Emoji-cation and Children as Autonomous Health Managers

The potential of the emoji as an education tool, what I will call more broadly as, is intriguing given the ubiquity of the emoji.
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In 2014 the Bloomberg Administration introduced a New York City Soda Ban that was intended to limit the maximum size of a container for sugary drinks to sixteen ounces. The ban was challenged by the American soft-drinks industry which succeeded in having the measure repealed before enactment. The New York State Court of Appeals ruled that the city's Board of Health exceeded the scope of its regulatory authority by enacting the ban.

At that time I wrote a post, "Portion Distortion: Why the Soda Ban Makes Sense", about why I supported the ban. I referred to an American Journal of Preventive Medicine article, "Ice Cream Illusions: Bowls, Spoons, and Self-Served Portion Sizes," and research conducted by Brian Wansink (Cornell University) and K. Van Ittersum (Georgia Institute of Technology) referring to "portion distortion" occurring in supermarkets, restaurants and homes. Broadly, the research shows that visual information such as the size of a plate or bowl influences your decisions around how much you take and consume. Typically the larger the plate, the larger the serving size and do not forget, what you take you consume -- think about your last time at the buffet line.

Prohibiting or banning things restricts supply and typically adds a punitive consequence to violating the ban but enforcement can be costly and ineffective. Ideally, legislating behavior works because the legislation has legitimacy. The ban is an output of a legitimate process created and introduced lawfully (civil society trusts the process and the authorities), upheld if challenged, people believe in it... and in the best of all worlds it is easy to abide by.

The soda ban limited the serving size to 16 ounces, not the number of servings. The ban would have introduced a point-of-decision at a lower quantity threshold mitigating the "distortion." If the ban were in place, the purchaser had a decision to make, refill when empty or buy two servings straight away. It was not asking you to make a more informed decision; rather it imposed circumstances that pushed the consumer into a "better" decision. (You would not buy two because of the cost and you wouldn't wait around if you could refill your drink.) Arguably it would have affected how school-age children purchase large-serve-sized sodas more than adults in New York City.

A Harvard School of Public Health "sugary drinks fact sheet" notes that:

"In the U.S. two out of three adults and one out of three children in the United States are overweight or obese and the nation spends an estimated $190 billion a year treating obesity-related health conditions. Rising consumption of sugary drinks has been a major contributor to the obesity epidemic. Beverage companies in the U.S. spent roughly $3.2 billion marketing carbonated beverages in 2006, with nearly a half billion dollars of that marketing aimed directly at youth ages 2-17. (7) And each year, youth see hundreds of television ads for sugar-containing drinks. In 2010, for example, preschoolers viewed an average of 213 ads for sugary drinks and energy drinks, while children and teens watched an average of 277 and 406 ads, respectively."

What this says is that the soda industry clearly sees children as central to the purchase decision while public health initiatives often disenfranchise children from the role of decision-makers.

In the public health domain making healthy decisions and consistently repeating those behaviors will determine the success or failure of many health programs. Health programs are typically a blend of awareness, education, intervention and follow-up. Education to inform healthful decision making and embed healthy habits is a key tenet of prevention.

In an article last week by Megan McDonough, "Can Emoji help kids make better food choices?" she writes about efforts to fight child obesity with the child as a key decision maker. This is crucial as the role of children as decision makers/influencers takes on greater importance. The article discusses a 2015 study, "Emolabeling increases healthy food choices among grade school children in a structured grocery aisle setting" . The abstract of the emolabeling study defines "emolabeling is an image-based labeling strategy aimed at addressing this problem by conveying health information using emotional correlates of health using emoticons (happy = healthy; sad = not healthy) ... Hence, adding emolabels was associated with healthier food choices among children, thereby demonstrating one possible strategy to effectively overcome health literacy barriers at these ages." Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

Megan McDonough's Washington Post article describes the study setting. Kindergarten through sixth grade children were instructed on how to interpret two emoji. The first was a happy face which represented healthy and a sad face meaning unhealthy. The children then walked through an area set up to resemble a grocery-store aisle and select four food items. In one aisle, the 12 foods were "emolabeled" with stickers. Smiley yellow faces enticed children to select more nutritious snacks (fruits and vegetables), while frowny faces discouraged kids from choosing high calorie options (chips, cakes and cookies). The other aisle was identical, except that the colorful labels were removed. When emoji were used, 83 percent of students switched one of their food choices to a healthy food option. The results were largely consistent among every grade level.

The potential of the emoji as an education tool, what I will call more broadly as emoji-cation, is intriguing given the ubiquity of the emoji. The possible applications go far beyond public health but for now Greg Privitera, study leader and current research chair at the Center for Behavioral Health Research for the University of Phoenix School of Advanced Studies, hopes that the findings will garner support for a population-based study in the near future.

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