‘We can’t expect people to eat less if we continue serving them too much food.’
Dr Deborah Cohen1
AS WE HAVE seen, the obesity pandemic has arisen from multiple causes, from the way food is grown, processed and sold, to the ways in which consumption is advertised and marketed. It has arisen from the relentless promotion of high energy-dense foods, manufactured to be enormously rewarding, and as a result of the techno-physiological revolution which has led to diets that, typically, are too high in calories and fats and too low in fruits and vegetables.
‘A century ago,’ reports the US Department of Agriculture, ‘nutritional problems centred on the inadequate intakes of certain vitamins and minerals, resulting in nutritional deficiencies such as rickets, scurvy, and beriberi. Now, nutritional problems in America are driven by the discovery of strong links between nutrition and chronic diseases such as coronary heart disease, cancer, and stroke.’2 It has also been reported that Americans have increased their annual food intake by over 190,000 calories per person since the 1970s.3 And like it or not, where America leads, other nations will typically follow.
Finding our way back to a slimmer, healthier way of living demands an understanding of consumer behaviour and the factors influencing food choices.
What we eat is the end result of pulls in many directions, a response to the multiple forces creating the national nutrition environment. This is just as true today as it was two decades ago.
Instead of viewing obesity as the reflection of personal failure, we need to approach it as an issue of public health; the concern not just of the overweight but of society as a whole. The pandemic affects us all, both slim and obese, as a result of the social and financial burdens associated with its medical consequences.
We now recognise and accept the importance of food hygiene in safeguarding our health, and sanitary standards are enforced through a combination of education and regulation. Health inspectors have the legal powers to enter commercial premises to enforce stringent rules about the way food is stored, prepared and sold. Companies that fail to pass inspection can be closed down, their proprietors taken to court, fined and put out of business. At home and in school, children learn from an early age to wash their hands before eating, and to avoid food that looks or smells tainted.
No one, so far as we are aware, resents such sensible precautions or feels their personal freedom has been diminished by these steps taken to avoid the distressing and even potentially fatal sicknesses caused by bacteria such as salmonella or listeria.
We believe that the same combination of regulation and education must now be urgently adopted to combat the equally avoidable disease of obesity.fn1 Given the mounting costs of the pandemic to individual and public health, this seems no more than common sense to us. Yet, after more than three decades of increasing obesity, the necessary stringent legislation has still not been put in place in Britain, in the US, or in other parts of the world.
There are several reasons for this.
One is fear of arousing hostility from press and public on the part of democratically elected governments. They are wary of being accused of trampling on individual liberties by imposing a ‘nanny state’ and patronising responsible adults who are capable of exercising their own judgement over what and how much they choose to eat. When a simple move by Mayor Bloomburg to limit soda (fizzy drink) size to 16 oz (a pint) was put forward, also known as the ‘Portion Cap Ruling’, it was to the relief of millions working in public health and also citizens throughout the US. At long last, it looked as though there was some leadership supporting the transition towards a healthier eating environment. Ultimately, we do need to start building concrete barriers to limit our boundless access to food and expanding appetite. Unfortunately, after months of regulatory battles, the New York State of Appeal issued the final decision, ruling: ‘We hold that the New York City Board of Health, in adopting the “Sugary Drinks Portion Cap Rule,” exceeded the scope of its regulatory authority. By choosing among competing policy goals, without any legislative delegation or guidance, the Board engaged in law-making and thus infringed upon the legislative jurisdiction of the City Council of New York.’4
The question remains: if all parties and citizens are united in their concern for their health, and we can’t start putting limits on portion size, what chance do we stand of reforming our food environment to allow for greater health?
The enormous financial clout and high-level lobbying power of Big Food is in itself a serious obstacle to effective new regulation. The industry’s capacity for watering down or blocking any legislation likely to harm their profitability is as awesome as it is shocking.
However, more optimistically we should remember that in many countries, the same battles have been fought and largely won against the equally powerful tobacco and alcohol lobbies. Just as governments have realised the need to bring these two pleasurable, but unhealthy products under regulatory control, so too must they now adopt a similar approach to the foods which fuel obesity. Indeed, in this book we hope we have convincingly made the case that HED foods can prove just as dangerous as any hedonically excessive behaviour, such as smoking or drinking – a view most leading obesity researchers and neuroscientists share.
In addition to new legislation, bringing the obesity pandemic under control will require educational campaigns sufficiently imaginative and well-funded to match the billions spent on advertising and marketing by Big Food. Starting in nursery school, we need to bring about fundamental changes to the way people relate to food and to the obesogenic environment in which they live. It’s a vast and daunting task. ‘We haven’t scratched the surface of what we need to do,’ Deborah Cohen of the RAND Corporation told us. ‘Some of the solutions seem so obvious and so simple, but nobody is talking about them.’5
She is right. And while there can be no single solution to a problem that is, as we have seen, extremely complex and multifaceted, we have identified a number of measures that would help our planet become slimmer and healthier.
Before considering these, however, let’s review two currently favoured approaches – the search for a magic bullet slimming pill, and the formation of public–private partnerships.
There’s no business like the obesity business. Dieting, surgery, gyms, spas, pills, potions and lotions, personal trainers and dieticians are just some of the means people employ in what has become a multi-billion pound battle against the bulge.
No sooner has some high-profile TV medic (or even a celebrity with little if any nutritional knowledge) endorsed the latest fad diet than millions rush to follow it. Out of desperation to lose weight, people will also follow any ‘guaranteed’ quick and easy diet or slimming book, DVD or television show. They will believe almost any research and swallow any nostrum if marketed persuasively, especially when the claims being made are backed up with apparent medical opinion.
‘You may think magic is make-believe, but this little bean has scientists saying they found a magic weight-loss cure for every body type,’ announced American cardiologist Dr Mehmet Oz, when describing the supposed fat-shedding benefits of green coffee bean extract.6 He made this statement after Indian-based researchers, funded by the US company Applied Food Sciences, reported that participants who had been fed the extract had lost around 18 lb and 16% of fat in just one week. Eager not to miss out on such an effortless way to lose weight, and encouraged by the endorsement of respected medics like Dr Oz, people rushed to buy this latest answer to their slimming prayers – it sounded almost too good to be true.
And it was.
The results had been fabricated. A subsequent investigation found those taking the green coffee extract had, over the course of a week, lost an average of only 2 lb while participants given a placebo had lost 1 lb. While the beans seemingly had some effect, it was nowhere near as dramatic or as significant as the marketing and advertising had implied.
After months of deliberation, Applied Food Sciences reached a $3.5 million settlement with the Federal Trade Commission.7 Summoned before a Senate Commerce Committee, Dr Oz was told by Senator Claire McCaskill: ‘I don’t get why you need to say this stuff, because you know it’s not true. So why, when you have this amazing megaphone and this amazing ability to communicate, would you cheapen your show?’8 Sadly this isn’t a unique case. The obesity business peddles more extravagant promises, contains more hucksters and creates more dashed hopes than any other we know. It’s a fiercely competitive market in which, as the Victorian poet Matthew Arnold wrote: ‘Ignorant armies clash by night.’
Still, many pharmaceutical companies have invested and continue to invest millions in the search for the perfect slimming drug. Often with nothing to show for their investment, as in the case of leptin (see Chapter 5). There are, however, some drugs that can bring about modest weight loss – an average of around 5%. Available on prescription only, they include topiramate and contrave, both of which can help suppress binge eating.9
However, because the interactions between the central nervous system and the endocrine system are so complex, it could be decades before any drugs that have a really significant effect on obesity come on to the market. Even were such a drug to be developed, should society really favour ‘medicalising’ a condition caused, at least initially, by living in an obesogenic environment? While medical interventions, including surgery, may well prove necessary when lives are threatened by excessive obesity, they surely ought not to become the universal panacea for everyone who needs to shed a few pounds.
Once such a pill was available there would be such a demand for this ‘no effort’ way to lose weight that doctors would be overwhelmed, not only by patients with serious, weight-induced health conditions, but also individuals anxious to drop a few pounds for purely cosmetic reasons. Furthermore, such a drug would also enable people to continue to eat unhealthily, so even if they were thin, they might still be denying their body essential nutrition. And finally, although external factors are a strong cause, we arguably shouldn’t be completely absolved of responsibility for our own welfare. Adopting a pharmacological ‘cure’ for something as intimately tied to survival as eating might well lead to greater problems in the long run.
The fact that new drugs are frequently misused and overprescribed is something that physician Allen Frances addresses in his book Saving Normal. 10 ‘Primary care physicians,’ he notes, ‘are prescribing potentially dangerous medications, outside their competence, for people who should not be taking them. Proof again that drugs that are too easy to give and too easy to take will be taken far too often, especially when lots of money is behind them.’11 Frances is talking about the drugs used to treat bipolar affective disorder, but the same warning applies to the possibility of treating weight problems through medication.
Far better, in our view, to tackle the environmental and psychological causes of obesity than seek a quick fix via the prescription pad.
Recognising that the food industry must be part of the solution to the obesity pandemic, a growing number of Big Food companies are joining forces with government and related agencies and making pledges to improve the status of our obesogenic environment.12 The rationale is simple; with public awareness of obesity rising, it would be commercially prudent for these companies to be seen to be offering lower-calorie, nutrient-dense foods. Big Food also knows that making a visible contribution to tackling obesity could help fend off the costs and restrictions of formal legislation.13
As a result, there are all kinds of public–private partnerships to tackle obesity in the world today. In the US, Michelle Obama’s ‘Let’s Move!’ campaign to end childhood obesity is defined as a ‘public–private partnership that, for the first time, sets national goals to end childhood obesity in a generation.’14 It is perhaps the most prominent campaign of its kind in all of history.
At a global level the World Health Organization’s 2008–2013 Action Plan for Non-Communicable Diseases made specific requests to the private sector to become a partner in their worldwide weight reduction efforts.15
The French-based partnership, EPODE International Network (Ensemble Prévenons l’Obésité Des Enfants) is a not-for-profit organisation operating in 15 countries and involving 150 million people. Supported by the civil and corporate sector, its aim is to reduce childhood obesity through community-based programmes.16
On a smaller scale, the Diet and Health Research Industry Club (DRINC) is a UK-based organisation, funded both publicly and privately, which seeks to innovate new, healthier food and drink products.17 Meanwhile another UK-based partnership, Responsibility Deal, involves around 150 companies pledged to improve the current food environment.18
Undeniably these partnerships do a great deal of good work overall. However, it has been argued that some companies are involved in them as a way of diverting responsibility for obesity from obesogenic big business and ensuring that it remains thought of as an issue of individual responsibility. Based on what little is known about their track record to date, such charges can be levelled against a number of these initiatives.19
For one thing, because ‘partnership’ is only loosely defined, the standards of what constitute models of best practice may be compromised.20 While many private-sector players have announced plans to improve food composition, nutrition labelling, and reduce marketing to children, specialists dispute the extent to which they have delivered on these promises.21 Independent studies have reported that the current self-regulatory framework – which tends to put pressure on the individual rather than looking at the societal factors that contribute to overeating – has not led to improvements in either diet or health outcomes.22
The Access to Nutrition Index (ATNI), funded through partnerships between the Global Alliance for Improved Nutrition, Bill and Melinda Gates Foundation and the Wellcome Trust, evaluates food and beverage manufacturers on their commitment to nutrition, disclosure, and efforts targeted towards obesity and food scarcity.23 Using a combination of public data, market research and direct interviews with company spokespeople, the ATNI have developed a scoring system to rank corporations according to the extent they have lived up to their promises. The ATNI is anything but a public–private partnership. It relies on scientific grant bodies to fund investigations, thereby eliminating any potential conflict of interest.
Their initial report, published in 2013, found that most corporate efforts were feeble at best, failing to measure up to the commitments that had been made. Moreover, it found there was a lack of transparency in the ways the initiatives improved health outcomes.24
So while they undoubtedly have some value, overall public–private partnerships are arguably a distraction, serving to reassure people that appropriate steps are being taken to tackle the obesity crisis and thereby prevent the more radical actions that are actually needed.
We believe there are at least seven strategies that governments around the world must adopt as a matter of urgency. None will be popular. All will face opposition from well-funded and powerful commercial interests, but each would offer enormous health benefits, and we must begin as soon as possible to improve the prospects of future generations.
There is a need to move beyond formulaic instructions such as ‘eat less, move more’, and beyond nagging people to eat more fruits and vegetables. While these are key messages, it is equally important to explain the adverse health consequences of overeating. To have any chance of being successful, these messages need to be communicated with the same persuasive power and reach as Big Food, and that will mean significant spending.
It’s important to begin imparting ideas about healthy eating to children at as early an age as possible. They need to be taught about the metabolic syndrome and the risks it poses not just to their physical and mental health, but to their self-image and sense of self-worth. The messages should be delivered in ways as compelling as that employed to promote HED snacks and drinks.
This can be done. In 2006, for example, the British Heart Foundation ran a campaign depicting a young girl drinking from a bottle of cooking oil with the slogan: ‘What goes into crisps goes into you.’25 This campaign was based on the discovery that British children, with their pack-of-crisps-a-day habit, were consuming upwards of 9 litres of oil a year. Attention-grabbing advertising has also proved successful in reducing smoking among adolescents. In the late 1990s, the ‘Truth’ campaign was established in Florida to help educate teens about tobacco use. Created by the advertising agency Crispin Porter & Bogusky, ‘Truth’ advertisements were featured on MTV during prime time, and funded to the tune of $15 million by the government of Florida, using money raised by legal action against the tobacco companies.26 One of the best Truth campaign advertisements featured a withered old executive wearing a bikini and smoking, with the tag line, ‘No wonder tobacco executives hide behind sexy models.’ To the left, in a warning box typical of those featured on cigarette packets, are the words ‘WARNING: Their brand is lies. Our brand is truth.’ It’s a fun and quirky visual, and diminishes the sexy edge that cigarette advertisements have traditionally relied upon.
A similar approach needs to be taken with advertising aimed at combating obesity and promoting healthy eating – the messages conveyed have to be as fun and contemporary as those that are being used to sell unhealthy foodstuffs. Having said this, care needs to be taken not to overemphasise an idealised appearance as a primary reason for eating healthily. Campaigns taking that approach run a serious risk of encouraging disordered eating and body dysmorphia. Children should not be made to feel inadequate through being asked to conform to ridiculous ideals of physical attractiveness; in its own way this is every bit as destructive as anti-obesity messages that suggest being overweight is a choice and is largely caused by personal greed. Instead young people need to be helped to understand the types of food their body needs – and does not need – in order to function healthily and effectively.
There should be a ban on showing commercials for foods and snacks with a high fat, sugar or salt content on children’s television. Such a ban could be voluntarily carried out by the channels, but realistically would probably have to be legally enforced. This measure would encourage manufacturers to focus more on the nutritional value of their breakfast products in order to allow them to continue to be advertised during such times. Similarly, promotion of HED foods aimed at children by celebrities should be prohibited. As we saw in Chapter 10, such adverts and promotions have been proven to prime children to prefer particular foods. In order to give them the best possible chance of developing healthy eating habits we need to prevent them, as far as possible, from being indoctrinated in this way.
Foods should be clearly categorised according to their nutritional values. One quick and easy way of doing this would be to adopt a traffic-light system – in fact, one was mooted for UK shops but never finally introduced. Here, red would indicate food with little if any nutritional value, amber (or yellow) would be for food with some value, and green would indicate food with high nutritional value.
Such a system would enable busy customers to quickly make informed choices about the food they are buying. It could be especially helpful to parents needing to determine which foods were best and worst for their children when out shopping with them (and probably being asked to purchase particular brands). To expect the parents of small children to find the time to read the small print on a food label describing its contents is simply not realistic.
Knowing their foods would be categorised in this way would also encourage food manufacturers to reformulate HED products. In much the same way that Hollywood producers anxious to make their films available to a juvenile audience will edit them in such a way as to ensure a child-accessible certification, it seems probable that they would do all they could to pull products into the amber and green categories to make parents feel comfortable buying them for their children.
It would also provide a simple way of determining the times at which such products could be advertised on television. Those with a red designation might be limited to slots after nine p.m., for example.
At the time of writing, Coca-Cola has announced plans to adopt a traffic-light system for beverages sold in the UK. In accord with the Responsibility Deal (an act made to encourage businesses and other influential organisations to enhance health behaviours), Coca-Cola will adopt red/yellow/green packaging labels to aid the customer in making decisions to reduce caloric intake. This change is perhaps indicative of an important inflection point; that is, the start of a change in attitudes on the part of some companies. A paradigm shift is certainly needed if the goal of transparent food policy is to be achieved. Critically, pressure is needed if change is to occur; our health merits tighter controls on what companies are allowed to produce and how those products are marketed. Coca-Cola’s decision to embrace the traffic-light system was well thought out, and is a welcome development. There is, however, still a very long way to go.
Keeping in mind the fact that there are striking similarities between brain responses to hyper-palatable foods, and brain responses to addictive drugs, we need to start treating highly processed food as the potentially problematic substance it really is.27 ‘Sugar may not pose the clear addictive characteristics of illicit drugs such as cocaine and heroin’, comments a Credit Suisse research report on the sugar industry. ‘But to us it does meet the criteria for being a potentially addictive substance.’28
In the light of these findings, school shops must stop selling nutritionally poor, hyper-palatable snacks or sugar-based drinks, and machines vending these products must be banished from school property. Children should be forbidden to leave the premises during the school day to top up on fast food, sweets and crisps from the nearest shop.
Extreme as it may sound, the law should arguably be changed to prohibit shops from selling HED foods to anyone under a certain age, in the same way that it is illegal in many countries for retailers to sell alcohol or tobacco products to underage children. Once introduced, these statutes should be policed and enforced just as rigorously.
Without doubt the Big Food lobby would fight hard to prevent such measures and maintain the status quo. But, as Deborah Cohen – who served on several advisory panels for the National Institute of Health in the US – told us: ‘Nobody likes this idea. When they first hear it, they find it odd. We have a misconception that individuals are always in full control of everything they do, including what and how much they eat. Until people understand they’re vulnerable to marketing and to convenient, easily accessible food, there won’t be support for protecting people against an obesogenic environment. Once people recognize they’re vulnerable, they’ll be really happy to have some help. The private sector has learned how to manipulate people, and it’s the government’s job to protect people from manipulation and the risks of chronic diseases.’29
No government should, or could, try to stop people from eating a bar of chocolate a day if that’s what they choose to do. However, governments surely have an obligation to protect their populations against marketing practices which, as Deborah Cohen puts it, ‘force you to confront chocolate bars every day.’30
This is an important distinction. As we explained in Part Four, the spend on food marketing is second only to the tobacco industry, with $1.79 billion going to advertise junk food aimed at children, compared to $280 million for healthier foods.31 We now know that those most vulnerable to the rewarding effects of food are also more sensitive and reactive to food-related imagery.32
In the UK, restrictions on impulse marketing have been addressed better than elsewhere in the industrialised world. Companies cannot direct television advertising for high fat, salt and sugar (HFSS) foods to children. The Food Standards Agency identifies which foods constitute as HFSS. Even foods that are not categorised as HFSS must abide by a set of rules established for television advertising.
A small, but important step has also been the ban on ‘treats at the till’ such as chocolate bars.33 This approach to limiting temptations to British consumers was thwarted by smaller retail stores, but embraced by big stores such as Tesco and Aldi.34
These kinds of measures – and additional ones – should become standard in all countries.
Hank Cardello, head of the Obesity Solutions Initiative at the Washington DC-based think tank, the Hudson Institute, has the task of demonstrating to companies the measurable financial benefits of offering healthier food to the public. Perhaps surprisingly, given all that we have said, he reports that it is not a task he is finding especially difficult.
‘Most growth in the food industry today is coming from healthier, lower calorie options,’ he told us. ‘Simply put, it’s just good business.’35 Healthier eating is, indeed, growing in popularity amongst certain groups in society.36 As reported in Chapter 12, farmers’ markets and those offering whole foods and fresh produce are becoming an important development within the food industry. However, this is not a general trend across the whole of the populace. It’s true that certain segments of the market can and will pay a premium for healthier, lower calorie, palatable foods; the challenge remains in making this food available to a wider variety of people.
Logistics present a significant problem in the distribution, and particularly creation of fresh produce. As we detailed in Chapter 12, not only are fresh fruits and vegetables vulnerable to spoilage, certain climates are inappropriate for growing them. Attempting to grow crops in climates without the appropriate soil conditions leads to increased waste and use of fertilisers.
This could, however, all be changed, with food grown hydroponically under cooler LED illumination. This could lead to a significant reduction in the energy needed, up to 85% according to some reports; one tenth of the amount of water used by conventional growing operations and carbon dioxide falling by some two tons a month.37
‘By growing our crops vertically, we are able to pack more plants per acre than we would have in a field farm, which results in more harvests per year,’ says Robert Colangelo, founding farmer/president of Green Sense Farms. ‘We produce little waste, no agricultural runoff and minimal greenhouse gasses because the food is grown where it is consumed.’38
This kind of technology makes economical production of healthy foods a real possibility – it is to be hoped that companies do not squander that opportunity by opting instead to try to squeeze profit margins still further.
There have been attempts in some countries to lower people’s caloric intake. For example, the Healthy Weight Commitment Foundation has compelled US businesses to reduce calories across all products offered to the American public. To an extent, this has been successful, with 6.4 trillion calories being removed from American food over the last three years.39 It is also an example of the food industry proactively trying to create palatable, healthier alternatives to less nutritious foods. Sodexo, the French conglomerate, for example, collaborated with ConAgra to create ‘Ultragrain’, a product that tastes like white flour but is in fact made from whole grains.40
While this is a step in the right direction, the food industry is under pressure to continue to perform, so we as consumers have a responsibility to choose healthier foods to demonstrate that there is demand.
The strategies described above would not be especially irksome for either the companies who produce, market and retail food, nor for the customers who buy them, were we to take a different attitude towards the way we eat.41
As with other changes introduced to improve health and reduce the risk of premature death, initial resistance can be expected. It happened when it came to improvements in food hygiene, the introduction of building regulations and the ban on smoking in public places. Although fiercely objected to at first, these were soon generally accepted.
And what is the alternative? Over the next twelve months, the obesity pandemic will take the lives of almost three million people and undermine the health of billions more.42 Obesity is estimated to present as much of a financial burden as either smoking or armed violence and terrorism, with costs estimated at around $2 trillion globally.43 In light of this enormous cost to health-care systems, both industry and people must work together to minimise this cost. Families should not have to bear the pain of such preventable losses. Individuals should not have to suffer years of pain and discomfort resulting from mindless overeating, nor society the soaring public health costs of coping with this crisis.
We must abandon our deeply ingrained prejudices about obesity and come to understand that we are all physiologically and psychologically ill equipped to resist the temptations of our obesogenic environment. We must return to viewing food as an essential fuel rather than a recreation. We must curb the power of big businesses to market high energy-dense foods and encourage them to produce nutritious alternatives, supported by technological advances that make this course economically viable. And yes, we must all take personal responsibility for our own health.
If we do not, we risk devastating consequences for everyone on this increasingly fat planet.
fn1 The diagnostic characterisation of obesity as a disease was made by the American Medical Association in June 2013.