Sunday, December 10, 2006

Phat Marketing: The problem of using current social marketing campaigns to address adolescent obesity in the Kentucky—Amy Dunaway

Russell Simmons is not from the south, but Simmons knows what sells in the south. Baby Phat line of clothing, which includes clothes for adolescents, can be found across shopping malls and on the backs of elementary and middle schoolers from the Mason Dixon to New Orleans. What sells is phat, and phat as an urban appropriation is, quite simply, cool. The Baby Phat clothing line is estimated to generate $302 million in the third quarter of 2006 alone (Skinner 2006).

What adolescents aren't appropriating, however, are better nutrition and more physical activity. While phat may be cool for adolescents, being fat or overweight is a growing concern among public health practitioners, particularly those in the south where high rates of adolescent obesity are concentrated (Annie E. Casey 2006). The problem of adolescent obesity is particularly difficult because as Dr. Ernest Levister told Black Voice News Online, “fat kids will more than likely become fat adults” (BVNO 2006). Obesity in children is defined as having a Body Mass Index (BMI)/age percentile equal to or greater than the 95th percentile (CDC 2006). In order to combat the problem of adolescent obesity, public health officials have been trying to vie for a piece of the marketing pie with a national socially marketed obesity campaign named VERB™.

The Center for Disease Control (CDC 2005a) piloted this campaign in 2001 in eight cities across America (CDC 2005a). The thrust of the VERB™ campaign is to inspire adolescents or tweens, aged 9-13 years, to increase their physical activity (their “verb”) to an hour a day, and to see physical activity as fun. This strategy was developed out of focus groups and formative research. The campaign itself is unique for its decision to pay for media spots rather than rely on public service announcements (PSAs) (CDC 2005b).

Some states hoped to save funds and used the marketing materials of VERB™ and built in their own interventions for adolescents (or tweens). Kentucky is one southern state that has used the VERB™ materials in order to combat its obesity problem in children, and if any verb were to describe the obesity problem in Kentucky, explode would be it.

The latest figures from the KIDSCOUNT report from the Annie E. Casey Foundation ranks Kentucky as having the highest rate of child obesity in the nation, at 38 percent (based on children aged 10-17 years old) (Annie E. Casey Foundation 2006). Such a ranking speaks to the urgency for adolescent obesity interventions.

Interventions, however, have many barriers, and in the rural and inner city areas of Kentucky, key barriers include few transportation options, cultural norms such as stoicism and shrinking state funds (Samuels 2004). Just over half the population of Kentucky lives in urban areas; the remainder is classified at 43% living in rural areas (ibid). All of the rural areas of Kentucky have obesity rates above the national average (ibid).

In light of the growing adolescent obesity problem in Kentucky, the state partnership led by the Lexington Tweens Nutrition and Fitness Coalition (Spence 2006), recruited local teens to serve on the Youth Board to help make program decisions, and conducted formative research with parents and tweens in the state (CDC 2005b). Armed with input and suggestions, the coalition instituted their own program based on VERB™ in Lexington/Fayette County: the Summer Scorecard (ibid).

Tweens used the scorecard over the summer in 2005, and similar to summer reading initiatives, kids who were active could have their cards stamped by sponsoring organizations and parents, earning points to free or low-cost activities such as swimming and skating venues (CDC 2005b). The focal point of the summer campaign was “The Longest Day of Play,” an event that was first held in 2005 and had over 1000 attendees participating in various physical activities (ibid).

Targeting is not tailoring

Championing the scorecard in Kentucky, the CDC states that the coalition leading the initiative tailored the VERB™ materials to the Lexington/Fayette County community. While tailored and targeted may seem to be synonymous and are often used as such, there remains a significant difference between the two. Targeted communication vehicles are designed to “reach some specific subgroup of the general population, usually based on a set of demographic characteristics shared by its members” (Kreuter et al. 2000). On the other hand, true interventions that are tailored apply to the individual, and use various data on subgroups and incorporate behavioral patterns (ibid). Both the use of personalized assessments and how individualized the communication vehicle is make any communication strategy truly tailored to an individual (ibid).

Simply changing contact information to a local address is not tailoring. The CDC also suggests that the tailored Kentucky program will be expanded to other areas around the state and possibly to other states (CDC 2005b). However, scaling up the Kentucky program for tailoring necessitates both the planning and investigating through formative research. While it is a southern state, Kentucky has many different constituencies, such as a significant migrant-labor population and a growing minority population (Samuels 2004). Part of the formative research worth investigating is determining how many adolescents in the campaign areas have access to the Internet or use cell phones. This information would aid in deciding how health communicators can make truly tailored programs for adolescents and their families. Perhaps tailored VERB™ programs that tie into a school’s sports teams and discusses a student’s difficulty with weaning herself from soda pop might be more relevant options.

Additionally, formative research for tailoring would also tease out the consideration of secondary audiences and influences. While the VERB™ campaign is a readily available packaged program, states adopting this social marketing framework would be well served to also consider making advocacy part of the VERB™ “product”. For instance, while the verb or physical activity that adolescents perform is the “product”, an additional component of the verb product can be directed to parents, teachers, church leaders and other community decision makers to not only make physical activity a part of their lives, but to act in the best interest for the children of the state. A meaningful and immediate way to create change is at the state political level, and educating parents about their own interest in continued funding for VERB™ or to lobby for a trans-fat ban in school lunches is crucial. After all, obesity is more than a 12 year-old eating too many Twinkies, and the ideal program would address issues of socio-economic status (SES), structural inequities, and budgetary restraints from a holistic perspective. Thus advocacy for better policies would have to be integrated into that perspective, and developing strategies for tailored approaches to advocacy behavioral changes are in order.

Another instance where the issue of funding and tailoring may marry is in changing or creating new print pieces of well-known athletes. In the CDC’s print pieces featuring Venus Williams, Williams is featured as a great role model for girls, which she undoubtedly is; however, basketball is far more popular than tennis in Kentucky. Using Kentucky’s own “Phat 5”, male and female college basketball teams (Vaughan 2006) might be a better tie-in for the tailored Kentucky campaign, since the popularity of basketball and University of Kentucky players could help reinforce the need for regular exercise and eating healthily. Planners could strengthen their scorecard program by hosting a “Phat Wildcats” showdown, having kids play with the UK players, instead of just hosting a meet and greet with the tweens, as was done during the finale summer scorecard event (CDC 2005b). This incongruency may be an opportunity where the image of “phat” might be addressed in a more targeted manner.

Ultimately, thinking about how to better tailor all messages to tweens and who are the key influences around them are areas in which the Kentucky program can improve.

Put the theory into practice

Any good health intervention usually has one or more behavioral theories to guide the course of a campaign, and the theories from the Kentucky intervention named two: Stages of Change and Social Cognitive theories.

These theories are fine on paper but in practice are questionable. For instance, the Stages of Change Theory incorporates five components of social behavior: 1. pre-contemplation, 2. contemplation decision/determination 4. action and 5. maintenance and tries to account for a person’s changing commitment to a behavior change (Family Health International 2002). A behavior change itself is regarded as positive, but maintaining the behavior change is where the truth of a program’s effectiveness comes to light.

While the summer scorecard campaign of Kentucky’s VERB™ intervention addressed the first four components through formative research and selling physical activity as fun (note the emphasis is not on the word “exercise”), the issue of behavior maintenance requires a longer commitment—at least six months in order for an individual to be successful with a behavior change (Family Health International 2002). A summer of play is great, but what happens to a tween in January when the weather is cold and a Happy Meal is cheaper for her family than buying fresh produce at the grocery store that’s a half hour away? Maintaining a health behavior change in conjunction with tailored messages can reinforce the changes or attitudes a tween or his family has already made.

The main criticism of the campaigns (both national and in Kentucky) is that program designers may have inadvertently lost key collaborators in schools, homes, communities and particularly for the South, churches. This criticism may call for the use of the Community Organization Theory (US Department of Health & Human Services 2004). Such a theory incorporates perspectives from the beginning that call for communities to be part of the assessment of the problem, defining the cultural norms and barriers to healthy behaviors, and identifying possible solutions for execution. This perspective often also aids in encouraging groups typically marginalized, such as African Americans and other minorities, and giving them a place at the decision making table (ibid). This act of leveling can be a huge step for communities such as those in the south where racial, religious and sexual orientation issues still very much divide people. For example, a success of EPA regulation of environmental contaminants and the creation of Superfund legislation for the costs for environmental cleanup in affected areas, derived from a momentum created by a group of parents and community members in Woburn, Massachusetts who organized together to find out why leukemia was more prevalent in Woburn children. The community group organized under the name FACE (For A Cleaner Environment), and worked with scientists and public health professionals to determine the link between trichloroethylene (TCE) contamination and disease, and what needed to be done to clean up their community (Maxwell 2006). While parents in Kentucky may not see obesity as gravely as childhood leukemia, public health practitioners could show evidence of obesity-related health and economic problems to community leaders and parents, in order to emphasize the importance of obesity prevention.

Public health practitioners and campaign planners should also remember one of the key ideas surrounding brand retention: building a long-term relationship. William J. McEwen, a former account manager for many well-know advertising firms, reinforces this key in his book, Married to the Brand. McEwen states that brand campaigns often “focus instead on registering a brand name…creating awareness of its advertising, producing attractive packaging, and developing intriguing promises…In short, there’s nothing to connect with;” what marketers need to refine and sell is a relationship (McEwen, 2005). This point fits well into the larger picture of Community Organization Theory and laying the foundation for long-term relationships of support for lasting behavior change.

If the Kentucky program expands within the state or is adopted by others, local community needs assessments would be beneficial before branching the Lexington VERB™ campaign out into the rural areas. Such assessments could also glean more information about risk factors that may be associated with adolescents who are obese or are at-risk of becoming so. Factors surrounding community and family issues are also important to consider, as adolescents who live in the eastern side of Kentucky are at much higher risks for becoming obese versus their counterparts who live in the western half of the state (Samuels 2004). Data on the nutritional options to tweens and their families would be helpful here as well, particularly since the southern diet of fried foods and heavy sauces can easily cancel out an hour’s worth of physical activity.

Diversifying the funding stream

Success of the national VERB™ campaign was measured by overall awareness of the campaign and after the first year, children aged 9-10 years old participated in more unorganized sessions of physical activity than those children who had no knowledge of the campaign (Huhman 2005). However, among 11-13 year olds there was no difference between those exposed to the campaign and those not (ibid).

Despite the early data showing the success of the campaign, national VERB™ funding was cut for fiscal year ’06, and the radio and television ads have ended. The CDC intends to keep the web site ( up for another year; however, few know what will happen after that time (Parker-Hope 2006). The Kentucky summer scorecard initiative was funded through a 2003 grant from the CDC (CDC 2005b) and will likely need alternative funding streams to continue.

As mentioned previously, part of the problem was that the campaign targeted children and did not include their parents, which perhaps if the program design were altered would have helped in lobbying Congress to keep the funding for the program (Parker-Hope 2006). When adults have wide brand recognition of the campaign and see the benefits to their children and families, they are more likely to respond to a cue to action such as a notice about the demise of program funding, and write letters or call their legislators in order to preserve the program.

In regard to cost cutting, a significant portion of the cost of the campaign was the price for placing print and television ads (Bauman 2004). On the local level these costs would break the program budget. Partnering with the state teacher’s association, school districts and parent-teachers’ association could be one alternative to paying high placement costs—placing announcements about the scorecard program in church bulletins, local shopping centers and laundromats where low-income families may frequent may also be others.

Additionally, while better strategies to deliver targeted messages can be developed out of Laundromats, use of the Community Organization Theory can further foster more effective message diffusion. Community groups once involved are more likely to tell their families and friends about events that they personally are invested in and want to see succeed (US Department of Health & Human Services 2004). Again, the concerned parents of Woburn are just one example of community members who networked together to raise awareness of TCE contamination and were a powerful force to leverage federal funding for the environmental cleanup (Maxwell 2006). That community investment cannot be easily bought through traditional mass media strategies, and likely saves significant program funds.

However, local grassroots efforts need more momentum within America’s consumer-driven society, and public health practitioners should seriously consider culling sponsorships to offset costs not covered by unpredictable government funding. Although questionable to some, it would be worth considering program sponsorship with firms like Dove, whose Campaign for Real Beauty would be a better fit than say Coca-Cola. The Dove selling point that all girls are beautiful could be helpful in fighting the stigma of being overweight that many girls feel. Such a stigma has led to reluctance to join sports activities and greater sedentary habits (NASSO/The Obesity Society 2006).

Furthermore, South Carolina created a behavior change program, Lighten Up Forever, to combat obesity that was housed out of churches, and members of the program were supported by parish nurses, recipes, body mass index monitoring, spiritual readings and health conferences and support groups (Egan, n.d.). In Kentucky where just under half of the population are religiously affiliated with the Southern Baptist Convention, it would be important to engage this population segment (KY Council of Churches 2000).


Ultimately, VERB™ may be the best socially marketed obesity campaign to target adolescents yet executed. In order to apply this campaign to the south, several key adjustments need to be made, including tailoring the program to adolescents specifically (in addition to current targeted efforts), developing strategies for all of the components of the Stages of Change and Community Organization models, and opening the campaign up to adult stakeholders, such as parents and teachers. Finally, with a commitment to fund an intervention such as this, a state could achieve better health outcomes for adolescents, making phat meaningful to only t-shirt marketers as the lingo for kids of urban cool.


Annie E. Casey Foundation, 2006. ‘KIDSCOUNT State-level data online State Differences in Rates of Overweight or Obese Youth.’ Available at: . Accessed November 12, 2006.

Bauman, A 2004. ‘Commentary on the VERB™ campaign — perspectives on social marketing to encourage physical activity among youth’, Prev Chronic Dis, July 2004, pp.1-3. Available from: Accessed October 20, 2006/

Center for Disease Control and Prevention, 2005a, ‘VERB Campaign Overview,’ Available at: Accessed November 12, 2006.

Centers for Disease Control and Prevention, 2005b, ‘CDC Case Study: Kentucky. Kentucky adapts national media campaign to influence tweens’ physical activity.’ Available at: Accessed October 11, 2006.

Centers for Disease Control and Prevention, 2006, ‘BMI — Body Mass Index: About BMI for Children and Teens,’ Available at: Accessed November 12, 2006.

Egan, Brent, n.d., ‘The Healthy South Carolina Initiative: A Church Based Approach to Lifestyle Change,’ n.d. Available at: Accessed November 12, 2006.

Family Health International, 2002, ‘Behavior Change — A Summary of Four Major Theories,’ January 2002, Available at: Accessed October 11, 2006.

Huhman, Marian, Potter, Lance D., Wong, Faye L., Banspach, Stephen, Duke, Jennifer C., Heitzler, Carrie D, 2005, ‘Effects of a Mass Media Campaign to Increase Physical Activity Among Children: Year-1 Results of the VERB Campaign,’ Pediatrics, 2005, vol. 116, no. 2, pp.277-284. Available at:
Accessed October 12, 2006.

Kentucky Council of Churches, 2000, ‘What Religious Groups are the Largest in Kentucky, 2000, Available at: Accessed November 13, 2006.

Kreuter, Matthew, Farrell, David, Olevitch, Laura, Brennan, Laura, 2000. Tailoring Health Messages: Customizing Communication with Computer Technology 2000, Lawrence Erlbaum Assoc. pp.4-6.

Maxwell, Nancy, 2006. Environmental Health Lecture slides. February 14-28, 2006.

NASSO/The Obesity Society, 2006, ‘Obesity, Bias and Stigmatization.’ Available at: Accessed November 13, 2006.

Parker-Hope, Tara, 2006, ‘Passing the Ball: Hip Campaign That Got Kids to Be Active Looks for Its Next Move,’ Wall Street Journal September 5, 2006. Available at: Accessed November 12, 2006.

Samuels, Michael E., Whitler, Elmer, 2004, ‘Health Disparities and Inequities in Kentucky,’ Presentation September 13, 2004 Northern Kentucky Convention Center
Covington, Kentucky. Available online at: Accessed October 11, 2006.

Spence, Carol, 2006, ‘Active Kids Take 'Lazy' Out of Summer's 'Lazy Days',’ University of Kentucky College of Agriculture Agricultural Communications News and Information. Available at: Accessed November 12, 2006.

US Department of Health & Human Services, National Institutes of Health, National Cancer Institute, 2004, Making Health Communication Programs Work.
NIH Publication No. 04-5145, August 2004, pp.225-226.

Vaughan , Derrick E., 2006, ‘The 'Glory Road' For Texas Western's 1966 Championship Run Over Kansas, Duke, and Kentucky Increases Historical Impact says,,’ Black Athlete Sports Wire, Jan 15, 2006. Available at: Accessed November 12, 2006.


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I found your article to be quite enlightening! I especially thought it was clever how you incorporated the idea of "phat" clothing and America's "fat" problem. Thank you for addressing these concerns.

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