WEIGHING IN ON CHOOSE HEALTH L.A.S CAMPAIGN EFFECTIVENESS: Public vs.

Scholarly Perception

Improving Nutrition, Increasing Physical Activity and Reducing Obesity in LA County

Overview: Choose Health L.A.s approach to health is simple: empower the individual to make small changes in consumption to help develop long-term healthy eating habits. The key words in the organizations approach are thoughts that differentiate this campaign from other health campaigns, but just how effective is this methodology? Obesity is an issue attached to a number of societal factors including socio-economic status, race, age and education. Because the issue does not stand alone, it is important to fully understand the bigger picture. In order to do so, the basis of this report is two-fold: to measure the effectiveness of the Choose Health L.A. campaign by comparing it to the publics behavioral changes as a response to health campaigns as well as experts opinion and recommendation of components to successful health campaigns. I seek to understand and evaluate the why in Choose Health L.A.s campaign in the following components: Key messages: Choice in key messages in relation to other local and national campaigns Purpose: End goal of the campaign Target demographic: Choice in target audiences Audience reach: Methods/means to reach target demographics

Ultimately, this report will seek to answer 2 critical questions: 1. How does the general public respond to health campaigns? 2. How does Choose Health L.A. fare based on scholarly research on health campaigns? Group Hypothesis: Choose Health LA is raising awareness and causing healthier eating within low income communities. Group Methodology: Choose Health LA Content Analysis

WEIGHING IN ON CHOOSE HEALTH L.A.S CAMPAIGN EFFECTIVENESS: Public vs. Scholarly Perception Extensive online research proved the viral nature of the Choose Health LA sugary soda graphic. I took charge of the content analysis part of the project and looked for print/digital and broadcast coverage of specifically the sugary soda topic. I continued to research the campaign coverage throughout the October, November and December. Interview with Matthew Leveque of Choose Health LA We met with Matthew Leveque on three occasions to go over the details of the campaign, his direct role, the impact of the campaign and how the measured success. This interview took place on October 1st, 2012. We followed up with Matthew on two separate occasions to receive additional guidance and statistics. Child intercept surveys We polled 92 elementary school students (grades 2-5) to measure their exposure to the ad. We chose these students because they attended elementary school in a low-income neighborhood and were part of the target demographic of the Choose Health LA campaign (low income families). The surveys took place at weekly afterschool tutoring programs over a two-week period in November. My Methodology: Online survey regarding health-related campaigns in general We designed and launched a Qualtrics campaign to gauge the general publics response to health-related campaigns. The purpose of this survey was to see how health-related campaigns impact their audiences and if people actually made lifestyle changes based on the advertising and marketing efforts. This online survey was helpful in that it provided a very basic backdrop of a campaigns effect in everyday life. While not all campaigns can be considered equal, this survey did reveal interesting notions about human nature and the overall mentality of getting healthier. Scholarly, Peer-Reviewed Articles I took a close look at scholarly, peer-reviewed articles to answer the questions what are the issues that underlie obesity, what do scholars and experts deem as critical components to an effective health campaign to address these issues, and how does Choose Health L.A. address these methods? By answering these questions, I will be able to more critically evaluate the campaign. *See Appendix for article information. Group Findings Choose Health LA Content Analysis

WEIGHING IN ON CHOOSE HEALTH L.A.S CAMPAIGN EFFECTIVENESS: Public vs. Scholarly Perception Simple, visual ads were extremely effective in penetrating the healthconscious/fitness online community. Interview with Matthew Leveque of Choose Health LA Spanish language transcreation (translation with respect to vernacular and context) was essential to hitting the Latino market. Cultural relevancy was vital for print/digital and broadcast marketing. 80-90% of people recalled and memorized the sugary soda ad To better influence eating habits, choose a realistic comparison (dont go from fast food straight to spinach and quinoa, choose a healthier fast food option instead) Child intercept surveys

Out of 92 children, 67.4% had seen the sugary soda ad Children knew the sugary soda ad, but did not necessarily equate the sugar content as unhealthy. While awareness was definitely attained, perhaps impact and messaging was lost in young children. This was expected, as children were not the main or sole target of Choose Health LA. My Findings: Qualtrics Survey: 55% changed eating habits after seeing/reading/watching a food-related health campaign Of those who changed their eating habits o 40% made permanent changes o Changes included: eating more fruits and vegetables (44%), purchasing different items at the grocery store (43%), and looking at nutrition labels more often (41%) 59% of ALL participants believed that healthier eating campaigns changes personal diets 78% of ALL participants believed that healthier eating campaigns changed the overall communitys diet 25% of respondents who think healthier eating campaigns changed their personal diet did NOT believe that healthier eating campaigns change the overall community. However, 55% of those who think healthier eating campaigns changed their personal diet agreed that it also changed the overall community.

Scholarly, Peer-Reviewed Articles:

WEIGHING IN ON CHOOSE HEALTH L.A.S CAMPAIGN EFFECTIVENESS: Public vs. Scholarly Perception Social issues that affect obesity and should be addressed in health campaigns include: o Growing portion sizes in fast-food restaurants o Challenges faced by low-income minority residents o Lack of nutritional alternatives in urban areas Most effective methods for effective health campaigns o Multi-level efforts o Emphasis on portion control

Conclusions: After several rounds of variable research, we can concluded that Choose Health LA definitely created awareness among its target demographic, but long term, systemic health conditions remain to be seen. Many local low-income children had seen the ad either on a bus or at a bus stop and even a few college students were aware of the campaign. However, as the AIDA triangle tells us, awareness does not equal action. In order to track long term health changes, we would have to follow the community for several years in the future. While we proved awareness and widespread reach, we could not prove how Choose Health LA changed eating or drinking habits. In general, Americans were familiar with health-related campaigns. I think with the intense scrutiny of obesity and with a healthy lifestyle being trendy, we can expect even more spotlight on anti-obesity campaigns in the near future. From the Qualtrics survey, we found that many people think health-related campaigns work, but just not on them. They assume that others are motivated to eat better, but not necessarily themselves. The content analysis showed that an extremely graphic ad with simple text could become extremely viral, especially in niche communities such as health and weight loss. With the text overlay, the graphic almost became a story by itself. A simple graphic can be shared very easily without having to copy and paste any text or read an article. In fact, some key messages, including that the campaign was backed by the Los Angeles County Department of Public Health, were lost in the virtual world where bloggers relied on the striking visuals to cut down on text. With all of this research, it is still difficult to prove actual behavior change. Even with the official metrics from Matthew Leveque (Youtube hits, tumblr posts, press hits), these numbers do not equate actual lifestyle changes and/or lowered obesity rates.

WEIGHING IN ON CHOOSE HEALTH L.A.S CAMPAIGN EFFECTIVENESS: Public vs. Scholarly Perception CHOOSE HEALTH L.A. Key message: To empower the individual to make small, doable changes through two educational advertisements on sugar levels in beverages and portion control (1) 22 packets of sugar in Coke ad and (2) Choose Less, Weigh Less ad Purpose: To decrease obesity in low-income African-American and Hispanic residents by instilling simple and smart daily eating habits Target demographic: Low-Income African-American and Hispanic residents in Los Angeles Audience reach: Public transport advertisements and Internet Qualtrics Survey The online survey consisted of the following 11 questions:
Demographics On Health

1. Gender

6. Which of these food-related campaigns have you heard of?

2. Age

7. Have you changed your eating habits after seeing/reading/watching a campaign for healthier eating?

3. Education Level

8. How long did you maintain these changes in your diet?

4. Household Income

9. Which of the following did you begin to do?

5. Race/Ethnicity

10. Do you think healthier eating campaigns change your personal diet?

11. Do you think healthier eating campaigns change the overall communitys diet?

Research Question: What is the impact (if any) of existing health campaigns on the general public? Though there were no significant differences cross-tabulating demographics (as most of the participant were Caucasian or Asian 18-24 year olds), there were significant findings cross-tabulating question 6 and 8, 6 and 9, and 10 and ll. Overall, 55% changed their

WEIGHING IN ON CHOOSE HEALTH L.A.S CAMPAIGN EFFECTIVENESS: Public vs. Scholarly Perception personal eating habits ranging from a day to permanent changes and believed that health campaigns affected the overall community. Questions 6 and 8: When examining the duration of changes made by the participant as a result of a health ad in relation to specific ads, I found that the message of the health campaign correlated with the health behavior changes experienced by the participant. Taking the top three foodrelated campaigns into consideration (Supersize Me, Fast Food Nation and MyPyramid.gov), it is clear that a sizeable number of those who have merely heard of the campaigns made changes. *Note that respondents had the option of selecting multiple health campaigns that they heard of, but the results focus on the campaigns with the highest number of respondents. Roughly 70% of respondents purchased different items at the grocery store, looked at nutrition labels more often and ate more fruits and vegetables as a result of encountering Supersize Me and Fast Food Nation (independently). Similarly, 70% of respondents ate more fruits and vegetables; 67% of respondents purchased different items at the grocery store, looked at nutritional labels more often and made healthier menu choices at restaurants as a result of encountering MyPyramid.gov.

Questions 6 and 9: When examining food-related campaigns the participants were aware of in conjunction with sustained behavior changes, I found that those who maintained the longest term changes were those who were aware of Supersize Me, Fast Food Nation and Food Inc. All of these are very media heavy, visual campaigns. *Note that respondents had the option of selecting multiple health campaigns that they heard of, but the results focus on the campaigns with the highest number of respondents. Of those who permanently changed their eating habits, 96% did so as a result of Supersize Me. Supersize Me had the biggest impact on those who decided to change their diet, followed by Fast Food Nation, then Food Inc., which had a >95% behavior change rate.

WEIGHING IN ON CHOOSE HEALTH L.A.S CAMPAIGN EFFECTIVENESS: Public vs. Scholarly Perception

Questions 10 and 11: When all participants were asked if they believe healthier eating campaigns changed their personal diet and the communitys, I was surprised to find that a sizeable number who believed that these campaigns personally affected them did not affect the overall community, and even more surprising is those who believed that these campaigns did not change personal eating habits do change the overall community. 25% of respondents who think healthier eating campaigns changed their personal diet did NOT believe that healthier eating campaigns change the overall community. However, 55% of those who think healthier eating campaigns changed their personal diet agreed that it also changed the overall community.

Though there is a fairly even divide on those who decided to change their eating habits and not, it is evident that among those who were impacted, a significant number permanently changed their eating habits and of those individuals, many were affected by highly visual media messages. Additionally, it was interesting to find that though most believe that campaigns change both personal and community diets, more than half of the participants who changed their eating habits did not believe that it had a greater impact. Additionally, overall, only 4% of respondents knew what Choose Health L.A. was while Lets Move, MyPyramid.gov, Supersize Me, Food Inc., and Fast Food Nation were the most popular health campaigns. However, this is so primarily because Choose Health L.A. targets low-income minority populations in very specific neighborhoods in Los Angeles as opposed to targeting a national audience like the more popular food-related campaigns mentioned in the survey.

WEIGHING IN ON CHOOSE HEALTH L.A.S CAMPAIGN EFFECTIVENESS: Public vs. Scholarly Perception Scholarly Research Research Questions: 1. What are the issues that underlie obesity? Supersize Me It is not new to hear that portion sizes have increased over the years. The supersize option is a true indicator of how big meals have been getting and unnecessarily so. Americans are eating more, but is there a correlation between larger portion sizes and greater overall energy intakes? Experts say yes. In a study conducted by Ledikwe on energy density in foods, she found that adults consumed a significantly greater number of calories when their portion sizes were larger. For example, when adults were served four different portions of mac and cheese on different days, they consumed 30% more energy or calories in a day when offered the largest portion. This was so despite rating a similar hunger and fullness on all four days. Not only do adults eat more when there are larger portions, but they can easily skip the extra calories without feeling any less hungry or full. Additionally, the study found that even when participant actively chose a larger portion, they were likely to eat most, if not the entire portion. For example, when participants were offered a small (6) or large sandwich (12), those who chose the small sandwich consumed 31% fewer calories that day compared to those who chose the large sandwich. The Dietary Advisory Committee agrees with such findings as they have consistently acknowledges the importance of energy density in making food choices and suggested that limiting portion sizes, especially of these highly caloric foods could help reduce overall calorie intake. By addressing this issue, perhaps individuals would realistically follow the very generous 2,000-calorie a day diet.

WEIGHING IN ON CHOOSE HEALTH L.A.S CAMPAIGN EFFECTIVENESS: Public vs. Scholarly Perception There is increasing evidence that excessive food portions, akin to the supersize option at fast food restaurants, contribute to the overconsumption of energy, which directly feeds the obesity epidemic. Larger portions lead to high intake. High intake leads to weight gain. Those with high BMI (body mass index) consumed portions as much as 100% than those consumed by those with a lower BMI (29). It is a vicious cycle that millions of adults and children face. These experts state that telling people to simply "eat less" is not likely to be an effective solution, because it is not just large portion sizes that increase energy intake, but rather large portions of energy-dense foods. Thus, it is important to target energy-dense foods commonly found in fast-food restaurants and attacking portion sizes from there. Obviously, eating less of a large plate of broccoli does not compare to eating less of a large plate of fries. Experts are suggesting that individuals focus on the importance of eating less highly caloric snacks and foods. When the Underserved are Overserved The obesity epidemic has been proven to be racialized and gendered, meaning that it is an issue that affects a specific group of people in specific neighborhoods. These groups of people are African Americans and Hispanics. Time and time again, studies have found that compared to the white population, the prevalence of obesity is 51% higher in African Americans and 21% higher in Hispanics. (Firth) The prevalence of obesity among these minority groups speaks volumes to a number of other social issues that they face such as having low socio-economic statuses. Being both a minority group and having low SES exponentially increases ones risk of obesity. This can be more clearly seen in young children, who mirror the health habits of

WEIGHING IN ON CHOOSE HEALTH L.A.S CAMPAIGN EFFECTIVENESS: Public vs. Scholarly Perception their parents or guardians. Childhood onset obesity and related health problems are major clinical and public health issues in the United States, particularly among African Americans and Hispanic/Mexican Americans who are low-income. (Hollar) Compared to a mid-to-high income family, or one that makes more than $59,000, low-income families, ones that make less than $19,000, are three times more likely to be obese. (Driscol) These low-income families share similarities and interests including sugary soda consumption, frequent fastfood restaurant dining, and lack of exercise. Low-income, minority children are a key group that is underserved yet easily moldable. However, it is important to note, fundamentally, parents and caregivers are responsible for their children's health and development. They instill and promote certain values, reward or reinforce specific behaviors, and shape choices that form life-long healthy habitsChildren learn from the choices adults make." (White House, 2010: 23) Thus parents are a critical factor in shaping not only their personal health, but also their childrens. Parents and caregivers must be constantly educated in health and eating habits throughout the early stages (6 months and 2 years) of their childs life to make habits into lifestyle. (The Lancet) By educating parents, children will naturally learn healthy eating habits, ones that will help dictate what children eat for the rest of their childhood lives or longer. Access Denied A key health issue that this demographic in particular faces is access. There is simply a lack of nutritious foods available in their immediate community. Transportation for low SES is difficult as it is, but when only 42.2% of residents in urban areas have access to a

WEIGHING IN ON CHOOSE HEALTH L.A.S CAMPAIGN EFFECTIVENESS: Public vs. Scholarly Perception supermarket or large grocery store within a mile (Ghiradelli), it is not surprising that this demographic turns to the fast food chain less than one block from their homes. The lack of healthful foods in an area is otherwise known as a food desert and has been found to specifically be limited to low-income, predominantly black or Latino communities (Firth). Food deserts have essentially stripped large groups of the population without access to foods that should be consumed on a daily basis. And even in the small number of markets that carried healthful foods such as produce, the caliber of these items were not at the same level as any other neighborhood (Ghiradelli). In a study completed by primarily African Americans in an urban neighborhood, researchers found that the groups chief complaint was the lack of available fresh, affordable produce, especially easy-to prepare (pre-washed, pre-cut) varieties, and reducing exposure to fast foods. (Lucan). With such startling social issues, it is no wonder that these low-income individuals are pigeon holed into obesity. This ultimately demonstrates that the issue goes beyond individual choices and on external, environmental factors. 2. What do scholars and experts deem as critical components to an effective health campaign to address these issues? Multilevel Efforts The common thread through eight out of ten research studies considered in this report was the notion that a healthy society and community comes from larger, societal changes. When action is placed on the individual, there is little to no change; however, when the action is placed on communities, which include policy makers and health professionals, there will be advancements in the health movement. Despite this finding, the

WEIGHING IN ON CHOOSE HEALTH L.A.S CAMPAIGN EFFECTIVENESS: Public vs. Scholarly Perception focus of several social marketing campaigns has been inherently behavior change in the individual [but] virtually non are sustainable in the long term (Walls). This is particularly so because individuals have a difficult time acquiring the motivation to eat/act differently to the people in his/her social and peer groups or consume a diet markedly different to that readily available in the community (Walls). However, when there is a whole-systems approach or multilevel approach (Hollar) in a health campaign, meaning that the individual, in addition to, the community and government work towards health, there are statistical improvements in BMI. In a 2-year study by Hollar et al that observed low-income minority children, researchers found that by addressing interpersonal characteristics (feeding styles, family demands), community characteristics (foods available in schools and other institutional cafeterias, presence of vending machines and fast food, lack of access to physical activity facilities), and government influences (policies regarding food, education, urban design, marketing), is the most effective methodology in reducing obesity. Of the multilevel approach, it has been made clear that the individual cannot be isolated in his or her health journey, which has led researchers to hold that the most important level in which policy and system changes take place is the local level. Whereas the governmental level requires long-term efforts, the local level is able to foster both a sense of community and large enough change to impact the individual. The ultimate expert recommendation is to help direct local resources and create partnerships among city, county and local organizations to improve the community food environment (Ghiradelli). Portion Control: How much is too much?

WEIGHING IN ON CHOOSE HEALTH L.A.S CAMPAIGN EFFECTIVENESS: Public vs. Scholarly Perception Experts also agreed that in order to prevent obesity is to educate the public on reasonable portions. In addition to policy change on high fat and energy dense food and beverages, Ledikwe claimed that it came simply down to providing the appropriate portions to consumers. When the supersize option costs the same as the smallest option, it is only natural for consumers to opt for the most cost-effective meal size. However, other experts agree that if consumers were more educated on limiting the consumption of foods high in energy density, namely processed or junk foods, they would eat reasonable portions for better health. More specifically, in a study involving low-income African-American residents in an urban neighborhood, beyond education about how to shop for and prepare healthy food [which have been the key message of a number health campaigns], the participants advocated greater education about the health implications of dietary choices (Lucan). Ultimately, the consensus amongst experts and consumers is that through education of portion sizes and food choices, the community can move forward towards health. 3. How does Choose Health L.A. address these underlying issues and methods? Choose Health L.A. has a unique and specific campaign that identifies itself with several expert opinions of effective health campaigns. Its ads are exclusively featured on various modes of transport to target low-income minority residents. Firstly, in response to the issue of growing portion sizes, Choose Health L.A. speaks specifically to this problem in its second public advertisement of choosing the right portion. Because the organization understands that not only are portion sizes increasing, but they are increasing in calorie and fat rich foods such as fast foods. Their specific campaign to Choose Less, Weigh Less conveys the message to its audience that even if individuals are

WEIGHING IN ON CHOOSE HEALTH L.A.S CAMPAIGN EFFECTIVENESS: Public vs. Scholarly Perception choosing to eat at fast food restaurants, make a slightly smarter decision by downsizing. By doing so, they are saving an exorbitant number of calories for that day. Additionally, in response to expert opinion about choosing low-energy dense foods as opposed to choosing smaller amounts of high-energy dense foods, Choose Health L.A. is taking a small step, which they find to be empowering individuals to select lower caloric foods when they are eating out. Because it is difficult to make a drastic change from eating junk food to eating fruits and vegetables, Choose Health L.A. appropriately adjusted its message to educate individuals on appropriate portion sizes in the foods that their audience loves. The audience that Choose Health L.A. wonderfully aligns with the audience whom experts find to be in high need of education and support. This is the low-SES Hispanic and African-American population in urban areas. Especially in a large metropolis that is Los Angeles, there are high numbers of low-income minorities, which is the perfect avenue to promote and establish a campaign such as Choose Health L.A. In Los Angeles, 49% are Hispanic and 10% are African American. These people are centralized in South and East Los Angeles, which is where Choose Health L.A. ads are featured. The Choose Health L.A. ads are featured on various modes of transportation, which a majority of low-income residents take consistently. By targeting adults, it is the hope that knowledge at a parental level will trickle down to their children and grandchildren. As research has proven that the most important individuals to learn about food choices are adults as their children are direct mirrors of their eating habits and choices. Though educational initiatives at schools would have also been effective, for mass awareness

WEIGHING IN ON CHOOSE HEALTH L.A.S CAMPAIGN EFFECTIVENESS: Public vs. Scholarly Perception amongst this demographic, Choose Health L.A. has wisely informed the adult demographic in the placement of their advertisements. Continuing their methodology, Choose Health L.A. speaks to both individuals and communities. The advertisements that the campaign uses targets individual choices, which by itself has proven to be ineffective; however, Choose Health L.A. takes it one step further by involving the government as it is in direct collaboration with the Center for Disease Control and the Department of Human Health Services. Because all three organizations are working closely on this one campaign, there is agreement on the messaging and the need for greater health changes on a broader level. This approach to the health campaign aligns with expert recommendation that a multilevel process is the best way to effectively get health messages to the intended audience. Lastly, based on the topline recommendations of high need health related issue addressed earlier in the report that has not been identified by Choose Health L.A. are food deserts. There are high numbers of fast food restaurants in the low-income neighborhoods targeted by the campaign and not enough quality grocers that offer fresh produce; however, such an issue is one that requires more foundational efforts, which Choose Health L.A. is laying the groundwork for. By first educating its audience on the basics of food portioning and nutritional information, it will give its audience more information to eventually advocate for greater reform in its neighborhood. To approach health top-down, or from legislation to the individual would not be effective if the ultimate purpose is to affect individual dietary behaviors. Challenges

WEIGHING IN ON CHOOSE HEALTH L.A.S CAMPAIGN EFFECTIVENESS: Public vs. Scholarly Perception Overall, there were little to no challenges working with Melody and Evelina. We were a cohesive unit that really supported each others research. For example, when I could not make it to Matthews interview, Melody and Evelina went together to conduct the interview. I then transcribed the document. This really is representative of how we all pulled our own weight for the overall benefit of the team. Though we did have somewhat of a shaky start to the project, we all brainstormed together to develop the most effective research. At first, we did not know exactly what issue to tackle in terms of obesity; however, with the help of Professor Floto, we were able to hone our topic in as well as confirm our research methods. We all moved through this somewhat challenging start together and were able to successfully conduct and analyze our research. In terms of the research, we had trouble scheduling a time to meet with Matthew Leveque, who is an incredibly busy individual. After weeks of trying to find time, we were fortunate enough to meet with him. Additionally, we went into the interview hoping that we were going to be able to use the research that he and his team conducted to support our hypothesis, but were not able to. However, we were able to develop our own research to measure the effectiveness of his campaign. Our group was unified and always available. We really did work as a team throughout the entire semester. Everyone conducted their own research and contributed to the group in effective ways. I had absolutely no problem working with Evelina or Melody throughout the semester.

WEIGHING IN ON CHOOSE HEALTH L.A.S CAMPAIGN EFFECTIVENESS: Public vs. Scholarly Perception Scholarly, Peer-Reviewed Articles reviewed in the report include: 1. Public health campaigns and obesity- a critique (BMC Public Health) 2. Obesity among state's low-income teens nearly triple that of more affluent peers (La Prensa San Diego) 3. Portion Sizes and the Obesity Epidemic 1, 2 (The Journal of Nutrition) 4. Effective Multi-level, Multi-sector, School-based Obesity Prevention Programming Improves Weight, Blood Pressure, and Academic Performance, Especially among Low-Income, Minority Children (Journal of Health Care for the Poor and Underserved) 5. Healthy Choices and Heavy Burdens: Race, Citizenship and Gender in the 'Obesity Epidemic' (Journal of International Womens Studies) 6. Community Approaches to Preventing Obesity in California (American Journal of Public Health) 7. Hispanics' use of Internet health information: an exploratory study (Journal of the Medical Library Association) 8. Childhood obesity: affecting choices (The Lancet) 9. Using Geographic Information Systems and Local Food Store Data in California's Low-Income Neighborhoods to Inform Community Initiatives and Resources (American Journal of Public Health) 10. Concepts of healthy diet among urban, low-income, African Americans (Journal of Community Health)