Challenging Dogma - Fall 2008

Tuesday, December 16, 2008

The Smallstep Campaign against obesity and its Small Effect- Navid Shams


In the past 30 years we have witnesses the obesity problem in this country develop into a major epidemic and a predominant issue in public health. Just in the first 20 years, the percentage of obese adults doubled from 15% to 30%. In a similar time period the prevalence of overweight children increased from 5% to 17.4%. [i] Now about 64% of the US population is either overweight of obese. [ii] This striking progression also brings with it direct and indirect costs that are estimated to be as high as $117 billion dollar annually. [iii] These costs are so high due to the fact that being overweight or obese has been shown to increase the risk for a series of diseases, including osteoarthritis, Type 2 diabetes, coronary heart disease, stroke, gallbladder disease, sleep apnea, respiratory problems, and even breast and colon cancer. i

The steady and significantly increase in the prevalence of obesity as well as the associated costs have pushed the government to act. In November of 2005, the US Department of Health and Human Services in conjunction with the Advertising Council mounted a $1.5 million a year media-based campaign called smallstep. Its goal is to “increase awareness, change behavior and promote healthier lifestyles among the millions of Americans who are currently unhealthy and overweight and at risk for obesity and long-term chronic diseases.” xvi A series of professionally produced television, magazine, and radio public service advertisements get people’s attention by using humorous visual images and then refer them to the companion website so they can learn about more than 100 small steps that can lead to a healthier lifestyle. The small steps are thought to be manageable enough to fit into a busy schedule without requiring drastic changes and therefore should promote long-term, sustained weight control and good health.

In conjunction with this campaign, a sub-campaign, smallstep kids, has recently been added to encourage children to eat healthier and be more active. It uses similar media outlets to portray healthy fruits and vegetable as fun foods that can be used as fuel for play. It also utilizes NFL players, LPGA golfers, and Shrek characters to promote the “Play 60” and “Be A Player” concepts that urge children to get out and play everyday.

The smallstep campaign uses a novel approach to obesity problem. It integrates healthier eating and a more activity into the typical American’s life in a reasonable manner. It even incorporates a non-traditional model by using advertising theory. However, it still doesn’t seem to be effective enough to produce positive health outcomes. In the following analysis, I provide an evidenced-based criticism that illuminates why this public health campaign is not succeeding.

Argument 1: Dependence on the HBM does not account for the impact of social networks on behavior change.

The smallstep campaign uses the Health Belief Model (HBM), which is an individual-level, value-expectancy model that posits that people will engage in healthy behavior when they intend to do so because they value the outcome and believe it will result from their behavior. [iv] In their campaign report, the smallstep developers emphasize how the program promotes self-efficacy, a trademark of the HBM. [v] They highlight the idea that having to complete only a few simple and small steps (i.e. take the stairs instead of the escalator, get off the bus a stop early and walk, try smaller sized items when snacking or eating out) will boost confidence in one’s ability to perform the behaviors.

Although this tactic makes the tasks seem more manageable, it is counterproductive to give each step a number. The actual numbers associated with each “step” on the main webpage make it seem like one’s goal should be to complete each one as if it is a task. Also, mentioning that there are over 100 of them makes it seem less manageable and can be intimidating for people, especially those who are already not very hopeful about their ability to eat right and exercise regularly.

Besides not considering the previously explained challenges facing individuals in vulnerable economic situations, the select use of the HBM also doesn’t permit the developers to address the influence of social networks on predicting behavior. Social Networking Theory tells us that the relationships with a person’s peers, teachers, teammates, friends, neighbors, and family are of great importance and can significantly affect a person’s decisions. This effect depends on the nature of the relationship, which involves reciprocity, frequency and complexity of interactions, and the setting. [vi] This theory is especially important to consider because the “network phenomena appear to be relevant to the biologic and behavioral trait of obesity.” [vii] By focusing on individuals, the smallstep campaign neglects research that suggests the obesity tends to “spread” through social ties and develop in clusters.

For instance, being friends with an obese person increases one’s risk of becoming obese by 57% and having a sibling who becomes obese increases it by 40%. [viii] Although the smallstep kids advertisements do promote activity that involves friends and peers, the smallstep adult and teen section doesn’t recognize that an individual’s social network plays a role in determining actions related to health, the health information one is exposed to, and the social support people have available to them. Only one of the exercise related tips even addresses the idea of involving another person in your physical activity: Tip # 44 states “Ask a friend to exercise with you). Most of the activities are very individual-based, such as the use of a step tracker, which includes an online component that promotes setting activity goals and tracking progress using an interactive calendar.

A lack of consideration of Social Network Theory (SNT) is apparent in the discord between the adult/teen and kids sections. The developers should have considered the relationship between parent’s obesity status and its effect on their children. Children are known to adopt parent’s diet and health related behavior due to daily exposure. [ix] Children with 2 obese parents have an 80% chance of becoming obese in their lifetime, while those with one obese parent have a 40% chance and those with no obese parents have only a 7% chance. [x] Considering that part of this is related to the social-norms established by parents, the developers should have taken more steps to link the kids and adult sections of their campaign.

Lastly, a person who has overweight/obese social contacts has a different perception of the acceptability of being overweight/obese. It may even be a social-norm for them. This partially explains why weight gain by same-sex friends and siblings had such a large impact on the risk of the individual becoming obese. xvi Approaching the public with more group level smallstep interventions could be more effective at instituting long lasting behavior change.

It is important to link appropriate individual and population-based theories when designing interventions. This produces a richer intervention because, after all, we are all
individuals but we are also enmeshed in social networks. The specific importance of social networks in the obesity problem warrants using a group-based theory like SNT to combat the limitations from HBM. Neglecting this aspect leads to a smallstep campaign that does not have a strong multi-level intervention.

Argument 2: Poor Use of Advertising Theory

The inclusion of the Ad Council in this public health intervention was a good decision because it allows for the use of multiple media outlets (TV, internet, newspapers) that have a large audience. Also, it allowed for the addition of aspects of the intervention that are based on Advertising Theory. This theory involves two essential components: a promise and its support.

The support aspect can be implicit and even laughable, but should include compelling visual images, music, etc. In the case of the smallstep ads, the support has drawn confrontation and is being laughed at instead of being laughable. As Michael Jacobson of the Center for Science in the Public Interest says, it so “namby-pamby [that] I think people will shrug it off.” [xi] This is a criticism of the commercials that show people finding love handles, double chins, and other fatty and unwanted pieces of flesh in public places because they have lost them due to simple exercise (e.g. taking the stairs, walking to the office).

We know that “viewers pay more attention to ads that evoke feelings of personal loss, sadness, anger, disgust or fear [and] tend to remember such ads longer,” xvii so it’s unfortunate that the developers didn’t use more vivid, dramatic effects to get their point across. They even admit that research showed the ads to be humorous, instead of evoking any of the above feelings. Even the “lost” fat isn’t particularly disgusting, or as disgusting as it could be. This also applies to the magazine ads that are supposed to look like lost cat type signs, but lack attention-getting colors. These ads are poorly designed and do not evoke the right emotions from the audience, which is critical to their success.

The promise aspect of an advertisement is of critical importance and must be researched thoroughly so as to identify what exactly it is that your target population most aspires to at a core level. Unfortunately, the text that delivers the promise on the print ads is also impossible to read as it is very small, not colorful, and written vertically. In addition, framing theory tells us that the ads would be more effective if they identified core values. Unfortunately, only a couple of them do this reasonably well: “Now runs the risk of being mobbed by female admirers.” Most of them miss the mark: “No longer dependant on wearing vertical stripped shirts.” Also, the use of humor continues in these ads: “fights urge to run on the soccer field and play forward.” So, even if you manage to read the promise, it may not even be effective.

It is surprising to me that the Ad Council didn’t come up with more promising material and leads me to be suspicious of the partnership with the “Coalition for Healthy Children,” which includes Coca Cola, Pepsi, Hershey, and the National Confectioners Association. Their products are serious contributors to obesity, yet there is no mention of them. There could be conflict of interest issues that led to the absence of candy and soft drinks in the advertisements.

The smallstep kids advertisements are also flawed, especially in regards to the “brand name” they developed. The “Play 60” and “Be A Player” show groups of kids having fun and playing easy outdoor games like tag, 4-square, football, kickball, cheerleading. Respectively, they include well known professional football players and LPGA golfers, and Shrek characters that are involved in the kid’s activities. The impressive recruiting the developers did is counteracted by the use of “brand names” that emphasize the wrong idea. Play 60 advertisements specifically tell the kids to play for 60 minutes every day and suggest that this should be their goal. However, research tells us that kids would be more responsive if values like improved appearance or social standing were addressed. [xii] [xiii] The well respected athletes could have been used more effectively in this way.

On the other hand, the Shrek characters, although they are certainly popular are not exactly the most athletic group that could have been used to promote physical activity. However, that is exactly the point: you don’t have to be an athlete to enjoy and benefit from physical activity. This raises issues around the effectiveness of the message delivered by the advertisement and the coordinated online system, which gives health tips based on personal exercise and health statistics. Shrek isn’t focused on physical activity but instead on improving health, which we know is not a core value for children. [xiv] We know that the kids watching these are already displaying sedentary behavior, so the smallstep kids developers need to be sure to dissuade the inactivity while they have the children’s attention. [xv]

Argument 3: Developers Overlook the Sociological Perspective

When designing a public health intervention, it is critical to know the traits of the problem. However, the designers of the smallstep campaign have overlooked the socio-demographic characteristics that are an important part of the obesity problem. In the US, we have seen the prevalence of obesity rise more than twice as fast among minority groups compared with white groups. [xvi] Moreover, we know that black and Latino children are as twice as likely of being overweight compared with white children. [xvii] Among adult women, obesity prevalence varies significantly by ethnic group: 31% among whites, 40% among Mexicans, and 52% among African Americans. In terms of obesity, the concepts of race/ethnicity and SES are interlinked. [xviii] Namely, the highest rates of obesity occur among populations with the highest poverty rates, and poverty disproportionately affects minorities. [xix] Keeping this connection in mind there are a couple of reasons why overlooking socioeconomic status, specifically, is a major flaw of the smallstep campaign.

The idea of a family’s socioeconomic status (SES) is a key factor that influences food options. People from lower SES backgrounds are more likely to become overweight due to limited access to health-related stores and local food shops with available fresh and healthy foods. [xx] So, even if people want to eat the healthy, fresh fruits and vegetables that smallstep suggests, they are not readily available and can be prohibitively expensive. [xxi] A related factor is the lack of reliable transportation. Also, there are there are fewer supermarkets with fresh, affordable produce and many more small independent grocers that provide low cost, high-energy foods in low-income areas. This leads to the purchasing of cheaper meals and snacks that are convenient but offer little nutritional value. [xxii] These are factors that will certainly impede the effectiveness of the “Can your food do that?” aspect of the smallstep kids campaign, which is well designed enough that is can succeed at getting children to want to eat fruits and vegetables. Unfortunately, when it succeeds and the children want those foods, they may not have access to them.

SES can also restrain physical activity. Lower income neighborhoods can have more crime and street violence. This does not allow children to safely use parks and open spaces; children in lower income neighborhoods get less physical activity when compared to children in safer, wealthier neighborhoods. [xxiii] Besides the safety concerns, the built environment itself can impact physical activity. Geographic areas occupied by low SES and minority populations are known to have less availability of physical activity facilities than those occupied by higher SES populations. [xxiv] Studies have shown a correlation between the accessibility to sidewalks, gyms, gardens, and parks and increased physical activity. [xxv] Understandably, areas with more facilities have been associated with lower rates of overweight and obese people. So, although the “Shrek” and “NFL Play 60” ads [xxvi] can get kid’s attention because of the presence of popular football players and movie characters, the fun they have playing in seemingly safe, sizable parks and well equipped and maintained sports facilities is not possible for many of the more vulnerable children. It is especially unrealistic for those in urban areas.


The US Department of Health and Human Services’ smallstep campaign has tackled the complex obesity problem with a media-based approach that certainly has possibilities. It focuses on perceived barriers to individual behavior in a novel and worthwhile manner. However, this epidemic requires multi-level interventions that address the underlying causes of obesity from various dimensions. The individual’s behavior must be viewed in relation to the social network and also social environment. Its failure to do this is common among public health interventions, but is still unforgivable. The use of creative solutions based on Social Network Theory, coupled with a better use of Advertising Theory is warranted.



The US Department of Health and Human Services’ smallstep campaign has tackled the complex obesity problem with a media-based approach that certainly has possibilities. It focuses on perceived barriers to individual behavior while integrating healthier eating and a more activity into the typical American’s life. Their approach is novel and worthwhile. However, it still isn’t effective enough to produce positive health outcomes because this epidemic requires multi-level interventions that address the underlying causes of obesity from various dimensions. The individual’s behavior must be viewed in relation to the social network and also social environment. The use of creative solutions based on the sociological perspective and Social Networking Theory, coupled with a better use of Advertising Theory is warranted. In the following proposal, I present an intervention that builds upon the smallstep campaign by capitalizing on its strengths and addressing its weaknesses.

Step I: Accounting for the impact of social networks on behavior change.

A major strength of the smallstep campaign is its unique approach to addressing self-efficacy by providing simple and small steps. This tactic does, in fact, make the tasks seem more manageable and will be effective once the numbering of steps is removed. Because each step is independent (i.e. take the stairs instead of the escalator, try smaller sized items when snacking or eating out) they can be effectively understood and implemented no matter what order they are used in. Not using numbers also adds to their self-efficacy by removing the intimidation brought on by knowing that there are over 100 possible small steps.

Along with the Health Belief Model (HBM), Social Networking Theory (SNT) will be utilized. The new campaign should recognize that obesity tends to “spread” through social ties and develop in clusters. It should promote individual’s involvement in their social networks so that they can give and get support and health information from them. The tips that are given to adults and teenagers should specifically address the inclusion of others. This can be done by referring to general characters in a person’s life. For instance, “Make a pact with a coworker to use the stairs.” We could even modify the step tracker program so that it allows for teams of people to join online and have inter-departmental competitions.

Along with promoting the inclusion of coworkers and friends, the new campaign will consider the parent’s obesity status and its effect on their children. Because the effect is related to the social-norms that are established by parents, it can be used to have a more positive effect on the child as well. We will take more steps to link the kids and adult sections of the campaign so that each group is addressed separately and also as one social unit. For instance, the children could be asked to make a grocery list after using the interactive “Can your food do that?” interface. It could recommend that they discuss it with their parents, which would expose the parents to the campaign and perhaps promote the purchase of those healthy foods. On the other end, suggesting that the parents walk their kids to school or to activities would get the children to view that activity as more normal.

This part of the new campaign links appropriate individual and population-based theories and ultimately results in a richer, multi-level intervention.

Step II: Effective Use of Advertising Theory

The use of multiple media outlets (TV, internet, newspapers) and the inclusion of the Ad Council is another major strength of the campaign. However, just because a larger audience is exposed to an intervention, does not necessarily mean that it will have better results. A better understanding and use of advertising theory will increase the new campaign’s effectiveness.

First, we will adjust the emotions that the images evoke. Instead of laughter, we will aim for disgust, which is known to cause viewers to remember an ad longer. This will be accomplished by using attention-getting colors on the magazine ads and vivid, dramatic effects in the commercials. For instance, in portraying the “lost” love handles, double chins, and other fatty and unwanted pieces of flesh, a “surgeon’s view” of fat will be used in place of the simple looking plastic objects that were used in the previous set of advertisements. Adding this type of drama to the ads will make sure that the “support” that advertisements are using isn’t just being viewed, but noticed and having an impact.

Concurrently, the “promise” aspect of the new advertisements will be enhanced. First, the text that conveys this on the magazine ads will be large, colorful, and horizontal so that it is easy to read. Using framing theory, we will create more effective ads that identify core values (i.e. “having to buy that new bikini” and “leaving work early because you are the captain of the soccer team”).

Lastly, this new campaign will recognize the importance of having a captivating “brand name.” This is especially critical in the aspects that target kids and teens. These groups have been shown to be quite responsive to brand names that address values like improved appearance and social standing. The VERB campaign that the CDC ran until 2006 can be incorporated into this campaign. Using this model, we can successfully increase and maintain physical activity by getting kids to find, take ownership of, and integrate their own verb into their personal lives. In this way, the campaign isn’t focused on improving health, which we know is not a core value for children, but instead on physical activity.

This new brand name, coupled with the well known professional football players, LPGA golfers, and Shrek characters that were part of the previous advertisements will make for an innovative approach that will likely be popular and catchy enough to spread through communities. Along these lines, it can address social networks by having parents, teachers, doctors and coaches also targeted by using advertisements that expose them to the slogan “it’s what you do” and have them utilize it in their interactions with the kids.

By using a provocative brand name with effective, theory based, advertisements in a mass communication medium this new campaign makes some warranted improvements.

Step III: Including the Sociological Perspective

The designers of the smallstep campaign overlooked the socio-demographic characteristics that are an extremely important part of the obesity problem. The new campaign will take into account the interlinked concepts of race/ethnicity and SES and adjust the intervention to specifically target the social and ethnic communities that suffer the most from the epidemic.

Because of the large audience that this intervention reaches and engages, it has the awesome possibility for meaningful health education. The online portion of the campaign can be especially useful to introduce viewers to programs like Women, Infants, and Children (WIC), which are in place to provide food, nutritional counseling, and access to health services for low-income families. Because few families recognize that programs like this exist, having links to their website or even including them among the tips can have lasting effects for those at highest risk. Although there are certainly still challenges, like dependable transportation, these programs can at certainly decrease the number of factors that stand in the parents way.

This type of community health education can be expanded from only addressing access to healthy foods to encouraging local programs that promote the use of safe outdoor space. This campaign can’t change the built environment, but it can identify the local programs and give people information about them in region specific ways via the website. Also, the new campaign will replace the safe, sizable parks and well equipped sports facilities that were in the previous advertisements with settings that are more realistic for those living in low income and urban areas.


The US Department of Health and Human Services’ smallstep campaign is attempting to address an obesity epidemic that is 30 years in the making. The media-based framework of the approach has great utility in promoting long-term, sustained weight control and good health. However, we must recognize that obesity has been a predominant issue in public health for this long because no one theory or intervention is going to address each important dimension. In light of this, the intervention I have presented capitalizes on the strengths and properly addresses the weaknesses of a previous program in hopes of creating a well enhanced program. It involves creative solutions based on the sociological perspective, Social Networking Theory, and Advertising Theory. Even so, it understands that it is dependant on other programs and factors to achieve the positive health outcomes that it seeks.


[i] CDC National Center for Health Statistics. Health E-Stat. NHANES data on the Prevalence of Overweight Among Children and Adolescents: United States, 2003–2004. 28 Mar. 2008.

[ii] Flegal K, Carroll D, Ogden L, Johnson L. (2002) Prevalence trends in obesity among U.S. adults, 1999-2000. JAMA, 288(14), 1723-1727.

[iii] U.S. Department of Health and Human Service (2001). The surgeon generals call to action to prevent and decrease overweight and obesity. Rockville MD: US Department of Health and Human Service, Office of the Surgeon General.

[iv] Becker MH, ed. The health belief model and personal health behavior. Health Educ Monogr. 1974;2:Entire Issue.

[v] Ad Coucil/Healthy Lifestyles and Disease Prevention Media Campaign Report. March 2004

[vi] Edberg M. Essentials of Health Behaviors: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.

[vii] Moffitt T. Adolescence-limited and life-course-persistent antisocial behavior: A developmental taxonomy. Psychology Review. 1993; 100:674-701.

[viii] Christakis NA. Fowler JH. The spread of obesity in a large social network over 32 years. New England Journal of Medicine. 357(4):370-9, 2007 Jul 26.

[ix] Birch LL, Fisher JO. Development of Eating Behaviors Among Children and Adolescents. Pediatrics 1998; 101:539-49.

[x] Whitaker RC, Wright JA, et al. Predicting obesity in young adulthood from childhood and parental obesity. New England Journal of Medicine 1997;337:869.

[xi] Stobbe, M. Critics say ads on obesity lack punch: Call ‘Small Steps’ spot too tame. The Boston Globe. October 23, 2007

[xii] Strauss RS, Rodzilsky D, Burack G, Colin M. Psychosocial correlates of physical activity in health children. Archives of Pediatric and Adolescent Medicine 2001:155:897-902

[xiii] Sothern M, Gordon S. Prevention of obesity in young children. Clinical Pediatrics 2003;42:101.

[xiv] Ward-Begnoche W, Speaker S. Overweight youth: Changing behaviors that are barriers to health. Practical advice for dealing with the family, the child, and socioeconomic environment. Journal of Family Practice 2006; 55(11):957-963.

[xv] Standford Prevention Research Center. Building “Generation Play:” Addressing the crisis of inactivity among America’s children. Stanford, CA. Stanford University School of Medicine, 2007.

[xvi] Ebbeling CB, et al. Childhood obesity: public-health crisis, common sense cure. Lancet. 2002, 360: 473-82.

[xvii] Haas JS, et al. The Association of Race, Socioeconomic Status, and Health Insurance Status With the Prevalence of Overweight Among Children and Adolescents. American Journal of Public Health. 2003; 93: 2105-2110.

[xviii] U.S. Census Bureau. Current Population Survey (CPS). Annual Social and Economic (ASEC) Supplement. Income Distribution Measures, by Definitions of Income: 2006. (INC RD-AEI 1).

[xix] Drewnowski A., Specter SE. Poverty and Obesity: The Role of Energy Density and Energy Costs. American Journal of Clinical Nutrition January 2004; Vol. 79, No. 1, 6-16.

[xx] Stafford, M. et al. Pathways to obesity: Identifying local, modifiable determinants of physical activity and diet. Social Science and Medicine 2007, 65, 1882-1897.

[xxi] Ard, J.D., et al. Informing Cancer Prevention Strategies for African Americans: The Relationship of African American Acculturation to Fruit, Vegetable, and Fat Intake. Journal of Behavioral Medicine, Volume 28, Pages 239-247.

[xxii] Cummins, Steven & Sally Macintyre. Food Environments and Obesity –
Neighborhood or Nation? International Journal of Epidemiology, 2006. 35(1): 100-104

[xxiii] Lumeng, J.C., Appugliese, D., Cabral, H.J., Bradley, R.H., & Zuckerman, B. (2006). Neighborhood safety and overweight status in children. Archives of Pediatric & Adolescent Medicine, 160(1), 25-31.

[xxiv] World Health Organization. Global Strategy On Diet, Physical Activity And Health. 28 Mar. 2008.

[xxv] Duncan MJ, Spence JC, Mummery WK. Perceived environment and physical activity: a meta-analysis of selected environmental characteristics. Int J Behav Nutr Phys Act 2005; 2:11.

[xxvi] U.S. Department of Health and Human Services. Washington, D.C. SmallStep Kids.

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