Ronald McDonald: public health ne'er-do-well, or harmless spokesclown?

Fast food companies are having a rough couple of years. The bad economy took a toll on revenues for almost every major chain. Books like Fast Food Nation and the documentariesSuper Size Me and Food, Inc. have surely been a P.R. nightmare. The recent health reform legislation includes a federal mandate for all chain restaurants to post nutritional information for regular menu items in highly visible spots on the menuboard. (Fun fact: I heard a story on NPR that Starbucks customers had "sticker shock" after learning that their beloved Frappucino had well over 500 calories. In response, Starbucks switched the recipe from whole milk to 2%.)

Rough, right? Well, the hits just keep on coming. Apparently, the advocacy group Corporate Accountability International has called for McDonald's to retire their cartoon spokesclown Ronald McDonald. They say Ronald is a marketing ploy to get kids to eat unhealthy food - and in light of the childhood obesity epidemic, it's unethical for McDonald's to continue to use him to sell Happy Meals. The group held a retirement party in McDonald's homestate of Illinois, and sent "Happy Retirement" cards to McDonald's restaurants all around Chicago.

I wouldn't take this group's efforts too lightly - CAI is kind of a big deal. They're the ones who stomped cigarette spokes-ungulus Joe Camel out of the advertising world. And even though many first believed that a cartoon was harmless, the public ended up siding with CAI's anti-Joe stance. Most now agree that a company that uses a kid-friendly cartoon as a marketing mascot is, intentionally or unintentionally, marketing their products to children. And marketing to children is a real ethical minefield.

So is Ronald McDonald on the same playing field as that malicious dromedary Joe?

Economically, yes. I just read a study that said the national health costs of obesity are about the same as the national health costs of smoking - both hovering around $50 billion per year in medical expenditures.

Magnitudinally, yes. For children between the ages of 2 and 19, 17% are obese. For youth ages 11 to 19, 9% are "established" smokers.

Behaviorally, yes. A recent study published in Nature Neuroscience reports that, like drugs and alcohol and cigarettes, high-fat, high-calorie food is addictive.

When you really think about it, the advocacy group CAI isn't making a real stretch here. Like cigarettes, fast food causes loads of downstream health costs; obesity is much more prevalent than youth smoking; and on top of that, like nicotine, fast food is addictive. Many people say, "One happy meal isn't going to kill you." Well, one cigarette isn't either. It's the fact that people who regularly consume fast food are less able to control their urge to eat (much like people who regularly use cigarettes can't control their urge to smoke). And this is what worries Corporate Accountability International.

McDonald's counters these arguments with two key points. One, Ronald is the spokesperson for the Ronald McDonald House, a very active charity organization. They don't want to lose that branded imagery, which makes sense. Two, they say Ronald is, in fact, an advocate for making good choices and for being physically active and for having good meals with family. (I think this second argument is just one of those things spokespeople say because there's no way to refute this. Yeah, in '05 they "slimmed down" Ronald to say he promotes an active lifestyle. But I'm not sure he could have possibly achieved this on a McDonald's diet alone ... he had to have been cheating on his Big Macs with a Subway sandwich.)

I don't think McDonald's has to send poor Ron off to retirement. I think they just need to use him more as a role model for children to make smart choices - and that means making Happy Meals that are actually nutritious. Apples instead of fries. Grilled chicken sandwiches instead of processed chicken nuggets. Milk - plain milk, not flavored and loaded with sugar - instead of soda. Let Ronald show how much he loves vegetables.

CAI has a point that I think we should make sure McDonald's takes seriously. The analogy between the health effects of the cigarettes Joe Camel peddled and the junk that Ronald sells is hard to deny. Sure, keep Ronald around, but make him serve as a role model for making healthy eating choices. The childhood obesity epidemic is only going to continue to grow if big players like McDonald's don't start thinking creatively about how to change the food environment for consumers and their Happy Mealers.

(Well hey, if nothing else, at least we can sleep soundly knowing that they retired the posse from McDonaldland years ago. I'm not sleeping better because of the lessened threat to childhood obesity - I'm sleeping better because these characters are creeeeepy. *Shudder*)

nudge to eliminate pudge

I just finished the book Nudge: Improving Decisions About Health, Wealth, and Happiness, written by economics professor Richard Thaler and law professor Cass Sunstein, both of the University of Chicago. Lovers of Freakonomics or Blink will definitely appreciate Thaler and Sunstein's look into the field of behavioral economics. In one sentence, Nudge is about why people make the decisions they make and how policy can "nudge" people into making better choices.

I realized that the ideas in this book are the theoretical basis for many disease prevention government public health programs. These programs are attempts to improve "choice architecture" - that is, many public health initiatives attempt to redesign the context in which people make choices about their health behaviors in order to improve the chances that people will make the most healthy choice possible (while still giving people freedom of options).

Here's one of Thaler & Sunstein's examples of "nudges":

"[Nudging] is a relatively weak, soft and nonintrusive type of paternalism because choices are not blocked, fenced off, or significantly burdened. If people want to smoke cigarettes, to eat a lot of candy, to choose an unsuitable health care plan, or to fail to save for retirement, libertarian paternalists will not force them to do otherwise - or even make things hard for them. ... [Libertarian paternalists] are self-consciously attempting to move people in directions that will make their lives better. They nudge." (pg 11-12)

I can't stress enough how great this framework can be for public health professionals. We don't want to force people to make a certain health choice - we want to make it easier for people to make good choices, we want to provide incentives for people to make these types of choices, we want people to have as few barriers as possible. What we don't want to do is penalize those who make "the wrong" choices, because taking away someone's choices to behave as they wish infringes on personal liberties.

How about a more concrete example of public health "nudging"?

Like every other man and woman in America, I absolutely adore Michelle Obama. She's young, beautiful, and smart as hell. And, like many of the First Ladies before her, she has taken a national-level role in promoting a cause: encouraging Americans to improve nutrition and increase physical activity. Last week she spoke at the Grocery Manufacturer's Association, calling for major food manufacturers like ConAgra, Kraft & General Mills to reinvent the products that they sell in grocery stores - especially those products that are marketed toward children.

Michelle is asking these food producers to chance the choice architecture for people who shop in grocery stores and restaurants, especially for parents shopping for their kids. Children are drawn to food that's marketed to them during youth television programming, or that's marketed to them by colorful, cartoon packaging. But the food kids gravitate toward are *overwhelmingly* some of the most unhealthy food in the store. Margo Wootan, of the non-profit Center for Science in the Public Interest in Washington, said, "If companies were marketing bananas and broccoli, we wouldn't be concerned. But most marketing is for sugary cereals, fast food, snack food and candy."

The idea here is that childhood obesity has become such a national epidemic because of the availability and affordability of unhealthy food that children want to eat. Michelle is, first, trying to encourage these manufacturers put less salt, fat and sugar in the food marketed to children. Secondly, Michelle is calling for these companies to make labels less confusing for the average shopper - many foods with the word "healthy" on the box aren't. Hopefully, the changes for which Michelle is advocating will (1) make children want to eat food that's better for them, and (2) make it easier for parents to pick out and purchase the healthy food options.

There's an important but subtle point in all of this. Michelle is not trying to ban unhealthy food. People can still go to the grocery store and buy their kids donuts if they wish. But if healthy food is marketed to children, and parents can easily understand the nutritional value of the food they're purchasing, they just might be persuaded to put the donuts back and buy some fruit instead. No options are being eliminated - certain options are simply being nudged.

From start to finish of the book, I began to look at public health news with these "nudge" concepts. I think this book could be incredibly important for professionals and students in this field, because it made me understand from a theory-based perspective how public health programs should influence behaviors: through conscious structuring of a people's choice architecture to "nudge" them towards healthy decision-making. Loved the book. And I think anyone in a policy role (or aspiring to be in one) should give it a read.

(And a special shoutout to Brian Merry, second-year public health student, who let me borrow Nudge. Sorry about the coffee stains in Part IV ... turbulence + coffee from the flight attendant = minor spillage.)