healthy eating and physical activity through the media. In keeping with the focus of this book, the roles of media in the obesity epidemic are discussed in the context of the United States. However, as noted in several chapters in this book (see Chapter 11 in particular), the obe- sity epidemic is a global phenomenon, and the reach of electronic media into both urban and rural areas throughout the world links the issues discussed in this chapter to a wider, global stage (Hawkes, 2004).

Chapter 10

Media, Marketing and Advertising and Obesity

Sarah E. Samuels, Lisa Craypo, Sally Lawrence, Elena O. Lingas and Lori Dorfman

209

Types of Media and Trends in Use of Media

The media have long played a central role not only in the way people in the United States receive news and information, but also in how they think about politics, culture, family, and leisure activities. Over the years the types of media that people turn to have developed and changed dramatically. This section will provide a brief overview of current media use and trends in the United States and describe how media have been used to convey nutrition and physical activity information.

Print

The primary vehicles for print media in the U.S. are newspapers and magazines.

Newspapers, available in the U.S. since the 1700s, remain an important source of local and international news for Americans. However, readership of newspapers has significantly decreased in recent years, with only sixty-two per- cent of Americans reporting reading the Sunday newspaper and only about 50 percent reporting reading a newspaper during the rest of the week (Editor and Publisher Yearbook, 2003). Many younger adults are shifting away from news- papers and turning to the Internet for their news. Remaining readers are much more likely to be older, white, and have high education levels (The State of the News Media, 2006). Although ethnic newspaper readership has increased in recent years African American, Asian, and Hispanic newspaper readership remains much lower then white newspaper readership (The State of the News Media, 2006).

Unlike newspapers, the readership for magazines is holding steady and in some cases increasing (The State of the News Media, 2006). There has been an increase in readership for entertainment, lifestyle and pop culture maga- zines (The State of the News Media, 2006). Data indicate that in 2003 pop culture magazines, such as People, Us, and The Star, were read by roughly 180 million people. News magazines were read by nearly 70 million, and business magazines by slightly less then 40 million (Mediamark Research, 2003). The audience for news magazines tends to be aging and more affluent. Fewer news magazine titles have been released in recent years for younger generations (The State of the News Media, 2004). In 2003, readers of news magazines tended to be 29 percent more affluent then the overall population (Mediamark Research, 2003).

Magazines reach readers of all demographics with general news and a wide range of special interest material (The State of the News Media, 2006).

Magazines are also a source of health, beauty, and fitness information for women and men. There are a number of magazines that focus specifically on health and fitness issues and reach narrowly defined target audiences. These magazines cover everything from the latest nutrition research and diet fads to workout routines for weight loss.

Radio

Radio was introduced to American households in the 1920s and by 1994,

ninety-nine percent of U.S. households had radios (U.S. Department of State,

1997). Radio has held its audience numbers over the years, providing a source

of both news and entertainment. Ninety-three percent of Americans 12 years

and older report listening to the radio at least weekly (Arbitron, 2006). The recent introduction of satellite radio, Internet radio stations, ipods, podcasts, and mp3 players has contributed to a 45 minute decrease in radio listening per week, but the average radio user still spends roughly 19 hours per week listen- ing to the radio (Arbitron, 2006).

Radio advertising is often considered an inexpensive way to reach audiences, and young audiences in particular. Public health officials have also used the radio to spread healthful messages through Public Service Announcements (PSAs). For example, the Food and Nutrition Services Division of the United States Department of Agriculture (USDA) has created radio PSAs to promote the food stamp program to specific low-income ethnic populations. Many of the radio PSAs created by the USDA were in Spanish and played on Spanish language news and music stations (USDA, 2006).

Television

Since its introduction in the 1940s, television has become one of the most popular forms of media in the United States (Baughman, 1992). Data indicate that television viewing among both adults and children has increased dramati- cally in the past few decades. According to Nielsen Media Research, over 100 million homes in the United States currently have televisions, and in the average American home, the television is viewed for 8 hours and 11 minutes per day (Nielsen Media Research, 2005). It is estimated that children born dur- ing the television age will watch an average of seven years of television during their lives, spending more time watching television than any other activity, except sleeping (Kubey & Csikszentmihalyi, 1990). A study by Rideout, Foehr, Roberts, and Brodie (1999) on children and the media found that on a daily basis, 36 percent of children watch less then one hour of television, 31 percent watch one to three hours, 16 percent watch three to five hours, and 17 percent watch more then 5 hours of television (Figure 10.1).

A Henry J. Kaiser Family Foundation report revealed that African American and Hispanic children spend more time then white children watching televi- sion, videos, and playing video games (Rideout et al., 1999). Low income chil- dren are also heavier television viewers than their wealthier counterparts (Roberts, 2004). Detailed information on the demographics of television use can be purchased from Nielsen Media Research.

With increasing rates of television viewing there has been a concurrent increase in exposure to food and physical activity messages on television, and the

36%

31%

16%

17%

< 1 hour 1–3 hours 3–5 hours > 5 hours Figure 10.1 Daily television viewing hours of children and youth.

Source: Rideout et al., 1999.

higher rates of television usage among minority and low-income children expose them to an even greater amount of food and physical activity messages. Food and physical activity messages take many forms on television, including: in television news, television show storylines and product placements, advertisements, and public service announcements. In 1997 over 75 percent of the $7 billion spent by food manufacturers on advertising went to television advertisements (Gallo, 1999). Nearly 95 percent of the advertising budget for fast food restaurants also went to advertising on television (Gallo, 1999).

Internet

The early 1990s marked the beginning of wide-spread use of the Internet.

Since the early 1990s popularity of the Internet has skyrocketed. In 2004 it was estimated that 70 million people went online daily (Pew Internet & American Life Project, 2005). Americans currently use the Internet for a variety of purposes, including: accessing news, weather, paying bills, shopping, email, and meeting people. However, Internet usage is not equal across the popula- tion. Data from the 2003 U.S. Census indicate that only 62 percent of American homes have computers and only 55 percent have Internet access (U.S. Census Bureau, 2003). The census also revealed that higher income families are more likely than low income families to own computers and have Internet access; African American and Latino families are less likely to own computers or have access to the Internet than non-Hispanic whites. For children, roughly 76 percent had access to a computer and the Internet at home and 83 percent of children enrolled in school had access to a computer and the Internet at school (U.S. Census Bureau, 2003).

Advertisers and commercial marketers target the rapidly growing number of people using the Internet with a variety of new interactive techniques that can seamlessly integrate advertising and Web site content (Montgomery, 1996, 2001). For example, almost all of the major companies that advertise and market to children have created their own Web sites, designed as “branded environments” (Montgomery, 2000; 2001). New technologies and software can also collect data about the viewing habits and specific interests of children without the knowledge or consent of either the children or their parents.

Interactive Web sites, or “advergames,” ask children about their interests, habits, and preferences through surveys or quizzes embedded in the games or activities featured on the sites. Marketers can use this information to tailor their commercial marketing messages and to encourage impulse buying of products featured in programming or advertising.

Interactive television, which allows TV viewers to link directly to a Web site from a television program, allows advertisers to target individual viewers with personalized ads, increasing the likelihood of impulse purchasing (Center for Digital Democracy, 2001). Eventually, broadcasters hope to integrate televi- sion programming content, commercial marketing, and data collection.

Advertisers will be able to target viewers whenever they are watching and to transmit advertisements for products that are designed to appeal to a target audience—or more specifically, people of a certain gender, age, household income, race/ethnicity, or with certain interests.

In addition, product placements are increasingly incorporated into the sets

or even the plots of television programs, movies, video games, and Web sites.

This practice is on the increase as commercial marketers for products of all kinds seek to integrate product advertising directly into program content, thereby confounding viewers’ attempts to avoid commercials (Center for Digital Democracy, 2001).

Exposure to media is complex, involving multiple channels and multiple messages, with the potential for positive and negative effects. The media land- scape is evolving quickly. With the introduction of new media technology, the way that Americans receive news and information has changed dramatically.

Television, cable and digital media now play a dominant role in the lives of many Americans. Realizing the change in media use, commercial marketers have also changed the focus of how they advertise. Commercial marketing and advertising through these newer forms of media can be influential in setting norms and encouraging behaviors.

Media Regulation

In the United States, regulation of the media is primarily a federal function. The two main bodies given authority over the mass media are the Federal Communications Commission (FCC) and the Federal Trade Commission (FTC).

The Communications Act of 1934 established the FCC, and this independ- ent government agency reports to Congress and is “charged with regulating interstate and international communications by radio, television, wire, satel- lite and cable” (FCC, 2006). The FCC regulates media ownership and has required broadcasters to include a certain amount of programming that benefits the public, in exchange for being granted licenses to the public airwaves.

The FTC was created in 1914, and like the FCC, is an independent govern- ment body reporting to Congress. When created, the FTC’s purpose was to

“prevent unfair methods of competition in commerce” (FTC, 2006). Over the years, acts of Congress have also given the FTC the responsibility to protect consumers against “unfair and deceptive practices” (FTC, 2006). The FTC consists of three bureaus with multiple offices per bureau. Under the Bureau of Consumer Protection is the Division of Advertising Practices, which enforces laws regarding truth in advertising across multiple types of media (FTC, 2006).

Together, these two agencies have domain over multiple aspects of the daily lives of Americans. Among the areas of media regulation of particular relevance to public health are the FTC’s authority to regulate commercial marketing and advertising, including health claims, and the FCC’s authority over media consolidation and the responsibilities to the public of those licensed to use the public airwaves, such as providing time for educational programming.

In the 1970s, the FTC made an unsuccessful attempt to regulate advertising

and commercial marketing to children (Applbaum & Gould, 1981). Also in the

1970s, advertisers and commercial marketers began to take voluntary measures

to police their own members, through the Council of Better Business Bureau’s

National Advertising Review Council. There is a special unit dedicated to self-

policing children’s advertising, the Children’s Advertising Review Unit (CARU)

(CARU, 2006). Critics characterize CARU as ineffective, noting that it lacks

monitoring and enforcement mechanisms in addition to being funded by the very companies it is supposed to regulate, such as McDonald’s Corporation and the Grocery Manufacturers of America (Kelly, 2005).

Media Effects on Health

Media have an important role to play in stimulating and enhancing change in local communities and societies at large. The media, particularly the news media, can place subjects onto the public and policy maker agendas (McCombs and Shaw, 1972–1973), thereby introducing new topics or encour- aging new ways of viewing issues. Entertainment media and advertising can also play a role in societal knowledge and understanding of life.

The mass media can exert positive and negative effects on both individuals and populations, and these impacts may be either intended or not (Brown &

Walsh-Childers, 2002). The media may provide information on health conditions and treatments, such as that available on health Web sites as well as in newspaper and magazine health columns and articles, and this information can have positive benefits for those who receive the information and are in a position to understand and act on it for themselves or family and friends. The media may also convey negative health messages, such as promotions for alcohol and tobacco products, especially when targeted to children (Brown &

Walsh-Childers, 2002). Portrayals of alcohol use on television, in movies, music videos and music can have a particular impact on children and teens, because young people have little or no real-world experience within which to assess or countervail the messages they are exposed to in the media (Brown & Walsh- Childers, 2002). Overall, media have been shown to have effects on the accept- ability and understanding of public health issues as diverse as substance use and abuse (tobacco, alcohol, prescription and illegal drugs), violence, sexuality, nutrition, body image, and mental health (Brown & Walsh-Childers, 2002).

One strategy to help people increase their understanding of the media is improving their media literacy, which can be characterized as a process of

“informed inquiry” consisting of “awareness, analysis, reflection and action”

on the media (Center for Media Literacy, 2006). The aim of media literacy is to both understand the messages communicated by the media and why the messages are present; to “help people become sophisticated citizens rather than sophisticated consumers” (Lewis & Jhally, 1998, pg. 1). Media literacy training provides a means for people to critically examine and reflect on the pervasive messages with which we are constantly bombarded. On other public health topics, such as tobacco and alcohol consumption, media literacy has been useful in helping to inoculate consumers against the illeffects of advertising and marketing and programming by deconstructing the message.

This could potentially be a useful tool around food and beverage advertising and programming, particularly that aimed at teenagers.

Media Influence on Obesity

As obesity rates climb, there is both growing concern about the role media

may be playing in contributing to the obesity epidemic and increasing support

for finding ways media can help stimulate public action to address it. A recent

study found that young children who were exposed to two or more hours of television per day were more likely then those with less exposure to be over- weight, regardless of home environment or socioeconomic status (Lumeng, Rahnama, Appugliese, Kaciroti, & Bradley, 2006). A report by the Henry J.

Kaiser Family Foundation concluded that television and the media in general may contribute to childhood obesity in a number of ways. The time children spend using media displaces time that could be spent engaged in physical activity. Children’s food choices are influenced by food and beverage adver- tisements for high calorie-low nutrition foods. Children snack while using the media, often on relatively less healthful foods, and may consume more of these foods while eating in front of the television. Television may also lower children’s metabolic rates, although this line of research is not conclusive (Henry J. Kaiser Family Foundation, 2004).

Over the last several years, the public health issue of obesity has gained prominence among the news media, the public, and also in scholarly journals.

The number of news stories about the public policy aspects of the obesity problem rose from a few dozen in the last quarter of 1999 to over 1,000 stories in the last quarter of 2003 (Kersh & Morone, 2005). In addition to an increase in media cov- erage of obesity in the United States, the International Food Information Council (2004) has found an increase in the amount and depth of coverage of obesity issues in international media (Figure 10.2). By 2004, public opinion polls revealed that obesity was second only to cancer among the most important health problems in the United States (Schlesinger, 2005). Furthermore, a search for the term “obesity”

using Google Scholar for the year 1995 returned 3,600 citations, compared to a return of 20,300 citations for the same search for the year 2004, a 464 percent increase (Dorfman & Wallack, 2007). Clearly, the problem of obesity has gained widespread attention throughout the United States.

Global Trends in Obsity-Related Media Coverage

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Figure 10.2 Global trends in obesity-related media coverage.

Source: The International Food Information Council, 2004.

Media, Food Intake, and Obesity

Food and beverage marketers spend billions of dollars on advertising to encourage consumers to buy their products. Research has shown that (1) the majority of foods advertised are not healthful (i.e., are high in calories and low in essential nutrients) and that (2) advertising has the power to influence food preferences and purchases, especially in children.

Food Advertisements and Commercial Marketing

Americans view tens of thousands of television commercials and see hundreds of billboard and poster advertisements every year. The majority of these adver- tisements promote food and beverage products (Gantz et al., 2007). As a result, both children and adults are targeted and exposed to multiple food advertisements every day—including promotion of highly sweetened cereals, cookies, candy, fast foods, and soda— that are predominantly high in calories, sugar, and fat. In 2004 the food industry (eating and drinking establishments, food retailers, and food manufacturers combined) reportedly spent $11 billion on advertising, including $5 billion on television ads alone (Commitee on Food Marketing and the Diets of Children and Youth, 2006). A study that reviewed commercials aired during Saturday morning children’s programming found that roughly 50 percent of the commercials were for food (Kotz, 1994).

For children, television is the largest media source of advertisements. In 1999, money spent on children’s television advertising amounted to roughly

$1 billion (Nestle, 2003). For every five hours of television watched, children are exposed to an hour of commercials (Hastings et al., 2003). In addition, food preferences and advertising recall ability among children indicate that advertising is achieving its intended effects.

Commercial Marketing to Ethnic Groups

Though currently no data link food and beverage product marketing to obesity in communities of color, we do know that obesity affects Latinos and African Americans disproportionately to their white peers and that food marketers dispro- portionately target these population groups. Commercial marketers have demon- strated that within the communities of African American and Latino urban youth, this target marketing creates a loyal “super consumer” (Juzang, 2003).

To target communities of color, commercial marketers use specific images that are meaningful to the audience: celebrities such as entertainers, rap singers, athletes; models in fashionable dress; models using specific cultural associations expressed in language and mannerisms; youth representing peer approval; popular music that is uniquely identified with a specific group of children of color (Juzang, 2003).

Recent research studying the amount and type of advertising on prime-time television programs oriented to African American audiences compared to those for general audiences found that far more food commercials appeared on shows with large African American audiences and a larger percentage of these commercials were for high calorie-low nutrient foods (Tirodkar & Jain, 2003;

Henderson & Kelly, 2005). African American prime-time TV also showed

food items in non-advertising minutes or during the actual program more often

than did prime-time TV programs for general audiences (Tirodkar & Jain,

2003). A content analysis of advertisements during after school television

programming for children also revealed that there were a greater number of

high calorie-low nutrition foods and beverages advertised on BET (Black Entertainment Television) in comparison to the WB (Warner Brothers) and the Disney Channel (Outley & Taddess, 2006).

Magazines are another major vehicle used by food and beverage advertisers (Gallo, 1999), and magazines aimed at certain ethnic audiences carry a large amount of advertising for high calorie-low nutrient foods. For example, a study of health-related advertising in 12 women’s magazines was conducted to determine if magazine advertisements have an effect on health disparities between African American, Latina, and white women. The study compared eight “mainstream” women’s magazines (targeted at Caucasian women) to the four highest circulating, general interest magazines targeted to African American and Latina women. Results indicated that in the African American and Latina oriented magazines, there were a greater number of ads for products that could harm health and fewer for products that promote health (Duerksen et al., 2005). High calorie-low nutrient food and drink ads made up 52 percent of food and beverage advertisements in Hispanic magazines, 32%

in African American magazines and 29 percent in mainstream magazines (Duerksen et al., 2005).

Media Advertising Influence on Eating and Shopping Behavior

The large amount of food advertising and commercial marketing in the media can have an influence on eating and shopping behaviors in both children and adults. Increased exposure to advertising through the media can influence selection of higher calorie and higher fat foods.

A review conducted by Hastings et al. at the University of Strathclyde, Glasgow (2003) found strong evidence that commercial food marketing and specifically television advertising has been shown to influence children’s knowledge and food purchases. This review found that food advertising can, in specific contexts, decrease elementary school-aged children’s ability to differentiate healthful products from non-healthful ones. Commercial food marketing also impacts children’s food preferences. One study reviewed by Hastings et al. found that exposure to food advertising influenced children’s self-reported food preferences, and a number of the studies reviewed by Hastings et al., have shown that food advertising influences children’s food selection, either in school or at the grocery store.

Children’s food preferences, influenced by advertising, can also influence purchasing and eating habits for their entire family (Center for Science in the Public Interest, 2003). The Center for Science in the Public Interest found that the amount of time a child spends watching television was a predictor of how often they requested a food or beverage product at the grocery store. A study conducted by the USA Weekend/Roper Report on Consumer Decision Making in American Families indicated that 78 percent of children influence where their family purchases fast food, 50 percent influence what their family con- sumes at home and 31 percent influence which brands their family purchase at the grocery store. When children strongly influence their family’s purchasing and eating habits, foods selected tend to be less healthy (USA Weekend/Roper Report, 1989).

Food content in television shows and movies can also have an impact on

adult and child eating behavior. High calorie-low nutrient food choices are

much more likely than other types of food to be portrayed on television and in

the movies, encouraging consumers to eat a diet that contributes to diabetes and obesity. A study of prime time television shows in 1998 revealed that references to food occurred nearly 10 times per hour and that the majority of references were for high calorie-low nutrient foods and beverages (Byrd- Bredbenner et al., 2003). Likewise, one study indicated that foods high in fat and sugar are disproportionately shown over fruits and vegetables in high grossing films (Bell, Berger, & Townsend, 2003).

Television and Food Intake

In addition to influencing food preferences and purchasing, television may also contribute to an increase in snacking while viewing. Preliminary stud- ies in this area have shown that there may be a link between increased calo- rie intake and television viewing. One study found that families who watch more television are also more likely to consume a greater amount of their calories from junk foods than from fruits and vegetables (Coon, Goldberg, Rogers, & Tucker, 2001). Girls who have the television on during meal time have also been found to have higher calorie intakes than girls who did not watch television during meal time (McNutt et al., 1997).

Media and Body Image

Media play a role in shaping many cultural norms and has great influence on shaping norms around physical attractiveness. Overweight and obese television characters tend to be portrayed as unpopular and unsuccessful, while thin characters are portrayed as having more positive characteristics (Kaufman, 1980). There are fewer overweight and obese characters on tele- vision than exist in real life, and nearly a third of women on television are underweight (Greenberg, Eastin,

, 2003).

However, depictions of overweight and obese television characters may vary by ethnicity. A study of four sitcoms with a predominately African American audience found a much higher prevalence of overweight or obese characters and a higher number of food commercials than sitcoms with a general audience (Tirodkar & Jain, 2003).

While there is little evidence that there is a direct association between television viewing and eating disorders, studies have shown that increased exposure to media is associated with higher levels of body dissatisfaction (Borzekowski, Robinson, & Killen, 2000). Since body dissatisfaction is asso- ciated with eating disorders, media may be indirectly linked to eating disorders. For example, Borzekowski et al. found that frequent music video viewing among adolescent girls may be a factor in increased perceived impor- tance of appearance and an increase in weight concerns. In another study of girls in 5th through 12th grade, pictures in magazines had a strong impact on perceptions of weight and body shape (Field et al., 1999).

Media Promotion of Diets and Diet Products

Feelings of body dissatisfaction may cause many women and girls to turn to

diets and diet products promoted by the media. Commercial marketing and

advertising of diets and diet products is a major industry in the United States

that can have an effect on body image and overweight status. Commercial

marketers and advertisers promote everything from books to weight-loss shakes

and bars. Commercials for these products often contain ultra-thin models and

portray overweight people as unhealthy and lazy (Padgett & Biro, 2003).

Media and Physical Activity

The large amounts of time spent watching television or engaging in other sedentary media activities can decrease the time spent engaged in physical activity. Data from 1999 Nielsen surveys found that the average American over 12 years old watched television for more then 28 hours per week (Nielsen Media Research, 2000), but only 26.2 percent of U.S. adults are engaging in the recommended 30 minutes of moderate-intensity physical activity for five or more days per week (Brownson et al., 2005). While the research linking television viewing to physical activity levels is limited, we do have evidence that both youth and adults are not achieving the recommended levels of physical activity each day. According to the Youth Risk Behavior Surveillance System (YRBSS) roughly 24 percent of male and 38 percent of female high school students are inactive (Brownson et al., 2005; CDC, 2006). It is recommended that children and adolescents engage in 60 minutes of physical activity on most days of the week (CDC, 2006).

Media and Obesity Prevention

Using the media to raise public awareness, widely disseminate health educa- tion messages and advocate for changes in public policy have proven to be useful strategies for public health professionals. Major sources of news infor- mation about the obesity epidemic have helped to raise public awareness about the consequences of rapidly rising obesity rates. A poll of Californians con- ducted by Field Research for The California Endowment found that nearly all residents (92%) consider rising rates of obesity among children and teens to be a problem (Field Research Corporation, 2003). Social marketing and media advocacy are two public health strategies that use the media and may be important for obesity prevention.

Social Marketing

Social marketing involves the application of tools and techniques developed from private sector commercial marketing (Economos et al., 2001; Grier &

Bryant, 2005). By using techniques like market research, product positioning, pricing, physical distribution and promotion, social marketing programs seek to influence the behavior of target audiences to improve their personal health.

The VERB campaign is an example of a nationwide social marketing cam- paign focused on increasing the levels of physical activity among children (Wong et al., 2004)

Several social marketing campaigns, like the 5 A Day media campaign, the

1% Milk Campaign, and the national Project LEAN campaign have focused on

promoting healthy eating. For example, the national Project LEAN campaign

promoted low fat eating through public service announcements (PSAs) and

various other communication channels. Findings from the campaign indicate

that PSAs alone can generate increased awareness and demand for additional

information. PSAs in combination with other public relations and communica-

tion strategies can generate greater media attention and awareness of the prob-

lem (Samuels, 1993). California Children’s 5 A Day-Power Play! was a social

marketing campaign aimed at increasing fruit and vegetable consumption

among children and their families. The campaign used media in both schools

and the community during a one year time frame (Foerster et al., 1998). At the

end of the intervention there was an increase in the number of children who believed that they should be consuming more servings of fruits and vegetables per day and a slight increase in reported fruit and vegetable consumption among children in the intervention groups.

Similar to promoting healthy eating, mass media and social marketing campaigns have the potential to influence cultural norms and trends around physical activity. The VERB campaign, launched in 2002 by the Centers for Disease Control and Prevention (CDC), focused on reaching 9 to 13 year old children with the message that physical activity is “fun, cool, and socially appealing” (Huhman et al., 2005). Evaluation results indicated that the VERB campaign produced high levels of awareness and that many subgroups of chil- dren in the 9 to 13 age range reported increased levels of free-time physical activity (Huhman et al., 2005). Despite these promising results, long term funding for the VERB Campaign has not been obtained.

While social marketing campaigns have shown some effect in promoting healthy eating and activity in children (i.e., during developmental stages when habits are forming), success of social marketing interventions with adults have been limited (Alcalay & Bell, 2000). In addition, social marketing campaigns are costly, and their funding agencies usually have limited budgets in compar- ison to food marketers and advertisers. For example, Coca Cola spent $277 million on advertising in 1997 (Jacobson, 1998), while the National Institutes of Health/National Cancer Institute had a total budget of $1 million to promote the 5 A Day media message (Gallo, 1999).

Alcalay and Bell (2000), in their report on Promoting Nutrition and Physical Activity through Social Marketing, present several recommendations for improving social marketing interventions. These authors suggest that social marketing interventions are most effectively used to promote prevention to individuals who have not yet formed unhealthy habits, should focus on the environmental influence on people’s health, and should work to promote envi- ronments more conducive to healthy eating and activity. Carroll

(2000) also suggest that due to the challenges of changing individual behaviors through social marketing, interventions should be of substantial duration and complemented with policy approaches to maximize the possible impact and benefits.

Media Advocacy

Media advocacy is the strategic use of mass media to support community organizing and advance healthy public policy (Chapman & Lupton, 1994;

Wallack et al., 1993, 1999). It differs fundamentally from traditional public

health campaigns and social marketing. However, in practice, media advocacy

uses some of the same media relations techniques that practitioners of social

marketing or public information campaigns might use: sending out news

releases, pitching stories to journalists, monitoring the media and keeping a list

of media contacts, and paying attention to what is newsworthy. Winett and

Wallack (1996) note that media advocacy’s purpose is to put pressure on policy

makers and reframe public debate on key public health issues. The focus of a

media advocacy campaign is to set the agenda and shape the debate to include

policy solutions in news coverage of health issues. Media advocacy targets pol-

icy makers, other advocates, and community members who can become active

in the political process of making change. In the case of preventing obesity,

media advocacy has been used for advocating for policy change in schools or neighborhoods to increase access to healthy foods and reduce access to high calo- rie-low nutrient foods, as opposed to promoting consumption of healthier foods directly to students or residents, which would be better suited to social marketing.

For example, in 2000, the release of a report on the prevalence of fast foods on California high school campuses (Craypo et al., 2002) brought the issue to the attention of state law makers and resulted in the introduction and passage of leg- islation to reduce access to high calorie-low nutrient foods on school campuses.

Media advocacy differs from other types of health communication because it seeks change in the social, physical, or policy environment surrounding individuals, rather than seeking change in individual behavior.

Thus, the “target audience” for media advocacy efforts will be a policy maker or body who has decision-making capabilities, such as a school board determining whether to allow sodas to be sold in campus vending machines.

This is a fundamentally different understanding of the target than is used in most health communications where the target is the person with the problem.

It is often the best media strategy choice when the overall strategy involves changing policy (Dorfman, 2003).

In fact, because most public health problems are complicated and deeply imbedded in social organization and behavior routines, they require long-term and evolving communications strategies. Preventing obesity will require motivation for individuals to adopt healthy eating behavior and active living;

social marketing campaigns may help inform them about the most effective ways to do that. But to be successful, people will need affordable access to healthy food, and environments that encourage activity, conditions that will require policy change in many communities. Media advocacy is likely to be a very useful tool to help public health advocates make the case to policy makers for those policies. Public health practitioners need to know which communication strategies are suited to which goals.

Working with Entertainment Media

The media environment is both diverse and specialized, and there are many places for public health professionals to try to leverage opportunities for improv- ing individual and population health. In addition to using social marketing and media advocacy, health organizations have partnered with the entertainment industry to incorporate healthful behaviors into television programs around top- ics such as pregnancy prevention, substance abuse prevention, and HIV/AIDS.

The Henry J. Kaiser Family Foundation (KFF) has partnered with television entertainment programming in order to convey health messages to television viewers; KFF partnered with the hospital-based drama ER to get factual health information into episode story lines (Brodie et al., 2001). KFF also worked with MTV to produce programming that included health messages for youth.

Media and Public Policy

Policy strategies to address the role of media in the obesity epidemic are under con-

sideration in Congress and state legislatures across the country. For example,

Senator Tom Harkin introduced legislation in May 2005 that would, among other

provisions, restore the authority of the FTC to regulate the advertising and market-

ing of food and beverage products to children (U.S. Senate, May 18, 2005). Also in

2005, Senator Joseph Lieberman introduced a bill to establish a research program

in the National Institute of Child Health and Human Development “to study the

role and impact of electronic media in the development of children” (U.S. Senate, March 9, 2005). Increasing the understanding of the impact of both newer and older types of media on children may provide further avenues for intervening to protect and promote child health and wellness. Organizations, like Children Now, maintain active programs in media as it specifically affects children and seek regulatory and policy changes to make sure media interactions are healthful and not harmful (Children Now, 2006).

Conclusions

While many efforts have attempted to use media to positively impact physi- cal activity and nutrition behaviors, media play a large role in promoting overeating and sedentary behavior. Both children and adults are targets of intensive commercial marketing campaigns promoting soda, fast foods, and high-calorie snacks, along with passive leisure-time activities, including TV, movies, and video games. Portrayals of food, physical activity, and body image in news and entertainment media also have an influence on poor nutrition choices and sedentary behavior.

On the health promotion and policy sides, strategies, like social marketing and media advocacy, have been used to influence individual health behaviors and broader policy adoption to sustain environmental changes that support good health. Strategies for creating a media environment more supportive of health and wellness will take sustained efforts on the part of public health practitioners and other professionals and community advocates, acting at local, state, and national levels to address the spectrum and variety of media influences in our daily lives.

With increased awareness and understanding of the presence and impact of media, increased opportunities abound for public health to be proactive and engaged with this important component of the broader social environment.

References

Alcalay, R., & Bell, R. (2000). Promoting nutrition and physical activity through social marketing: Current practices and recommendations. Davis, CA: Center for Advanced Studies in Nutrition and Social Marketing, University of California.

Applbaum, A., & Gould, S. (1981). Mike Pertschuk and the Federal Trade Commission.

Kennedy School of Government; President and Fellows of Harvard College.

Cambridge, MA

Arbitron. (2006). Radio today: How America listens to radio.

http://www.arbitron.com/downloads/radiotoday06.pdf.

Baughman, J. L. (1992). The republic of mass culture: Journalism, filmmaking and broad- casting in American since 1941. Baltimore, MD: Johns Hopkins University Press.

Bell, R., Berger, C., & Townsend, M. (2003). Portrayals of nutritional practices and exercise behavior in popular American films, 1991–2000. Davis, CA: Center for Advanced Studies of Nutrition and Social Marketing, University of California.

Brodie, M., Foehr, U., Rideout, V., Baer, N., Miller, C., & Flournoy, R., et al. (2001).

Communicating health information through the entertainment media; A study of the television drama ER lends support to the notion that Americans pick up information while being entertained. Health Affairs, 20(1), 192–199.

Borzekowski, D. L., Robinson, T., & Killen, J. (2000). Does the camera add 10 pounds? Media use, perceived importance of appearance, and weight concerns among teenage girls. Journal of Adolescent Health, 26, 36–41.

Brown, J. D., & Walsh-Childers, K. (2002). Effects of media on personal and public health. In J. Bryant, & D. Zillman (Eds.), Media effects: Advances in theory and research (2nd ed., pp. 453–488). Mahwah, NJ: Lawrence Erlbaum Associates.

Brownson, R. C., Boehmer, T. K., & Luke, D. A. (2005). Declining rates of physical activity in the United States. Annual Review of Public Health, 26, 421–443.

Byrd-Bredbenner, C., Finkenor, M., & Grasso, D. (2003). Health related content in prime-time television programming. Journal of Health Communication, 8, 329–341.

Carroll, A., Craypo, L., & Samuels, S. (2000). Evaluating nutrition and physical activity social marketing campaigns: A review of the literature for use in community campaigns. Davis, CA: University of California, Center for Advanced Studies in Nutrition and Social Marketing.

Center for Digital Democracy. (2001). TV that watches you: The prying eyes of inter- active television. http://www.democraticmedia.org/privacyreport.pdf.

Center for Media Literacy. (2006). About CML. Retrieved April 13, 2006, from http://www.medialit.org.

Center for Science in the Public Interest. (2003). Pestering parents: How food companies market obesity to children. http://www.cspinet.org/pesteringparents.

Centers for Disease Control and Prevention. (2006).

http://www.cdc.gov/nccdphp/dnpa/physical/recommendations/young.htm.

Children’s Advertising Review Unit (CARU). (2006). Retrieved March 3, 2006, from http://www.caru.org.

Chapman, S., & Lupton, D. (1994). The fight for public health: Principles and practice of media advocacy. London: BMJ Publishing Group.

Children Now. (2006). http://www.childrennow.org/.

Committee on Food Marketing and the Diets of Children and Youth, Food and Nutrition Board, Board on Children, Youth, and Families. (2006). Food marketing to children and youth: Threat or opportunity? Washington, DC: Institute of Medicine, National Academies Press.

Coon, K. A., Goldberg, J., Rogers, B. L., & Tucker, K. L. (2001). Relationships between use of television during meals and children’s food consumption patterns.

Pediatrics, 107(1), E7.

Coon, K. A., & Tucker, K. L. (2002). Television and children’s consumption patterns.

A review of the literature. Minerva Pediatr, 54, 423–436.

Crapyo, L., Purcell, A., Samuels, S. E., Agron, P., Bell, E., & Takada, E. (2002). Fast food sales on high school campuses: Results from the 2000 Californian high school fast food survey. Journal of School Health, 72(2), 78–82.

Dorfman, L. (2003). Using media advocacy to influence policy. In R. J. Bensley, &

J. Brookins-Fisher (Eds.), Community health education methods: A practitioner’s guide (2nd ed., chapter 15). Sudbury, MA: Jones & Bartlett Publishers.

Dorfman, L., & Wallack, L. (1993, November–December). Advertising health: The case for counter-ads. Public Health Reports, 108(6), 716–726

Dorfman, L., & Wallack, L. (2007, March–April). Moving nutrition upstream: The case for reframing obesity. Journal of Nutrition Education and Behavior, 39(suppl. 2), S45–50..

Duerksen, S. C., Mikail, A., Tom, L., Patton, A., & Lopez, J. (2005). Health disparities and advertising content of women’s magazines: A cross-sectional study. BMC Public Health, 5(85). http://www.biomedcentral.com/1471-2458/5/85.

Economos, C. D., Brownson, R. C., DeAngelis, M. A., Novelli, P., Foerster, S. B., &

Foreman, C. T., et al. (2001). What lessons have been learned from other attempts to guide social change? Nutrition Reviews, 59(3, Pt. 2), S40–S56; discussion S57–S65.

Editor and Publisher Yearbook. (2003).

http://www.editorandpublisher.com/eandp/resources/yearbook.jsp

Federal Communications Commission (FCC). Retrieved March 3, 2006, from http://www.fcc.gov.

Federal Trade Commission (FTC). Retrieved March 3, 2006, from http://www.ftc.gov.

Field, A. E., Cheung, L., Wolf, A. M., Herzog, D. B., Gortmaker, S. L., & Colditz, G. A.

(1999). Exposure to the mass media and weight concerns among girls. Pediatrics, 103, e36.

Field Research Corporation. (2003). A survey of Californians about the problem of childhood obesity. Conducted for the California Endowment.

h t t p : / / w w w. c a l e n d o w. o r g / r e f e r e n c e / p u b l i c a t i o n s / p d f / d i s p a r i t i e s / TCE1126-2003_A_Survey_of_Ca.pdf

Foerster, S. B., Gregson, J., Beall, D. L., Hudes, M., Magnuson, H., Livingston, S., et al. (1998). The California children’s 5 a day-power play! campaign: Evaluation of a large scale social marketing initiative. Family and Community Health, 21(1), 46–64.

Gantz, W., Schwartz, N., Angelini, J. R., Rideout, V. (2007). Food for thought:

Television food advertising to children in the United States. Menlo Park, CA: The Henry J. Kaiser Family Foundation.

Gallo, A. E. (1999). Food advertising in the United States. In E. Frazao (Ed.), America’s eating habits: Changes and consequences (pp. 173–180). Washington, DC: USDA, Economic Research Service.

Greenberg, B., Eastin, M., Hofschire, L., Lachlan, K., & Brownell, K. (2003).

Portrayals of overweight and obese individuals on commercial television. American Journal of Public Health, 8, 1342–1348.

Grier, S., & Bryant, C. A. (2005). Social marketing in public health. Annu Rev Public Health, 26, 319–339.

Hastings, G., Stead, M., McDermott, L., Forsyth, A., Macintosh, A. M., Rayner, M., et al. (2003). Review of research on the effects of food promotion to children. Prepared for the food standards agency. Glasgow, Scotland UK: Center for Social Marketing, University of Strathclyde.

Hawkes, C. (2004). Marketing food to children: The global regulatory environment.

Geneva, Switzerland: World Health Organization.

http://whqlibdoc.who.int/publications/2004/9241591579.pdf

Henderson, V. R., & Kelly, B. (2005). Food advertising in the age of obesity: Content analysis of food advertising on general market and African American television. J Nutr Educ Behav, 37(4), 191–196.

Henry J. Kaiser Family Foundation. (2004, February). The role of media in childhood obesity. http://www.kff.org/entmedia/upload/The-Role-Of-Media-in-Childhood- Obesity.pdf

Huhman, M., Potter, L. D., Wong, F. L., Banspach, S. W., Duke, J. C., & Heitzler, C. D.

(2005). Effects of a mass media campaign to increase physical activity among children: Year-1 results of the VERB campaign. Pediatrics, 116(2), e277–e284.

International Food Information Council. (2004). Trends in obesity-related media coverage. Washington, DC: International Food Information Council.

http://www.ific.org/research/obesitytrends.cfm.

Jacobson, M. (1998). Liquid candy: How soft drinks are harming Americans health.

http://www.cspinet.org/sodapop.

Kaufman, L. (1980). Prime-time nutrition. Journal of Communication, 30, 37–46.

Kelly, B. (2005). To quell obesity, who should regulate food marketing to children?

Globalization and Health, 1, 9. http://www.globalizationandhealth.com/content/1/1/9.

Kersh, R., & Morone, J. A. (2005, October). Obesity, courts, and the new politics of public health. Journal of Health Politics, Policy and Law, 30(5), 839–868.

Kotz, K., & Story, M. (1994). Food advertisements during children’s Saturday morning television programming: Are they consistent with dietary recommendations?

Journal of the American Dietetic Association, 94, 1296–1300.

Kubey, R., & Csikszentmihalyi, M. (1990). Television and the quality of life: How viewing shapes everyday experience. Hillsdale, NJ: Lawrence Erlbaum Associates.

Lewis, J., & Jhally, S. (1998, Winter). The struggle over media literacy. Journal of Communication, 48, 1.

Lumeng, J., Rahnama, S., Appugliese, D., Kaciroti, N., & Bradley, R. (2006).

Television exposure and overweight risk in preschoolers. Archives of Pediatric and Adolescent Medicine, 160, 417–422.

McCombs, M., & Shaw, D. (1972–1973). The agenda setting function of mass media.

Public Opinion Quarterly, 36, 176–187.

McNutt, S. W., Hu, Y., Schreiber, G. B., Crawford, P. B., Obarzanek, E., & Mellin, L. A. (1997). Longitudinal study of dietary practice of black and white girls 9- and 10-year-old at enrollment: The NHLBI growth and health study. Adolescent Health, 20, 27–7.

Mediamark Research. (2006). Magazine Audience Estimates 1995–2003.

http://www.mediamark.com.

Montgomery, K., & Pasnik, S. (1996). Web of deception. Washington, DC: Center for Media Education.

Montgomery, K. C. (2000). Children’s media culture in the new millennium: Mapping the digital landscape. The Future of Children, 10, 145–167.

Montgomery, K. C. (2001). Digital kids: The new online children’s consumer culture.

In D. G. Singer & J. L. Singer (Eds.), Handbook of children and the media (pp. 635–650). Thousand Oaks, CA: Sage Publications.

Nestle, M. (2003). Food politics: How the food industry influences nutrition and health.

Berkeley, CA: University of California Press.

Nielsen Media Research, Inc. (2000). 2000 Report on television.

http://www.nielsenmedia.com

Nielson Media Research, Inc. (2005). Nielsen reports American watch TV at record levels. News release.

http://www.nielsenmedia.com/newsrelease/2005/AvgHoursMinutes92905.pdf Outley, C., & Taddess, A. (2006). A content analysis of health and physical activity

messages marketed to African American children during after-school television programming. Archives of Pediatric and Adolescent Medicine, 160, 432–435.

Padgett, J., & Biro, F. (2003). Different shapes in different cultures: Body dissatisfaction, overweight, and obesity in African-American and Caucasian females. Journal of Pediatric Adolescent Gynecology, 16, 349–354.

Pew Internet & American Life Project. (2005). Internet: The mainstreaming of online life. http://www.pewinternet.org/pdfs/Internet_Status_2005.pdf.

Rideout, V., & Hoff, T. (2002). Shouting to be heard: Public service advertising in a new media age. Menlo Park, CA: Kaiser Family Foundation. Publication #3152.

Rideout, V., Foehr, U., Roberts, D., & Brodie, M. (1999). Kids and media at the new millennium. Menlo Park, CA: Kaiser Family Foundation.

Roberts, D. (2004). Kids and media in America. New York: Cambridge University Press.

Samuels, S. E., Craypo, L., Dorfman, L., Purciel, M., & Standish, M. B. (2003, November). Food and beverage industry marketing practices aimed at children:

Developing strategies for preventing obesity and diabetes. A report on the proceed- ings from a meeting sponsored by the California Endowment held in San Francisco in June of 2003.

h t t p : / / w w w. c a l e n d o w. o r g / r e f e r e n c e / p u b l i c a t i o n s / p d f / d i s p a r i t i e s / TCE1101-2003_Food_and_Bever.pdf

Samuels, S. E. (1993). Project LEAN-lessons learned from a national social marketing campaign. Public Health Reports, 108, 45–53.

Schlesinger, M. (2005, October). Editor’s note: Weighting for Godot. Journal of Health Politics, Policy and Law, 30(5), 785–801.

The State of the News Media, (2004). Journalism.org.

http://www.stateofthenewsmedia.org/

The State of the News Media, (2006). Journalism.org.

http://www.stateofthemedia.org/2006

Tirodkar, M., & Jain, A. (2003). Food messages on African American television show.

American Journal of Public Health, 93(3), 439–441.

USA Weekend/The Roper Organization. (1989). A USA Weekend/Roper report on con- sumer decision-making in American families. New York, NY.

U.S. Census Bureau. (2003). Computer and Internet Use in the United States.

http://www.census.gov/prod/2005pubs/p23-208.pdf.

U.S. Department of Agriculture, Food and Nutrition Services. (2006). Newsroom, Radio Features. http://www.fns.usda.gov/cga/radio/radio.htm.

U.S. Department of State. (1997). Chapter 12: The media and their messages. In Portrait of America. http://usinfo.state.gov/usa/infousa/facts/factover/ch12.htm U.S. Senate. 109th Congress, 1st Session. S. 579, A Bill to amend the Public Health

Service Act to authorize funding for the establishment of a program on children and the media within the National Institute of Child Health and Human Development to study the role and impact of electronic media in the development of children.

[Introduced in the U.S. Senate; March 9, 2005]. Congressional Bills, Library of Congress, Thomas. http://thomas.loc.gov/cgi-bin/query/z?c109:S.579.

U.S. Senate. 109th Congress, 1st Seassion. S. 1074, A Bill to improve the health of Americans and reduce health care costs by reorienting the Nation’s health care system toward prevention, wellness, and self care. [Introduced in the U.S. Senate;

May 18, 2005]. Congressional Bills, Library of Congress, Thomas.

http://thomas.loc.gov/cgi-bn/query/z?c109:S.1074.

Wallack, L., Dorfman, L., Jernigan, D., & Themba, M. (1993). Media advocacy and public health: Power for prevention. Newbury Park, CA: Sage Publications.

Wallack, L., Woodruff, K., Dorfman, L., & Diaz, I. (1999). News for a change: An advo- cates’ guide to working with the media. Thousand Oaks, CA: Sage Publications.

Winett, L., & Wallack, L. (1996). Advancing public health goals through the mass media. Journal of Health Communication, 1, 173–196.

Wong, F., Huhman, M., Heitzler, C., Asbury, L., Bretthauer-Mueller, R., & McCarthy, S., et al. (2004, July). VERB – A social marketing campaign to increase physical activity among youth. Prev Chronic Dis, 1(3), A10. Epub 2004 Jun 15.