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 Et AL

Alfred Sommer, MD, MHS

It has become difficult to "do the right thing," even when it is in our own best interests. Who really wants to be overweight, let alone obese? It's not good for one's self-image, let alone for one's risk of diabetes, heart disease, and stroke. Yet everything in our environment drives us to eat, even as popular culture extols the gaunt physique.

During a recent visit to our local multiplex, my wife suggested we buy a small soda. The "small" cup I was handed was at least half a liter! Burger King doesn't even make the pretense of selling a "small" fries—the smallest portion I could order was "medium." In any case, the pricing structure for most fast foods suggests you'd be an idiot to buy anything less than "supersize" (now a noun, adjective, and a verb).

Fast food portions are not only big, they are calorie-dense (lots of fat and carbohydrates). Taking an early morning flight from Fort Lauderdale, I decided to have breakfast at the airport. The coffee bar sold small (and large) muffins. I chose the smallest, pre-packaged version. While waiting to pay, I eyed the "nutrition" label that's required by law. This small, unglazed muffin contained fully a third the calories and half the fat one should consume over an entire day.

Fast food chains are not intrinsically evil: "The business of business is business." At a meeting hosted by our Center for a Livable Future, food industry executives said they would sell salads and "McLeans" if people would buy them. There is probably some truth to that. Major supermarket brands have largely abandoned their caloric and fat "lite" items for lack of consumer demand.

Fast foods are large-portioned, calorie-dense, and ubiquitous. More than a third of America's top hospitals have fast food on the premises. Children's hospitals and wards are particularly egregious—"Happy Meals" are everywhere. Few children will get fat during their short stay in the hospital, but it sends a powerful message when your trusted health professional condones fast foods, even as adolescent obesity skyrockets. An obese child invariably becomes an obese adult.

In a particularly cynical strategy, Coke and other beverage producers have entered into exclusive marketing agreements with school systems. I naively thought Coke was simply trying to muscle out Pepsi (and vice versa). In reality, these contracts are often more diabolical. A Colorado school system agreed to sell exclusively Coke, and more of it, in return for school grants. When the system failed to achieve its "sales quotas," a senior school administrator urged principals and teachers to allow children greater access to vending machines and permission to sip soda during class.

A brief attempt to "do the right thing" elicited howls of protest. Nurses at another school system sent confidential, warning letters to the parents of overweight children. The parents responded in righteous indignation that it was "none of the school's business" how fat their children were. (Hopefully, researchers will investigate the origin of this bizarre parental behavior.)

Our epidemic of obesity is not just the result of plentiful, inexpensive food but of a long-term business trend and its associated marketing. The perpetrators did not necessarily mean to increase our girth any more than purveyors of television, video games, automobiles, and other sedentary-promoting devices meant to reduce our physical fitness.

The challenge to public health is to change unhealthy behavior or institute systemic measures that reduce their health consequences. Systemic change is often more effective. Professor Sue Baker's legendary campaign for safer cars drastically reduced highway fatalities, just as increased taxes on cigarettes and banning smoking from public places has helped reduce tobacco use. The U.S. eliminated waterborne infections by providing every household with safe drinking water, not by instructing everyone to boil their water before drinking.

One industry has recently "weighed in" on the side of public health. Southwest Airlines announced in June that, henceforth, passengers would pay for the number of seats they occupy. Those whose girth intrudes onto an adjoining seat would need to purchase two tickets. With the incidence of obesity in the U.S. increasing by 6 percent a year, Southwest is clearly on to something.

One day, processed foods might, like cigarettes, contain appropriate "health hazard" warnings; but cost, proportionate to the food's health risk, would likely prove more effective. If we "supersize" anything, it should be the taxes on unhealthy food.

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