The Obesity Epidemic: Solutions for Discussion

1. The Obesity Epidemic:Solutions for Discussion Deborah Cohen, MD, MPH

2. Agenda • Brief presentation as to why most people cannot control intake in an obesogenic environment • Open discussion of future approaches: • Should we demonize the snack food industry or emphasize the vulnerability of people to an obesogenic environment: • Rating and labeling?? What about restaurants? • Structured grocery shopping.

3. More at www.healthscaping.org

4. Current Assumption about Obesity • With the right information and sufficient motivation, people can reduce their food intake over the long term and prevent obesity, regardless of their environmental conditions

5. The Environment Is Stronger than Individual Willpower • Eating is an automatic behavior that occurs in response to food and other cues • People typically don’t have insight into the cues that make them eat too much • People have no internal mechanism to precisely regulate calorie consumption • People often have the illusion that they are independently and consciously controlling what and how much they eat

6. Why Aren’t We Aware of Everything We Do? • Human cognitive capacity is limited • We can only think about one thing at a time, so everything else functions automatically • Human beings can process only 40-60 bits per second - equivalent to a short sentence • However our entire processing capacity, which includes the visual system and the unconscious, is estimated to be 11 million bits per second. • The brain needs mechanisms to perceive the environment and react without awareness

7. The Brain Relies on Shortcuts Called “Heuristics” • Simple, efficient rules, hard-coded by evolutionary processes which have been proposed to explain how people make decisions, come to judgments, and solve problems-- “shortcuts” • Brands • Prices • Salience • What other people do • Appearance/ color/ size/ shape • The more we are overwhelmed by information, the more we rely on shortcuts • Shortcuts facilitate automatic behaviors

8. Eating Is an Automatic Behavior (To be considered automatic, it doesn’t have to be automatic all the time) • Lack of awareness • Lack of intent • Lack of effort • Lack of control, meaning the inability to stop if we choose

9. Portion Sizes Play a Role in How Much We Eat • Subjects consumed 30% more calories when offered the largest portion than when offered the smallest portion • Larger portions led to greater calorie intake regardless of serving method and subject characteristics • Rolls BJ, Morris EL, Roe LS. Portion size of food affects energy intake in normal-weight and overweight men and women. The American journal of clinical nutrition. Dec 2002;76(6):1207-1213.

10. Visual Cues Influence Consumption • Subjects received soup in different colored bowls • Half the subjects had soup in self-refilling soup bowls, half had normal bowls • They were told to rate the soup and estimate how much they ate

11. Results: People with Self-Refilling Bowls Ate 73% More • People given self refilling bowls ate 73% more • The groups perceived that they ate the same amount • Both groups thought they ate less than they did • People in the self refilling bowl condition did not feel more full than the other group (Wansink et al, Obesity Research 2005;13:93-100)

12. Variety Increases Consumption Having many different choices (colors, flavors) increases consumption • People offered an assortment of 10 colors of jellybeans ate 43% more than the group offered 7 colors • People offered the jellybeans in a mixed assortment ate 69% more than the group offered jellybeans sorted by color Wansink B. Environmental factors that increase the food intake and consumption volume of unknowing consumers. Annu Rev Nutr 2004;24:455-79.

13. Subliminal Priming Influences Consumption • People are usually unaware of influences • Compared to people shown subliminal pictures of a frowning person, those exposed to subliminal picture of a smiling person: • Poured greater quantity of drink • Drank more • Rated drink more favorably and were willing to pay more! Berridge KC, Winkielman P. What is an unconscious emotion? (The case for unconscious "liking"). Cognition and emotion. 2003;17(2):181-211.

14. Mimicking Leads to Increased Liking: Animal Crackers and Goldfish • In a study the interviewer and the participant were both given a bowl of goldfish and a bowl of animal crackers to munch on while they talked. • In one condition, the interviewer ate the goldfish, in the other, he ate the animal crackers Chartrand T. The Role of Conscious Awareness in Consumer Behavior. Journal of Consumer Psychology 2005;15(3):203-210.

15. Mimicking Leads to Increased Liking: Animal Crackers and Goldfish • People unconsciously mimicked consumption of either goldfish or animal crackers, depending on what the interviewer ate. • Participants more likely to report preferring the product they ate, which was determined by interviewer’s choice. • No insight among participants Chartrand T. The Role of Conscious Awareness in Consumer Behavior. Journal of Consumer Psychology 2005;15(3):203-210.

16. Ice Cream Taste Test • Participants invited to judge ice cream. Confederate took a sample of ice cream first • Participants took a portion that was the same as the confederate • How much they ate depended on scoop size the confederate took • Participants were unaware of why they chose the amount of ice cream Dijksterhuis et al (2005) Jl of Consumer Psychology

17. Doubling shelf space increases sales by 40%

18. Summary • Definite causal relationships between environment and eating behaviors • Environment dominates and eating is a responsive, automatic behavior • We can’t control what we are unaware of

19. We Need to Change the Food Environment • Reduce cues to eat • Reduce food availability • Control portion sizes • Increase relative prevalence of nutritious foods

20. Lessons from Tobacco Control Techniques that worked: • Taxing cigarettes • Media campaign making smoking unattractive • Reducing tobacco accessibility (removing vending machines, placed behind counters) • Frequent cues reminding people not to smoke • Restricting places where smoking is allowed (Clean air laws)

21. Food Industry Marketing is a BIG Problem • Most people need protection from the food industry’s aggressive marketing, especially marketing of junk foods and sugar-sweetened beverages.

22. Pavlov’s Dog • Pavlov conditioned dogs by ringing a bell when food was available • Dogs salivated when they heard the bell • Humans are also conditioned to “feel hungry” • stimulated by symbols, smells, memories associated with food, and especially food itself

23. Snack Foods Are Everywhere • Car washes • Book stores • Hardware stores (Home Depot) • Gas stations • Office buildings (vending machines) • Health clubs/gyms • Video stores • Car repair shops

29. IDEAS • Media campaign against sugar-sweetened beverages and junk foods • Restaurant rating • Structured grocery shopping

30. Media Campaign • Most anti-obesity campaigns focus on promoting fruits and vegetables and increasing exercise • Need negative ads/messages that constrain excessive consumption • Efforts limited primarily to removing soda and the worst energy dense foods from schools.

31. Louisiana STEPS Campaign • Created a billboard likening soda (generic) to IV drugs

32. What Happened? • Coca Cola Company complained • City Council removed the billboard

33. British Heart Foundation • “Gross me out” campaign (2005) • Short-lived– now some references on their website

37. Media Campaign

38. H.R. 554 [109th]: Personal Responsibility in Food Consumption Act of 2005 (3) a person's weight gain, obesity, or a health condition associated with a person's weight gain or obesity is based on a multitude of factors, including genetic factors and the lifestyle and physical fitness decisions of individuals, such that a person's weight gain, obesity, or a health condition associated with a person's weight gain or obesity cannot be attributed to the consumption of any specific food or beverage; and (4) because fostering a culture of acceptance of personal responsibility is one of the most important ways to promote a healthier society, lawsuits seeking to blame individual food and beverage providers for a person's weight gain, obesity, or a health condition associated with a person's weight gain or obesity are not only legally frivolous and economically damaging, but also harmful to a healthy America.

39. Acceptability of Anti-Junk food/beverage messages? • Should we demonize snack foods or the snack food industry? • Eg. Sunkist soda story • Do people and/or policy makers need to believe that we are vulnerableto marketing techniques first and that eating is an automatic behavior?

40. The Market for “Lemons” • If quality is an important but cannot be assessed by a buyer, competition will be on price and other observed characteristics (e.g.. larger portion size) • This drives out higher quality products even if they would be preferred by buyers with more complete information. • When informational problems are sufficiently severe, regulation is needed for an efficiently working market. Akerlof GA. The Market for 'Lemons': Quality Uncertainty and the Market Mechanism. In: Akerlof GA, editor. In: Explorations in Pragmatic Economics: Selected Papers of George A. Akerlof (and Co-Authors); 27-38; Oxford and New York: Oxford University Press; 2005.

41. Restaurant Rating • Restaurant inspections concerned primarily with food safety/infectious disease. • Chronic disease are currently more important. • Restaurants are regulated by the Dept. of Health • Need a new inspection protocols and rating systems based upon risk for chronic disease.

42. Success of Inspections, 1996 • 25% had "A" level in 1996; >50% of restaurants "A" in 1998 • 13% drop in the number of patients admitted to the hospital for food related illnesses. • Quality of restaurants in the entire county became more equitable, • Average score increased from 74.5 to 89.8 in areas below the median county income, • Score increased from 78.8 to 89.5 in restaurants located in areas above the median county income Simon PA, Leslie P, Run G, Jin GZ, Reporter R, Aguirre A, et al. Impact of restaurant hygiene grade cards on foodborne-disease hospitalizations in Los Angeles County. J Environ Health 2005;67(7):32-6, 56; quiz 59-60. Jin G, Leslie P. The Effect of Information on Product Quality: Evidence from Restaurant Hygiene Grade Cards, Quarterly Journal of Economics 2003;118(2):409-51.

43. New Restaurant Inspection Protocol • Measure compliance with USDA guidelines • Rate the ability of patrons to obtain meals that include 1 cup vegetable, 1 cup fruit, < 5 oz meat, equivalent of 1 glass milk, 2 servings of grains (1 whole). • Include the portion sizes, make sure meals fall within a range for maintaining weight (500-1000 calories) (average 750); • Check availability of 500 calorie meals., • Post their score: “A” “B” “C”

44. Restaurant Ratings for Chronic Diseases • What is the acceptability? • Will they help people choose better?

45. Structured Grocery Shopping • 60% of supermarket purchases are impulsive • People frequently purchase non-nutritious foods from special displays, end aisles, candy check-out, just because they see them • What about putting together a grocery bag with everything needed to comprise a healthy diet for people, accounting for personal preferences?

46. How It Works Now • People select • food on their own • Impulsive buying • and eating • People eat in • restaurants with • excessive portions • and unhealthy • ingredients OBESITY and Chronic Diseases Wrong quantity and quality of food

47. What do families eat now? The book Hungry Planet featured 3 American families and showed what they eat and spend on food for a week • A California family of 4 thinks they are eating healthy and spends $159/week on groceries • A Latino family of 5 in Texas spends $242/week • An African American family of 4 in North Carolina spends $342/week

48. How well does the California family meet RDA guidelines? Spend $159/week on food including $12 at restaurants Sufficient fruit, low fiber No legumes Little other vegetables Low milk Low calcium Low Vitamin E and K 140% fat 250% salt Appropriate calories Caven

49. How well does the Latino family meet RDA guidelines? Spend $242/week on food including $54 at restaurants 128% calories Sufficient fiber and fruit No dark green vegetables No legumes Little orange vegetables Little milk Little calcium Low Vitamin E and K 200% meat 225% fat 400% salt Fernandez

50. How well does the African American family meet RDA guidelines? Spend $342/week on food including $78 at restaurants Insufficient fiber and fruit No orange vegetables Low starchy vegetables Low milk Low calcium Low Vitamin E Low Vitamin K 175% meat 300% fat 250% salt Appropriate calories Revis