The Cure for Obesity and Diabetes Is Processed Food (Part 2): Incentives, Influence, and Innovation
Continued from: The Cure for Obesity is Processed Food (Part 1): When the Poison is the Antidote. Original article appeared on Actualize.
‘Big Food’ is the New ‘Big Tobacco’: Using Economic and Social Deterrents
In 1994, the CEOs of the seven largest big tobacco companies testified under oath to Congress, shamelessly claiming “nicotine is not addictive”, despite mountains of evidence to the contrary. Like obesity, smoking seemed like an unwinnable war at the time. But major successful lawsuits against ‘Big Tobacco’ paved the way for successful public health efforts. Progressive state governments like California delivered a one-two punch that helped many people kick the habit. First, they significantly taxed cigarettes, which skyrocketed costs from $1/pack to currently over $10/pack, which financially penalized consumption to cost thousands of dollars a year for chronic smokers.
Second, by banning cigarettes from workplaces, restaurants, and bars, societal norms around smoking dramatically changed. Not that long ago, I distinctly remember sitting in a confined meeting room at an international office of McKinsey, where a partner felt it was fine to smoke in front of everyone. However, such behavior has become less acceptable: a Match.com poll showed that only 22% of people in 2004 would “absolutely not” date a smoker, which increased dramatically to 58% in 2017 (and an additional 22% saying they would “probably not”). Thus, whenever 80+% of people disapprove of a behavior, there is a major tipping point where it becomes socially shunned (now there’s even specific dating sites now just for marginalized smokers!) Thus, the combination of financial and social deterrents effectively slashed adult smoking prevalence in California in half from 1988 to 2014, from 24% to 12%:
Saving Lives: Using Economic Taxes and Subsidies
The lesson from Big Tobacco also shows that we must use ‘top-down’ economic influence as well. I propose the federal government and states tax unhealthy processed foods, which objective experts (not on Big Food’s payroll) deem to be formulated in a way that does not prioritize health. For example, researchers have estimated that if ‘Big Food’ companies cut down excess salt in processed foods by about 3 grams per day, it would prevent tens of thousands of cardiovascular deaths, and save $10–24 billion in health care costs annually. We’re talking about removing ingredients, so such efforts would not necessarily raise food prices if Big Food companies complied and reformulated their products.
This idea is not revolutionary: the US government has been subsidizing nutrition for low-income Americans through the Supplemental Nutrition Assistance Program (SNAP aka ‘food stamps’) for over 50 years. While SNAP payments can be used to purchase produce, people can unfortunately purchase soft drinks, candy, cookies, snack crackers, and ice cream. Given recent proposals to extend basic health care and basic income to all Americans, if we “want to fix America’s health care, we must first focus on food” as Dr. Mozaffarian wrote. Thus, I propose the government extend SNAP to subsidize “basic nutrition” to all Americans, but limit spending to only healthier foods (whole foods, minimally-processed foods, and specially-fortified ultra-processed foods), so ‘junk’ foods have to be purchased out-of-pocket. This is not without precedent; my mother worked as a public health nurse for the US Department of Health, and piloted programs in which SNAP cards could be redeemed at local farmers markets to increase access to whole foods.
Researchers have estimated that a multi-pronged policy of subsidizing a national mass media educational campaign (MMC), along with subsidizing the price of fruits and vegetables (F&V) by 10% for everyone (and 30% for those on SNAP), and imposing a 10% tax on sugar-sweetened beverages (SSB), could lead to over 200,000 deaths prevented or postponed (DPPs) over the next 15 years:
Social Norms: The Role of Private Organizations
In applying the social lesson from Big Tobacco, community-based/grassroots efforts are a ‘bottom-up’ way of leveraging the power of social influence to nudge individuals to make better choices than they would on their own. In particular, private organizations can be better models for health, given that employers, schools, and hospitals directly pay for or provide health care.
Having worked in government and academic medical centers for over a decade, I was always shocked that hospital cafeterias sold terrible choices like fried chicken and french fries to the very diabetes patients I treated in the same day. Even Silicon Valley giants like Google, though offering healthier options, still offer free and unlimited sugar-sweetened beverages and snacks (when visiting my brother’s office, even Coca-Cola and candy were pretty available). When workers are hungry, tired, or stressed, and thus willpower is depleted, most people become tempted to choose these options.
As a result, I helped shape the food policy at my last company, which subsidized a daily salad bar lunch with healthy animal and plant-based protein options, and offered healthy snacks. Employees had the freedom to bring in whatever food they wanted or go out to eat, but the company only subsidized healthy foods, since we strongly believed we should practice what we preach to our own patients. As a result, most of our employees would default to choosing the in-house lunch option, even if they preferred fast food, because of the triple-reinforcement of convenience (not having to leave the office), social reinforcement (eating communally with colleagues), and economic reinforcement (who doesn’t like free food?). Though it is not a cheap investment, employers who subsidize food at work (or even groceries outside of work) receive short-term return on investment (ROI) due to increased employee satisfaction and productivity, and long-term ROI in terms of saving health care costs.
Social Networks: Leveraging Technology for Positive Social Influence
A very simple explanation of weight gain is that it’s basically driven by consuming low quality and high quantity of calories, including food choices that are high in refined carbohydrates and sugars (as Gary Taubes argued in “Why We Get Fat”), and is also influenced by behavioral factors. Research has examined which factors are associated with overeating, and while there are obvious ones (e.g. how hungry you are, eating on an empty stomach, a long time since your last meal, and how tasty the food is), the two most interesting are social and time factors. People tend to eat much more when greater number of people are eating with them, and also overeat on evenings and weekends.
As shown below, people tend to eat about 500 more calories on Saturdays (2550 calories/day) than on weekdays (2150 calories/day). People also tend to eat a whopping 1200 calories/day more if always in the presence of 4+ people (3000 calories/day) versus if only eating alone (1800 calories/day).
So what explains this phenomena? Researchers believe that when more people are present during meals, meal times become longer, and so people literally continue to eat as they go for ‘seconds’ and more. Furthermore, evenings and weekends are treated socially as times for celebration, in order to compensate for the diminished willpower and stress that comes from the workweek. At these times, people will often indulge in nutrient-poor calories such as excess alcohol and sweets that provide psychological relief and pleasure.
As I’ve argued, when relying on individual responsibility is not effective for most people, we can use the ‘poison’ as the ‘antidote’. Given that social influence can drive people to overeat, we can also leverage social influence to encourage people to eat more reasonably. One the major issues is that few people prepare their own food anymore. Only 10% of Americans love to cook, with the other 90% being split between hating cooking or being lukewarm about it.
But what if a eating healthy food in reasonable portions could be convenient, cost-effective, and socially reinforced? In Europe, “supper clubs” are a staple of some communities, in which families and friends prepare and eat food communally in long-table-style dining halls. While whole foods take time and skill to prepare, this is made significantly easier when small groups of people work together to divide the expertise and effort.
In order to popularize this tradition in the US, we can leverage the accessibility and virality of technology to combine old world European social tradition with new world online social networking. Here’s a fanciful idea: imagine a social eating app you could open anytime, which would show you an upcoming communal meal at a neighbor’s home within a few mile radius. With the press of a button, you could ask to attend the meal, and in exchange, be asked to either donate towards the cost of the ingredients (with a simple cryptocurrency payment) or bring an ‘in-kind’ food donation (of 1–2 requested ingredients), and help with cleanup.
Hosts would be incentivized to host meals at their homes, since their own meals would essentially be paid for by attendees plus a nominal fee covered for responsibility of hosting, and attendees would benefit from enjoying home-cooked food in the presence of good company. Individuals would also be incentivized to choose healthier, portion-controlled options. For example, smaller plates could be used and food only served during the first 30 minutes in order to prevent overeating while allowing time for socialization afterwards (if any technologist would like to implement this idea, email me to collaborate). Obviously this won’t meet the needs of all families or communities, but such bottoms-up solutions can help revive isolated and lonely Americans to reconnect again over “breaking bread”, instead of “bowling alone”.
Minimally-Processed Foods: Bringing Sexy Back to Whole Foods
Minimally Processed Foods, which can be prepared through traditional kitchen methods, are a critical technology to bringing back the appeal of whole foods. These include traditional dairy products (e.g. cheese, butter, yogurt, kefir), bagged/washed salad greens, pre-cut vegetables and fruit, and roasted nuts. Jennifer Zaft commented on my last article and shared examples of packaged minimally-processed snacks, such as dried and flavored beans or chickpea snacks:
My favorite example comes from Jeffrey Dunn, who tried to pay penance for his “karmic debt” of being a Coca-Cola executive, by inventing baby carrots. Most people are surprised to find out that baby carrots are not young carrots at all, but actually deformed adult carrots that were considered too ugly to sell, and were purposefully shaved down to be clean, bite-sized, and crunchy. This form of processing retains the majority of nutrition from carrots, but makes them more convenient and appealing to eat, especially to children:
While these foods are technically “processed,” they are “processed with purpose” as commenter Kathleen Grassi put it, with the intent not to make them superstimuli as discussed, but to provide the consumer with the convenience of not having to peel, cut, and wash them. In Part 3 of this series, I’ll introduce what I call “Nutrifoods”, or healthy, processed foods that are fortified nutritionally, and can be an effective adjunct for losing weight and avoiding junk food.
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Originally published at goactualize.com.