Because of the complex aetiology of modern obesity patterns, isolated therapeutic or public health measures will not solve the obesity problem.
Consumers must be made aware of the ways in which the food industry influences their food purchases.
Government needs to prioritise health ahead of industrial productivity and increased consumption.
An obesity intervention wish list is presented as a suggested reform package:
prohibit all forms of marketing of energy-dense, nutrient-poor foods;
introduce measures such as kilojoule caps, prohibition of bundling, and greater uniformity in packaging design to make energy-dense, nutrient-poor foods less enticing and less amenable to bulk purchase;
redesign supermarkets to promote fresh rather than energy-dense, nutrient-poor foods;
cease provision of government subsidies to food processing industries;
tax energy-dense, nutrient-poor foods to create a disincentive to purchasing of these foods; and
regulate the location and number of fast-food outlets by enacting urban planning laws
Over the past 50 years, as food purchasing practices have changed, so too have our waistlines. We used to buy what we could carry. We interacted with a shopkeeper behind a counter, and we asked for the items we wanted, often by weight. Processed foods were neither ubiquitous nor hugely varied. Packaging of individual items was an exercise carried out by the shopkeeper using nondescript paper bags, newspaper and butcher’s paper. In Australia until the 1960s, there were no supermarkets or franchised fast-food outlets. We were not continually confronted by advertising of food or fast-food outlets on the emerging medium of television, or by prominent street signage and billboards. Neither was there subtle corporate marketing masquerading as philanthropy.
We cannot turn back the clock, but, if we really want to reduce obesity and promote good nutrition in the population, there are some strategies that could be tried. Unfortunately, these strategies probably cannot be tested before being implemented, and so may not satisfy the usual standards of scientific rigour. However, we believe that they are based on reasoned and reasonable assumptions and, if championed by government, could be implemented. First, we need to explain these assumptions.
Obesity is conceived of here as a symptom of market failure and as facing issues similar to those bedevilling climate reform.1-3 Thus, the starting point for policy development is the symbiotic relationship between industry, whose imperative is to maximise productivity and profit, and government, whose obligations are inherently conflicted; protecting population health must compete with other often more-compelling concerns. Most importantly, industry ostensibly provides income that supports government activity, and governments believe their reputations rest on enabling industrial productivity, accompanied by sustained employment and profits.
The food and beverage sector is Australia’s largest manufacturing industry. It accounts for around 18% of employment in manufacturing and is a major employer in rural and regional Australia.4 Ordinarily, the promotion of productivity, employment and consumption, including consumption of food, will trump — if not wholly, certainly in large part — other government priorities, such as the environment or health. This is mediated primarily by the need to act in the greater public interest to preserve votes, and at times by genuine concern. A cursory examination of government policy will reveal as prominent themes: reducing red tape, promoting competition, expanding employment opportunities, and creating avenues to subsidise business. For example, in Victoria, a “business impact assessment” must be undertaken if proposed legislation is, among other matters, likely to:
create a disincentive to private investment;
add significantly to business costs;
place Victorian businesses at a competitive disadvantage with respect to interstate and overseas competitors;
impose restrictions on firms entering or exiting a market;
impose higher costs on a particular class of business or type of products or services; and/or
impose restrictions that reduce the range or price or service quality options provided in the marketplace.5
No similar requirement is demanded for health impact. However, if we are to slow the obesity “epidemic”, the food industry cannot remain in its current form and on its current trajectory. To effect change will require government to depart from what can be seen as its standard industry agenda.
Legislating to reduce the amount of “junk” food advertising directed towards children is unlikely to have a significant impact on obesity, if other forms of marketing are left intact. Sweden has prohibited advertising directed towards children on Swedish television channels since 1991, with no advertisements allowed during children’s programs. However, this has not stopped foreign channels advertising in Sweden, and there has not been a reduction in obesity rates in children.6,7
A ban on one form of marketing will challenge industry to invent other avenues to reach children. In reality, this is not difficult, as the food manufacturing and retail sectors are among Australia’s top 10 advertisers.8,9 McDonald’s “MathsOnline” initiative, supported by Deputy Prime Minister Julia Gillard — but singled out for a Parents Jury shame award10 — is an example of marketing inventiveness.11,12
To produce a detectable impact, it is necessary to have a blanket prohibition on direct or incidental marketing associated with energy-dense, nutrient-poor (EDNP) food — including so-called diet food. This must include a ban on oversized street signage and billboards; attribution of corporate philanthropy; television, radio, internet, mobile phone messages, newspaper and magazine advertising; as well as advertising through other existing and emerging technologies. A one-line acknowledgement in statements of income in annual reports may be permissible.
The debate about the value of food labelling, including the introduction of “traffic-light” labelling, is misplaced.13 Comprehensible labelling should fulfil a consumer’s right to information, but should not be regarded as a flagship strategy to counter obesity. The comparative benefits, if benefits exist at all, of the many similar EDNP foods that dominate supermarket shelves are difficult to discern from the labelling. This being so, greater attention should be paid to the factors that induce members of the public to overconsume EDNP foods. Caps on kilojoules, unbundling of individual items, and greater uniformity in packaging design, colour and descriptions would make it somewhat less enticing and physically more cumbersome to buy multiple packs of oversized items. For example, carbonated and juice drinks could be available only in quantities no greater than 250 mL and sold as single units in recyclable containers with a mandatory return deposit.
Since the birth of self-service shopping in 1916,14 increasingly sophisticated research into consumer psychology has informed supermarket floor planning (and customer movement around the shelves), lighting, allocation of shelf space, check-out flow, merchandise packaging and presentation, and so on, all designed to encourage consumers to buy the more profitable “value-added” or EDNP products.15-17 In addition, market practices (one of which is “slotting allowances” — fees paid by suppliers to obtain preferential shelf space for their products) determine what is available to us, and belie claims that what is on supermarket shelves is a reflection of unreconstructed consumer choice. Attention to altering these practices is vital, as it has been estimated that supermarkets account for about 81% of grocery sales (as measured by dollars spent18), with processed food sales growing faster than sales of other supermarket stock.19 An examination of anticompetitive practices must also be included, as is currently underway in the United States, led by the Department of Justice. The US investigation is focused, among other matters, on vertical integration of the food system and the increasing retailer concentration; lack of market transparency; and discrepancies between payments to farmers and costs to consumers.20
Bans on government subsidies should not only apply to food processing and packaging industries, but should also extend to related industries and conglomerates with any subsidiary involved in food processing, manufacture or retail.
The food processing industry creates products that contribute to excess energy content and receives government subsidises to do so. For example, AusIndustry recently provided a research and development (R&D) tax concession to the confectioner “Fyna Foods” to produce, among other things, a squiggle-shaped chocolate stick.21 This concession allows companies to deduct 125% of their R&D expenditure when lodging their tax returns. Subsidies and grants provided by both the federal and state governments to the food manufacturing industry are substantial. However, given that the purpose of processing is principally to increase profit margins, often at the expense of good nutrition, such subsidies are unnecessary.
As has occurred with alcoholic beverages,22 taxation could create a disincentive to purchasing of EDNP foods. Taxes could be used to subsidise fruit and vegetable purchases, and such subsidies would have to be considerable to offset the up to 1200% mark-up that supermarkets place on some items.23 The Goods and Services Tax (a broad-based tax of 10% on most goods, services and other items sold or consumed in Australia) presents one mechanism that might be adapted for this purpose. A limited list of exclusions may be necessary. To guarantee independent decision making, determinations concerning exclusions must be made by committees with no industry representation, and the decisions should not be subject to judicial review. Opening these decisions to review in the courts would mean that industry would appeal the decisions, making the system costly and unworkable.
There is evidence to suggest that regular consumption of EDNP fast food is linked to increased body mass index.24,25 Low-cost, fast-food restaurants are more prevalent in disadvantaged areas where obesity rates are highest.26,27 Urban planning schemes could be used to limit the density of fast-food restaurants by requiring that they be a minimum distance apart, or by limiting where they might be located and/or how many are permitted within any municipality. Some local governments have successfully passed and enforced provisions of this type.28
The logic behind these recommendations is clear — if EDNP foods are not marketed, are displayed less prominently, are not available for bulk purchase, are less supported by government, and are less convenient and comparatively more expensive, we are likely to consume less of them. These measures will reduce the physical, economic and psychological availability of EDNP foods. However, these foods will continue to be produced and sold, and jobs in this industry will be retained.
Our suggestions are intended to indicate desired directions for change, without being prescriptive. The environmental harms done by the current ways in which we grow, store, process, manufacture, package, transport, distribute, and sell food have not been addressed here, but would be essential aspects of a comprehensive strategy. Our wish list has not tackled further important elements — the content of EDNP foods, and options to limit the capacity of the EDNP food lobby to shape government decisions.
Those concerned by our wish list’s “nanny state” implications might helpfully redirect their focus to the many unseen measures intentionally adopted by the food industry to shape our behaviour. When government acts, we know we are being regulated, whereas the regulation of our behaviour by industry is largely hidden and unaccountable. It seems that without our knowledge or consent we are subject to the pervasive “nannying” activities of industry — often industry that could operate well beyond our borders and our individual and national interest.
The pattern of obesity we experience as individuals, as a community, and as a country has a complex aetiology. We believe that it is a mistake to invest principally in piecemeal and, perhaps, at times, misdirected therapeutic or public health responses, in the expectation that they will slow the so-called obesity epidemic. If we continue to ignore the vastly altered market in food that has developed over recent decades, we may be deluding not only the public but also ourselves.
- 1. Anand P, Gray A. Obesity as market failure: could a “deliberative economy” overcome the problems of paternalism? Kyklos 2009; 62: 182-190.
- 2. Friedmann H. The political economy of food: the rise and fall of the postwar international food order. AJS 1982; 88 Suppl 1: S248-S286.
- 3. Magdoff F, Bellamy Foster J, Buttel F, editors. Hungry for profit: the agribusiness threat to farmers, food, and the environment. New York: Monthly Review Press, 2000.
- 4. Australian Government Department of Agriculture, Fisheries and Forestry. Australian food statistics 2007. Canberra: Commonwealth of Australia, 2008. http://www.daff.gov.au/__data/assets/pdf_file/0003/680745/foodstats2007.pdf (accessed Jul 2009).
- 5. Government of Victoria. Victorian guide to regulation. 2nd ed. Melbourne: Department of Treasury and Finance, 2007. http://www.vcec.vic.gov.au/CA256EAF001C7B21/WebObj/FINALPDFVersion ofVictorianGuidetoRegulation-2007Edition--D07-324787/$File/FINAL%20PDF%20Version%20of%20Victorian%20Guide%20to%20Regulation%20-%202007%20Edition%20--%20D07-324787.PDF (accessed Nov 2009).
- 6. Ashton D. Food advertising and childhood obesity. J R Soc Med 2004; 97: 51-52.
- 7. Livingstone S, Helsper E. Advertising foods to children: understanding promotion in the context of children’s daily lives. London: Department of Media and Communications, London School of Economics and Political Science, 2004. http://www.ofcom.org.uk/research/tv/reports/food_ads/appendix2.pdf (accessed Aug 2009).
- 8. Chapman K, Nicholas P, Supramaniam R. How much food advertising is there on Australian television? Health Promot Int 2006; 21: 172-180.
- 9. Nielsen. Australia’s top advertisers. Special report. AdNews 2009; 27 Mar. http://au.nielsen.com/site/documents/TopAdvertisers2008ADNEWS March2709.pdf (accessed Jan 2010).
- 10. The Parents Jury. 2009 Fame & Shame Awards. http://www.parentsjury.org.au/tpj_browse.asp?ContainerID=2009_fameshame (accessed Nov 2009).
- 11. MathsOnline [website]. http://www.mathsonline.com.au/ (accessed Aug 2009).
- 12. Gillard defends “McMaths” program. ABC News 2009; 20 Mar. http://www.abc.net.au/news/stories/2009/03/20/2522078.htm (accessed Aug 2009).
- 13. Sacks G, Rayner M, Swinburn B. Impact of front-of-pack “traffic-light” nutrition labelling on consumer food purchases in the UK. Health Promot Int 2009; 24: 344-352.
- 14. World Retail Hall of Fame, Hall of Fame Biographies, Clarence Saunders, Piggly Wiggly. http://www.worldretailcongress.com/page.cfm/action=Archive/ArchiveID=1/EntryID=16 (accessed Jan 2010).
- 15. Zimmerman M. Tomorrow’s supermarket. J Marketing 1946; 10: 384-388.
- 16. Applebaum W, Carson D. Supermarkets face the future. Harvard Business Rev 1957; 35: 123-135.
- 17. Choice. Supermarket sales tactics. http://www.choice.com.au/Reviews-and-Tests/Food-and-Health/Food-and-drink/Supermarkets/Supermarket-sales-tactics/Page/Introduction.aspx (accessed Nov 2009).
- 18. Report of the ACCC inquiry into the competitiveness of retail prices for standard groceries. Chapter 3, Retail industry structure, retail concentration and growth. July 2008. http://www.accc.gov.au/content/index.phtml?itemId=838251 (accessed Aug 2009).
- 19. Australian Food Statistics 2007. Department of Agriculture, Fisheries and Forestry. Commonwealth of Australia, 2008. http://www.daff.gov.au/__data/assets/pdf_file/0003/680745/foodstats2007.pdf (accessed Aug 2009).
- 20. US Department of Justice. Agriculture and antitrust enforcement issues in our 21st century economy. http://www.justice.gov/atr/public/workshops/ag2010/index.htm#issues (accessed Nov 2009).
- 21. AusIndustry. An Australian Government Initiative. Tax breaks for innovation help confectioner. http://www.ausindustry.gov.au/CustomerStories/Documents/Customer%20Stories%20December%202008%20Updates/fynafoods%20111208%20web.pdf (accessed Aug 2009, link no longer available).
- 22. Chisholm D, Rehm J, Van OM, Monteiro M. Reducing the global burden of hazardous alcohol use: a comparative cost-effectiveness analysis. J Stud Alcohol 2004; 65: 782-793.
- 23. Parliament of New South Wales Legislative Assembly. 1999–2000. Second Session of the Fifty-Second Parliament. Votes and Proceedings No. 36, 25 May 2000. http://www.parliament.nsw.gov.au/prod/la/lapaper.nsf/0/A42158B2C85AD546CA2568EA00253FCF/$file/36-vap-f.PDF (accessed Jan 2010).
- 24. Bowman SA, Vinyeard BT. Fast food consumption of US adults: impact on energy and nutrient intakes and overweight status. J Am Coll Nutr 2004; 23: 163-168.
- 25. Jeffrey RW, French SA. Epidemic obesity in the United States: are fast foods and television viewing contributing? Am J Public Health 1998; 88: 277-280.
- 26. Reidpath D, Burns C, Garrard J, et al. An ecological study of the relationship between social and environmental determinants of obesity. Health Place 2002; 8: 141-145.
- 27. Burns CM, Inglis AD. Measuring food access in Melbourne: access to healthy and fast foods by car, bus and foot in an urban municipality in Melbourne. Health Place 2007; 13: 877-885.
- 28. Blue Mountains City Council. Local Environmental Plan No. 144. http://www.bmcc.nsw.gov.au/ (accessed Nov 2009).
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