Croakey’s North American correspondent, Dr Lesley Russell, writes:

“While an excellent discussion is underway on Croakey about the value of calorie labeling in tackling obesity, it has been shocking this week to confront front page news that the number of Americans who don’t have enough food is at an all-time high, largely as a consequence of the nation’s economic crisis.

Every year the Economic Research Service of the US Department of Agriculture compiles a report on Household Food Security.

The 2008 report released this week revealed that last year almost 50 million people in 17 million households (14.6% of all US households) were food insecure and families had difficulty putting enough food on the table at times during the year. This is an increase from 13 million households (11.1%) in 2007. The 2008 figures represent the highest level of food insecurity since national food security surveys were initiated in 1995.

Given that unemployment has risen from 7.2% at the end of 2008 to 10.2% today, this might now be an under-estimate of the number of people struggling to put enough food on the table.

The magnitude of the increase in food shortages, or in some cases outright hunger, has startled even anti-poverty advocates and those who have noticed the increasingly longer lines at food banks and soup kitchens.  It is especially concerning that so many children are going hungry.  In 2008 nearly 17 million children (4 million more than in 2007) lived in households where food was sometimes scarce, and children in more than half a million households faced “very low food security”.

The USDA did not actually use the word “hunger”, but President Obama did and in a statement yesterday, he called the report “unsettling.”  Others were even more forthright.  Mariana Chilton, a Drexel University public-health professor, said: “This is a catastrophe. This is not a blip. This recession will be in the bodies of our children.”

The fundamental cause of food insecurity and hunger in the US is poverty and a lack of resources to provide housing, food and health care.  The Obama Administration has taken action to help needy families through the American Recovery and Reinvestment Act of 2009, which provided a significant increase in nutrition assistance benefits for the 36.5 million people (half of whom are children) who participate in USDA’s Supplemental Nutrition Assistance Program (SNAP), formerly the Food Stamp Program.

The USDA also has a National School Lunch program which serves 31 million children a healthy meal each school day – for some children in need, this is their most important meal that day. Also, nearly half of all infants in the US participate in the Special Supplemental Nutrition Program for Women, Infants and Children, or WIC program, which ensures mothers and their children have access to nutritious food.”

• Dr Lesley Russell is the Menzies Foundation Fellow at the Menzies  Center for Health Policy, University of Sydney/ Australian National  University and a Research Associate at the US Studies Centre, University of Sydney.  She is currently a Visiting Fellow at the Center for American Progress in Washington DC.

Would such a move be useful and welcomed in Australia? Read on…

Associate Professor Tim Gill, Institute of Obesity, Nutrition and Exercise, University of Sydney:

“Requiring calories counts to be placed on menu boards in restaurant chains is a good thing but as Jane Martin points out, it is unlikely to have a profound effect on food choice by itself.

It is akin to putting up speed advisory signs at dangerous bends in the road. They are useful if you understand and are accepting of the benefits of such advice; recognise your own limitations and the need to be cautious of road conditions; are not distracted by other issues and thus fail to acknowledge such advisory signs; or over-ride the advice because of your perceived lack of time to slow down.

Unfortunately with both calorie counts and speed advisory signs they are often ignored.

This is not a reason to avoid instituting such measures because they will be of benefit to those who are in a receptive state and can effectively process and act on the information.

Rather it is a reminder that such measures need to be instituted in combination with a variety of other strategies to encourage and support people to be more receptive to these signals.

Of course the preferred method of dealing with dangerous bends in the road is not to encourage people to slow down but rather to take that responsibility away from them by remaking the road at great expense to remove the bend.

Funny, no one ever suggests that this is a nanny-state approach to road safety.”

***

David Gillespie, author of Sweet Poison, Why Sugar Makes us Fat:

“Would you feed your kids a glass of milk or a glass of Coke for breakfast?  Yep, I’d go with the milk too.

How about if you know that the milk has 168 Calories but the Coke has only 108.  Would you switch to the Coke then?  No? You’ve just explained to yourself why Calorie labelling is a pointless waste of time.

You’ve also explained to yourself why Big Sugar is particularly keen on Calorie labelling.  They know a few things which most nutritionist have either forgotten or didn’t know in the first place.

Fat serves up 9 Calories per gram whereas everything else (including sugar) is only 4 Calories.  Calorie labelling is therefore really just fat labelling by another name.  The reason the milk has more Calories than the coke is because it contains fat and the Coke doesn’t.

The study referred to by Dr Russell tells us that it doesn’t really matter anyway.  Just over a quarter of the respondents noticed the Calorie information and it didn’t influence their choices anyway.

Big Sugar knows that no-one knows or cares what a Calorie label means and even if they did, sugary products would come out looking good by comparison.  Do we really want people being steered towards high sugar, low fat foods by Calorie labels?

Ignorance of the number of Calories in food has nothing to do with why we are all fat. We are fat because our food supply is laced with sugar.  Sugar has been proven to significantly interfere with our body’s internal Calorie counter (by making us resistant to the hormones which tell us when are full).

When our appetite control system is working, we eat exactly the number of Calories we need.  If they come from fat, we eat less of everything else.  If they come from protein or carbohydrate, we eat more.

We are fat because our fuel gauge is broken.  We are not fat because we don’t know how much fat is in what we are eating.  We don’t need Calorie counts on menus, we need our built in Calorie counters to start working again.  And the way to do that is eliminate sugar from the food supply.

But don’t fret too much about lobbying for Calorie counts, Big Sugar will implement them voluntarily soon enough.”

****

Stephen Leeder,  Professor of Public Health and Community Medicine at the University of Sydney and Director of the Menzies Centre for Health Policy:

“My personal view is that the more nutritional information that consumers can be given access to, the better.  The work that Tom Friedan, former chief health officer of New York City and now boss of CDC, in getting restaurants to label their menus is part of a larger enterprise to raise community and commercial awareness of nutritional responsibility. He did the same with tobacco control to good effect.

People DO take an interest in food labelling. Come with me one weekend to Coles in Katoomba – hardly the socioeconomic pinnacle of NSW society – and observe how often customers stop and read and compare food labels.

Many would argue, with evidence, that colour coding of foods with red, orange and green to indicate the safety levels of key components such as saturated fat, calorie density and whatever else.

The food industry presents elaborate objections to the ‘traffic light’ labelling. But in the meantime, until this is resolved, clear nutritional labelling makes sense. I think one of the craziest moves ever was the move away from the calorie, which many people understood, to kilojoules, which people don’t understand.

Food labelling is very political and much engagement with the food industry by action oriented politicians (and not all are) makes great sense.”

***

Boyd Swinburn, Professor of Population Health, and Director, WHO Collaborating Center for Obesity Prevention Deakin University:

“I am just travelling at the moment but have discussed this people here in the US.  It started in New York City where to got in regulations to include the calorie content next to the price on the menu boards of chain restaurants.  They also had an anchor that about 2000 kcal is what was needed for a typical day for a typical adult.

Several other cities/states started following suit and expending the provisions. The industry could foresee an escalating situation and called for federal regulations which require the calorie information but prevent local authorities for pushing it further.

I definitely think the Australia should follow suit and all the arguments that it is not possible have evaporated. Our use of kJ will add complexity however.”

Croakey’s North American correspondent, Dr Lesley Russell, has been investigating the history of calorie-counting menus, while a local obesity policy expert, Jane Martin, looks at whether such an option might be useful in Australia.

Lesley Russell writes:

“In 2006, in a controversial move in response to rising obesity rates, New York City’s Health Department amended the city health code to  require the posting of calorie counts by chain restaurants on menus,
menu boards, and item tags.

This move was based on the following key facts:

*nearly one-third of Americans report that they are trying to lose weight;

*people are unaware of the calorie content of food, and when asked to
estimate the number of calories in food, they greatly underestimate
them; and

*consumers who were provided calorie information were much less likely
to choose the higher-calorie items.

Many fast-food chains make nutrition information available, but not in places or at times when consumers can easily use it when they buy their food. Most often, the information is available for download on Web sites.

According to the company, McDonald’s Web site nutrition page receives approximately 2,000 visitors per day, but since McDonald’s serves more than fifty million people per day, this suggests that only about one in 25,000 customers obtain nutritional information from the Internet.

The law was finally implemented, after a series of tough legal battles with the restaurant industry, in July 2008.  The system has since  become a model for similar rules intended to combat obesity and  promote good nutrition being implemented in California, other parts of  New York state, the cities of Seattle and Portland, and elsewhere.

Now some of the early findings about the success or otherwise of the New York initiative are available, in a paper (sub or pay per view only) published recently in Health Affairs.

The study compared patrons of fast-food restaurants in low-income, minority New York City communities with those in nearby Newark, NJ, a city which had not introduced menu labeling. About half of the New York respondents reported noticing calorie information, but only a  quarter of these reported that the information influenced their food  choices. However the study found that even those who indicated that  the calorie information influenced their food choices did not actually purchase fewer calories.

Last week New York City health officials delivered a more upbeat  assessment of their own, saying that New Yorkers ordered fewer calories at four chains – Au Bon Pain, KFC, McDonald’s and Starbucks – after the law went into effect. There was a significant increase in calories ordered at Subway, which researchers attributed to a continuing $5 special on foot-long sandwiches which has tripled demand for them.

The results are good enough to cause policy-makers to think that calorie labeling might be one component of a multi-faceted plan to  tackle obesity.  Certainly that’s what US lawmakers think.

Tucked away in the 1990-page health care reform bill that passed the  House of Representatives last Saturday night is a provision that will require anyone who operates chain restaurants with more than 20 locations to provide a calorie count for each standard menu item.  In addition, anyone who owns or operates 20 or more vending machines would have to provide a sign in close proximity to each item of food or the selection button that includes a clear statement about the number of calories the item contains.

The National Restaurant Association supports the labeling  requirements; the National Automatic Merchandising Association is less enthusiastic.  We assume that the Republicans, still complaining about  the size of the bill, did not read it and therefore don’t know about  this provision, otherwise we would surely have heard.”

• Dr Lesley Russell is the Menzies Foundation Fellow at the Menzies  Center for Health Policy, University of Sydney/ Australian National  University and a Research Associate at the US Studies Centre, University of Sydney.  She is currently a Visiting Fellow at the Center for American Progress in Washington DC.

Should Australia require calorie-counting menus? Jane Martin, a Senior Policy Adviser to the Obesity Policy Coalition, writes:

“This is something the Obesity Policy Coalition supports. This is yet another study showing, like restrictions on junk food advertising, that an initiative with a modest effect can have a large impact on a population.

This study is an excellent assessment of the situation.  Currently in Australia, even if there is information given about meals in chain restaurants, it is on websites or on the packaging of the meal that you order (McDonald’s), therefore people are not making informed decisions at the point of purchase.  If there was a system such as in New York, together with an education campaign, the potential impacts could be large.

This is definitely something that should be on the table here, as part of a comprehensive approach.”

But the real food war to watch is underway in the US, and you can read more about it in this investigation, “The Food Lobby’s War on a Soda Tax”, jointly undertaken by the Centre for Public Integrity and the Huffington Post Investigative Fund.

The investigation reports that:

Washington lobbyists have been enjoying a multi-million-dollar sugar rush from the food industry. Soft drink makers, supermarket companies, agriculture and the fast-food business have poured millions into campaigning against what they fear could be a burgeoning national movement to raise money for health care reform by taxing sweetened beverages.

During the first nine months of 2009, the industry groups stepped up their lobbying in Congress. They have spent more than $24 million on the issue of a national excise tax on sweetened beverages and on other legislative and regulatory issues, according to an examination of lobbying reports filed with the Senate Office of Public Records. The review shows that 21 companies and organizations reported that they lobbied specifically on the proposed tax on sugar-sweetened beverages — which among other things would include sodas, juice drinks and chocolate milk.

About $5 million of the money was spent on a national advertising campaign aimed at Capitol Hill lawmakers and promoting a newly formed coalition called Americans Against Food Taxes. The group bills itself on its website as a coalition of “responsible individuals, financially-strapped families, [and] small and large businesses” but its 400-plus membership list is dominated by industry heavyweights such as Burger King Corporation, Coca Cola, PepsiCo and Domino’s Pizza.

The heavyweight lobbying and spending is not so surprising, given what’s at stake for the industry.

In California yesterday, legislators were hearing arguments in favour of a soft drinks tax, including from Professor Kelly Brownell, who was the lead author on this landmark article in the New England Journal of Medicine arguing that there are “compelling” reasons for taxing sugar-sweetened beverages.

According to this LA Times report, one senator told the hearing that he wants “to end the Pepsi Generation,” and compared the marketing of soft drinks to cigarette marketing.

Brownell told the hearing that the landscape for the soda industry is not unlike what it was for the tobacco industry when governments began to increase taxes on cigarettes as a strategy to get people to stop smoking.

Meanwhile, Kellogg has announced that it will withdraw the IMMUNITY claim on Cocoa and other Rice Krispies cereals. The withdrawal follows this report in USA Today, citing concerns held by the San Francisco city attorney and prominent public health experts (including Kelly Brownell).

A collector's item...

On related matters, the SMH is  reporting on a project by the International Consortium of Investigative Journalists examining the climate lobby in eight countries including the US, Canada, Australia, India, Japan, China, Belgium and Brazil. The conclusion is that “big greenhouse polluting companies around the world, employing thousands of lobbyists, are exerting heavy pressure on governments to weaken climate change laws at home and slow progress on an international climate agreement in Copenhagen”.

It all starts to sound so familiar doesn’t it….

Boyd Swinburn, Professor of Population Health, and Director of the WHO Collaborating Center for Obesity Prevention at Deakin University, writes:

“Stephen Leeder makes a well argued plea for people to quit blasting the food industry with moral indignation and to work with them to find solutions to the food over-supply and over-promotion which are important drivers of our current obesity epidemic.

Indeed, there are many, many nutritionists, food technologists, dietitians and researchers working with the food industry helping them to re-formulate and market their products.   This is largely positive but that is not the role of everyone.

Public health is politics and effective public health gains have always had as a driving force the combination of passion and science being brought to the political debate. The passion, which I like to think comes from a strong ethical basis rather than a quasi-religious moralistic basis, is an essential ingredient to progress and I would be interested in the rationale or evidence that it is making things worse.

If the passionate advocates, like Rosemary Stanton, had not continually spoken out about the ways that the food industry has been contributing to the obesity problem and has been white-anting the solutions, we would have made very little progress.

It is an unfortunate fact of politics that Rosemary’s approach  will more likely catalyse the ‘banging heads’ meeting of the PM and the industry CEOs that Stephen talks about than will the cooperative approach of the embedded nutritionist or the industry-funded scientist.

But both are important for progress.”

However, Stephen Leeder, Professor of Public Health at the University of Sydney, argues that the public health community needs to move beyond moral indignation to effective engagement with industry.

He writes:

“The recent Croakey conversation about obesity and the soft drink industry is imbued with strong moral concerns, as is the public health community more generally – many members march at the front of the platoon that seeks to secure equitable access to health care, even, indeed, equal health outcomes from care or equality of health status.

No great problem there: this moral concern has motivated deep inquiry into the social determinants of health and action to tackle maternal and child survival, extreme poverty, the humane care of people with AIDS and Indigenous health.  It is in sympathy with international movements that promote human rights generally and those pertaining to health specifically.

While this moral concern has generated power in the grid of modern public health action – including the battles fought and partially won with tobacco companies – paradoxically it may inhibit progress in achieving better health for people who suffer because of the negative effects of global economic expansion, city building and food manufacture.  Illnesses caused by these changes now dominate the lists of global mortality and morbidity.

Why may our moral indignation in public health be a problem?  Before answering that question we need to hear a word from the philosopher John Rawls.

As Denver ethicist Jack Donnelly wrote recently in a monograph on concepts of human dignity, Rawls distinguishes notions of justice that derive from religious and philosophical doctrines such as Islam and Marxism from “political conceptions of justice”.

These, in Donnelly’s words, “address the political structure of society, defined (as far as possible) independent of any particular comprehensive doctrine. Adherents of different comprehensive doctrines may be able to reach an overlapping consensus on a political conception of justice.”

What Donnelly is getting is that while the foundational motivations and ideology of different people will vary, and sometimes radically so, it remains possible “to achieve an overlapping consensus [that is] partial rather than complete.  It is political rather than moral or religious.”

Many of the solutions to our current health woes undoubtedly sit outside the health sector, and will involve stakeholders with sometimes very different values and objectives and different concepts of morality.  Finding the points of ‘overlapping consensus’ is key for us to move forward towards  health gain.

Recently in Sydney we listened to two points of view – from Derek Yach and Rosemary Stanton – about nutrition and how it might be altered in favour of a slimmer society.  Derek works with PepsiCo and Rosemary definitely does not!  Both are people of impeccable public health credentials and they deliberated about how we might enter an age where obesity and its dark consequences did not dominate our thinking.

It has generated lively debate but I do not see how we can make progress until such time as we accept that a solution to this problem will be based on a political conception of social justice, to use Donnelly’s term – at the school, local government, state and federal levels.  It will be a political and pragmatic rather than ideological notion of justice that will motivate action.

Instead of allowing ourselves the indulgence of shouting from the moral high ground about the motivations of industry, perhaps we should seek a consensus around what a social conception of justice in regard to food means.

We need as public health people to get over our shock and horror at food companies being primarily motivated by profit.  We need to move beyond saying, “Their good will is just PR!”  A mutual understanding of each other’s values and goals is essential to merit a seat at the table, a table of policy and politics.

This applies to many public health policy problems.  Recognising a problem, and even understanding it is different to choosing the most effective course of action, knowing how to speak in terms that industry will take seriously, being pragmatic and knowing how to go about getting things done when success more often than not requires people to negotiate the politics.

This viewpoint is reinforced by my previous experience.  Two years ago I participated in a Canberra meeting hosted by Senator Guy Barnett about obesity.  I chaired a small working group that included representatives from the food industry, academic nutrition, advertising, media and urban designers.  Naturally we sparred about traffic light food labeling, advertising on children’s TV and other contentious topics, but we all stayed till the going home bell sounded.  The conversation was prickly but OK.

Just before we went, one of the participants turned to me and said, “You know, professor, you have the wrong people at this forum.  We’re middle managers. You need the CEOs. If they say something is going to change, it will.”

I was pondering the good sense of this suggestion – and others were nodding affirmatively, when my colleague added, “And you’re the wrong person to be chairing it.  We should have the PM and a few of his ministers without their bureaucrats at the table.  He could say to them all, ‘We have a problem and we are all going to contribute to its solution, so before you leave today I want to hear what you are going to do to help!’”

Besides revising our attachment to moral indignation, the other thing we need is a clear view of how long it has taken us to get into a situation where nearly half of all Australian adults and close to three in every 10 Australian children are overweight or obese, a mess that has disturbing similarities to global warming.  Decades: so it will probably take decades to get out.

The history of public health progress is nearly always of incremental change with many people taking many different actions.  Even the apocryphal wrenching removal of the Broad Street water pump handle has a richer context than we commonly recognize.

That is why public health is accurately perceived as a community movement and public health research workers as social scientists.  There are times when aggressive advocacy and the force of the law are necessary.  At other times they are not.  Then, as Churchill put it, we need jaw-jaw and not war-war.

The rise and rise of obesity is complex.  Recruiting the food industry – or a bit of it anyway – to our cause, while being true in our policy discussions with them to a “political conception of justice,” strikes me as a good move.

I am not at all convinced that confrontation and moral indignation do anything in this context other than make things worse.   This does not mean that we should be silent if we find abuse and hypocrisy but rather in conversation we should define those interests that are common and where, if a consensus is struck – by the PM if not by us – we can inch forward.”

It turns out the doctors aren’t the only ones taking Coca-Cola’s money. Believe it or not – dentists have too.

It’s enough to make your teeth ache.

Obesity control expert Professor Boyd Swinburn has sent in his observations while travelling in the US. He writes:

“I am currently in Boston and read with interest the comments about Derek Yach and Pepsi’s PR mission to Australia.

The TV in the US is currently carrying a series of advertisements about a regular Mom complaining that the government is thinking about raising taxes on foods and drinks (actually the talk is only about taxes on sugar-sweetened sodas).

“They say its only going to be pennies, and it may not matter to those people in Washington but it matters to me when I am struggling to feed my family”. Who is behind the ads: an outfit called Americans Against Food Taxes.

And who is behind this front group: Pepsi Co and all the other usual suspects.

One of the most powerful influences big food has is in undermining public health initiatives. Pretending to be the good guy at the same time gives it an even greater influence over government as we have recently seen with the softly, softly Preventative Health Taskforce report.

Derek used to speak  for the benefit of public health, now he speaks for the benefit of food giants.”

• Boyd Swinburn is Professor of Population Health, and Director, WHO Collaborating Center for Obesity Prevention

He writes:

“The pity is that Melissa clearly did not absorb the objective data I offered re modest but important examples of change across food companies (from 60% less calories sold in schools in the USA; to tons of less salt in many products in the UK; to 90& reductions in certain ads to kids across Europe; to 30 000 products reformulated for many nutrients; to real impacts of portion sizes on total calories consumed)…all the data being measured and mostly independently audited!

Many of these changes do not come with increased profits in the short term and are part of deep structural changes underway across industry. They include responding to the World Health Organization’s call for support of the Global Strategy on Diet and Physical Activity; developing coordinated approaches across many multinationals to tackle a variety of nutrition issues; and stepping up investments in innovation.

Further, to call addressing hunger a distraction is the very worst type of cynicism. I attach our CEO’s speech from last week at the World Food Prize on this. Some might call it a giant distraction–most I work with regard it as an imperative we cannot and must not avoid tackling!

Melissa would do well to relisten to the debate and take note of the above points as well as many impediments to progress in tackling obesity that require more effective actions by governments, NGOs and individuals. For Australia this includes fully supporting the new Preventative Task Force recommendations.”

“To my frustration I missed the Rosemary and Derek show at Sydney Uni – but it would have been a bit of a drive home…

But it seems we are asked to pick between 2 narratives here.

1. The public health warrior -fresh from wins in the tobacco wars bringing proven commitment and skills to offer direction to the well meaning but slightly misguides food conglomerates, to modify their business practices to the benefit of humanity

OR

2. The clever and once pure champion of the people who has sold out to play the role of chief PR man and government manipulator – driven by a big salary but with the prime goal to prevent or at least substantially forestall meaningful and effective regulation to reduce the so far unfettered commercial freedoms of the multinationals who are profiting while driving the international obesity epidemic.

The truth may be 1. or 2. or more likely, some complex combination of both.  But ultimately the importance of the accuracy of the narrative plays a very poor second fiddle to this essential question.

Is Pepsico, and big food more broadly, increasing, decreasing or remaining static on the hard measure of the amount of sugar, fat and salt being poured into the world’s food supply?

When Derek and mates can answer that question – via independently audited means – we’ll have useful information to wrestle with. The rest is largely spin.”