A Big Fat Crisis (24 page)

Once we recognize that restaurants and supermarkets create conditions that interfere with health, we may be more likely to act collectively to change those conditions.

It’s Time to Regulate “Away from Home” Foods

Just as we regulate restaurants to prevent food-borne diseases and require food to be obtained from an approved source, prepared in an inspected kitchen, and stored and served in a hygienic manner, we should establish standards that will prevent chronic diseases, or at least not increase the risk for them. At a recent national conference on “Performance Standards on Away from Home Foods,” sponsored by the National Institutes of Health, a group of experts and advocates from academia and the food industry developed a series of recommendations to help restaurants offer healthier meals and adopt business practices that would lead to healthier choices and lower calorie consumption. These standards could be implemented first through voluntary approaches; then with a government health-labeling and certification program; and potentially, after evaluation, through enforceable regulations. Development and application of these standards might shift both industry offerings and consumer choices, and ultimately improve public health. The group developed guidelines for healthier meals as well as principles for the operation of restaurants that would help customers moderate their intake.

The healthy meals had two major requirements: not to exceed seven hundred calories for adults (six hundred for children) and to include 1.5 cups of fruits and/or vegetables (at least 0.5 for children). Seven hundred calories is about one-third of the daily caloric requirement of Americans. (See
Appendix
.) There is an emphasis on fruits and vegetables because these are typically deficient in the average American diet.

For those of us who don’t routinely eat healthy meals, think of how hard it is to make up for missing fruits and vegetables. Adults are supposed to consume about 4.5 cups of fruits and vegetables every day. If we don’t get any fruits or vegetables at breakfast or lunch, that means we would have to eat all 4.5 cups at dinner. If we miss a whole day of fruits and vegetables, imagine how hard it would be to eat nine cups the next day. And if we tried to catch up after missing them for two days, we would probably get an upset stomach from eating thirteen cups of fruits and vegetables all at once.

Having food available in portions that are appropriate for the majority of individuals does not preclude the minority, who may eat once or twice a day or need more calories at each meal, from ordering additional items to augment their caloric intake.

In addition to defining the minimum characteristics of a healthy meal, the group developed a list of thirty criteria that would support healthy choices when dining out. To be certified as compliant, restaurants would have to offer at least three healthier meals, or 10 percent of the menu options, whichever is greater, and would have to adopt some of the guidelines on the list to help people moderate their intake. Some examples include not automatically putting free bread or chips on a table, not providing free soft drink refills, making whole grains and skim milk available, and limiting the serving sizes of soft drinks and desserts. (See
Appendix
.)

Evaluating Changes in Restaurant Standards

Although the benefits of discouraging restaurants from serving too much food may seem intuitively obvious, in reality, changes do not always work the way they are intended. People may not compensate for eating too much, but they may compensate if they think they are eating too little. Rigorously assessing the impact of changes is necessary to ensure that a bad situation is at least not being made worse. To do that, we need experimental laboratories in working restaurants.

The “Restaurant of the Future” in Wageningen, Holland, is a consumer behavior laboratory built into a restaurant.
⁶
Developed and supported mainly by industry—including companies specializing in food preparation, software development, and the manufacture of professional kitchens—the restaurant features taste-testing laboratories and video cameras to observe consumer behavior, and it has the capacity to alter elements like lighting, music, and the presentation of food. The purpose of the restaurant is to help the food industry identify the most effective ways to package and launch new consumer products, not necessarily to improve health.

When I visited in March 2011, the managers were experimenting with the concept of food carbon footprints and sustainability. As I walked
around the food displays—arranged in a manner that was a cross between a cafeteria and a convenience store, with stations for hot food and refrigerated cases of sandwiches, salads, yogurts, and cheeses—I saw small signs in front of most items with an indicator pointing to a spot on a color spectrum from green to yellow to red. A placard explained that green signified a low carbon footprint, meaning the food was produced locally (for example, apples) and used less energy, causing smaller amounts of pollution; red meant it was imported (bananas and oranges) and contributed more to global warming because of the energy it took to import. The color scale indicated not only the distance the raw ingredients traveled to get to the restaurant, but also the time and energy it took to grow, process, and prepare it, with local raw fruits and vegetables having a lower carbon footprint than cooked foods and meats. The question being studied (and still not published at the time of this writing) was whether these cues would encourage consumers to choose more sustainable products.

Although I am not confident that the signs will help customers eat more sustainably, I know that unless such research is done, we will never know. Without consumer research, we will also never be able to figure out the best ways to change our restaurants and supermarkets so that people will be able to make healthier choices in ways that don’t overwhelm us, drain our brains, force us to be obsessive-compulsive, or just generally drive us crazy.

There have been no studies that link marketing practices with diet, so we cannot be sure how changes in restaurants will affect consumers’ diets over the long term. But we could do these studies, which would likely be very helpful in understanding exactly which policy regulations would be most useful in controlling obesity. Drawing upon Holland’s Restaurant of the Future, we should create laboratories not only in restaurants, but in supermarkets as well. My dream is to create a Supermarket of the Future, a food store devoted exclusively to understanding the ways and means of improving the American diet.

When asked why he robbed banks, Willie Sutton replied, “Because that’s where the money is.” The supermarket is where we get most of the food we eat and is the venue in which we would most rapidly
identify practical and scalable solutions that may ultimately make all of us healthier. To solve the obesity epidemic, the National Institutes of Health should devote just a fraction of its nearly $30 billion research budget to this. If any other organizations, foundations, or “angels” want to accelerate progress in chronic disease control, I urge them to consider funding supermarket-based consumer research, because it will be the quickest way to get there.

The Supermarket of the Future

How could a supermarket be redesigned to help people make better choices? Once people bring food into their homes, they will most likely eat it. Therefore, helping people to make better choices at the grocery store is one key to a healthier diet.

The Supermarket of the Future could employ many of the current marketing strategies used to promote junk food, but instead apply them toward helping people choose foods that promote health. Researchers and developers would start by using the checkout scanners to figure out the best way to design the Supermarket of the Future. The food industry currently mines its scanner data to evaluate how store placement and other promotional strategies influence profits. (This is how the industry knows that the ends of aisles are choice locations from which to sell goods, for example.) By tracking what sells from which locations, we can begin to make changes that would maximize healthy choices and limit approaches that undermine a healthy diet.

Before we do that, we should start by quantifying just how much the current design of supermarkets increases our risk of diet-related chronic diseases. Although we know impulse marketing strategies increase the sales of candy bars, chips, and sodas, we don’t know the magnitude of their impact on diet. Do they increase the risk of a poor diet by a few percentage points, or is their contribution on the order of doubling or tripling the excess calories consumed? If we followed a group of shoppers we could see the chain of causation—from store to home to diet to disease. By tracking purchases and then having individuals report what they eat, and by offering regular medical exams, we could directly see, for example, the extent to which discounts on soda
and candy lead to a complication from diabetes. Once we know what store factors are the most problematic, we can change them.

How different would the Supermarket of the Future be from the standard supermarkets we shop at every day? Right now, the ingredients needed for a balanced meal are scattered all over the store. Why not organize the store by meal, so there is a section for breakfast, one for a cold meal (like lunch), and one for a hot meal (like dinner)? Having all the elements for a balanced meal in one place would aid customers in choosing all the items needed for a healthy diet, especially because it would mean we would see the same healthy foods in multiple places. After all, one of the most common strategies for selling chips and soda is to place them in several locations in the store. If we miss them at the entrance, in the third aisle, or on the special display, we can pick them up at the cash register. If we did the same thing for fruits and vegetables, I suspect more people would be eating bananas, broccoli, and melons.

Sure, it would be a bit inconvenient if the food products we are used to seeing in a certain part of the supermarket suddenly end up in a new spot. But after shopping at the Supermarket of the Future (which would be much smaller than a traditional supermarket) we would quickly get the lay of the land. Many of us would be delighted to avoid foods full of sugar, fat, and empty calories. Just imagine a store that doesn’t assault you with chips, soda, and cakes on eye-level shelves and on every end aisle display!

(Of course, junk food would still be available. You just might have to go to aisle two and look on the bottom shelf for your favorite candies and chips.)

To promote eating at home, the Supermarket of the Future could also feature routine cooking demonstrations and tastings that would show consumers how to prepare healthy foods like whole grains and legumes. A few upscale stores like Williams-Sonoma already do this occasionally, but these stores cater to only the most well-heeled consumers. Why shouldn’t all of us have the benefit of seeing easy ways to prepare delicious and wholesome foods on a daily basis?

Cooking demonstrations might be one of the Supermarket of the Future’s most attractive highlights; consider the popularity of the Food
Channel and the nearly universal appreciation of free samples. Imagine multiple demonstration areas where you could see five different ways to prepare seasonal vegetables, as well as stations where you could taste foods you have never before prepared or tried.

University of Southern California professors Peter Clarke and Susan Evans found that low-income families who relied on food pantries and were most vulnerable to obesity were not getting enough fresh fruits and vegetables. They arranged for unsold produce to go to these food pantries rather than in the trash. When the food pantry had a shipment of cabbages or broccoli, families could get bags of it—as much as they could carry home. But they quickly tired of eating it, and ended up throwing it out after a day or two.

Clarke and Evans investigated why this healthy food was being discarded. It turned out that most families knew only one or two ways to prepare the vegetables, like boiling or frying; this can make those veggies bland and unappealing. To address this problem, they provided dozens of recipes that helped the pantry users learn new ways to prepare foods. As we saw earlier, variety is critical to whet the appetite. The recipes were personalized and printed in a booklet with the family’s picture on the cover. As a result, the families ended up consuming more of the vegetables and wasting less.
⁷

If supermarkets provided cooking demonstrations, samples, and recipes, many more families would likely expand the variety of fruits and vegetables and whole grains they would eat, which could lead to substantial improvements in the American diet across all social classes.

Of course, to be sustainable the Supermarket of the Future has to be profitable—or at least to break even. If such a store keeps people healthy and doesn’t lose money, then it is a no-brainer for the government, health insurance companies, and large employers to sponsor the enterprise. There appears to be a widespread belief in the food industry that the only way a supermarket can be profitable is by selling foods that increase our risk of chronic disease. I believe, however, that there is a good chance that healthier supermarkets would also be very successful.

For example, Whole Foods’ business model is built on the premise that it offers its customers healthier foods. As a consequence, it has
become a highly profitable company. But a new kind of supermarket model could go well beyond what Whole Foods offers and provide more support for consumers to choose a healthy diet without the higher cost.

We need supermarkets that link meal planning, purchasing, and consumption so that people can optimize their nutrition. Having a functioning, practical supermarket-based consumer laboratory that studies how people decide on food purchases could be a critical scientific endeavor that could make an enormous difference in population health.