Regulating the Food Industry: An Aspirational Agenda

EDITORIALS body mass index standards, overweight Regulating the Food Industry: An Aspirational Agenda is now normal for adults and becoming so for children. What happened in about 1980 to promote so sharp an increase in weight gain? Genetics did not change; neither did thermodynamics. From the standpoint of thermodynamics, weight gain Marion Nestle, PhD, MPH occurs when energy intake exceeds ABOUT THE AUTHOR expenditure. Whether energy expendi- Marion Nestle is professor emerita with New York University, New York, NY. ture decreased significantly from 1980 on is debatable, but energy intake most T he coronavirus pandemic reveals of ultra-processed foods with elevated definitely increased and by enough an urgent need: the marketing of risks of chronic disease and overall calories a day to account for the 10- to 4 stopped. Until now, the food industry be the most important nutrition study has gotten away with pushing con- done in decades, a clinical trial con- sumption of high-calorie, highly proc- ducted in a controlled metabolic ward essed products—as often and in as at the National Institutes of Health com- many places as possible, and in pared the effects of consuming two increasingly large amounts—all in the nutritionally similar diets differing only name of profit.1 In this business-first in their degree of processing.6 The result: food environment, obesity and its asso- when study participants were offered ciated type 2 diabetes, coronary heart ultra-processed diets, as opposed to disease, and, these days, severe out- diets constructed of minimally proc- comes from COVID-19, are collateral essed foods, they consumed an aston- damage.2 Because poor health more ishing average of 500 more calories a strongly affects the most vulnerable day and gained commensurate amounts 3 members of society, public health of weight. Participants judged the diets advocates ought to be demanding equally palatable and were unaware of immediate, forceful government action overeating when presented with ultra- to discourage food industry production processed foods. These findings make a and marketing of unhealthful products. strong case for regulation. 1980 to 2000.9 What did change was the food environment, and in ways that encouraged people to eat more food. Food companies marketed wider availability of their products, even in places never previously permitted such as libraries, bookstores, and clothing stores, and they promoted frequent snacking (more calories).10 Because the cost of food is low relative to that of labor, transportation, and rent,11 restaurants could increase portion sizes, as could companies making ultraprocessed products. Larger portions promote greater calorie intake in three ways: they provide more calories, they encourage greater calorie consumption, and they mislead people into underestimating how much they are Ultra-processed foods are those con- eating. Obesity prevalence rose in par- structed from industrially produced ingredients unavailable in home kitch- 20-pound average weight gain from HISTORY SINCE 1980 allel with increasing portion sizes.12 The low prices of ultra-processed ens and formulated to be “addictively” delicious (“you can’t eat just one”). Centers for Disease Control and Preven- foods also encourage overconsump- Box 1 gives my working definition. tion data demonstrate an increase in the tion. Since 1980, the prices of all foods Familiar examples are carbonated soft prevalence of combined overweight and have risen with inflation, but those of drinks, flavored chips, children’s cere- obesity among adults, from 47% in 1980 soft drinks and snacks rose much less als, chicken and fish “nuggets,” and to 74% in 2018,7 and among children than average, whereas fruits and vege- products with long lists of additives. from 15% to 35%,8 with higher levels tables became relatively more expen- among those who are Black, Hispanic, or sive.13 Low food prices democratize 4,5 We have the evidence: ultra-processed Published online ahead of print April 21, 2022 mortality. And, in what I consider to AJPH ultra-processed “junk” food must be 2,3 We products promote excessive calorie socioeconomically disadvantaged. intake and poor health. Many recent can argue about the precise cutpoints for rants where portions are large and studies associate frequent consumption increased health risk, but, by current more calories are consumed. eating in fast-food and other restau- Editorial Nestle e1 EDITORIALS BOX 1— Ultra-Processsed Foods: A Working Definition In contrast with foods that are unprocessed or minimally processed, ultra-processed products are  Not obviously related to the whole foods from which they were derived  Formulated with industrially produced ingredient additives (e.g., colors, flavors, sweeteners, texturizers) not usually available in supermarkets  Unable to be made in home kitchens  Formulated to be hyperpalatable (“addictive”)  Heavily marketed  Attractively and conveniently packaged  Relatively inexpensive  Highly profitable Note. Selected examples: Coca-Cola, Tang, Doritos, Oreos, Froot Loops, Spam, chicken nuggets, most commercial ice creams. Source. Adapted from Monteiro et al.4 US POLICY PROPOSALS During the 1980s and 1990s, calls for policy approaches to prevent excessive weight gain focused mainly on personal responsibility. But, in 2000, Michael Jacobson and I, recognizing the food industry’s role in weight gain, recommended measures such as taxes and advertising restrictions that would improve the environment of food choice.18 In 2001, the Surgeon General called for obesity policies to reduce racial, ethnic, gender, and AJPH Published online ahead of print April 21, 2022 FOOD INDUSTRY GROWTH IMPERATIVES age disparities and stigma; to encourage to report growth in profits every 90 food companies to provide foods and days.15 For food companies, expanding beverages in reasonable portion sizes; I attribute the causes of intensified sales in the face of 4000 calories a day food industry marketing since 1980 to per capita was a difficult challenge. To policy shifts in three areas: agriculture, meet it, they developed new products, Wall Street, and food regulation. Histor- promoted snacking, expanded fast- ically, Farm Bills paid agricultural pro- food outlets, sold food in new venues, ducers to leave parts of their land and increased portion sizes. unplanted as a means to prevent over- These efforts were supported by the and examine its marketing practices (my emphasis).19 Federal Dietary Guidelines for Americans explicitly target personal choice: they advise individuals to reduce consumption of sugar, salt, and saturated fat. The 2020 guidelines do not mention production and maintain crop prices antiregulatory policies of the Reagan “ultra-processed” except indirectly: “Food high enough for farmers to make a liv- administration, which allowed health manufacturers and retail establishments ing. But when Earl Butz became US claims on food packages and more can support Americans . . . by providing Department of Agriculture Secretary in aggressive marketing to children. Food healthy options in all the places where the early 1970s, he shifted policies companies increasingly targeted mar- foods and beverages are purchased. . . . from supply management to rewarding keting to children, to people of low Portion sizes also can be reduced. . . . farmers for producing as much food as socioeconomic status, to racial minori- Food manufacturers are encouraged to possible. Farmers responded. Between ties, and to populations in low-income consider the entire composition of the the late 1970s and 2000, the calories 16,17 countries. food or beverage, and not just individual available in the food supply per cap- In creating this “eat more” food ita—amounts produced domestically, environment, the food industry had or reformulating products” (again, my plus imports, less exports—rose from only one goal: to increase sales. Food emphasis).20(p50) about 3200 per day to 4000, an companies are not social service or amount roughly twice what the popula- public health agencies; they are busi- Healthy People objectives for nutrition tion needs on average.14 Caloric over- nesses required to put stockholder and weight status also mainly focused abundance forced food companies to earnings as their first priority.13 They on personal choice but are now begin- compete fiercely for sales. did not intentionally promote weight ning to address the need for environ- gain, and they saw no reason to take mental improvements. The 2020 greater competition. The early 1980s responsibility for it. They could blame objectives include modest goals for marked the advent of the shareholder excessive weight gain on personal increasing the proportion of schools value movement, which demanded choice and externalize the substantial that exclude sugar-sweetened bever- higher and more immediate returns on personal and medical costs of its ages and for increasing the number of investment. Never mind slow-earning consequences. states that provide incentives to retail Changes on Wall Street forced even e2 blue-chip stocks; companies now had Editorial Nestle nutrients or ingredients when developing Since 1980, the Public Health Service EDITORIALS outlets selling foods consistent with “should be encouraged [that word industry viewed these proposals as far dietary guidelines.21 again] to use their creativity and too restrictive and forced the FTC to resources to develop or reformulate back off from setting marketing tives not only ignore ultra-processed more healthful foods for children and standards.10 foods but also ignore three valiant but young people.”22(p60) Current guidelines and health objec- These attempts took place before unsuccessful attempts to address the One recommendation addressed food the COVID-19 pandemic exposed the food industry’s role in childhood obe- industry marketing. Echoing the Institute increased risks posed by obesity and sity (an easier target than in adults). In of Medicine report, the Task Force related chronic diseases and the 2006, the Institute of Medicine pub- warned that if voluntary efforts to limit disparities in their prevalence and lished a remarkably hard-hitting report marketing did not yield substantial before ultra-processed foods were on food marketing to children. This results, the Federal Communications recognized as a distinct category of report thoroughly documented the Commission “could consider revisiting foods and beverages. The categorical adverse effects of marketing on child- and modernizing rules.” Michelle Obama distinction is critical; it helps clarify ren’s food preferences, demands for reinforced this idea in an eloquent policy needs. branded products, eating habits, and speech to the Grocery Manufacturers body weight. It urged use of multiple Association: “We need you not just to policy approaches to prevent childhood tweak around the edges, but to entirely AN (ASPIRATIONAL) ADVOCACY AGENDA Antismoking advocates succeeded in education and assistance programs. It these products, and how you market reducing use of cigarettes through even warned that if food companies do those products to our children.”23 mass-media campaigns but also by cre- not voluntarily stop marketing unhealthy Let’s Move! did lead to improvements ating an environment less conducive to foods to children, Congress should enact in school food. But its other major smoking through higher prices, smoke- mandating legislation.14 But a follow-up achievements—calorie labeling in free policies, warning labels, and tobacco workshop in 2013 identified only mar- fast-food outlets and improved food control programs that addressed socio- ginal improvements in food industry labels—addressed personal choice. economic disparities. Strategies for responses, noting that regulatory actions The White House had no authority to curbing food industry promotion of would face difficult political and legal force food company compliance with barriers.16 overeating could follow this model.25 marketing or other public health meas- Changing the food environment is, of ures that might reduce sales, and its course, more complicated: we must Michelle Obama’s Let’s Move! campaign efforts to promote even minimal regu- eat to live. But taking action to reduce to end childhood obesity within a gen- lation were consistently and effectively the wide availability and promotion of eration, based on a 2010 report from blocked by heavily funded, concerted the White House Task Force on Child- opposition from the food industry.24 The second attempt was First Lady hood Obesity appointed by President The effectiveness of industry opposi- Published online ahead of print April 21, 2022 rethink the products that you’re offering, the information that you provide about AJPH obesity—agricultural subsidies, taxes, legislation, regulation, and nutrition ultra-processed foods could help reduce the overall burden of diseases related to dietary practices as well as the socioeco- Obama. While the Task Force focused tion was also evident from the third most of its policy recommendations on failed attempt, that of the Federal Trade personal choice (dietary guidelines, Commission (FTC) to set nutrition stand- food labels, calorie labels), it aimed sev- ards for foods marketed to children. In eral at the environment of food choice 2009, Congress directed the FTC to (portion sizes, school meal nutrition establish an Interagency Working Group standards, farm-to-school programs, (IWG) to develop such standards. The subsidies for healthier foods in food IWG proposed upper limits for sugars assistance programs, and economic and salt among other measures, but incentives for fruit-and-vegetable pro- made them voluntary and did not duction). “The food, beverage, and res- require implementation for six years. ously state “Avoid ultra-processed taurant industries,” the report said, Despite this generosity, the food foods” or at least follow the lead of nomic disparities in these conditions. Encouraging personal choice of healthier diets is helpful but not sufficient; the food environment needs to encourage healthy choice and to discourage consumption of ultra-processed foods, especially in large portions. Let us advocate the following:  Dietary guidelines to unambigu- Editorial Nestle e3 EDITORIALS the American Heart Association: a b “Choose minimally processed foods instead of ultra-processed foods.”26 Note: US dietary guidelines directly influence federal food assistance, school, and child care feeding policies and programs.20  Mass media campaigns to help the FIGURE 1— Two Suggestions for Front-of-Package Warning Labels for Ultra-Processed Foods public recognize ultra-processed foods, reduce (but not necessarily Note. Figure 1a: Ultra-processed added to the Nutri-Score label; this summarizes a food product’s composite balance of nutrients and ingredients. The color-coded scores range from the healthiest— A (dark green—very healthy) to B (light green), C (yellow), D (orange), and E (red—best to avoid).29 Figure 1b: Ultra-processed added to warning labels about salt, sugar, and saturated fat used in Latin American and other countries.30 Source. Figure 1a courtesy of Serge Hercberg. Figure 1b courtesy of Trish Cotter. eliminate) their consumption, and understand the food industry’s role as a commercial determinant of poor health.27  Taxes on ultra-processed foods. Taxation of sugar-sweetened bever- intake. Mandating pre-1980 por- forced the government to block dietary ages is associated with reduced tions could help renormalize rea- guidelines from addressing sustainabil- sonable serving sizes. ity and weakened nutritional standards Farm subsidies. We should subsi- for pizza, potatoes, and tomato paste in the nearly 20% reduction in sugar dize the production of healthy food schools. In such instances, and in soda availability since 1999 and to strate- for people and stop subsidizing companies’ willingness to spend for- gies to reduce the cost of healthier feed for animals and fuel for tunes to fight tax initiatives, the food automobiles.33 industry has positioned itself as a prime consumption and health improve- foods.28  AJPH Published online ahead of print April 21, 2022 ments. Taxes could contribute to  Warning labels on ultra-processed Would policies like these stand a saturated fat, and calories already chance in today’s political and social affect a large percentage of these context? They would confront formida- products, but recent suggestions ble attitudinal, legal, and legislative for specific warning labels on hurdles. In the United States, lifestyle unrealistic, but they are not impossible. ultra-processed foods deserve seri- mandates of any kind are especially Legal scholars have identified laws that ous consideration (Figure 1).29,30 fraught (witness opposition to mask could be tweaked to improve the envi- Marketing restrictions. As with wearing). Food companies design and ronment of food choice, among them cigarettes, legal authority is needed market ultra-processed products to be the Farm Bill (Pub L 115-334 [2018]) to consider plain packaging, curbs widely available, appealing, and inex- and regulations governing school nutri- on television and social media pensive (hence, “addictive”5); people tion standards.35 Even seemingly weak advertising, restrictions on retail love eating them and may not be able advocacy groups can harness their product placements, sales and ser- to afford healthier foods. The normali- power to effect change when they share vice in schools and institutions, and zation of overweight only expands the a compelling vision, organize commu- other such measures, especially as proportion of the population likely to nity support, and build coalitions.36 directed toward children. The resist imposed measures. Aspirational goals also have power. rather than in the public—interest.34 These policy suggestions may seem Unrealistic public health goals can motivate action, expand expectations, edu- “nanny-state” measures. They also cate, and attract resources; sometimes, Portion size restrictions. Before invoke First Amendment protections. they can even be achieved.37 the pandemic, restaurant and Just as the tobacco industry used its this, as have several countries in 32 Latin America. Editorial Food companies and trade associa- induce government to act in their— tions take advantage of resistance to 31 e4 example of how corporations can foods. Warnings about salt, sugar, United Kingdom has started doing   We could too. While we are thinking in aspirational fast-food meals accounted for at “playbook” tactics to oppose regulation terms, let us not forget root causes. We least half of Americans’ calorie of cigarettes, the food industry has must also demand policies that link Nestle EDITORIALS agriculture to public health, keep corporate money out of politics, reduce corporate concentration, and require Wall Street to evaluate corporations on the basis of social as well as fiscal responsibility. In comparison with those challenges, taking on the food industry should be easy. Let’s get to work. [Note: For additional reading, please see the supplemental references, available as a supplement to the online version of this article at https:// ajph.org.] CORRESPONDENCE Full Citation: Nestle M. Regulating the food industry: an aspirational agenda. Am J Public Health. Published online ahead of print April 21, 2022:e1–e6. Acceptance Date: March 11, 2022. DOI: https://doi.org/10.2105/AJPH.2022.306844 ACKNOWLEDGMENTS The author thanks Malden Nesheim, Jennifer Pomeranz, and four anonymous peer reviewers for helpful comments on an earlier draft of this article. CONFLICTS OF INTEREST The author has no conflicts of interest. 6. Hall KD, Ayuketah A, Brychta R, et al. Ultraprocessed diets cause excess calorie intake and weight gain: an inpatient randomized controlled trial of ad libitum food intake [errata in Cell Metab. 2019;30(1):226 and Cell Metab. 2020; 32(4):690]. Cell Metab. 2019;30(1):67–77.e3. https://doi.org/10.1016/j.cmet.2019.05.008 7. Fryar CD, Carroll MD, Afful J. Prevalence of overweight, obesity, and severe obesity among adults aged 20 and over: United States, 1960–1962 through 2017–2018. NCHS Health E-Stats, 2020. Available at: https://www.cdc.gov/nchs/data/ hestat/obesity-adult-17-18/obesity-adult.htm. Accessed March 4, 2022. 8. Fryar CD, Carroll MD, Afful J. 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