Consider the following:
1) In its peak year, the primary U.S. government nutrition education program (called 5 a Day) was given $3 million for promotion. The food industry spends one thousand times that much to advertise fast foods, just to children.
2) The most recognized corporate logo in China, aside from those of Chinese companies, is KFC’s.
3) Ronald McDonald is the second most recognized figure in the world, next to Santa Claus.
4) Creating major news in September of 2002, McDonald’s announced that by February 2003 it would change the oil used for its fried products to decrease (but not eliminate) trans fats. McDonald’s President Mike Roberts spoke of a “healthier nutrition profile” in heralding the company’s concern for public health, and the CEO lauded his company for being a “leader in social responsibility.” In February of 2003, the company quietly announced a change in plans (there would be a “delay”). The delay is still in effect.
5) Kraft Foods announced in 2003 it would cut portion sizes of some products to “help arrest the rise in obesity.” Less than a year later, Kraft announced this plan had been scrapped.
6) Promoters to the juvenile market have declared the cell phone their next horizon, noting that tens of millions of children power up a cell phone at the same time each day (after school). Satellite technology allows marketers to know a child’s precise location, and enables them to beam advertisements, coupons, and directions to nearby eating establishments.
7) The Food Guide Pyramid created by the U.S. Department of Agriculture (USDA) recommends that meat, poultry, fish, and eggs comprise 14 percent of the diet, yet 52 percent of USDA food-promotion resources are allocated to these foods. The pyramid recommends 33 percent of the diet from fruits and vegetables, but they receive 5 percent of the USDA budget. The meat and dairy industries “outlobby” the fruit and vegetable sectors by orders of magnitude.
This list could include thousands more. Stampeding technology, corporate interests, authorities caught unaware, and the market stigmatization of overweight people (which emphasizes personal over corporate responsibility) have created an environment that guarantees poor diet, physical inactivity, and obesity. The world now faces a crisis of overfeeding.
Until recently, a book on feeding the future would have focused solely on the need to feed the world’s population. Without a doubt, hunger is still a major issue, but it will soon be surpassed in many countries by overconsumption as the leading public health nutrition issue. In countries not traditionally considered prone to obesity, such as Mexico, Brazil, Morocco, Thailand, and China, hunger and obesity coexist. The World Health Organization (WHO) has declared obesity a global epidemic, increasing in every country throughout the world.
Words like “crisis,” “epidemic,” and “global emergency” used to describe a public health problem evoke a predictable backlash of blame on those affected by obesity. Such has been the case with AIDS, tobacco, drug abuse, and other problems. Business interests are commonly pitted against public health, and there are calls for change focusing either on the individual or broad social factors. Food must now be considered in a similar light.
The world faces important questions about what and how we eat. Who is responsible for increasing rates of obesity? What are the causes? What are the relative contributions of poor diet and physical inactivity? Can the food industry be trusted? Must children be protected from a “toxic” environment? What must change?
In this chapter I focus on the causes and consequences of overfeeding the world, and, most importantly, on some solutions.
The most visible consequence of poor diet and physical inactivity, obesity involves a cascade of other medical, social, and psychological issues. The explosion of media coverage has brought attention to this significant problem, but its downside implies that obesity is the only consequence of modern living. In fact, poor diet and sedentary lifestyle are risk factors for many major chronic diseases independent of a person’s weight. For example, children in affluent countries frequently show detectable signs of heart disease, regardless of weight.1 For the first time in North American history, experts have asked whether children will lead shorter lives than their parents.
Throughout the 1980s and 1990s, paper after paper in the scientific literature showed that obesity is increasing around the world. Rates are burgeoning in industrialized countries (the U.S.A., Canada, Britain, Australia, and so on), in particularly wealthy countries such as Saudi Arabia, but also in little-known island nations and developing counties. Clinics for the treatment of obese children opened in Beijing, where only decades ago malnutrition was the most serious problem.
In 1998, the WHO released a report declaring obesity a global epidemic. Since then, the organization has been at the forefront in raising global awareness, documenting rising weights in country after country and highlighting the associated disease burden.2 The WHO has also proposed proactive solutions, as we will see later.3
Related to many of the leading causes of death, obesity is also involved in problems such as sleep disturbance, pain, and arthritis that can affect quality of life (see Table 1). The risk of coronary heart disease increases nearly 60 percent in men and 179 percent in women, and risk for diabetes increases five-fold for men and eight-fold in women as weight increases from normal to very obese. The poor diet and inactivity causing obesity contribute independently to many of the same outcomes. Rand Corporation economist Roland Sturm has shown that obesity’s health effects now surpass those of smoking, and that it carries the same risk as aging two decades.4
Since poor diet and inactivity can affect health, they are likely to have other powerful impacts. Lost productivity, a less alert work force, and declining school grades are some. It is well documented that poor diet affects cognitive and intellectual performance in undernourished children, and the same could well occur in the case of overnutrition.
Researchers estimate obesity-related health care costs in the U.S.A. alone to be $75 billion, with taxpayers financing about half these costs through Medicare and Medicaid.5 In a study of 200,000 employees of General Motors, researchers estimated that obese individuals incur up to $1,500 more in health care costs per year compared to normal-weight peers.6
Obese individuals incur severe social stigmas. They include a phalanx of negative characteristics such as laziness and lack of motivation, and also charges of core personality and integrity defects (being stupid, dishonest, dirty, and more). An imperfect body reflects an imperfect personality, so the thinking goes, hence bias and discrimination can be justified by the old adage that people get what they deserve and deserve what they get. These attributions result from cultural norms in which obesity is repulsive, that link social status with physical attractiveness, and construct weight as a matter of personal control. Research clearly shows that overweight people are targets of discrimination in areas central to health and happiness (employment, housing, income, and health care).8
Given the prevalence of obesity, it is natural to ask whether a more overweight population would lead to less bias. In a 1961 study, a group of researchers showed children line-drawings of children who were obese or had a variety of physical disfigurements.9 The majority ranked the obese child as the one they would least like to have as a friend. Latner and Stunkard repeated the study (in 2003) and found even stronger bias against the overweight child.10 Weight stigma is very difficult to shake.
If bias and discrimination affect the happiness and well-being of stigmatized groups, they affect health. The experience of bias may affect health directly, say, by influencing risk factors such as blood pressure, lipids, or immune function. Bias can also exert influence through psychological factors (such as vulnerability to depression), which in turn influence health or it can alter a person’s experience with the health care system. There are studies showing that overweight individuals are less likely to obtain preventive care, perhaps due to shame from interacting with providers and fear of negative comments.
Combining the more and less obvious consequences of unhealthy eating with sedentary lifestyle and obesity, we see problems that cannot be ignored. Tremendous human suffering is occurring. Young adults in their twenties and thirties now suffer from complications of Type 2 diabetes (formerly called adult onset diabetes), which begins before the age of ten. Some are blind, some have limbs amputated, and some have died.
In other words, overfeeding the world is a crisis by any standard — one that demands aggressive, innovative action. How to take action depends in great part on how nations construe the causes.
The world is increasingly exposed to what I have labelled a “toxic environment,” in which food and agriculture companies produce too many calories, particularly in meat and highly processed foods. Food has become artificially inexpensive and is engineered to maximize taste. Reasonable at first glance, this exacts a tragic price on both health and the environment. The U.S.A., Canada, Britain, and Australia exemplify these negative conditions, but nearly every country is following suit.
Eating is influenced by a number of factors, the most powerful being accessibility, convenience, promotion, taste, and cost (see Table 2). Each has been distorted in ways that encourage unhealthy eating.
It is standard to say that obesity has multiple causes — to cite biology, psychology, and the environment as contributors. This explains everything and nothing at the same time. Of course obesity has multiple causes — everything does, but not all causes are equal. Much depends on whether we look for causes in individuals or in larger groups like a country or even the world.
Conceptualizing the cause of obesity for an individual necessitates understanding a variety of factors, including biology, a person’s upbringing, psychology, and socio-economic status. But when one looks to population increases in obesity, we ask, for example, why Japan has more obesity this year than last, why some nations are heavier than others, why an entire population is vulnerable to changing diets, and what might be done to reduce the problem. From this point of view, there is a clear explanation for rampant obesity — the environment has become fattening or “obesigenic.”
Because so many people are overweight, we can infer that most individuals have a “willing” biological profile that fosters high energy intake and the efficient storage of energy as body fat. The environment, however, causes energy intake to rise and calorific expenditure to decline. High levels of obesity in developed countries, and low levels in poor countries, cannot be explained by population genetics, particularly considering studies documenting weight gain as a predictable consequence of moving from a country with little obesity to another with more.
In the absence of a fattening environment, few people will become overweight. Obesity occurs as the environment promotes unhealthy eating and inactivity. The cause is the environment, and the environment in a growing number of countries is an ideal recipe for fattening the population.
Barry Popkin and his colleagues have done the most careful and extensive work on the “nutrition transition” that occurs as nations modernize.12 He and colleagues define five patterns that characterize this transition:
Pattern 1: Collecting Food. Food comes from hunting and gathering. The diet is high in carbohydrates and fibre and low in fat. Activity levels are high and there is little obesity.
Pattern 2: Famine. Diet is less varied, scarcity occurs, and malnutrition is common. Obesity is rare.
Pattern 3: Receding Famine. Consumption of fruit, vegetables, and animal protein increases, as do inactivity and leisure time.
Pattern 4: Nutrition-Related Non-Communicable Disease. The diet is high in fat, cholesterol, sugar and other refined carbohydrates, and low in polyunsaturated fat and fibre. Sedentary behaviour increases. Obesity increases as does chronic disease.
Pattern 5: Behavioural Change. The desire to prevent disease leads to changes in diet and physical activity, sometimes self-driven by consumers and other times stimulated by government action.
Popkin notes that many countries are in Patterns 3 and 4. Developing nations in particular are transitioning from receding famine to energy-dense diets and declining physical activity. A good example is China, where in the 1970s 10 percent of calories came from fat. Now one-third of families eat a diet with more than 30 percent of calories from fat, the number of televisions has risen dramatically, and the number of jobs requiring physical labour is decreasing. Popkin notes that in countries like China, with rapid advances from food shortages to a healthier diet, the line is quickly crossed where eating too much, and corresponding weight gain, become key concerns.13
As you might expect, supporting the growing calorie-needs of a world gaining weight requires more food. This issue is particularly acute when one considers that highly processed foods and certain meats are particularly resource intensive. To get the staggering amounts of cheap food the world consumes, the food system must be structured for mass production. To fully understand the obesity crisis, one must look at how food is produced. This is what Michael Pollan did in an important article published in 2002.14
Pollan, a well-known food and agriculture writer, bought a cow that was raised for beef. He followed the cow from farm to fork, in order to document exactly this part of the food chain. Pollan considered the amount of energy used to raise the cow, compared to the energy the cow would later introduce into the food supply. One analysis is that fully 283 gallons (1,071 litres) of oil are used to bring a 1,250-pound (570-kilogram) steer to your table.
Most of us are not aware of the considerable energy from fossil fuels required to create hamburger or steak. Energy is needed to produce the fertilizers and pesticides applied to feed-grain and corn; for the hormones injected into the cow to optimize its growth; to truck the meat to distant markets, and to keep it refrigerated. Also relevant is the environmental damage (such as the 12,000-square-mile (31,000-square-kilometre) “dead zone” in the Gulf of Mexico from nitrogen and pesticide runoff into the Mississippi River), pollution created from shipping, and depletion of the world’s energy supplies. In Pollan’s words, “We have succeeded in industrializing the beef calf, transforming what was once a solar-powered ruminant into the very last thing we need: another fossil-fuel machine.”
The energy quotient of Pollan’s cow can be supported by many different examples. An estimated 2,200 kcal of energy are needed to produce a 1-kcal can of Diet Coke. In parts of India, public outcry has denied water licences to Coca Cola and Pepsi, where they have significantly affected groundwater resources to the point of producing shortages for local residents.15 Table 3 shows estimates of the environmental impact of food production.
One could argue that overconsumption occurs where food and agriculture industries exploit the environment to maximize production, and governments fail to intervene.
Food subsidies are another little-known factor allowing high consumption at low consumer-cost. Raising the 1,250-pound steer requires a great deal of feed, and most cattle in North America are raised on grain and then on corn. Corn can be an expensive crop, but the U.S. government subsidizes the farmers, making certain the price of corn remains artificially low, which in turn allows the fast food restaurant to sell you a “supersized” beef patty for a startlingly low price. And then what happens? Consumption of beef and similar products escalates.
The same dynamic helps sell soft drinks. Many soft drinks are sweetened with high fructose corn syrup, which again comes from subsidized corn crops. It costs companies like Coca-Cola and Pepsi little to sweeten a litre of water and sell it for a few dollars. This allows companies to increase portions at virtually no cost, again making overconsumption more likely.
Table 2 shows so much the reverse of what is needed that one could say the food system is totally backward.
Unhealthy food is ubiquitous. The proliferation of vending machines, fast-food restaurants, convenience stores, and eating opportunities in gas stations, shopping malls, and drug stores, makes food everywhere available around the clock. Long gone are school days when children ate only during lunch periods, when highway rest stops were not oriented around fast food, and when snacks were not designed for automobile cup-holders. High-calorie foods are available from drive-through windows, in microwaveable containers, and carry-out packages. Hurried lifestyles increase the value of convenience, particularly for second-income families. Unhealthy foods far outnumber healthy foods.
Most troubling is the massive promotion of unhealthy foods directed at children. The typical American child sees 10,000 TV advertisements per year, mostly for soft drinks, fast foods, candy, sugared cereals, and snack foods. Children at all ages (even very young children) are affected in ways that health experts deplore — hence the repeated, and repeatedly ignored, calls for regulation.17 Leading sports stars, cartoon characters, and music celebrities continue to promote unhealthy foods.
Product placements in movies and video games, virtual product placements in reruns of television shows, television food promotions in schools (for example, Channel One, the education channel, now runs in 12,000 U.S. schools), vending machines in schools (which lend themselves to advertising), all these — and more — add to the commercial bombardment. Children receive a great deal of nutritional “instruction,” most of it delivered by a food industry that has strong incentives to maximize children’s consumption of unhealthy foods.
Taste is a key determinant of human eating. In general, foods high in sugar, fat, or both, taste good. Such foods tend to thwart any regulatory system the body may have, so that weight gain occurs. Our ancestors ate as much energy-dense foods as they could. Their dietary pattern enabled them both to survive periods of scarcity and thus contribute to the gene pool. This once-adaptive tendency is now mismatched to modern conditions of abundance.
Cost is another important cause of obesity, especially for poorer individuals. Studies show that a market basket of healthy foods costs more than a basket of unhealthy foods. People in some neighbourhoods do not have access to supermarkets, and therefore pay a premium in small markets, even in the rare cases when the markets carry items like fresh fruits and vegetables.
Consider pricing incentives. Fast-food restaurants have package (“value-added”) meals that offer the customer more when foods are grouped together. Larger or “supersized” drinks and fries are retailed at an apparently slighter additional cost. The concept of more product for less money isn’t inherently bad, but it is applied almost exclusively to unhealthy foods. If one buys six oranges rather than three, the price per orange does not decline.
Pricing incentives for larger portion sizes create a real problem. Value can be added to the consumer by offering the same amount of food for a lower price, or by increasing the amount for smaller price increases. The latter approach maximizes producer profits. Big portions, highly desirable for the industry, redefine a reasonable serving. The current small serving of fries at fast-food restaurants was once the large size; soft drinks, once in 8-oz. (237-ml) bottles, are now in 12-oz. (355-ml) and 20-oz. (591-ml) servings; and a muffin, once the size of a baseball, is now softball size.
Paul Rozin and others have made a cultural comparison of serving sizes in the United States and France.18 The French serve smaller portions of attractively presented and nicely prepared foods than Americans. French meals (even at fast-food restaurants) are eaten slowly, and their amount is not enough for leftovers. (The “doggie bag” is unknown in much of the world.)
Research by Barbara Rolls and others shows that people served more food eat more.19 Consumers are drawn to large portions, and the food industry exploits this by attaching words like “super,” “mega,” and “extreme” to their foods. Thus the same hype plays out over and over: the consumer who buys more food, consumes more. And the companies maximize profits from selling larger portions. A fast-food patron may happily pay 39 cents to “upsize” to the largest size of fries and drink, and the bargain is struck. The incremental cost to the company is small, and it also seems minimal to the consumer. But excessive calorific intake can be the consequence.
These powerful and unrelenting factors encourage unhealthy eating. It occurs partly because of the food industry’s marketing practices, which are woven into economics, technology, and the fabric of modern life. To identify the threads, to reverse the troubling situation we now face, which has already had a profound global impact, environmentally and individually, will require nothing short of aggressive action.
In Food Politics, Marion Nestle documents how profoundly the food industry has influenced legislation, regulation, and public policy related to nutrition.20 Her examples include the industry’s undue influence in establishing the U.S. Food Guide Pyramid, and in blocking attempts to regulate food advertising directed at children. Food and agriculture companies demand that governments act in their interest, and that politicians grant their wishes.21 Nonetheless, agribusiness claims it can be trusted, and that the obesity problem will not be solved without industry involvement. The language of cooperation and “involvement of stakeholders” is used to justify this stance.
The food industry is no monolith. Generalizations cannot apply to all players. Organic tomato growers, supermarkets now specializing in organic, natural, “whole” foods, Girl Scouts selling cookies — these are part of its diversity. But the industry does include massive companies like Kraft (large enough to own Nabisco), McDonald’s, PepsiCo (large enough to own Frito-Lay), and Coca-Cola. To complicate matters, companies that sell unhealthy products nearly always sell healthier ones as well, so it can be difficult to separate the good from the bad. McDonald’s, for example, has yogurt and salads on its menu. Yet, as we have seen, it has indefinitely delayed in coming through on its promise to change cooking oils. And it has a massive budget to promote energy-dense foods to children.
Some food companies devote considerable resources to publicizing healthier new products, hoping perhaps to escape the tidal wave of unhealthy food marketing. Creating the appearance of corporate social responsibility is now a priority, but whether appearance is matched by substance is yet to be determined. As the food industry faces new challenges, we can revisit important lessons learned from the deadly history of another industry, tobacco.
Tobacco companies asked for the same privileges food companies now demand, namely, that their promotions be taken at face value. Tobacco companies, like the food industry, claimed concern for public health, pledged cooperation with the government and health authorities, introduced filtered cigarettes they claimed were better for consumers, and assured the public they had the best interests of children at heart. These tactics were accepted by government authorities for years, with tragic consequences. The food industry, which also asks to be trusted, makes many of the same arguments as did tobacco companies almost to the word.
In A Question of Intent, David Kessler, former Commissioner of the U.S. Food and Drug Administration, wrote “Devised in the 1950s and ’60s, the tobacco industry’s strategy was embodied in a script written by the lawyers. Every tobacco company executive in the public eye was told to learn the script backwards and forwards, no deviation was allowed. The basic premise was simple — smoking had not been proved to cause cancer. Not proven, not proven, not proven — this would be stated insistently and repeatedly. Inject a thin wedge of doubt, create controversy, never deviate from the prepared line. It was a simple plan and it worked.”22 The script was written and performed by lobbyists, public relations firms hired by the industry, scientists paid by the industry, members of Congress financed by the industry, the main industry trade association (Tobacco Institute), and of course company executives themselves.
How does the food business resemble tobacco? In a paper I wrote with Kenneth Warner, examining tobacco and food industry responses to health crises, we noted striking similarities in the scripts (playbook) used by the food and tobacco industries to still public concern and stall or prevent policies that would hurt business.23 The fact the food industry has a script is indisputable. Trade associations, some of the same public relations and advertising agencies formerly used by tobacco, scientists funded by the industry, and of course company spokespersons — all have their parts in the playbook. The key features are as follows:
• Introduce products perceived to be healthier.
• Publicize corporate social responsibility.
• Fund programs focusing on physical activity.
• Claim that lack of personal responsibility is at the heart of the population’s unhealthy diet.
• Plead that personal freedom is at stake, hence government should not contemplate regulation or legislation.
• Vilify critics with totalitarian language, characterizing them as the food police, leaders of a nanny state, even “food fascists,” and accuse them of desires to strip people of civil liberties.
• Emphasize physical activity over diet.
• State there are no good or bad foods, hence no food or food type (soft drinks, fast foods, and so on) should be targeted for change.
• Dispute the science to plant doubt.
The first three items in the playbook may have positive consequences, but vigilance is in order. The industry often introduces products that are made to sound healthy. Examples are snacks and drinks with “fruit” in the name. Cynicism about corporate social responsibility is also natural, given the tobacco experience. In 2000, Philip Morris spent $115 million on social causes such as the arts, helping flood victims, and supporting shelters for abuse victims. The company spent $150 million publicizing these acts. The remaining six parts of the script are likely to have negative consequences.
The food industry notes that food is different from tobacco, in that people have to eat. Hence, the argument goes, big food can profit as much if people eat healthier foods. In their attempts to alleviate controversy, industry insiders argue that we are all on the same side. This argument can be challenged on several grounds. A move by the public toward healthier foods means lower sales of foods with high profit margins (highly processed convenience foods). But the stark reality is more important: the only way the population can lose weight is if food intake goes down (and activity increases), hence less food must be sold overall. This places the industry squarely at odds with public health priorities.
Given these factors, the world must assess whether food companies can be trusted. It must also decide whether the industry should be included or excluded from policy decisions. But there are other ways of establishing an industry’s trustworthiness. One is to examine the use or misuse of science.
A robust literature currently exists on the impact of food advertising directed at children. In the U.S.A. alone, children under twelve spend $35 billion a year on their own, and influence another $200 billion of household spending.24 A number of scientists and authoritative organizations have examined the available science, reaching a remarkable consensus.
For example, the World Health Organization concludes that “. . . marketing affects food choice and influences dietary habits, with subsequent implications for weight gain and obesity.”25 The American Psychological Association concurs: “Such advertising efforts, in our view, are fundamentally unfair because of young children’s limited comprehension of the nature and purpose of television advertising, and therefore warrant government action to protect young children from commercial exploitation.”26
The American Academy of Pediatrics has issued this position statement: “Advertising and promotion of energy-dense, nutrient-poor food products to children may need to be regulated or curtailed.”27 In a comprehensive report, the Kaiser Family Foundation reached a similar conclusion: “. . . it appears likely that the main mechanism by which media use contributes to childhood obesity may well be through children’s exposure to billions of dollars of food advertising and cross-promotional marketing year after year, starting at the youngest ages, with children’s favorite media characters often enlisted in the sales pitch.”28
In an excellent review article, Mary Story and Simone French conclude, “The research evidence is strong showing that preschoolers’ and grade school children’s food preferences and food purchase requests for high sugar and high fat foods are influenced by television exposure to food advertising. . . . The heavy marketing of high fat, high sugar foods to this age group [< age 8] can be viewed as exploitative because young children do not understand that commercials are designed to sell products.”29
These statements, based on considerable science, paint a clear picture. Contrast the industry’s position, exemplified by William McLeod, representative of the Grocery Manufacturers of America (the world’s largest food industry lobbying group), in response to questions about the damaging effects of advertising to children raised by the Kaiser Family Foundation report: “There is very little evidence that we have seen. As a matter of fact, I think the conclusions in the report we’ve heard today indicate that the jury is still out.” McLeod added, “The evidence that is not in these studies and the evidence that I don’t think we are ever going to see is that advertising is telling kids or encouraging kids to eat too much or exercise too little.”30
Here is another food industry spokesperson on the issue. When asked, “What, if any, is the relationship between marketing and obesity?” Shelley Rosen, speaking for McDonald’s, said, “There is no connection.” And, “When you ask if obesity is a marketing and communications issue, the answer is no.”31
The science on soft drink consumption, calorie intake, and body weight reveals a similar pattern. Here, the considerable literature ranges from laboratory studies with animals to large-scale human epidemiology studies. First, let’s look at the conclusions from scientists. A research paper by David Ludwig and colleagues on soft drinks and childhood obesity concluded, “Consumption of sugar-sweetened drinks is associated with obesity in children.”32 George Bray, Samara Nielsen, and Barry Popkin, who conducted research on obesity and high fructose corn syrup (HFCS) in beverages, concluded, “It is becoming increasingly clear that soft drink consumption may be an important contributor to the epidemic of obesity, in part through the larger portion sizes of those beverages and from the increased intake of fructose from HFCS and sucrose.”33
In yet another research paper, Samara Nielsen and Barry Popkin looked at changes in beverage consumptions: “. . . soft drink consumption is rising and is a significant contributor to total caloric intake for many individuals, especially children and adolescents.” Further to the point, “This would seem to be one of the simpler ways to reduce obesity in the United States.”34
Now for the soft drink industry position, as stated by the industry’s trade association. According to the National Soft Drink Association, “Soft drink consumption by children is not linked to pediatric obesity, poor diet quality, or a lack of exercise.”35 Sean McBride, the spokesperson of the National Soft Drink Association, was asked to respond to schools’ eliminating soft drinks. Employing the familiar diversion tactic of physical activity, he stated that obesity “is about the couch and not the can.”36
The industry’s disingenuous response on children’s food advertising and soft drinks illustrates larger problems. There are many other cases where industry competes with public health and where its actions are the opposite of what health experts recommend (for example, snack foods in schools, fast food consumption and obesity, and agriculture subsidies). The education system is one place where this conflict is acted out.
In some countries, the sale and promotion of unhealthy food in schools has occurred for so many years that it has become part of the funding equation for education. The problem is especially acute in the United States. It is common for schools to have “pouring rights” contracts with soft drink companies, multiple snack food machines with high-calorie products, food company logos on scoreboards, abundant food advertising on “free” news channels (such as Channel One), and homework programs rewarding children with free food from companies like Dunkin’ Donuts and Pizza Hut.
Schools often perceive these arrangements as consistent with their educational mission: food sales fund important programs, appear to be a “free” source of money, and allow communities to provide less funding for education. The soft drink industry exploits these relationships for both money and public relations (they boast of their caring about children and their role in education).
In fact, these connections drain money from communities. Children put money into the machines and the companies take away the profit. The band uniforms or school trips the money supports are purchased by children and their parents, but with the industry first taking its share. And beyond the direct profits from sales, the industry benefits from the massive advertising exposure on vending machines, sports spectators seeing logos on scoreboards, and more.
Business self-interest may be expected, but governmental failure to correct the situation, or worse yet, collusion in ways that damage public health, is especially troubling. On the issue of children’s food advertising, does the U.S. government side with science/public health or with the industry?
The U.S. government found itself isolated from the world community in 2003 – 04 by its stiff opposition to a report of the World Health Organization that proposed a global strategy for confronting problems with diet, inactivity, and obesity.37 In particular, the sugar industry exerted heavy pressure on both the U.S. government and the WHO to change recommendations that sugar intake should decrease. Part of the U.S. response to the report was a pointed letter to the WHO from an assistant to Secretary of Health and Human Services, Tommy Thompson, saying, “The assertion that heavy marketing of energy-dense foods increases the risk of obesity is supported by almost no data.”38 The Federal Trade Commission chairman, Timothy Muris, took the same stance on food advertising directed at children: “A ban would be ineffective because there is no reason to think that the ads kids see make them obese.”39
Example after example could be interpreted as collusion between government and the food industry. National nutrition policy in the U.S.A. is established by the USDA, whose primary task is to help the food industry sell more products. For years there has been an open “revolving door” of industry executives running the USDA and then returning to industry. A few examples occurred in 2004 when the head of the USDA appointed a deputy chief of staff who was vice president of legislative affairs with the International Dairy Foods Association, along with a director of communications who had worked with the National Cattleman’s Beef Association.
There is abundant evidence that the food industry has not always acted in the interests of the public eating less food or better food. Which prevails when public health and profits are in conflict? Kraft’s and McDonald’s highly visible pronouncements suggest that the answer is clear. McDonald’s promised to use healthier oil for its fried foods, and Kraft said it would offer its food in smaller portions. To date, both companies have failed to follow through on their announcements. Public opinion may ultimately force the industry to act differently, or courageous government officials might one day overlook business interests and be creative with legislation and regulation. Until that day, a skeptical eye must be turned to industry’s pleas that it be trusted.
Fundamental shifts in public opinion are necessary before unhealthy eating habits can change. Public opinion did turn against the tobacco companies, permitting unprecedented policy changes: the smoking ban in public places, very high taxes, forbidding the use of an icon — Joe Camel — that allegedly encouraged children to smoke, and so on. The realization that there were victims (children being seduced to smoke, non-smokers hurt by secondhand smoke), awareness of the human toll produced by smoking, and the release of internal documents from the industry showing callous, calculating behaviour designed to maximize sales of products that can kill users — all this facilitated an enormous attitude shift. When the history of the obesity issue is finally written, key shifts in public opinion will probably be seen as preceding key advances.
Some of those changes may be occurring already. We see children as a protected group. Nations safeguard children by requiring immunizations, mandating the use of safety restraints in automobiles, and more. There is increasing recognition that great harm has occurred by not protecting children from conditions that lead to unhealthy eating and a sedentary lifestyle. Moves to ban soft drinks and snack foods from schools and to regulate children’s food advertising are examples of actions based on a needed shift in thinking. There are more.
The time-worn argument against legislation is that eating is a matter of personal responsibility, and that the “nanny state” should not tell people what is good for them because it infringes on free choice. It is a powerful argument, and one that bears refuting.
As an aside, there are food police who tell people what to eat. That police force is the food industry with billions of dollars at its disposal to convince people, particularly children, what to eat. Even if the government were willing to fight the industry, as it finally did tobacco, the resources it could bring to the effort would be trivial in comparison.
In an article I wrote with Marion Nestle, we noted four fundamental points in response to the argument that personal responsibility is the cause and solution to the obesity problem:40 Fundamentally wrong, the argument cannot be supported by either science or common sense. The rate of obesity increases year after year, in country after country. It is difficult to argue that the world’s people were less responsible in 2002 than in 2001 or that irresponsibility is sweeping the globe.
Secondly, the argument ignores biology. Humans like foods high in sugar, fat, and calories as a survival strategy. Lab animals, responding strictly to their biology, can triple their body weights when given access to high-fat, high-sugar foods found at any convenience store. Imagine the folly of attributing the animals’ normal weights to the exercise of responsibility, and the heavier weights to failures in animal character.
Thirdly, the argument fails to lead to constructive action. For years, food companies have urged that people should eat better and exercise more — in other words, should be more responsible. How much higher can obesity rates climb before such blandishments are seen for what they are?
Finally, the personal responsibility approach is a trap. It insists that the environment should remain unchanged, that the food industry will do business as usual, and that pious government officials will continue to defend the status quo while claiming credit for taking action. The picture startlingly resembles the history of the tobacco industry, which argued that damage caused by dangerous products were the fault of the people who used them.
Will change occur from the top down, with central governments taking the lead? Or will it come from the bottom up, with grassroots, local, and state changes forcing central change? It appears that the victories are occurring in a bottom-up fashion in the United States, but in Europe and Scandinavia there is more hope for constructive action from the top.
In the U.S.A. the federal government talks much about obesity. Looking beyond this rhetoric, one sees minimal allocation of resources — and the classic escape tactic, imploring people to be more responsible. Outside North America, central governments are more likely to take constructive action. The British government is considering action to limit food advertising directed at children, and politicians are debating food taxes. Sweden prohibits advertising aimed at children. Finland has undertaken impressive health promotion efforts. Such efforts must be tracked and evaluated so other countries can consider taking action.
At the local level, many impressive changes are occurring.41 School districts are banning soft drinks and snack foods, school lunch programs are improving in some areas, communities are building bike/walking trails, there is increasing pressure on schools to add back physical education, organic gardens are being built on school grounds and are integrated with the core education, calls are being made for regulation of children’s advertising, and more. Even though the support for such programs is insignificant compared to food industry promotion, these programs can become models for other communities and may ultimately have a major impact.
These programs have national or even global potential, but only if evaluated and spread around the world. Rapid evaluation of these efforts would be very helpful, as would better understanding about how positive contagion can occur (when other communities adopt successful programs).
A number of actions have been suggested for reducing obesity. The key is to develop cost-effective preventative approaches that improve diet and enhance physical activity.
It is important to hold the food industry accountable. We should insist it earns the trust it seeks. Constructive actions, say, when a company introduces a healthier product, cannot excuse countless damaging practices. It would be helpful to establish specific criteria that industry must meet to be considered trustworthy. A beginning would be for the industry to develop a new playbook. That playbook would include the following criteria:42
• Promote only healthy foods to children and, ultimately, minimize promotion of unhealthy foods to adults.
• Cease sales and promotion of unhealthy foods in schools.
• Change marketing, pricing, and promotion strategies that encourage overeating and the consumption of unhealthy foods.
• Alter the industry focus from personal responsibility to environmental changes that encourage and enable people to make healthy decisions.
• Place approximately equal emphasis on diet and physical activity.
• Permit objective parties to interpret science and avoid manipulating science as a marketing and public relations tool.
• Acknowledge that personal freedom is enhanced as the environment becomes healthier.
One suggestion my colleagues and I have repeatedly made is to introduce a food tax. A lightning rod for controversy, the proposal has been attacked with great vehemence by the food industry, food trade associations, and conservative political groups. Once thought completely radical but now part of legitimate debate, a food tax is being considered by several national governments.
A tax could be conceptualized in several ways. The most dramatic would be to impose a tax on unhealthy foods. The tax would be large enough to decrease consumption, and to raise sufficient revenue to subsidize the sale of healthy foods. Research would be needed to determine the necessary level of tax.
Less radical would be a small tax on soft drinks, snack foods, and fast foods to generate revenue for needed programs.43 For instance, a U.S. national tax of one penny per soft-drink can or bottle would raise $1.5 billion per year. The revenue would be much larger if the tax were just two pennies, and was applied to other classes of foods. I have recommended that the revenue be earmarked for a “nutrition superfund” that could be used to promote healthy eating to children.
Such small taxes are now in effect in a number of American states and municipalities, but in all cases have been implemented to raise general revenues rather than to improve nutrition. Such taxes are acceptable to the public. The challenge is to earmark the revenue to healthy eating.
Based on what is known, my colleagues and I have suggested a number of actions that might be considered to improve the nutrition landscape.44 The hope is to develop approaches that offer promise in preventing obesity, change conditions in ways that improve diet and physical activity, and are cost effective.
• Focus on environmental change and recognize that personal resources (responsibility) can be overwhelmed when the environment is toxic.
• Replace the “no good foods or bad foods” stance with a public health focus on what foods must be generally consumed.
• Recognize that treating obesity is very difficult and can be costly, thus making prevention and children the priorities. See obesity as a matter of social justice: As obesity is highest in low-income groups, social justice and race issues are linked with diet, inactivity, and obesity. Correcting social disparities is one means of fighting obesity. Civil rights, anti-poverty, anti-hunger, and community organizations might be allies for public health experts working on obesity.
• Learn from successes in countries such as Finland and Mauritius about large-scale efforts to change diet and activity.
• Support research to understand transitions in nutrition and activity.
• Emphasize disparity issues and the impact of obesity on developing countries.
• Work with the WHO as the prime organizing unit.
• Establish a world culture where promoting unhealthy food is unacceptable.
• Develop national strategic plans to increase physical activity.
• Earmark transportation funding for non-motorized transport.
• Design activity-friendly communities and offer incentives for activity.
• Build and promote exercise opportunities in communities, schools, worksites, and physician practices. Promote walking and biking to school.
• Prevent exploitation of children as market objects.
• Protest the use of cartoon characters and celebrity endorsements to promote unhealthy foods.
• Discourage product placements in movies, TV shows, video games, and food company web sites with games for children.
• Encourage legislators to prohibit marketing of products to children, or at least to create equal time for pro-nutrition messages.
• Create a nutrition “superfund” to promote healthy eating, perhaps from fees placed on food advertisements or small taxes on the sale of unhealthy foods.
• Promote media literacy (advertising inoculation) among children.
• Identify how eating and activity affect academic performance. Education and public health officials should be allies in this effort. Soft drinks and snack foods will be banished from schools, the instant schools officials learn that poor diet is affecting standardized test scores.
• Prohibit TV programming with food promotion, rid schools of food company logos and references to unhealthy foods in educational materials, have only non-food fundraisers, and use only healthy foods as academic incentives.
• Improve school lunch programs and use the cafeteria as a learning laboratory.
• Find alternatives to snack foods, soft drinks, and fast foods.
• Improve nutrition and activity instruction.
• Use zoning laws to prohibit food establishments from operating near schools.
• Have only healthy foods/beverages in vending machines.
• Raise awareness that larger portions lead to more eating, encourage companies to sell and advertise reasonable portions, and educate people on serving sizes.
• Require food labelling at restaurants, and food companies to list the number of USDA servings on the front of containers.
• Increase awareness of the fundamental imbalance of incentives to eat well versus poorly, and highlight the connections of poverty with obesity.
• Engage programs such as the U.S.A.’s National School Lunch Program, Food Stamp Program, Head Start, and WIC (the special supplemental nutrition program for women, infants, and children) to fight poor diet.
• Change the food price structure, first by lowering costs of healthy foods and perhaps by increasing the costs of unhealthy foods.
• Think of food taxes not as punitive measures but as a means to support nutrition programs.
• Support positive industry changes, but also increase public awareness of industry tactics that influence policy and promote unhealthy eating.
• Challenge the industry for hidden funding of political and nutrition front groups.
• Encourage bold action free of industry influence among political leaders.
• Curb food commercialism in public institutions (such as ads in museums, in hospitals, on police cars).
• Promote activities known to help with body weight (for example, breast feeding, decreased television watching).
• Mobilize parents to demand a healthy environment for their children.
• Making coalitions of concerned groups increases the power of social movements. Because improved diet should boost academic performance, explore coalitions with education groups, and also with traditional medicine. Other creative avenues could include connections with groups focused on environmental sustainability.45 Improving dietary habits would benefit these groups as well as public health.
Poor diet, inactivity, and obesity are severe global problems. Modern conditions, which have bred the obesity pandemic, simply must change. This will require considerable attention to the food and physical activity environments, bold action on the part of national leaders (who must be separated from their food company interests), support of creativity at the grass-roots, considerable funding, and the will to persist in the face of vexing systemic problems.
Blaming individuals for obesity, table-pounding exhortations for increased personal responsibility, and protecting the food industry’s status quo do not work. They have been tried for years and have failed, yet they are precisely what many in government propose as a means of moving ahead. Helping the population make responsible decisions by creating an environment that promotes rather than prevents healthy eating and activity is a worthy goal, but it will require fundamental changes in the economics of food, the activity environment, and the way the food industry does business.
Positive signs exist. Awareness of the problem is increasing, the media are publicizing obesity as a public health issue (not just how to diet), and government leaders are beginning to resist industry pressures. Grassroots victories have occurred, and are having a contagious effect. Support of these movements offers the greatest hope of progress. But it has yet to be combined with the work that legislators must do.
