“The most important reason for policy failure is the one that nutritionists are most reluctant to admit: many people are not interested in healthy eating”.
An important aspect of evidence-based health policy is that one has to base policies not only on evidence of what works, but also on evidence of what does not work. According to Jack Winkler, there’s a great deal of that in the healthy eating field. Last summer, Winkler, a former professor of nutrition policy at London Metropolitan University, published a commentary on this theme in the British Medical Journal, entitled “Brutal Pragmatism on Food”. We reprint it in full (with permission from the BMJ).
Nutrition policy has failed. Everywhere people grow fatter and fatter. It is time to do something different, something that works.
We must start by honestly acknowledging what has proved inadequate and what is politically improbable, then select among the options remaining, in a spirit of brutal pragmatism. The choice is not what is ideal but what might be effective.
Special diets do not work. They are transformative for some people, but most resign or relapse. Dieting is not a public health solution for societies where more than half of adults are overweight.
Education does not work either. Surveys by the World Health Organization and the Organization for Economic Co-operation and Development show that developed countries overwhelmingly rely on information programmes directed at consumers, urging them to choose different foods. But such information motivates only a minority.
The most important reason for failure is the one that nutritionists are most reluctant to admit: many people are not interested in healthy eating. Some people have other priorities with food. Others are repelled by well meaning advice that comes across as hectoring.
For some advocates the problem is processed foods, the greedy companies behind them, and cowardly governments that won’t control them. There is evidence for this analysis. I have produced some myself (1) . But their solution, returning to “real food,” is daunting. It takes time and skill to prepare meals from raw ingredients. Wastage is high because fresh food spoils. Crucially, it is more expensive. In calories per penny, buns are better value than broccoli.
The dish of the day in nutrition policy is taxation of “bad” foods (2, 3). But such taxes are economically ineffective. The most comprehensive review of UK purchasing and consumption ever published showed that a 10% tax on soft drinks would reduce intake by 7.5 ml per person a day, less than a sip (4).
Policy advocacy also needs political awareness. Last year Britain experienced a “pasty tax” revolt. In the United States similar taxes are consistently rejected in referendums. Denmark, one of the most tax tolerant nations on earth, is repealing its taxes on fat and soft drinks (5). In electoral democracies, food taxes will not be a policy option for years to come.
But enthusiasts carry on regardless. The UK has seen six such tax proposals since the pasty controversy, two from medical royal colleges. The committed continue preaching to the already convinced.
From politicians’ perspective, nutrition is altogether an unappealing issue. Any robust action looks like telling people what to eat and requires challenging powerful commercial interests, who are often also party donors. It’s little wonder that politicians everywhere settle for limp and limited exhortation.
For some the food industry cannot be trusted, so it must be regulated. However, western governments no longer see food law as consumer protection but a “burden” on industry. They favour “light touch” regulation: fewer requirements, not more. In any case, writing regulations is only the start. The hard part is enforcing them, as shown by the recent horse-meat scandal. Distinguishing a horse from a cow is one of the easier enforcement tasks, but Europe could not manage even that. The future will be worse. In the worldwide recession governments everywhere are cutting frontline services.
Education, taxation, regulation. These have long been the principal instruments for public health in many fields. With food—for the foreseeable future—all are ineffectual, unacceptable, or both. What’s left?
If people will not choose different foods, we must start from the foods they actually eat most of the time, then improve their nutrient profiles. Reformulation of mass market products was the foundation for the most successful nutrition policy in the UK since the second world war: the salt reduction programme that has cut the average national intake by 16% in its first six years (6). The eventual savings in stroke prevalence, human misery, and care costs will be enormous.
Prodding may be necessary. Nutritional reformulation can be reinforced by frequent, well publicised comparative product surveys, such as those done regularly by Consensus Action on Salt and Health (7), identifying the good and bad and naming brand names. Public naming, shaming, and praising affects companies where it matters, in sales and share prices.
We need a second support: giving consumers economic incentives. Reward good choices rather than punishing bad. Food companies often charge higher prices for healthier products, even when they cost less to produce. They reason that nutritionally aware people are often affluent, willing to pay more for better food.
Reducing those extra margins would create a price differential in favour of healthier choices, shifting purchasing. That should become the core of “corporate social responsibility” for the food industry.
Two principles underlie this alternative strategy: change foods as well as changing people; and offer economic incentives as well as moral injunctions.
Would they work? There are grounds for “black optimism”: imminent developments may make the already dire situation intolerably worse, forcing change. The financial consequences of the diabetes epidemic may finally compel politicians, the business sector, and policy wonks into effective action on food—an outbreak of pragmatism.
This article was originally published in the British Medical Journal BMJ http://www.bmj.com/content/346/bmj.f3728
Note: References are in the version on bmj.com
About the author
Jack Winkler is a Former Professor of Nutrition Policy London Metropolitan University.