Authors: Deborah Cohen
Moving Forward
Societies have been very serious about alcohol control for centuries and have developed a large portfolio of regulations that have kept alcohol-related problems under control. But alcohol policies, especially those seen to infringe on business (such as restrictions on outlet density or excise taxes, which might be an inconvenience or burden to moderate drinkers), have been subject to a great deal of controversy. Yet over time, many of these measures have become widely accepted and have been shown to be effective in curbing alcohol-related problems.
Even though alcohol is an addictive substance and it is legal, its accessibility and salience in our society have been kept under control; it has not been allowed to proliferate the way food has. Moreover, the long-term consequences and costs to society of overeating are now considerably higher than the consequences of immoderate alcohol consumption. While some of the laws that are acceptable and feasible for alcohol control may seem overreaching for obesity control at present, I believe this is only because comparing the alcohol environment to the food environment constitutes a new way of thinking.
Innovations for regulating the food environment will likely have to start at the local level, with courageous leaders who are not beholden to special interests. Our towns and cities will likely lead the way by passing model ordinances and demonstrating that regulating the food environment will not be the end of the world but instead will provide a measurable benefit to local constituents.
Some localities are already trying to implement policies that regulate the food environment. In 2010, the City Council in Watsonville,
California, passed regulations that define a “healthy” restaurant. All new restaurants have to adhere to new standards regulating the food that is offered in order to obtain a business permit.
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In South Los Angeles, activists successfully pushed for a ban on new fast food outlets.
Some of the other policies mentioned, like standardizing portion sizes, could be adopted fairly quickly and may actually have a positive impact on profits if outlets sell smaller quantities of food at the same price or higher. Other policies, like prohibiting bookstores and hardware stores from selling junk food, will undoubtedly reduce the profits of those businesses. Policies like density limits might be the most difficult to pass, but they could eventually be achieved by not issuing new licenses once an outlet closes.
Our society has implemented multiple laws and regulations to protect individuals. Efforts to control tobacco use, like raising the taxes on cigarettes, only affect smokers. Regulations that require people to wear seat belts in cars or helmets when they drive a motorcycle mostly benefit the wearers. Yet any regulation that prevents people from becoming sick and injured has a secondary benefit to families and society by reducing the burden of health-care costs and disabilities. Therefore, society has a strong rationale for intervening on the factors that lead to obesity.
As the prevalence of obesity grows, and with it the costs of dealing with its associated health problems, the need for society to take stronger action is becoming increasingly apparent. Just as regulating alcohol accessibility has been effective in reducing problem drinking, regulating food accessibility is a promising way to control the obesity epidemic. No single policy will be a panacea. Like alcohol control policies, policies that address obesity need to be multipronged, incorporating a mix of approaches that include restrictions on access to problem foods, reductions of impulse marketing, point-of-purchase warnings, and portion control. Alcohol control policies represent a middle ground in the regulation of a substance that is healthful when consumed moderately and harmful when consumed to excess. In the face of the emerging challenge of obesity, alcohol control policies are important models to follow.
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Whenever I ask my husband what he wants me to make for dinner, he says, “You decide. Whatever you want to make. Just make something and tell me to eat it.”
He has a very demanding job. He gets up before the crack of dawn, drives to work, puts in at least ten hours (or more), and when he comes home he is mentally exhausted and doesn’t want to have to make any more decisions. He also knows that he usually likes whatever I prepare.
Sometimes he does the same thing in restaurants. When he can’t decide what to order and he narrows it down to a couple of choices, he asks the waiter, which one do you like? And then he orders what the waiter likes!
Most of the time he takes the leftovers from dinner for lunch the next day. That way, he is not at the mercy of nearby lunch trucks, and he doesn’t have to take the extra time out of his day to go to a restaurant. But he also doesn’t have to waste his mental energy figuring out what to order.
All of this means that the burden of figuring out what my family should eat falls on me. I’m the one who has to spend a significant part of my limited mental capacity on meal planning. Some people solve this problem by having the same food based on the day of the week—Monday is spaghetti, Tuesday is chicken, Wednesday is hamburgers,
etc. Even though I can see the wisdom of such a routine, I hate to have the same thing over and over. But I also find it challenging to find a variety of recipes that are easy to prepare, tasty, healthy—and will be liked by everyone in the family.
If I haven’t planned it ahead of time, I might not have the ingredients for a meal that I would otherwise like to prepare. Sometimes I am too fatigued to come up with something that could make use of whatever is in the house. When this happens, we might just splurge and go out to eat. But that also means we end up with food that usually has too many calories, salt, sugar, and fat.
I doubt that we are the only family that finds putting food on the table every day a bit taxing, especially if we care about flavor, freshness, and health. Right now, the design of most supermarkets and restaurants makes it difficult for families to meet the Dietary Guidelines for Americans. But it doesn’t have to be this way. Supermarkets and restaurants could be redesigned to help us meet these standards.
Because most people don’t grow their own food, these two types of food outlets are the most logical places to change to help people moderate their intake of food. As described in Part II of this book, the design and management of restaurants and grocery stores are among the primary factors that lead people to make poor dietary choices. But even though we know how these places lead people to make poor food choices, we have less evidence about how they could be changed to help people make healthier choices.
We devote an inordinate amount of effort and resources to studying how to improve the quality of health care and to promoting adherence to medical treatment regimens for people with diabetes and heart disease. But we spend precious little on making sure these same people eat a healthy diet that won’t exacerbate their medical conditions. It’s time we focus on the factors that lead people to consume foods that lead to chronic diseases in the first place.
Even though we may not believe that people have a limited capacity to eat wisely in the current environment, Americans might accept this if there was strong evidence that designing and managing food outlets differently would make it easier for people to change their own behaviors.
Americans place great faith in science and usually believe the results of carefully done studies. For this reason, establishing scientific laboratories in real-world food outlets is vital. We need these laboratories to identify, deconstruct, and make transparent the elements of the food environment that lead to unhealthy food choices, as well as to create outlets that help us make us healthier choices automatically.
Most of the time when people eat away from home, they choose foods of a quality worse than what they would prepare at home: foods that are more likely to increase their risk of getting chronic diseases. The reasons behind this are twofold: first, lower-quality food is predominantly what’s available and salient; second, in the restaurant setting, people’s choices are more likely to be impulsive and thus to favor high-calorie, low-nutrient foods that increase the risk of chronic diseases.
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And when people eat too much (or too little) of a particular food or nutrient at one meal, they don’t naturally compensate by eating less (or more) at another meal. If people ate out only occasionally, the poor quality of restaurant meals would not be a problem, but most Americans eat away from home routinely.
About one-third of Americans’ daily calories come from food purchased for consumption outside the home, yet we eat out less than one of every three meals.
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The average American eats commercially prepared food about three times per week. Nearly 20 percent of males and 10 percent of females eat commercially prepared foods six or more times each week, while 56 percent of Americans eat out two or more times per week and fewer than 24 percent eat out less than once a week. The more people eat out, the more likely they are to be overweight.
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Although most Americans hold the government responsible for making sure that the water we drink is safe and the air we breathe is clean, until recently, we have had no expectations that the government will ensure that restaurant food will not contribute to diseases like diabetes, heart disease, or cancer.
This is beginning to change. For example, following Denmark’s lead in banning trans fats, a type of oil known to increase the risk of heart disease, New York City banned them. This was followed by bans
in California and in a variety of localities like Philadelphia, Seattle, and Puerto Rico. Similar bans are being considered by dozens of other jurisdictions. This ban has been broadly accepted—and no one has yet demanded that it be rescinded.
Another food regulation policy being pursued on a national basis is salt reduction. Substantial efforts are under way to persuade food companies to voluntarily decrease the amount of salt they put into food because consuming too much salt increases the risk of hypertension and stroke, among the most common causes of death.
Restaurants are now regulated primarily on criteria related to hygiene and the prevention of food-borne infectious diseases. Typically inspectors from the health department check the kitchens of all restaurants to ensure that they are following hygienic procedures with respect to food preparation, storage, and service. These regulations are lengthy and rigorous, yet restaurants all over the country have found it possible to comply, even when it means they have to add ventilation systems, plumbing, and expensive cold-storage equipment.
In Los Angeles, sanitarians, also called environmental health specialists, have a checklist of more than one hundred items they inspect in every restaurant. They measure the temperature of storage and preparation of “potentially hazardous foods,” like meats, cut fruit, and even garlic in oil mixtures. They look for signs of rodents and cockroaches, check that the shellfish have tags showing the date of purchase, make sure wiping cloths are clean and that food preparers wear hairnets, and they even check the toilets to make sure they are clean and equipped. Our health departments devote considerable effort to preventing food-borne infectious diseases, but they do next to nothing to prevent diet-related chronic diseases, which are far more prevalent and cost considerably more of our health dollars.
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The magnitude of the risk from a poor diet is not well appreciated. For example, the increased risk of getting lung cancer from exposure to secondhand smoke as the result of living with a smoker is estimated to be between 13 percent and 47 percent, which is about the same increased risk we face of getting colon cancer by eating red meat every day.
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We have regulations that ban smoking in restaurants, but not a single warning to help people reduce their consumption of red meat,
much less reduce the gargantuan portion sizes that steakhouses and BBQ restaurants typically serve.
Obesity doubles the risk of premature mortality. Compare this to the risks we face from chemicals and toxins in air and water, which are usually banned or carefully monitored when they increase the risk of cancer by just one case per one hundred thousand individuals.
A primary reason that we have not been more aggressive in regulating what restaurants offer is that we assume what people choose to eat is a result of their conscious decisions. No one is forced to go to a restaurant. We also believe that customers in a restaurant are free to choose the foods they want.
Herein lies a misconception about individual agency and capacity. Many people eat out not because they want to but because they have to. Business meetings are often conducted over meals in restaurants, and failing to participate would be a detriment to one’s ability to compete professionally. Social gatherings occur in restaurants, and failing to attend would isolate people from family and friends. Many people must use restaurants when they travel for business, and many have other justifiable reasons why they cannot prepare their own food at home. Some simply lack cooking skills.
But even this is beside the point. People should be able to eat out without putting their health on the line. They should not automatically be served foods that increase their risk of chronic diseases. Most important, as we have seen, people’s food choices are often influenced in ways they cannot easily recognize or resist, and in a restaurant those choices are constrained to what is available.
The political changes necessary to foster the Sanitary Revolution of the nineteenth century required a common belief that filth was bad. Passing alcohol control policies required understanding the harms from drinking and the foolish behavior people are capable of while under the influence. And advances in safe working conditions and legislation guaranteeing equal access and reasonable accommodations for the disabled required a sense of fairness and justice.