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EDITORIAL |
Correspondence: Requests for reprints should be sent to Marion Nestle, PhD, MPH, Department of Nutrition, Food Studies, and Public Health, New York University, 35 W 4th St, 12th Floor, New York, NY 10012-1172 (e-mail: marion.nestle{at}nyu.edu).
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INTRODUCTION |
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 TOP INTRODUCTION CAUSATION: A MATTER OF...COLLATERAL DAMAGE FROM BUSINESS...TIME FOR SOME STRAIGHTFORWARD...References |
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Twenty years later, such questions have gone mainstream. Unless current trends reverse, it seems likely that one third of all children born today—and even higher proportions of Hispanic and Black children1—will develop type 2 diabetes during their lifetimes and can expect a shortened life expectancy because of it.2 Such alarming estimates are based on the demonstrated connection between overweight and the type 2 form of diabetes, which comprises as much as 95% of diabetes cases. Among adults with diabetes, about 85% are overweight and 55% obese (as defined by body mass index cutpoints of 25.0 and 30.0 kg/m2, respectively).3 Diabetes is the sixth leading cause of death nationally, but the fourth in New York City, largely because of high rates of obesity among Hispanic and Black residents.4 Prevalence rates in children may appear low, but diabetes is routinely underdiagnosed in this population, and the prevalence rises in proportion to the degree of overweight.
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CAUSATION: A MATTER OF SOCIETAL CHANGES |
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TOPINTRODUCTIONCAUSATION: A MATTER OF...COLLATERAL DAMAGE FROM BUSINESS...TIME FOR SOME STRAIGHTFORWARD...References |
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At issue is how to put theory into practice, especially among children. Rising rates of obesity and diabetes did not occur by accident during the past 20 years, they resulted from profound changes in society that began or accelerated during this period (Table 1
). These societal changes affected the structure of families, schools, neighborhoods, consumer demands, agricultural production, business practices, and technology. All promoted eating more food, more often, in more places, and in greater quantities—as well as promoting inactivity.
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On the food side of energy balance, children of my era did not have access to large amounts of high-calorie foods with minimal nutritional value ( junk foods), which are now considered normal fare. It is now normal for children to spend their free time at home watching televised commercials for such foods or using computers to view clever food advertisements disguised as games. It is now normal for children to expect to eat foods marketed in these ways. Social expectations have changed, and recently.
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COLLATERAL DAMAGE FROM BUSINESS PRACTICES |
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TOPINTRODUCTIONCAUSATION: A MATTER OF...COLLATERAL DAMAGE FROM BUSINESS...TIME FOR SOME STRAIGHTFORWARD...References |
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From a business perspective, social norms that encourage people to eat more food make perfect sense. If you are in the food business, you want people to snack instead of eating regular meals. You are happy to serve larger portions: food is cheap, relative to labor costs, and customers love bargains. You want people to eat frequently throughout the day, drink sodas instead of water, and eat in formerly food-free places (e.g., clothing stores, bookstores, and libraries). You want it to be socially acceptable for children to bring snacks to school, have access to vending machines, and eat branded drinks, snacks, and fast foods during school hours.
Marketing to children also makes good business sense. It establishes brand loyalty early in life, encourages children to pester their parents to buy specific products, and undermines parental authority about food issues.11 It teaches children to believe that they are supposed to eat packaged foods designed especially for them. Food marketers want children to demand food that is sweet, candied, oddly shaped, amusingly colored, and in packages illustrated with cartoons. They want children to influence family food purchases, which is why McDonald’s spent more than $1.2 billion on US media advertising, PepsiCo spent $211 million on advertising soft drinks, and Kraft Foods spent $20 million on Kool-Aid ads and $25 million on Lunchables ads in 2004.12
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TIME FOR SOME STRAIGHTFORWARD ADVICE |
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TOPINTRODUCTIONCAUSATION: A MATTER OF...COLLATERAL DAMAGE FROM BUSINESS...TIME FOR SOME STRAIGHTFORWARD...References |
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The most recent federal dietary advice continues this tradition. The US Department of Agriculture (USDA) and the US Department of Health and Human Services have jointly issued a set of dietary guidelines at 5-year intervals since 1980. Although the guidelines began as public health advice for the general public, they have evolved to become increasingly complex and individualized. The earliest versions were small pamphlets outlining 7 simple precepts, but the 2005 edition contains 41 recommendations—23 for the general population and 18 for specific population groups, such as overweight children or adults.18
The increasing complexity of the guidelines is illustrated by the advice on sugar consumption. In 1980, it was "Avoid too much sugar." In 2005, it is "Choose and prepare foods and beverages with little added sugars or caloric sweeteners, such as amounts suggested by the USDA Food Guide and the DASH [Dietary Approaches to Stop Hypertension] Eating Plan." (The USDA Food Guide lists servings in 11 food groups at 12 levels of energy intake; the DASH Eating Plan lists servings in 8 groups at 4 levels of intake.) Buried within this 70-page document is excellent advice for individuals on managing overweight, but there is also much contradictory and confusing information about specific foods. With respect to sugars, for example, the guidelines recommend "decreased intake of . . . beverages with caloric sweeteners," but they also say that adding sugars increases the palatability of "nutrient-dense foods . . . thus improving nutrient intake." The guidelines say nothing about changes in the social environment that would make it easier for individuals to eat more healthfully. Similarly, the USDA’s Web-based, individualized food guidance system (available at: http://www.mypyramid.gov) is tailored to personal choice rather than to public health.
But advice focused on individuals has not succeeded in reversing current health trends. Food companies cannot be expected to take actions contrary to their own economic interests. Government agencies cannot easily act in the public interest if doing so runs contrary to the interests of food companies. Public health approaches to preventing diabetes must address the societal changes that have led to the current predicament. As the Institute of Medicine eloquently argues, prevention of obesity in children must become a national priority for government, the food industry, and health professionals, and pursuit of this goal must involve strong leadership with accountability for an action plan that involves the industry, schools, and communities.19 The prevalence of type 2 diabetes among children and the personal and economic costs of this condition for everyone concerned are reason enough to demand societal changes that promote public health.
Accepted for publication April 10, 2005.
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References |
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TOPINTRODUCTIONCAUSATION: A MATTER OF...COLLATERAL DAMAGE FROM BUSINESS...TIME FOR SOME STRAIGHTFORWARD...References |
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2. Olshansky SJ, Passaro DJ, Hershow RC, et al. A potential decline in life expectancy in the United States in the 21st century. N Engl J Med. 2005;352: 1138–1145.
3. Prevalence of overweight and obesity among adults with diagnosed diabetes—United States, 1988–1994 and 1999–2002. MMWR Morb Mortal Wkly Rep. 2004;53:1066–1068.[Medline]
4. Hu W. Diabetes is gaining as a cause of death, city health data say. New York Times. December 24, 2004:B1.
5. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000 [published correction appears in JAMA. 2005; 293:293–294]. JAMA. 2004;291: 1238–1245.
6. Ludwig DS, Ebbeling CB. Type 2 diabetes mellitus in children: primary care and public health considerations. JAMA. 2001;286:1427–1430.
7. Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess deaths associated with underweight, overweight, and obesity. JAMA. 2005; 293:1861–1867.
8. Lazar MA. How obesity causes diabetes: not a tall tale. Science. 2005;307: 373–375.
9. Schulze MB, Hu FB. Primary prevention of diabetes: what can be done and how much can be prevented? Annu Rev Public Health. 2005;26:445–467.[CrossRef][ISI][Medline]
10. Nutrient and other components of the US food supply. Updated December 21, 2004. Available at: www.ers.usda.gov/data/foodconsumption/spreadsheets/nutrients.xls#Totals!A1 (Excel file). Accessed June 28, 2005.
11. Linn S. Consuming Kids: The Hostile Takeover of Childhood. New York, NY: New Press; 2004.
12. Brown K, Endicott RC, McDonald S, et al. 100 leading advertisers. Ad Age. June 27, 2005.
13. Harnack L, Stang J, Story M. Soft drink consumption among US children and adolescents: nutritional consequences. J Am Diet Assoc. 1999;99: 436–441.[CrossRef][ISI][Medline]
14. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet. 2001;357:505–508.[CrossRef][ISI][Medline]
15. Schulze MB, Manson JE, Ludwig DS, et al. Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women. JAMA. 2004;292:927–934.
16. Pereira MA, Kartashov AI, Ebbeling CB, et al. Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis. Lancet. 2005;365:36–42.[CrossRef][ISI][Medline]
17. Nestle M. Food Politics: How the Food Industry Influences Nutrition and Health. Berkeley: University of California Press, 2002.
18. Dietary guidelines for Americans 2005. Available at: http://www.healthierus.gov/dietaryguidelines. Accessed June 28, 2005.
19. Institute of Medicine. Preventing Childhood Obesity: Health in the Balance. Washington, DC: National Academies Press; 2004.
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