A Big Fat Crisis (32 page)

If there is any lapse and anyone gets sick, the public screams, “Why isn’t the government doing even more to protect the food supply?” No one is clamoring to eliminate food policing. We do not tolerate leniency when an outlet sells food that threatens the lives of its customers with deadly viruses or bacteria. We demand that the business be shut down immediately.

Our system works fairly well: outbreaks of deadly food-borne diseases are uncommon, and infectious diseases from unclean food are no longer in the top ten causes of death in the United States. In 1900 enteritis and diarrhea were grouped as the third major cause of death, after pneumonia and tuberculosis. Today, an estimated three thousand Americans die annually from a food-borne disease—but that is a drop in the bucket compared to the estimated four hundred thousand who die annually from poor diets and lack of physical activity.
⁴

One argument for protecting people from food-borne infectious disease rather than from chronic diseases is that people cannot easily tell whether food is contaminated with viruses and bacteria. Customers may have no way to protect themselves from bacteria, but in theory they should be able to avoid unhealthy foods.

Yet under the current conditions, most people cannot make their short-term choices conform to their long-term goals. Regulating food outlets would make achieving one’s optimal weight within reach for the average person. Many people regret the decisions they have made to eat unhealthy foods. They recognize they are making poor choices, but they cannot easily change. Most of us are vulnerable to the positioning, placement, pricing, priming, and conditioning strategies that lead us to eat more than we intend.

Regulation of construction, from the designation of the types of bolts and screws to the allowable height of the building, has become very well accepted, and many, if not most, would consider it an absolute necessity. I have no doubt that regulation of the placement, presentation, and sale of food directly associated with chronic diseases will eventually stop the obesity epidemic and limit diet-related chronic diseases. Moreover, I believe that food outlets that exceed
these minimum regulations and take care to serve only food that protects against chronic diseases will eventually become the most exclusive and desirable.

Ironclad scientific proof that a policy will be effective is often demanded before enacting any regulation that might be burdensome. Yet obtaining proof may require implementing a policy. How can one know if something works if it has never been tried? Indeed, many laws and policies are “experimental” and instituted or revoked based upon whether the politicians in power find them to be an advantage or a disadvantage. Given the crisis we are in, we should be willing to try all sensible approaches that help people moderate consumption. If the approach doesn’t meet expectations in a reasonable period of time, it can be changed.

The regulations proposed herein are not bans on food, but rather constraints on salience, marketing, convenience, and accessibility.

Many people reading the ideas in this book will worry that I am proposing regulations that tell people what they can and cannot eat or that I am proposing a new cadre of food police to snatch prohibited foods out of people’s mouths or force people to exercise. Not at all. What I am advocating is really no different from the principles already being implemented by my County Department of Building and Safety. Just as we have standards that govern construction design, layout, and how raw building materials are used in homes, we also need standards for how foods are prepared and marketed to the public. “Choice architecture” is a term that suggests we should create environments and conditions that are conducive to better health. We should make certain that poor choices are deliberate rather than automatic, and make the consequences of a poor choice transparent. Healthier choices should be the easiest choices.

Because the current epidemic is primarily the result of wide-sweeping changes in the way food is marketed and sold, including the excess availability of high-calorie, low-nutrient foods, too-large portion sizes, and ubiquitous food advertising, we need to work collectively to address these root causes of the problem. Alone, our powers are extremely limited. We would have to remove ourselves from society to avoid its influences.

We can’t forget that the food industry’s aggressive marketing strategies undermine our health behaviors. Even though the food industry may claim it does not intend to exploit us, many current marketing tactics that are acceptable for items like tennis shoes, picture frames, or flowers should not be employed to push food. We won’t become overweight or sick with a chronic disease if we buy too many T-shirts, but we will if we purchase and eat too much food.

As a public health approach, diets are the wrong solution. Diets are only appropriate for select individuals. Diets place the onus on the individual, but we have to focus on and remediate the environment around us. We have to keep reminding ourselves that this new epidemic is not the result of people’s irresponsiblity, weakening moral fiber, or inferiority of character; it is the result of excess food availability and salience.

Placing the burden on each individual to avoid supermarkets, restaurants, and convenience stores, not to watch television or visit theaters, to avoid company meetings and common work areas, and to identify routes that do not pass vending machines is unreasonable. The placement of food and food cues where we don’t need to eat is similar to yelling “Fire” in a crowded theater. It gets us into action unnecessarily, artificially triggering a chain of events that force us to make a decision—to choose or resist. Making a decision to resist will tax our cognitive reserves, a waste of our precious but limited mental resources.

Increasing the level of government regulation in a country that abhors big government is not going to be easy. Contractors always complain about building code regulations, but people whose homes survive earthquakes and other natural disasters appreciate the fact that the buildings are strong. When buildings and structures are not built according to code, terrible disasters occur. Think of how the canal walls failed in New Orleans after Hurricane Katrina. Tens of thousands of people lost their homes because the contractors had taken shortcuts and did not ensure the canals’ structural integrity. And think of the children crushed in collapsed schools in earthquakes in China or the three hundred thousand killed in Haiti by buildings that were constructed
without the benefit of strict regulations, inspections, and architectural reviews.

When we finally realize how the current regulatory neglect results in our developing chronic, preventable diseases that make us miserable and shorten our lives, perhaps we will introduce public health policies that will be effective.

Most important, new rules and interventions should be accompanied by evaluations—we need a research agenda that carefully checks whether these policies are working. If the new policies don’t work, then we should change them.

These proposed new rules don’t ban foods or tell anybody what they should or shouldn’t eat. They would only make unhealthy foods a little less accessible and a little less attractive. In a world that protected people against obesity, we would still have plenty of food that satisfies our cravings for variety, novelty, and pleasure. We would dine on fresh fruits and vegetables, whole grains, and eat much smaller quantities of meats, sugars, and saturated fats.

In the future we will want to eat because we feel hungry, rather than having pseudo-feelings of hunger being constantly stimulated by cues on radio, television, billboards, posters, and personal computers. We will enjoy our meals, which will be designed to be tasty and satisfying and to keep us in optimal health. We will be able to spend our mental energies and time in pursuit of happiness, working on our careers, raising our families, participating in civic life, and getting sufficient leisure and recreation to maximize our health and well-being, rather than fretting about dieting or worrying about what to eat.

We won’t have to stay home and cook every meal for ourselves because restaurants and fast food outlets will be able to prepare healthy meals that are just what we need. The atmospherics in restaurants and other settings that previously made us buy and eat too much will be replaced by atmospherics that will both keep us in energy balance and keep the food industry in business. In fact, restaurants and food outlets will be able to customize the foods so that they are in the appropriate portion for each of us. An ID card or a driver’s license could encode our individual energy requirements so that when our cards are swiped with
our orders, the restaurant will know exactly how much to serve us. The grocery store will know our preferences and will present us with a bag of groceries that contains not only the foods that provide the nutrients we need but also the ones we like. If we want to override these selections, we can, but most of the time we will be delighted that we are being served exactly what we need, and we will be satisfied with that.

This idea is not that futuristic. Once restaurants figure out what the nutrient qualities of their food items are, which many already do, it’s only a matter of simple math and measuring spoons, cups, rulers, or kitchen scales to determine the right quantity to serve. Expecting that customers will be able to do this themselves, to be given an extra-large portion and then to have to carry their own measuring spoons and cups is unreasonable. We won’t be able to carry utensils and keep them clean, nor, as I showed earlier, will we be able to judge appropriate portions without measuring tools.

Instead of pointing fingers at overweight and obese individuals for having self-control problems, let’s recognize that, for the most part, they are doing the best that they can given the conditions in which we live. We will look back on this era with astonishment, and wonder how we allowed—without challenge—companies to create the illusion that drinks that are no more than sugar water and other highly processed junk foods are better, classier, more prestigious, and more valuable than nutritious beverages and foods.

We have to make some accommodations in the environment so that we can avoid overconsumption without having to struggle so much. If we can make reasonable accommodations for the disabled, no doubt we can accommodate the tens of millions who want to control their weight.

With any change there will be winners and losers. Although some businesses may adapt and maintain their market share, others may lose profits, and still others may gain if they can offer superior products or alternatives that meet new standards that reduce obesity and chronic diseases.

A society that will keep us healthy will not exist anytime soon unless we take steps to make it so. It will not come easily, but it can happen if we want it to. Between now and then, many incremental
steps have to be taken. The good news is that we have the resources to create a healthy, and more than sufficient, food supply. What we lack are leadership, vision, and the general acceptance of the fact that most individuals will not be able to improve their health without the support of society as a whole.

The steps we have to take to control obesity are not earth-shaking or unreasonable. In contrast to other societal reforms, the changes we need may be barely noticeable, especially if phased in gradually. While menu-labeling may seem revolutionary now, in a few years, it will seem archaic and slightly misguided as we find more effective ways to help people choose healthy foods. Similarly, once we institute practices like standardized portion sizes, impulse marketing constraints, counter-advertising, restaurant ratings, and other policies in worksites, schools, and communities, we will soon take them for granted, just as we now take for granted the conditions that have been engineered to make us overweight and obese.

It is neither normal nor natural for us to be confronted multiple times each day with images of and access to unlimited foods, especially candy, cookies, soda, pastries, fries, and chips. The environment is engineered on behalf of a food industry that is so concerned with profits that it will do anything to get us to eat as much as we can. A food industry that cared about us would not be pushing sugar, fat, and salt. It would not manipulate us to eat too much with extra-large portions and processed foods. We need to un-engineer the environment so that it doesn’t artificially make us hungry and provide us with too many foods that make us sick.

I have hoped to show in this book that being overweight is not an individual problem but rather a consequence of human nature functioning in normal, predictable ways when too much food is available. Ultimately, our personal behaviors depend on local conditions, conditions that we do not design and cannot control as individuals, but that are potentially controllable through public health policies and regulations.