Saturday, January 25, 2014

Applying Tobacco Control Strategies to 'Obesity' Prevention

[Note: In this post, I use the terms ‘junk food’ and ‘less healthy’ foods in quotes and interchangeably to mean foods and beverages which are high in calories but low in nutrients.  I am using the same terms that a consensus of nutrition researchers use; I am not making a value judgement.]

Being over fat (i.e., having excess adipose tissue) increases inflammation and disease.  Increased body size stresses joints and increases musculoskeletal instability.  Reducing the personal, societal, medical and economic burden resulting from these conditions is not going to be easy.  Some suggest that strategies from tobacco control may help.  I agree that we can use or modify tobacco control strategies to address ‘obesity’, but at the same time, we should recognize that some of those strategies, e.g., shaming people and offering one on one behavior change counseling are not likely to be effective. 

Instead, I suggest we apply tobacco related strategies to the structural causes of over fatness.  The strategies that had the greatest influence on decreasing the prevalence (percent of the population) of smoking targeted the physical and social environment, not individual smokers.  Successful strategies included price increases thru state and federal taxes, age limits, clean air laws, advertising limits and display bans.  (Warning labels are another strategy meant to deter tobacco use, but they are focused on the individual and do not have much success with current smokers.)

We can apply several of the above tobacco strategies to ‘obesity.’  The first is price.  A sin tax or ‘junk food’ tax is unpopular, but it is effective in changing food/beverage purchasing behavior according to some small studies.  In order to implement such a tax, we have to rely on current nutritional evidence about food ingredients and then determine the best way to increase prices of items that contain these ‘ingredients of concern’.  For example,  we know that adding sugar and solid fats to foods and beverages makes them calorie dense and calorie dense foods and drinks appear to be the main drivers of excess calorie ingestion and over fatness in the US and similar countries.  It is possible that taxing the ingredients themselves, as some countries have done, will lead food manufacturers to reduce their liberal use of sugar and solid fat. Another option is to tax the product itself, such as sugar-sweetened beverages. This strategy could lead people to purchase less of the taxed foods and beverages.  A result of taxation could be that companies start providing less calorically dense versions of their products (and not simply by reducing the portion size!) or people start buying different products. These are not mutually exclusive.

Another strategy we can apply is a modification of ‘clean air laws.’ The overwhelming presence or availability of calorie rich, ‘junk food’ also drives ‘junk food’ consumption.  Tasty, cheap, calorie dense foods and beverages are everywhere and even when people have the same access to fresh, nutritious low calorie foods they tend to choose the ‘less healthy’ ones.  My colleagues talk of food deserts – where fresh produce is scarce -but I focus on food swamps.  The main reason I believe food swamps, more than food deserts, influence food choices relates to my work in tobacco cessation and alcohol treatment programs.  Consider being in a meeting or rehab and counseled to not smoke or drink and then you leave the meeting and everywhere you go there are displays of alcohol and cigarettes and people smoking and drinking. [Hence the advice to alcoholics in recovery and recently quit smokers to change their playgrounds].  I have had smokers tell me that they want their work places – and restaurants and bars -to be smoke free (clean air laws), because it makes it easier for them to work through their cravings.  Their personal stories are evidence that whatever makes smoking harder (or less convenient, or less acceptable) makes quitting easier and smokers DO want to quit. They just aren’t too keen on failing over and over again.  The same desire and fear exists for people who understand that certain foods are less healthy for them.  People who struggle with calorie moderation (i.e., all of us) have even more challenges.  Because calorically dense foods are everywhere – neighborhoods, stores, restaurants, worksites, schools – there is no other playground for people to visit.  The playground (i.e., food swamp) is what must be changed.

The parallel to clean air laws for ‘obesity’ prevention are the steps we take to break up food swamps – for example:  zoning limits on the density of fast food restaurants and convenience stores, work site policies (e.g., ‘junk food’ free meetings), and candy free grocery checkout aisles. 

The low cost and constant presence of ‘junk food’ is not the only challenge to a maintaining an appropriate calorie level. We need to adopt tobacco strategies related to advertisement and age as well.  Food companies promote ‘less healthy’ food and beverages on billboards, in TV shows and TV commercials, through other media and in store displays.   The ads are entertaining, constant and often associated with celebrities.  The food industry shapes the environment, it shapes our tastes and it shapes our preferences. It makes sense for us to push back against THEIR influence on our behavior and our health.

At this time, the only parallel to tobacco control for advertising is predicated on age.  Food companies have voluntarily agreed to limit ‘junk food’ commercials during the airing of children’s television.  Another age related parallel could be the restriction of vending machine use or vending machine content in schools.  The candy free grocery aisles are also focused more on children than adults.

Lastly, nutrition information disclosures at restaurants and vending sites may be a parallel to warning labels on tobacco products IF those disclosures come with some type of interpretive label.  For example, an entrée with 900 calories and 15 grams of sugar should be labeled as HIGH in those two ingredients.  This is a more acceptable but weaker strategy.
It is important to remember that progress in reducing the burden of disease from tobacco is taking many years, but it began when people started to smoke less.  We should start seeing a decline in lung cancer and other smoking related conditions now as the prevalence of smoking has gone from 42% (1965) to 18 % (2013).  The strategies that led to a decrease in smoking were rolled out over time and met with great resistance, especially from the tobacco companies.  In fact, it took a near 50 state attorneys’ general lawsuit for tobacco companies to admit that their product was harmful.
We have a long way to go in reducing the personal, societal, medical and economic burden resulting from over fatness, but cajoling people to eat less and exercise more in an environment that makes it ridiculously easy to do neither is fruitless.
It’s the environment, stupid and it is time we stopped letting the food industry control it.

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