Views & Reviews Review

Obesity exposé offers slim pickings

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e4465 (Published 02 July 2012) Cite this as: BMJ 2012;345:e4465
  1. J T Winkler, retired professor, Nutrition Policy Unit, London Metropolitan University
  1. jtw{at}blueyonder.co.uk

This series explains that ballooning obesity has coincided with rising sugar consumption and growing portion sizes, pushed by industry and insufficiently controlled by government. Jack Winkler agrees, but where are the potential solutions?

Food companies and governments have much to answer for in the global obesity epidemic. The three part series on BBC Two, The Men Who Made Us Fat, is the latest of many television documentaries to allege bad behaviour by both in the United Kingdom and the United States. Companies are concerned about shareholders; governments about interest groups. For both, public health is peripheral.

This latest series contains little that is new. It is tabloid television: loose with evidence, generous with accusations, and zealous with conspiracies. Consumers are presented as innocent sheep led astray by cunning marketing men, and the UK as obediently following the US down the path to perdition. Nonetheless, industry irresponsibility and government connivance are fundamental parts of the problem, and every generation needs that knowledge refreshed.

The first two episodes focus on excessive sugar consumption and increasing portion sizes as causes of obesity. The last promises to unmask spurious so called healthy products. But like most food documentaries, this one is better at exposing problems than considering solutions. This series hardly even mentions potential options and this is inexcusable. This year the governments of both the UK and the US have initiated new obesity policies, radically different from previous strategies. At the very least, television producers should monitor developments while their programmes are being made.

In Britain, the calorie reduction pledge,1 part of the Department of Health’s public health responsibility deal, proposes reformulating mainstream popular foods to improve their nutrient profiles. The options include reducing fat and sugar content; increasing satiety inducing ingredients like fibre; and using different processes, such as the baking technology that reduces fat in crisps and chips by 70%. The Institute of Medicine, the US government’s expert adviser on nutrition, is working in a similar vein. The title of its recent report urges, “Leveraging food technology for obesity prevention.”2

For 30 years, both governments have concentrated on exhorting consumers to change their diets and to make what were called informed healthy choices every time they go into a shop or restaurant. That strategy has failed. We keep getting fatter and fatter. Official US projections indicate that obesity will increase 33% over the next 20 years.3

The new approach starts by considering the foods that most people eat most of the time, and making incremental improvements. Instead of vainly trying to change people, change food instead. This is the strategy that also lies behind the most successful nutrition policy in the UK since the second world war. The salt reduction strategy’s latest achievements were announced last week: average daily intake was cut from 9.5 g in 2000-1 to 8.1 g in 2011.4 The savings in strokes and care costs are enormous.5

Shifting responsibility from consumers to producers also has advantages for doctors. Under the previous individualist approach, most responsibility fell not just on eaters but also on their doctors. They had to treat obesity on a one to one basis, whether through weight loss clinics or bariatric surgery. In future, the focus will increasingly be on structural changes in industry and agriculture.

The arch devil in The Men Who Made Us Fat is the US secretary of agriculture from 1971-6, Earl Butz, who promoted high fructose corn syrup, a sweetener now common in processed foods. His farmer friendly subsidies made high fructose corn syrup the leading source of excess sugar in the US diet. He’s the man who made Americans fat.

But the series never mentions another former secretary of agriculture, Dan Glickman, who currently chairs the Institute of Medicine’s food and nutrition board, which has just published a new obesity strategy.6 For the first time, the institute proposes putting nutrition into US agricultural policy, explicitly urging “increased domestic production of foods recommended for a healthy diet.” But two other trends to reduce sugar consumption, long under way and directly relevant to doctors, are also overlooked.

In both countries, soft drinks are the leading source of sugar. In both also, the market share of sugar free drinks has been rising for decades. In the UK, for example, 66% of Pepsi’s sales are now from its sugarless Diet and Max variants. Shifting to such drinks is the quickest way to reduce sugar consumption.7 But this television series makes no mention of non-sugar sweeteners. Another reaction against the effects of sugar on obesity was the development of low carbohydrate diets. These have long been the most popular weight loss regimens in both countries. They are not mentioned either.

Television can get away with simply exposing problems, but doctors must provide practical help, especially once responsibility for public health is transferred to local level. The new strategy of improving popular foods creates opportunities. Firstly, the food provided in NHS and local authority facilities can be improved for staff as well as patients. This was the focus of the promising but underfunded district food and health policies in the 1980s. The key is to put nutritional standards into supply contracts. Secondly, limit the number of fast food takeaways and improve the quality of food they provide, which many local authorities are already doing. Belfast has transformed Chinese takeaways.8 Thirdly, doctors must keep abreast of good and bad options in changing popular foods. Product comparison reports by publications such as Which? and others provide essential information. Commissioning so called name, shame, and praise surveys of local retailers would enable doctors to guide people to healthier—and cheaper—options.

Notes

Cite this as: BMJ 2012;344:e4465

Footnotes

  • The Men Who Made Us Fat

  • A BBC television series

  • Part 3 shown on BBC Two on 28 June at 9 pm

  • www.bbc.co.uk/programmes/b01k0fs0

  • Rating: **

  • Competing interests: the author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • bmj.com archive: Editorial: Low carbohydrate-high protein diets (BMJ 2012;344:e3801, doi:10.1136/bmj.e3801); Analysis: Taxing unhealthy food and drinks to improve health (BMJ 2012;344:e2931, doi:10.1136/bmj.e2931); Analysis: Food policies for healthy populations and healthy economies (BMJ 2012;344:e2801, doi:10.1136/bmj.e2801).

References

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