••Fall 2006/Vol. 10, No. 3

Health Systems

Transcript edited by Jon Stewart, Public Policy Editor

Marion Nestle, PhD, MPH, does not lack for opinion about the role of the food industry in the etiology of America's obesity crisis. She freely expresses her point of view as one of the most outspoken and influential voices in the national debate on public health nutrition and food policy. Dr Nestle has devoted much of her professional life to the nutrition issues that individuals, institutions, and policymakers are struggling with today: how to make better choices about what we eat.

Dr Nestle is the Paullette Goddard Professor in the Department of Nutrition, Food Studies, and Public Health at New York University. Her degrees include a PhD in molecular biology and an MPH in public health nutrition, both from University of California, Berkeley. Her research focuses on the analysis of scientific, social, cultural, and economic factors that influence dietary recommendation and practices. She is the author of three books, Food Politics: How the Food Industry Influences Nutrition and Health, Safe Food: Bacteria, Biotechnology, and Bioterrorism, and her latest book, What to Eat (May 2006), a guide to navigating the supermarket and making sensible food choices.

In April 2006, Dr Nestle visited Kaiser Permanente (KP) in Oakland at the invitation of the KP Institute for Health Policy. She sat down with a group of about 30 KP practitioners and staff to talk about food policy and the connections with nutrition and health. The following is an edited transcript of her remarks.

Question: How can KP deliver clearer, more effective messages about nutrition and healthy eating?

You have to ask: where does the public get its information about diet and health? I would say mostly from the food industry, which uses health to sell products. Information also comes from the media, which tends to focus on single nutrients and single dietary factors, almost never on healthy lifestyles, mainly because it is too boring to talk about healthy lifestyles.

The central thesis of my new book, What To Eat, is that the key dietary messages are stunningly simple: Eat less, move more, eat more fruits and vegetables, and don't eat too much junk food. It's no more complicated than that. But there is no comprehensive educational campaign behind those messages, or any concerted effort to explain what they mean. Instead, the focus is always on single products, single nutrients, or single foods.

Question: What are the messages that seem to be getting through to consumers? What works?

Obviously, health claims on package labels work splendidly. I recently spent some time with a reporter from Time Magazine at a local Safeway supermarket where we went up and down the aisles looking at products. We noticed that practically every single product has a health message on it of one kind or another. The labels proclaim about vitamins, or heart disease, or cancer, or immune system function. People see the health claims and are deeply, profoundly confused. They're confused about vitamins, transfats, low fat, Atkins diet, the glycemic index, and their effects on all the different diseases. And no government or health agency is helping them to put all the information together to demonstrate that precisely the same diet can be appropriate for almost all of those diet-related conditions, or explaining that you really don't have to worry much about individual nutrients or foods if you're eating halfway decently. But to do so, you need to make food choices. But the current food environment promotes unhealthful eating as the default. We need to change the environment so the default is to make healthier choices--offering smaller portions, for example.

Question: Is the research community offering any useful directions for us?

Brilliant behavioral research is coming from experimental behaviorists and economists who are looking at environmental cues and triggers for overeating. Brian Wansink at Cornell, for example, has demonstrated the power of external cues that make people eat more than they should¹--if you serve food in larger bowls people will eat more; if you serve a whole sandwich instead of a half sandwich, people eat a whole sandwich even if they're not hungry; and if you give people a big muffin they consume more calories than if you give them a small one.

These cues can overcome any kind of cognitive information about healthy eating, and they completely overpower issues of personal responsibility. An environment that is full of these kinds of cues undermines people's ability to make reasonable decisions about how much they should eat, because nobody wants to be thinking about curtailing calories while they're eating. This research suggests that we must change the environment in ways that make it easier for people to eat in a more rational way, such as making smaller portions the default choice or keeping candy out of sight. More research needs to be done in this area, but I don't think randomized clinical trials are the best way to do it.

Question: What about the need for more evidence-based interventions?

The term "evidence-based" is so overused in nutrition that it sends up red flags every time I hear it. It is used to prevent giving useful advice--eat less sugar, for example. This is good advice (sugars have calories, but no nutrients) but no clinical trial can ever prove that following this advice prevents obesity. I don't think we're ever going to have the kind of evidence for diet and health that you can get for drugs and cigarettes. Diets are too complicated. We cannot do randomized clinical trials on these issues and expect to get clean, clear results.

The reports on low-fat diets that recently came out of the Women's Health Initiative have only added to the public confusion. And they ruined my life for two weeks. You can't expect large groups of trial subjects to change their diets that much for that long. The questions asked by these trials aren't really answerable by this approach, because they focus on single nutrients or dietary factors instead of the more complex dietary patterns. We need to rethink the way we study diets and whether we can find a better way than randomized clinical trials to answer the scientific questions.

Just because research on diet and physical activity is harder to do doesn't mean it isn't deserving of the best possible thought and planning. Complicated issues deserve serious attention to ways in which to study them. Nutrition is a thinking person's field, but it's not often treated that way.

Question: You've spoken about the analogy of the smoking campaign to the campaign for better nutrition and physical activity. But do you think it's going to take that long to make significant progress?

Yes and no. The food industry is responding by making healthier-looking products--what they call "better for you" products that are at least marginally lower in transfats, salt, sugar, and the like. They are pushing things like "whole grain." Whole grain sugary kids' cereals are a joke--they have practically no fiber. And I recently picked up a box of cereal in a New York supermarket that had no sugar at all. It was a completely unsweetened kids' cereal. It will be interesting to see how long it stays on the market.

The most obvious explanation is that the industry is trying to head off lawsuits by offering these kinds of products. If nobody is buying them, it is because the companies are not putting any money into marketing them. Advertising Age² recently came out with a diagram of the amount of money that PepsiCo spends to promote Frito-Lay healthy products as compared to the spending on Frito-Lay junk food products. They spend $20 million to $30 million each per year on media marketing of Doritos® and Tostidos®, but less than $1 million to $2 million on the healthier baked products. So you have to ask the question, is "healthier" junk food really an improvement, especially if it's not being marketed? I don't think so.

Real improvement will come from serving smaller portions. But few companies are offering products in smaller portions. With kids, it's easier. If you want kids to eat smaller portions, you give them smaller portions.

Question: What are the most promising food policy pressure points where the right interventions might really make a difference?

Promising isn't the same as effective. I've said many times that the two biggest barriers to doing something about obesity are Wall Street and campaign election rules--Wall Street because of the pressure on our big publicly traded food companies to emphasize short-term growth strategies: companies are forced to produce evidence of growth every 90 days. And campaign spending rules because we'll never get anything out of government as long as our leaders are beholden to those same big companies for campaign funds. Everything else is what my students call Band-Aid measures.

Having said that, many Band-Aids are worth doing, and the obvious place to start is in schools. In public health terms, schools are the low-hanging fruit. Lots of changes can be made in schools by parents who are committed and willing to pressure principals and school food service directors to do the work that is needed. I see what's happening in schools as a major national social movement--one that is grass roots from the bottom up. It's exciting to see democracy in action this way.

Question: How do you respond to claims that many of the targeted interventions to promote healthy eating have little evidence of effectiveness behind them?

No one change--like going from whole milk to low-fat milk, for example--is going to show evidence of effectiveness in changing the obesity rates. Look what had to change in order to cause the high rates of obesity. Between 1980 and 2000, farm production increased the number of calories in the food supply by 700 a day for every person in the country. That food has to be marketed and sold. So maybe the first thing you need to deal with is farm production. That's why there is so much interest in making health an issue in the 2007 farm bill.

Also, portion sizes increased, food became available in more places--vending machines came into schools in the 1990s. I like to ask: At what point did it become acceptable to eat in bookstores, as it is today? Gas stations have turned into food stores. And when did it become normal for kids to decide on their own what they were going to eat? These are huge social changes that need to be reversed or altered to make progress on obesity prevention.

You add up all those changes and it's clear that single, targeted interventions, like going from whole milk to low-fat milk, will make little difference in obesity rates. These need to be one of many environmental changes designed to make it easier for parents to eat better themselves and to feed their kids more healthfully.

Question: You mentioned farm production as a factor in food policy. As you know, the farm bill is coming up for reauthorization in Congress in 2007. How should healthy eating advocates try to influence that legislation? What should the focus be?

For starters, we need to get subsidies removed from corn and soybeans. Corn is the basis of corn sweeteners, and soybeans are the basis of soy oil which, hydrogenated or not, is used in many junk food products. Analyses of food products show that costs per calorie decline with increases in the proportions of corn sweeteners and soy oils in foods. Those are the ingredients in cheap junk foods. So the objective should be to make farm policy support the growers and producers of fruits, vegetables, and healthier food products.

Question: What are the most promising areas for focusing research efforts on healthy eating?

If you are concerned about obesity, you want to change the environment so it is more supportive of healthier food choices. The question becomes how to do that. This puts us in the realm of behavioral research, not clinical research. We need to know more about how to motivate people to change on the personal responsibility side, and how to make healthier choices easier for them on the environmental side. Both are necessary; you can't motivate people to make dietary changes unless those changes are easy to do. So the essential question becomes: How do you make it easier for people to eat more healthfully?

Question: Is the health care industry doing anything that's particularly useful in terms of promoting nutrition and healthier lifestyles?

Hmmm. Good question, but I can't think of any examples. The health care system is designed for treatment, not prevention, and until there's a way to make prevention pay nobody will talk about it or do anything about it. KP is the only game in town where prevention pays. Your organization benefits if people are healthier, but I can't think of any other institution in America where that is true. This gives KP a rare privilege and a responsibility, and if you don't take full advantage of it you will be missing a rare opportunity.

References

1. Wansink B, Cheney MM. Super bowls: serving bowl size and food consumption. JAMA 2005 Apr 13;293(14):1727-8.
2. Thompson S. Frito-Lay changes the channels. Advertising Age 2006 Jan 9;77(2): p 3, 36.

Building a Healthy Food Environment at Kaiser Permanente
By Lynn Garske, Environmental Stewardship Manager
Jan Sanders, Director, National Nutrition Services, Procurement and Supply
Loel Solomon, PhD, Director, Community Health Initiatives, Community Benefit Program

Kaiser Permanente (KP) has been working to improve the health of its members, employees, and the communities it serves as well as the health of the environment by increasing access to fresh, healthy food in and around KP facilities. For over 18 months, a multidisciplinary group of physicians, dietitians, food service managers, health educators, and operations support leaders have been working on a variety of healthy food efforts, both as part of a crossregional KP Food Workgroup and as participants in myriad local healthy food efforts.

Elements of this effort:

· Farmers' Markets. KP opened its first farmers' market on the grounds of the KP Oakland Medical Center in May 2003. The initiative took off like wildfire across the organization. As of April 2006, KP now hosts more than 28 farmers' markets of varying scope at medical centers in its Northern California, Southern California, Northwest, Colorado, Georgia, and Hawaii Regions. There are plans for more. The weekly markets provide a cost-effective community service, as they are open to the broader community and not only members and staff. The markets provide a clear community benefit, as many of the areas in which they operate previously had no regular access to fresh fruit and vegetables. The markets are part of KP's overall commitment to improve the health of not only our members but of the communities we serve.

· Cafeterias, vending machines, coffee carts, and catering. As part of its commitment to improving the health of its members and employees, KP is focusing on the provision of fresh, healthy food options in its cafeterias, vending machines, coffee carts, and catering. In the Northern California, Southern California, Northwest, and Hawaii Regions, medical centers are making nutritional changes in their food preparation methods and selection. For instance, many KP cafeterias have begun to use trans-fat-free oil in food fryers, providing low/nonfat dressings and is offering more salad bars with fresh fruits and vegetables. Other changes include offering trans-fat-free margarines, hormone-free milk, and more nutritional breakfast offerings. In the Northern California Region, all medical center cafeterias have switched to trans-fat-free oils. Earlier this year, KP facilities began implementing a "Healthy Picks" program requiring all vending machines to have at least 50% healthy options, accompanied by health education and promotions to encourage healthy vending machine choices. And hormone-free milk is now standard for inpatient meals and in hospital cafeterias in KP's Northern California, Southern California, Northwest, and Hawaii Regions. Other regions will soon follow.

· Seasonal and locally sourced foods. Seasonal purchasing of produce has been integrated with traditional purchasing practices, and fresh fruit is now the default dessert instead of a sweet dessert in KP's Northern California and Southern California Regions. In KP's Northwest Region, seasonal purchasing has been integrated with traditional food purchasing, and organic standards are being discussed with food suppliers. In KP's Hawaii Region, seasonal purchasing has been integrated with traditional purchasing for cafeteria and inpatient food services. KP is also working with local farmers, community-based organizations and food suppliers to increase the availability of locally sourced food through a number of "farm-to-hospital" demonstration projects. The primary goal of local sourcing is to reduce negative environmental impacts by decreasing the distance food travels from farm to plate. Local sourcing can also improve the economic vitality of communities in and around KP service areas and increase the freshness and taste of fruits and vegetables that enter KP's food supply. Farm-to-hospital demonstration projects are being conducted in Northern California, Southern California, and the Northwest Regions. In addition, weekly farm boxes are now being provided to KP employees in one of KP's regional office buildings in downtown Oakland. Over 200 employees participate in this program. The boxes are filled by farmers that participate in the farmers' market at Oakland Medical Center a few blocks away.