Monday, November 23, 2015

Resisting a challenging food environment

As the years have progressed and research findings amassed, it has become obvious to most people – experts and non-experts – that obesity is not caused by one thing. However, certain factors seem to have a greater impact on whether or not a person consumes more calories than they need or burn than others. For example, genetics have less of an impact than lack of physical activity. And a combination of risk factors intensifies the impact of any one. For example, a genetic risk, not exercising (or being sedentary), being female and using antidepressants is a perfect storm for gaining weight.

The risk factor that my research and my public health efforts focus on is the environment – the food environment, which I define as anywhere we make a decision about what to eat immediately or what to buy to cook or eat at home.  Within this huge food decision space, individual level factors (knowledge, stress, social and family norms, income) interact to make it harder for some to ‘resist’ what is sometimes called a toxic or obesogenic (obesity causing) environment.

To advance my goals – reducing caloric excess in the population - I support policy that aims to change the environment. Policy that changes the space where we make so many food (and beverage) decisions. I have spoken a lot about information policy, but that doesn’t directly change the environment (indirectly it could lead restaurants to supply lower calorie meals through a change in recipes or serving sizes). Strategies/laws that directly change the environment would include the failed NYC serving cap on sodas.  Other strategies, softer ones some will say, fall into the category of ‘choice architecture.’ In other words, someone (and this someone can be a contentious issue) decides that in order to help a person choose the healthier (? – definition pending) option, this healthier option needs to be easier to access or displayed more attractively than the non-healthy one. For example, instead of the huge display of 50 cent white bread at the front of the store, the owner places a display of whole wheat bread. Strategies that I am particular enamored with include taxes (price manipulations), zoning restrictions (do we need 10 fast food restaurants w/in a mile of a neighborhood or school?), and advertising constraints (do transit busses really need to advertise 2 dozen donuts for the price of 1?). The point of these efforts is to change perceptions about food consumption and the pressure to consume more food than we need. The changes of what is normal developed in response to our environment over the past 30 years. We have new social norms.

Changing the environment means reducing the amount of or display of ‘desirable’ foods.

I hadn’t realized that what I was talking about is also called ‘desire reduction.’ In other words, if the things – no the triggers - that lead us to overconsume calories are taken away, then our desire to overconsume is reduced. Take my donut example. If the ads for donuts are taken off the bus, then this might reduce my desire to go buy donuts. Certainly, if your work place bans junk food at office meetings, this would reduce the desire to eat those junk foods. I like these strategies because they attempt to reverse something that happened without our asking it to happen. The environment changed around us and what was normal changed. Now it is ‘normal’ to be served supersized meals. It is ‘normal’ to sit for hours. It is ‘normal’ to drink a 20 ounce sugary beverage or an 8 ounce glass of wine. And pushing back against the new normal in our social context is often met with shock and disapproval. Still, this push back, this resistance, is yet another strategy – an individual level strategy that some people promote. I am not convinced. 

The ‘new’ term for this type of individual level strategy or intervention is ‘desire resistance.’ I became familiar with both of these terms (desire reduction and desire resistance, but not the concepts) only recently, when I read an article by Dutton, Fontaine and Allison (abstract here).  I am a pretty big fan of Dr. Allison, he is the co-director along with Dr. Fontaine, of the Nutrition Obesity Research Center at the University of Alabama, and I pay attention to what he has to say. This is one of the few times I disagree with him.

In their discussion of desire resistance, the authors offer this example of the skills an individual might need to posses in order to resist their ‘internal desires’ or ‘external challenges’ (eg those brownies someone left in the break room):

“Desire resistance skills include strategies such as self-monitoring, meal planning, asking for social support, wearing a physical activity monitor, cognitive restructuring, making a public social commitment, and preparing oneself to anticipate, tolerate, and accept feelings of deprivation when they are encountered.”

I understand that the authors are advocating for both desire reduction and desire resistance, but desire resistance, to me, is going back to the individual focus that others have already found to be extremely challenging. Programs that work at this level usually do not produce lasting change. Yes, there is some evidence that teaching people to count calories or plan their meals will work for the short term and maybe in the long term, for some people, but it is rare. In my experience and in the literature, finding people who can actively, consistently and perpetually resist this 'in your face, food pushing society’ is unusual. I AM one of those people, so if I am against desire resistance as an obesity prevention strategy, it’s worth noting!

This idea of resisting cues to eat calorically dense foods or drinks, or any food or drink when you are not hungry, reminds me of the time I spent teaching people how to resist the trigger to smoke a cigarette when they were trying to quit. What worked the best was when there were LESS triggers. In other words, successful quitters are more likely to be around others who did not smoke, work and recreate in smoke free environments and live in a ‘space’ where smoking is not ‘normal.’ The environmental changes – and taxes on tobacco – have done far more to assist in smoking cessation than all the desire resistance programs!

It’s also ironic to me that in the Allison article, where the authors introduce the desire reduction and desire resistance terms, that they also point to the 2010 Recommendations from the US Surgeon General regarding obesity prevention as misguided. They note that most of the strategies are in the desire reduction category, as if that were a bad thing. I see it as a response to the years – decades – of efforts that did not include the environment at all. Still, in the end, the authors suggest that both strategies – reduce desire by modifying the space and increase resistance by teaching skills – be employed. And in their closing comments they make a valid, important point. The same point is true with smoking or in their example, managing anger, and it is: there is no world in which all temptation or triggers will be absent at all times. In those situations where temptations exist, a person will either indulge, relapse or resist.

Personally, I plan to do a little indulgence in a few days…. Thanksgiving here I come!

Wednesday, November 11, 2015

What do you think 'natural' means?

Remember past blog posts where I discussed the meaningless ‘all natural’ label declaration (see here and here, for example)? Well, it looks like enough people, or I should say, industries, have voiced similar concerns and with their clout, have moved this issue into the FDA action phase.

The FDA comments portal opens tomorrow and you can participate by clicking on this link.  The three main questions posed are:

Is it appropriate (for the FDA) to define the term “natural”?
If so, how should natural be defined (in regards to food/beverage products)?
How should the FDA determine if a manufacturer is using the term correctly on its food or beverage labels?

I have had two broad concerns with the labeling of an item as all natural (because that is the point of this, food companies want to boast a product as all natural, not just natural or containing natural ingredients). The first is that the term gives the product a ‘health halo’ that may not be justified. In other words, all natural just means all natural (except of course we don’t KNOW what that means). It does not mean health promoting, or nutrient rich, or low sodium/salt, or trans-fat free, or low calorie. None of the things that I want my purchases to be are described by the term natural - though I certainly want minimal processing. My second concern is within the parenthetical comment above- we don’t know what natural means! The old standard, but unenforced ethos from the FDA, was that it meant minimally processed, free of artificial dyes and such. That is far too subjective a definition. For something to be truly all natural, I believe it has to be a whole food, maybe it can contain preservatives, but surely it can’t come in a box. There are so many things that natural isn’t that I am of the mind that the word should NOT be allowed on any labels and thus it doesn’t have to be defined by the FDA. I think that is going to be my official comment. Instead of defining the term, I think that it should be banned from labels altogether.

What would your comment be? Speak up here… or the food industry will speak for you!

Update - 11/15/15 Oh my goodness, how could I have forgotten my favorite All Natural product - YES, peanut butter that isn't fortified or processed, that counts :)

Friday, November 6, 2015

Front of Pack Labels vs Labeling Laws

There is a difference in the requirements for vending operators when they post calorie counts for all items in their machines, starting December 2016, and what some candy, chips and pastry manufacturers are doing now - voluntarily.

According to the law, the font type, size and color have to be large enough and stand out enough to get the attention of the customer while the customer is deciding what to buy. I suppose if you go to the snack machine with nothing but Reese's peanut butter cups on your mind, you may not slow down to read calorie counts, but if you are browsing.....

The snack manufacturers, likely because they make their snacks for grocery and convenience stores too, have begun placing industry designed - industry criteria based - front of pack labels on their packages. On the face, this sounds really good. I love calorie disclosures as a general rule. And it looks like the manufacturers are giving counts for the full packages. 

From the pictures below, you can see some problems.

  1. The labels are too small
  2. The numbers do not stand out on the packages
  3. If the package is not placed in the spiral correctly (especially this happens with beverages) you can not see the label at all
  4. Sometimes the spiral actually covers the label
  5. Only some of the items have labels - how can you compare? 
  6. The labels are not in the same spot, so you can't really scan efficiently, and
  7. In this particular machine, the snacks with the most calories do not have labels (eg honey buns and tasty kake)

By the way, there doesn't seem to be any detectable pricing scheme - two items of equal calories or 'healthiness' can cost from $ .60 to $1.00. Or maybe there is, the chips or salty snacks in the machine below are 60 cents and the higher calorie items, the honey bun and pop tarts, are a dollar. Contrary to what we are told - the worse items cost more, not less.

Here the Cheetos and Oreos are labeled, possibly the pop tarts too

Notice the different label placements, upper right hand corner and lower right hand corner, and even the small side of a package