Food and Addiction: The Importance of The Environmental Change

this program is a presentation of uctv for educational and non-commercial use only you you I'm really happy to be in this place at this time in this place because the Bay Area is just has the most remarkable concentration of people who pay attention to food food policy issues and obesity the physiology of obesity everything and if you if you put together the people in San Francisco who work here academically and produce scholarly work the people in San Francisco who are doing public policy work the city the state of California many people are involved in this and of course the tremendous concentration of people on the other side of the Bay Bridge is really remarkable Pat Crawford's here from Berkeley with her colleagues and they're doing remarkable work there the prevention Institute in Berkeley people like Michael Pollan and the list just goes on and on and on there's just no concentration anywhere in the country of people doing this kind of work so it's a real pleasure for me to be here I'm happy to be here at this time because we're at this very interesting crossroads in dealing with this issue many of us have spent years and years trying to get people to pay attention to this problem that issue has been resolved that problem has been solved and we have so many people now that are attending to the obesity issue that range from the White House an unprecedented level of interest in this we all know about that people in Congress people in state legislators the state legislatures and even the state attorneys general are now engaged in this process in ways that I'll talk about a little bit later and this has been so helpful and so important and it leads us to this different challenge which is what to suggest should be done and that's not so easy so when legislators come to us and say what should we do we have a menu a mile long of things that could be done and everybody has their favorite ideas but what do we know about what can be done and what can we recommend in terms of empirically validated approaches things that have a scientific basis etcetera and then the question becomes but that's where we are and so it becomes a very interesting and challenging point in time so I'm happy to be here to talk to you about it and one of the the issues that I think is will soon explode on to the scene is the issue of food and addiction and the reason I believe it will explode onto the scene is that the science on this becomes more compelling almost by the day animal studies human studies testimony from people who've struggled with this issue you put this all together into a picture it becomes very interesting and provocative I became interested in the issue of food and addiction not only because it's scientifically fascinating and very important for the humans who deal with this issue but it has enormous public policy implications one can just imagine the legality or morality of marketing foods to children if they're found to be addictive one can imagine what legal authorities could do with this information one can imagine how the public will feel about the industry intentionally manipulating ingredients if those things are declared to be addictive so there are tremendously important implications and so I'd like to talk about some of those today elisa mentioned that I direct the center at Yale called the Rudd Center this is really a remarkable place full of energetic passionate people doing incredible work I'm the most blessed person in the world to be able to work with these individuals and we have a great website that's listed down there elisa mentioned that the website is rich with information on food food policy issues there's a free monthly newsletter that gets dispatched to people by email that talks about food and food policy issues so you're welcome to get that and we also have a series of podcasts that we've recorded we record more podcasts than any unit of the university at yale and we generally do them with people who have come through to get talks experts in the field come through to do talks so this is has been recorded with podcasts and a variety of other good people like Michael Pollan have done podcasts so they're really terrific and it's a variety of legal experts legislative leaders media people who are dealing with this issue and so I urge you to come to our website if your interests now we have a strained relationship with food a distant relationship with food and some of you who've heard me talked will know what the answer to this question is but I will very often show this list of ingredients and ask people if they can identify the food so it's not a trick question it's a food you've all heard of or know about but the question is can you guess what it is so those of you who haven't heard me talk and have seen this so you know the punchline can anybody guess what this is pop-tart Twinkies ships ahoy ok well the fact is you you could all be right you know there there are a hundred or a thousand or ten thousand products in the American food supply that would have some combination of this and greed in this ingredients so the the most noteworthy thing about this list of ingredients is how long it is there are 56 things in this ingredient list and it wasn't that long ago in American history even where if there had been such a thing as food labels it would have had one thing on it it would have been the food and it would have been lettuce it would have been beef it would have been whatever it happened to be but it wouldn't have had 56 things in it and the question is what does some of these things do to the brain what do they do to our internal homeostatic mechanisms that were put in place to protect us against disease and are these things hitting the brain in a way that created active processes and to the extent the answer to that is yes we've got a real problem on our hands now whoever guessed pop tart was correct it's a chocolate pop tart I've got a box of them for you because you won the contest and so one one that could could really ask what what is this and is this of food so people like Michael Pollan have made brilliant arguments about whether you should actually consider this a food is it found in nature no is it something that our ancestors would have recognized as food no is it something this class of food products is it's something that can go into the body and not create metabolic havoc well there are all these interesting questions that get raised that one could really ask if it's a food you know is it something that should be regulated by the EPA rather than the FDA and again who knows what these things are doing and then you know this is this is tongue-in-cheek but apropos of the title of the conference here is this the kind of thing that had been can create enough addictive properties or has enough addictive properties to it that there's a public health menace at work and those are the questions that we'll talk about today so we're distant from our food we have a distant relationship with food that humans never used to have it's physical distance and it's psychological distance psychological because we're no longer connected with who grew the food where it came from what was put on and whether it was genetically modified it said or the thing that people that worry about a lot of care about sustainability but then there's also the physical distance with things being mass-produced ship very long distances processed in ways that they have almost infinite shelf-life and as a consequence this distance from food has made us trust the food industry to put things in there that are ok for us and whether that trust is well-placed or not will depend on everybody whose opinion but we at least have to ask the question and so these this set of questions about how the food is grown and how it gets to us and things are more and more important but not important to many people still so we'll start off with the question about what might be addictive if food can trigger an addictive process what is it that might be doing it well we think first of the macronutrients like sugar and fat and you'll hear more I haven't heard the talks that are about to follow mine I'm imagining you'll hear more about sugar today than you will about anything else because that's been studying the most but there are a lot of other possible players in the picture all the additives that showed up in that 56 ingredient list are possible players here the food industry refers to these euphemistically as flavor enhancers things that maximize consumption of the product and I don't really know whether and in fact I kind of doubt whether the food industry has you internally uses addiction to talk about desire for their products and I don't accuse them of intentionally trying to get people addicted they are of course in the business of maximizing the consumption of their products and to what extent to those two concepts overlap maximizing consumption of a product and addiction and those are the questions that science has to answer and then there are things added like high fructose corn syrup that could potentially be a player here so it's very important that we look at the array of different things that are added to foods that may create an addictive process so in my mind these are the key questions within my min in my own belief from the bottom question being the most important of all so what's the relevance for public health here and what can we do as a society to address this issue of food and addiction so most everybody here knows obesity enough to have seen the CDC maps of obesity prevalence so I'm not going to go through them so so much but just to kind of show you the change in colors and it these these changing colors speak to a remarkable increase in the spread of a disease and it rivals something that would be a highly infectious disease even and so but given that it's not an infectious disease then how in the world could something like this be explained well there's a terrible food in physical activity environment it's not about biology for the most part it's not about personal irresponsibility this is clearly a product of a bad environment and the bad environment has a lot of features to it increasing portion sizes relentless marketing there's a long list of those things and the question is where does food in addiction fit in this picture does food have enough addictive properties to do this and this is not an issue that's just affecting the u.s. if you look at data say from the European Union in five-year chunks you'll see that countries change color as well these are for females but the male data look very similar so 80 to 84 up to 89 men the 94 99 and then 2005 so the developed countries share this problem and what about the developing countries well this slide shows data on the projected increases in diabetes between 2000 and 2030 we're expecting 37 percent increase in the US which is incredibly alarming given the high rates of diabetes that we have now but in China the numbers will look like this and in India they'll look like that so of course they started with a lower denominator than we did so you have to factor that in but the populations are so enormous that the increase world burden in terms of new cases of diabetes is basically going to be coming from countries like this and one would have never imagined the day when this would have happened you know back when I was a kid and we were told to clean our plates because they were starving children in China I mean now the whole situation has changed and the nutrition crisis in these countries has gone from under to over nutrition not that under nutrition has been wiped away it's certainly not but these uh problems are very severe and again what could be driving this if we collapse data across all developed and developing countries we get this kind of picture in the next 25 years or so so the question is what's gone so terribly wrong and is addiction a player in this picture so why should we care about it well to the extent food can trigger an addictive process understanding this process could help us know why people don't eat optimal diets certainly treatment for the people that are afflicted by this problem could be developed and refined and then what I'm going to be talking about most today are things like legislation regulation and even the possibility of litigation and how this might fit into the picture so is the concept plausible of food in addiction so it's plausible from the point of view of stories people tell us it's also quite plausible from the point of view of what people have been telling us for years in clinical settings so those of us who have worked with people and counseled people hear the word craving a lot hear the word withdrawal when people go on diets start to see patterns of eating that may look like tolerance and a lot of these things happen that make us think that this is possible but our field has ignored the possibility for way too many years finally now people are paying attention to it and then there's of course the empirical support and we'll be hearing a good about that good a good bit about that today now I remember way back when there was a very well-known pioneer in the field of obesity research named Albert's tongue curd who I worked with at the University of Pennsylvania one of his close colleagues and another pioneer in the field was a person at Columbia University named Ted then Italy and Ted did some wonderful studies early on and gave me actually these slides that I've been showing now for 25 years or however long it is animals given access to a diet that that look resembles the human diet so here the normal weight lab animal given much more than it will want to eat of the child will name to maintain normal weight but given access to what researchers call a supermarket or cafeteria diet will really look much different and the striking thing about this picture is that the pellets of Chow are sitting there and the animal if it were a good nutritional a regulator would ignore the the bad food and eat the child diet but it doesn't and so it's not uncommon for animals under these conditions to triple their body weight so I mean take your own weight in your mind and multiply it by three and you get a sense of what a changing environment will do and so is this an addictive process going on are the are the constituents of those foods affecting that animal in a way that creates strong desire for and craving for an inability to live without it etc that would mimic what humans tell us occurs and there's a lot to be learned from this kind of a model so if we look at the clinical picture certainly we hear a lot of lot of language of addiction and there's elisa mentioned repeated use despite adverse consequences high rates of relapse etc they would start that would make the clinical plausibility of this certainly an issue the research picture which you'll hear more about from subsequent speakers I think is very compelling both the animals and the human studies that have been done on this suggests to me that this issue of food and addiction is is profoundly possible if not a reality at the moment and therefore we need to start factoring this into the way we do the per we we think about the prevention of obesity we became interested in this enough where we held a meeting at Yale I think the first meeting on food and addiction several years ago and Mark gold who's a psychiatrist chair of psychiatry at the University of Florida and an addictions expert co-chaired the meeting with me and we drew together people who were experts on addictive behavior and people who were experts on nutrition and obesity and this is just a partial list of the people who were here who were at the meeting but it turned out to be a very interesting meeting and it also turned out to be the case that the addictions researchers were absolutely certain there was something going on here the nutrition and obesity people were much more reserved and reluctant to embrace this idea and I can't figure out exactly why that's the case because they're looking at the same data you know we should all be scientists and be objective about it but I think there's something mixed in there about who came on the idea first and and I think it was mainly the addiction people who started studying food rather than food people who start a study in addition with a few exceptions like the BART hobos group and the bean and that group had Princeton and elissa and others have done it but there them in the minority in the field and more studies have been done by addictions researchers so we published a report on this that is available on our website but listening to those researchers made me pretty convinced that this is a topic worth pursuing we got involved in this and Ashley gearheart who will be speaking after me developed of Yale food addiction scale and she'll talk more about the details of the scale but it's amazing what kind of a nerve that struck because once word got out about that people all around the country are using this food addiction scale in their research and it's not been translated into a bunch of light it's only been out for a short time in a journal but been translated in a bunch of languages people are using it all around so there's it's connecting with something that's really very important and then Ashley published another paper in the journal of addiction medicine looking at the diagnostic criteria for addiction and how those might apply to the obesity had food arena and that was an excellent paper and she'll talk more about that as well but I wanted to take my hat off to Ashley and to to say how important it's been to have her as part of our team to help study this food addiction issue so is there this disastrous interaction between the brain and the environment now the brain wouldn't have any there would be no addictive manifestation if the food environment we're different but modern food conditions have changed in so many ways and we'll talk to some extent about what those are that may be hitting the brain in this adverse way so it the the fact is the the environment pushes some foods over others so you're gonna see a lot more advertising for example for sugared beverages than you are for broccoli the schools are going to push one kind of food over others the portion sizes encourage people towards some foods and not others and so there are a number of environmental things that push certain foods and if those are the same foods that can trigger an addictive process or have some constituent that could act on the brain as an addictive substance then we've got a bad interaction between the brain and the environment so let's talk about what some of those features of the food environment might be and we can think then about what public policy things would make sense given the science on food and addiction so economics are certainly a player and there are people out in this area who study this kind of thing food access is a real issue food deserts for people that don't have access to healthy foods drives them in a certain direction towards some foods and not others and I'd like to talk about cost of foods as an issue so these are data from Adam danowsky and it's a complicated graph that I hope will become easier in just a second but on the x-axis as you go from left to right this graph represents the cost of food so you go from low cost to the left higher cost to the right and then the y-axis represents increasing energy density so number of calories per unit you know weight going from low to high from from bottom to top and I'm going to block out some foods here and you can get a sense of what this data show so if you look at the top left the the foods that are the cheapest tend to be the ones that are most energy dense and they're not the foods you'd like to see the population even more of the foods they're nutrient rich but calorie poor the ones on the bottom right tend to be the highest and cost so this phenomenon has been documented time and time again and it has partly to do with the realities of food there are things like shelf life and spoilage and things that drive up the cost of fruits and vegetables that don't apply to processed food so much but there are other government policies that are players in here too and the costs have not increased equivalent an equivalent way across food categories so soft drinks that you see on the left between 85 and 2000 increased in costs by 20% more or less staying stable given inflation sugar and sweets increased a little bit more but fruits and vegetables increased by this much so during that 15 year period of time it became relatively more untenable to purchase fruits and vegetables than it was before so the economic environment has grown more adverse with respect to the consumption of these different food categories there are of course the subsidies that people have talked a lot about and care a lot about and this becomes a real issue for the farm bill the next iteration of the farm bill will come around in 2012 and the subsidy program is written wide right into that the subsidy program has been untouchable from politicians for many years you got put into place when Earl Butz was flamboyant Secretary of Agriculture and the Nixon administration they put in the series of subsidies for commodity crops basically to help prop up the economic conditions of the American farmer and it helped to some extent although it had negative consequences as well but the idea was to encourage farmers to grow some crops over others to subsidize their price so the American farmer would be more competitive in the world market so corn and soybeans as you know led the charge there so America became the world's largest producer of corn by far we flooded the world market with low-cost corn that has all sorts of nutrition implications but even political implications having to do with world trade and the like so the there you know anecdotes like indigenous farmers in Mexico in India who were growing corn could no longer grow it because they were being outbid by the low-cost American corn that was flooding the world market those people would go bankrupt stories of suicide among these individuals many of these people were moved to the urban areas creating a whole different set of physical problems obesity and diabetes among them all affected by American farm policy so the subsidies to the the farmers work out in an interesting way so it becomes inexpensive to feed a cow a chicken or a pig because the grain is being subsidized by the government which makes it less expensive to produce something like this so when you buy this you're not paying anybody buys us they're not paying the real cost and it's what the economists call externalities because the government is helping underwrite the cost and there are negative consequences which is what the externalities are all about when Japanese scientists synthesized corn to create high fructose corn syrup in the 1970s it became very inexpensive to sweeten things and the government helps by this and and of course the oil from these things gets used to create foods like this so the way it works out more or less is that if you if you go to McDonald's or a Burger King and you buy a meal that's a combination of these foods somebody from the government standing there next to you opening their wallet helping you buy that meal if you buy order a salad in a bottle of water that government individual walks in the other direction it becomes disinterested so it's exactly the opposite set of economic circumstances that you'd like to see if agriculture agriculture policy were lined up with health policy but until recently there hasn't even been serious talk about it much less action on this food marketing becomes another really very important issue the you could collapse a massive the literature on food marketing into about three words it's powerful its relentless and it works and kids are especially targeted by this and so in my mind it's it's very hard to believe we can do anything about obesity and all until the food marketing problem is solved and it's not an easily solved problem because of the First Amendment protecting commercial speech and things like that but there are ways around it and there are some estate officials including city attorneys in San Francisco who are working on innovative legal ways to address this issue of food marketing and our group is working with these various groups you may know that traditional food marketing when I was a boy basically was Saturday morning cartoon television and ads for sugared cereals but that gave way a long time ago to other forms of marketing so now it's on Facebook it's specific to the individual it's on YouTube it's on basically everywhere and the internet especially and the industry has come up the ad industry and the industries that advertise through it have come up with a series of terms to describe modern marketing techniques and they talk about them as guerilla marketing viral marketing and stealth marketing now these are not terms that the nutrition crazies have come up with who were opposed to the marketing this is the industry itself boasting about how they can get do an end run around people's conscious defenses against marketing and and and can do an end run about around parents and parental authority to govern the marketing that their children are exposed to so I mean one could pretty readily ask about them ethics and morality of an industry that uses terms like this to describe how they're going after our children but these these forms of marketing take many different shapes so here's an example American Idols show which is watched by millions and millions and millions of people children included and at one point these coca-cola glasses showed up in front of the judges I met one of these judges at an event I was at and they asked about this and it was a multi-million dollar exchange between coke and the program just to have these there now to the extent you have cognitive defenses against marketing the defense's get ramped up when the commercial comes on you can leave the room you can call somebody you can do a lot of different things and you can also engage your children in a discussion about what marketing is attended to do intended to do but when it's woven right into the program's storyline like this then it becomes a whole different kettle of fish and so the marketing becomes a real problem this kind of thing is happening more and more and more and if you think about one argument that appeals to people who would more conservative political beliefs is that this is undermining parental authority if parents want the right to raise their children as they wish and this stuff is being done without their permission and even without their knowledge then it becomes a real problem and so there are lots of examples of this kind of thing here's an example of how much marketing there is you may know that the Robert Wood Johnson Foundation is the biggest funder of work in the world now on childhood obesity and they're spending a hundred million dollars a year to attack this problem so let's just say the foundation is going to spend every penny of that they're going to spend none of it to do this but let's just say they were going to spend all that hundred million dollars new public education campaigns to counteract what's going on in the food marketing arena so they do advertisements public service things all that kind of stuff so the question is what by what day of the year has the industry already spent that much just to advertise just junk food just to kids so you're gonna see a dot here and the dots going to go around and around and they will land on January 4th so when you hear the word education in the context of addressing obesity it's a trap and it's the sort of thing that the food industry uses all the time they embrace the idea of Education they don't fight education programs why won't why wouldn't they well here's the data right in front of you because they can undo it in a second what and the government government could mobilize and spend an incredible amount of money to launch a campaign on this and they can undo it in a day or two so it's just not tenable to think about approaching these problems through education here's an example of some research that we've done recently on food marketing this work was led by Jennifer Harris who's a colleague of mine at the Rudd Center and through a grant that we got from the Robert Wood Johnson Foundation and we wanted to look at marketing of specific categories of foods to children and the first year of the project we addressed the issue of sugar sweetened cereals and so we bought a lot of data from Nielsen and other media companies to find out how much marketing was going on who was being targeted by the marketing etc and how much and of what type of foods and we created lists so we didn't create a list of addictive foods but what I'd like to say is let's just say you could you could create a list of the foods that are most addictive if we created a list of the foods most market and overall and then the foods most marketed to children how similar with these lists look and to the extent they would look pretty similar then we've got a social problem to deal with so here's exactly what we did if you look at the foods that are marketed most to children's sugar cereals is the top of that list followed by fast food followed by sugared beverages this would include children and adolescents now if you created a list of the foods with the most addictive potential would it look like like these foods well we'll have to sort through the research and see but we at least have to ask that question so the report that we release was called cereal facts there's a website where all this information is available cereal effects org and we have this on our main website as well so what we did was created a rank ordered list and this will be a little small for you to see of the cereals with the worst nutrition rankings at the top and the best ones at the bottom so the healthier cereals like many weeds and things like that are at the bottom of the list the cereals that have the poorest nutrition are at the top and then these X's that you see to the right are the foods that are most heavily marketed to children so if you block this out if you take the top dozen or so cereals with the worst nutrition rankings those are the ones that are most aggressively marketed to children so if the industry were intentionally trying to make American children unhealthy wouldn't this be exactly what they would do and so is this a social problem is this something where public policymakers need to step in and do something our belief is yes now by the way the cereal industry claims that their their defense against data like this is that it's important for children to eat breakfast and the way you get children eat breakfast is to put sugar on the cereal so they've been saying this for a long time so we did a study my colleague Marlene Schwartz and Jennifer Harris did a study to test this so we they brought kids in game that randomly gave them access to either low sugared cereals or high sugared cereals gave them fruit on the side so they could put it whatever they thought on it and gave them sugar on the side so they can add as much sugar as they wanted and what they found is that children who got the low sugared cereals added a little sugar to it but not nearly as much as the sugar cereals had and they put more fruit on it and they ended up with just about the recommended level of nutrients intake for what a breakfast for a child should be the kids on the other hand who got the sugared cereals put less fruit on the cereal so it was less healthy from that point of view and they twice the recommended number of calories that an average child should have as a breakfast so we very often get asked why would an industry just market healthier foods healthier cereals to kids because they make healthier cereals well there's your answer you want kids D twice as much of your product you put sugar on it and you promote those kind of cereals so that's a problem now beverages become another issue and the issue of soda taxes comes up and I'd like to talk about that a little bit as a public policy proposal the why beverages are such a special case here well first the marketing of sugar sweetened beverages begins early in life here would be a dramatic example of that baby bottles with soft drink company logos on them but think for a moment about Coke and Pepsi so if you walk down the street and you ask people are you a Coke or a Pepsi person you'll get an immediate response people are one or the other you guys are probably one or the other if you ask people can you tell the difference between the two most people will say yes some people are completely convinced that they can tell the difference and then when you really do the test far fewer people can tell the difference then believe they can so how does this square up I mean how does this happen psychologically you've got basically indistinguishable products but you've got incredibly strong brand loyalty and people convincing themselves they can tell the difference when they may not be able to well it's all marketing of course you know it's it's who had the best colors who had the best athletic celebrity or music celebrity to attach to and things like this all happen and they're very they're very powerful and persuasive and this happens in young ages it could have been what who had the contract in your school it could have been a lot of different factors like that to drive this but this very strong brand loyalty develops that's out of touch with the the reality of these products doing being different from one another but of course people couldn't admit that people can't admit that they've been that they've succumbed to marketing and so what they do is they say that there are product differences and that's why I like went over and so mark one of the problems with trying to do something about marketing is that everybody in the country believes they're not affected by them but they believe everybody else is and so the idea is I'm strong because I'm not affected everybody else is weak so why should government have to do anything about it so you may know that the world's most valuable brand is coca-cola coke is the word coke is the second most widely recognized word in the world after okay and the consumption of different beverages has changed a lot so this graph shows the consumption trends in milk and soft drinks from the 70s through early 2000 and if you look at these these trend lines it looks like this and the date looks similar for adults and children so this is obviously a problem sugar sweetened beverage consumption one of the problems potential problems with calories that come in beverages is the body's poor compensation for them and there's a fair growing body of research on this that I find pretty well done that suggests that when people take in calories in liquid form the body doesn't hand doesn't handle them very well and the dust they sort of escape the battery's calorie detecting radar if you will so let's just put some hypothetical numbers to this let's say we divide the room in half right down the middle here and you all eat whatever your typical lunch is that will differ from person to person but whatever you normally eat you eat for lunch today this room this side of the room we give you 200 extra calories beyond your normal lunch and they come in solid food it could be pizza ice cream cookies anything this side of the room gets the same 200 extra calories but you get in and liquid beverages or lewin beverages with sugar in them and then we follow you at subsequent meals to see how well this side of the room and that's either room compensate for the extra 200 calories do you normally cut back to try to adjust for the extra calories this side of the room will do better than that side of the room according to the research and so it could be the drinking sugar beverages is an assault against the homeostatic calorie regulating mechanisms weight regulating mechanisms and the constant consumption of these some people drinking them all day long many people drinking much more than one serving a day could create enough weight problems to create a public health issue now sugar and addiction also becomes a key player in this and of course we'll hear more about that later but I find the research on this quite compelling there's also the issue of caffeine and what this does and with roland griffiths who's a professor at Johns Hopkins and Marc Gould who I mentioned before I'm writing a paper on the issue of caffeine and how how it's really amounts to a calorie carrying vehicle because most things with caffeine added not a hundred percent but many things with caffeine added have sugar attached to them as well and so caffeine comes couple with calories a lot the caffeine is added gratuitously to almost all the products of this in even things like the the flagship carbonated beverages people think the caffeine is there naturally well pretty little of it's there naturally most of its added its added things like food that ordinarily wouldn't have it alcohol and there's a big controversy now about that the industry says that it's a taste enhancer but when you do kind of carefully control studies people can't detect the taste of it so it's actually being added for other reasons and then of course caffeine itself has been shown to be addictive and has classes - classic addictive properties and so the question is when sugar and caffeine get put together is it it is an additive or multiplicative effect and we don't really know that but the fact that the two things occur together and a lot of foods becomes a problem and you've got the obvious examples of the energy drinks that are being promoted so heavily you've got things like this Butterfinger bar called Butterfinger buzz that has caffeine added to it and there are many examples of this in the food supply but it becomes a real issue because sugar comes coupled with it I'm going to skip over that and then then talk about this issue about what we should do about these sugared beverages and so if but before I get to the specific public policy proposals about sugar and beverages and things where should our focus be if this issue of food and addiction is a reality if there's really some substance here should we focus it on the individual who may struggle with this issue of food and addiction or should the focus be on the food and there's a very critical distinction there and I'd say that from a clinical point of view in terms of compassionate help for the people who struggle with these issues focus on the individual makes sense but from a public health point of view for affecting the broad range of people in the population focusing on the food rather than the people becomes a important strategic value so let's just say we can talk about a degree of addiction how addicted our people to food now again the concept has to be has to be worked out and more research has to be done but let's just say we could create a dimension of no addiction at all on the Left a very heavy addiction out here on the front on the right hand side so people who meet some diagnostic criteria if they're developed at some point let's say for the DSM for something like food and addiction are going to be the people out at the tail of this distribution and for those people who are in that tail it's incredibly important that they get help and they're they're suffering needs to be addressed and all that sort of thing has to occur but the number of people affected is small so from a public health point of view that's not going to help address the obesity problem at all what we believe is very important is once you cross a line where some addiction occurs that in between there and here is really where the public health significance is so the people who whose lives have been really completely disrupted by an addictive relationship with food are out here but the kids who want their soft drinks every day are in the middle the people that are eating just enough of this stuff they increase weight and undermine their nutrition are in the middle and that's really where the public health significance is and that's where you'd want to focus on the food than the people because and I'll give you some reasons for that here so if you focus on the individual it you you it's easy you don't really have too many enemies no industry is going to fight you because it's the person's fault that they're that way and you don't have to make systemic changes when you focus on the food the fight becomes much harder because then you've got an industry to war against down sides of the individual focus are that the problem can be dismissed because the people themselves can be dismissed as being outliers different week whatever it happens to be attributes that I think are unfair and untrue but will get assigned by society it further stigmatized as obesity potentially because people calling them food addicts who calling themselves food acts who then will get dismissed by society makes it harder to make the case that obesity is caused by the environment as I said it overlooks the majority the industry of AIDS blamed this way and you help people one and one at a time which is important for the people but from a public health point of view again doesn't is an efficient use of money so we believe the focus is better placed on the food and so I'm I would be less interested in finding out which individuals cross some diagnostic line and could be considered food addicts as I would be in identifying the foods most likely to trigger an addictive process because then that leads right down a positive Public Policy road because you could do something about access to those foods formulation of those who's marketing in the foods etc so the guiding philosophy that that we use at the Rudd Center has borrowed from both public health and economics and it has to do with changing defaults and then we'll loop this back to the issue of food and addiction so public health 101 is uses the upstream and downstream metaphor that you can wait till the stream is polluted and then spend a lot of money to try to clean it up and you may not be successful or you can prevent this from occurring in the first place and so this is clinical medicine up there is the public health approach and that's quite well accepted in the public health world but not by society in general not by the medical establishment so much and not by government authorities although the focus on prevention is becoming more and more keen at the moment so if we think about how to best make change in our culture we usually default to beginning with the individual smoking alcohol AIDS whatever you might happen to say we tend to think that if we give people knowledge or if we motivate them somehow they'll change their behaviors so we educate and we implore and this has been government's role this has been the White House's role until recently with the Obama administration in dealing with the obesity issue the White House has been little more than a cheerleader standing on the sidelines imploring the team to behave better and this is obviously not worked and it has has subverted the rightful role of government to get involved in these issues but this is how we've approached it so our hope is that we can educate and we implore this is what we begin with as a default in the case of obesity we have medical interventions as well we can put into the picture and we hope that this creates less obesity but this of course has been wishful thinking because we've been doing this for 40 years and prevalence has gone through the roof so at some point even the person most likely to embrace this concept would have to declare it's been a failed experiment and then we need to take a new approach so here's an example of how this may work so let's look at how well education works this is a graph of people in the population getting the recommended levels of physical activity each day from 86 to 2000 now during that period of time what happened a lot the Surgeon General's report on exercise health clubs opening everywhere exercise devices all over TV there's not a person in the country that doesn't know they should be exercising and so if knowledge and education and luring people exercise was going to work you'd expect to see increasing trends and physical activity over that period of time all right but maybe it's maybe it's different with diet so here the percentage of adults getting the recommended levels of fruit and vegetables every day over that period of time well maybe we're doing better with our children's intake of fruit and vegetables over time so educating and imploring and standing on the sidelines cheering people to behave differently just won't work and we need to do more and the question is what what more do we do well do we do more education and more imploring it doesn't seem to be a very useful Enterprise as I said before especially if you consider what the food industry is doing to educate people according to their view of things so if we look at what we're doing now we're both basically doing these things and the question is can we take a different approach can we just wipe the slate clean and start from scratch and take a different view so if we want the individual to change does it make sense to begin the picture before the individual ever gets involved in the decision making process can you create a different set of environmental circumstances that will make it easier for the healthy decisions to be made and that's what public policy can potentially do so can you change the environmental conditions can you use economic change how can legislation be used how can the regular thority authority of government be used to create what the economists have called optimal defaults so if you come away with anything from my talk today I hope it's these two words optimal defaults can we create a different set of defaults that lead people down a healthy road rather than the disastrous unhealthy road that we now have huge portion sizes are a suboptimal default relentless marketing of unhealthy food is a bad default the economic policy that pushes some foods over others is a bad default so you get the picture here and the question is can these things be changed can we create optimal defaults and will that lead to less obesity so here's an example right out of the economics literature late sending colleagues a group at Harvard have studied people enrolling in pension plans now when people take a job on some employers enroll them by default in a pension plan but give them the choice of opting out in other cases employers don't enroll the employee by default but they have the choice of opting in so that the employee has the same set of choices that they can be in or out it's completely free choice just the default changes what you're automatically either in or out to begin with and boy doesn't make a difference so if you consider enrolling in the Pension Plan of social good which most people do because you're saving money for your future you're less dependent on the state in ural your later years etc here are the numbers if the employee has to take the active decision to enroll you get about half people enrolling if it's automatic enrollment you get about a hundred percent now you could try to educate your way from fifty to a hundred percent you could try to implore people to do this and you might get some something done but it would cost a lot and you come nowhere near something like this is a simpler which is just to change the default now here's here's a stunning stunning example from the health arena people who are organ donors so if you look at this graph to the left of the line you see you're gonna see four countries in Europe Denmark Netherlands UK and Germany that have the u.s. model to be an organ donor where you're not an organ donor by default but you get your driver's license then you can opt-in to the program the countries to the right of the line do the opposite you're an organ donor by default but you're given the choice of opting out same choices same set of circumstances and you can imagine from seeing the pension plan data with these are about to look like but it's remarkable what they do look like so the u.s. model that's what you get the default changing the default you get that now the scientists in the crowd just can you can we get 99.98% of people to do anything to breathe I mean that's unbelievable those kind of numbers now again you could never educate your way from the left to the right no matter how much resource you devoted to it or you can just change the law you can just change the default so the question is are there dietary equivalents of this and things that could be done well there sure are and here's one example some of you may know that Thomas Frieden who's now the head of the CDC was the Health Commissioner in New York City he was supported by very activism health-related Mayor Michael Bloomberg to get rid of trans fats in New York City restaurants so this is something the industry fought against sued the city lots of things happen but the city city finally prevailed so if you go to a restaurant in New York City now you're not going to eat trans fat so they've been wiped out of the restaurant picture the industry said it was going to cost us too much it was going to restrict consumer choices it was going to make food expect more expensive none of that happened because it was an easy change for the industry to make and the default changed so again think of educating your way to that outcome trans fats is a hard concept to understand you have to label the heck out of everything restaurants would have to have alternatives it would be a mess or you can just change the default so there are other examples of this in the dietary arena things like menu labeling would be an example of changing the fall getting portion sizes to be different encouraging or mandating industry to reformulate the foods so they have less sugar fat and salt per serving would be an example of changing the default cleaning up the school environment creates a different set of defaults Marketing practice has become a different set of defaults so we approach this with what we call strategic science and we do a series of studies that try to help government officials gather the information they need in order to address this issue and so if we think about public policy priorities at the Rudd Center we're focused on a number of things one is to protect children from and so that would involve making the school environment a healthier thing and then restricting food marketing directed at kids we believe this is a winnable public victory because most people believe that children are a protected group and deserve a special level of protection from negative influences most people are now agreed to the fact that food marketing and school selling junk food is constitutes a negative impact and so there's a lot of momentum behind this we also believe changing the food economics becomes a very very important issue and I'll talk about taxes in a minute and then using legislation regulation and litigation to help do things like address food marketing become important so these are some but not all of the Public Policy Priorities we're working on we have been working hard on the issue of sugar-sweetened beverage tax and so one of the first recent papers we wrote about this was the thing I did with Tom Frieden that was in the New England Journal of Medicine and in this paper we proposed a penny per ounce tax on sugar on beverages with added sweetener so added sweetener that's quartz so any so any eseni sugar beverage wouldn't be included diet beverages were not we can talk about that water obviously would would not be a high percent juice would not be taxed under this idea this this concept now has been embraced to the extent that we're getting calls almost every day from some new city and state where they're considering taxes on sugar sweetened beverages places as unlikely as Mississippi have a group of mayors that are very committed to the idea of a sugar sweetened beverage tax legislation got announced yesterday by Dean Flores one of your senators in California on sugar sweetened beverage tax structured a little bit differently than penny announced but it's close to it New Hampshire has introduced legislation Vermont is considering it Connecticut New York states holding hearings in the next two weeks on this Philadelphia is holding hearings in the next two weeks it's just just out there now and it's an idea whose time we hope has come so my guess is that once you get a first couple of adopters you get a stayed in the city to do it then it'll happen quickly in other places one of the reasons that the revenue stream is just too enticing governments that are broke this these days so how well would a sugar sweetened beverage tax work we can only guess from economic estimates on the elasticity is a soda consumption but the most recent data we have is that a penny per ounce tax could drive down the average population consumption by 20 as much as 23% the adverts held today any of the healthcare savings over a ten-year period nationally would be projected to be 50 billion dollars that number comes from the Congressional Budget Office and the revenue generated from such attacks would be 150 billion dollars over a 10-year period and if some or all of that money were earmarked for programs devoted to the prevention of obesity especially programs that would disproportionately help the poor that would help offset any regressive nature of attacks and you get win-win you get can drop in consumption you get money to do prevention programs and I can think of no other intervention that's ever been proposed to deal with obesity that cost nothing that would work would have immediate impact and raise money that could be used for other programs so that's why this concept of sugar-sweetened beverage tax is so appealing to us the industry quarrels about this as you might imagine in a big way there was an article that some of you may have seen on the front page of the sunday Los Angeles Times two Sundays ago where they did an investigative report on how much lobbying money the sugar beverage industry has been spending to fight the soda tax idea and if you look at the graph Coke Pepsi and their trade association American Beverage Association how much they spent on lobbying 2003 2004 2005 it's a flat line at about a million dollars for each of these players and then you get to 2009 it goes up to 20 million bucks I mean an amazing increase in lobbying against that so how do you interpret this struggle from the industry well is it the fact that they're fighting us so hard could very easily mean and it does to me then we're on the right track that if it weren't politically feasible why would they have to fight it and if it weren't going to affect consumption why would they care to fight and so this means to me that this is a good thing so the sugared beverage I think would have a special appeal as an initial target to try to deal with the obesity issue if for no other reason then it's the single greatest source of added sugar in the American diet but and of course a great contributor to calories but given the addictive possibility that sugar and the caffeine and their combination may be created and then it becomes especially important in the context of what's happening in this conference so that's one public policy proposal but restricting marketing making the schools a healthier environment all these things become part of an overall collage of public policy possibilities that I think are really very important and offer a lot of hope for doing something about the obesity problem so I'm going to scroll to the end here we have on our website a number of public policy briefs about nutrition and schools menu labeling and restaurants access to food in populations of the sugar sweetened beverage tax and things like that so if you want to know about the arguments for and against these things and what the public public policy proposal should be they're all available on our website so I'm going to conclude with the following i'm delighted this conference is taking place i think mary for her you know intellectual inspiration that you know inspired alyssa and others here UCSF to have things like this I'm really happy I could take part and I really think that this topic is so so important from an intellectual but also a public policy point of view and a very human point of view for the people who struggle with these problems and that my prediction although my predictions are wrong as much as anybody else's is that within the next several years this is going to really become a big player and the way we discourse about nutrition and obesity issues and will become part of the public policy landscape is I think it should be and the best way to make it so and the best way to make the most informed decisions are for the best science to be done on it so those of you in the room who are contributing to that science thank god you're doing it I think it'll be very important in the overall scheme of things as we address this problem of city as a nation so thank you very much for being here and I'm happy to answer questions you you

Channel: University of California Television (UCTV)

Views: 31,304

Rating: 4.7925072 out of 5

Keywords: obesity, weight, environmental, nutrition

Id: NzUuSZ5u6cM

Length: 58min 17sec (3497 seconds)

Published: Thu May 06 2010