The role of government in preventing excess calorie consumption: the example of New York City.

AMERICANS CONSUME MANY MORE CALORIES THAN needed, and the excess is leading to diabetes, cardiovascular disease, and premature mortality. Since the 1970s, caloric intake has increased by some 200 to 600 calories per person per day. Although it is unclear how important changes in physical activity are to the surge in obesity prevalence, it is quite clear that this increase in calorie consumption is the major cause of the obesity epidemic—an epidemic that each year is responsible for the deaths of more than 100 000 Americans and accounts for nearly $150 billion in health care costs. As the obesity epidemic has mounted during the last few decades, Americans’ genes have not changed, but the “food environment” has changed markedly. Food has become increasingly ubiquitous, convenient, calorie-dense, offered in large portion sizes, and heavily marketed. Many foods contribute to excess calorie intake, but sugary drinks have drawn particular blame because of the near-tripling of consumption since the 1970s and their association in epidemiologic studies with obesity, weight gain, diabetes, and markers of cardiovascular disease. The size of sugary drinks sold has ballooned from a standard 6.5or 8-ounce size in the 1960s to 20, 32, and even 64 ounces today. A single 20ounce bottle delivers 250 calories of sugar, about twice the amount recommended by the American Heart Association for an entire day. The increase in portion sizes of these beverages is important because studies consistently show that when people are offered larger portions they simply consume more without recognizing it and without compensating for the increased consumption by decreasing intake later. The portion studies highlight a larger issue: the effectiveness of marketing of food. Food companies heavily market high-profit products, not just with billions of dollars in advertising, but also with convenient packaging, promotional pricing, and placement that facilitates impulse purchases. These food manufacturers would not continue to spend so much money on this marketing if it were not successful. In part the marketing of food is successful because humans evolved through many more periods of food shortage than excess. Humans are biologically driven to store calories when they become available and are limited in their ability to refuse food. The placement of calorie-dense, readyto-consume, inexpensive food and beverages at arm’s reach inevitably leads to the consumption of additional calories. How should government address the health problems caused by this successful marketing of food? To do nothing is to invite even higher rates of obesity, diabetes, and related mortality. One option is to encourage food companies to voluntarily alter their products or marketing to reduce health risks. Food companies understand how customers respond to their products and marketing better than anyone and could make many changes that would promote health. Food companies have indeed been responding to the obesity crisis by marketing products that have lower calorie contents by substitution (as with “diet” beverages) and more recently by offering smaller portions. However, as publicly traded companies responsive to the interests of their shareholders, food companies cannot make decisions that will lower profits, and larger portion sizes are more profitable because most costs of delivering food items to consumers are fixed. For example, PepsiCo’s attempt to emphasize healthier products was recently rejected by analysts and investors, a reminder of the limits of voluntary industry action to promote health. The balanced and most effective approach is for governments to regulate food products that harm the most people, simultaneously encourage food companies to voluntarily produce and market healthful products, and then provide information to consumers in ways that facilitate their choosing healthful products. That is what has been done in New York City. Trans fat is an artificial food ingredient that was dangerous and easily replaceable, so its use by restaurants has been prohibited by the New York City Board of Health. At the same time, the New York City Department of Health and Mental Hygiene has been working with food companies to voluntarily reduce the high levels of sodium in food. Chain restaurants are now required by the city’s Board of Health to post calorie counts on menus and menu boards so consumers can choose lower-calorie items. These actions followed similar steps to address smoking—steps that have led to a