[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.
