Why Education and Choice Won't Solve the Obesity Problem

The published industry commitments of the Australian Food and Grocery Council¹ state that members will:

• Expand the range of nutritious foods they produce

• Seek regulatory approval of health claims to encourage more companies to develop nutritious foods and deliver health messages into every home

• Promote information on nutrition and health to our consumers with our communication tools, such as nutrition information labels, in-store information, customer care lines, and Web sites

• Work with retailers, suppliers, advertising agencies, and the media to encourage broader promotion of nutrition and health information

• Encourage government to develop public education campaigns that raise awareness of the consequences of obesity, the benefits of being physically active, and the need to balance food intake and activity

• Advocate and participate in programs that promote nutrition education and physical activity in schools and in communities where food companies are located

Given that the raison d'être of industry is profit through increased consumption, it is significant that the Australian Food and Grocery Council should advance these health-promoting policies, which are similar to the goals of health professionals. Policies such as disseminating information about and increasing the availability of healthy food options are ultimately intended to reduce the consumption of unhealthy foods. These proposed solutions to the obesity epidemic have gained popularity with the media and the public as well as with health practitioners.^2–4 Information about good nutrition is primarily provided by health professionals and through social marketing campaigns to increase physical activity and consumption of nutritious food and to decrease portion sizes and consumption of sugary drinks. Thus far, the industry's response to these campaigns has been to increase the number of healthy choices available without reducing the selection of unhealthy foods.⁵

These popular approaches seek to provide consumers with the information and options necessary to make healthy choices; a failure to make a healthy choice, by implication, is a failure on the part of the individual (or possibly the campaign). Although education and access to information are fundamental rights and are important in a democracy, they have a negligible impact on obesity. Further, increasing choice is little more than a ruse, more likely to increase consumer confusion than to promote healthy eating.

Changing behavior in any context is a challenge. Attempting to change behavior in an environment that reinforces contrary practice is quite a bold endeavor. Increasing levels of knowledge and awareness (through education or other means) does not always result in behavior change, let alone long-term behavior change.^6–9 This is intuitively obvious to those of us who already know how our physical activity levels and diet could be improved but who fail to act accordingly.

Most importantly, it has been demonstrated that there is great variation in the way people from different demographic groups respond to education and social marketing. Typically, people with already high levels of education respond best to further education; people with lower educational attainment are much less likely to change their behavior as a result of education efforts.^10–14 This is consistent across many areas of public health and is particularly relevant in the context of obesity, which, in Australia and other developed countries, is much more prevalent in minority and lower socioeconomic groups, whose members are also likely to have less education. Few quality evaluations of education campaigns addressing obesity have been conducted, but evidence from other areas of public health suggests that social marketing and education are only somewhat effective at best in changing behaviors in populations that have the lowest incidences of obesity—hardly characteristic of a well-targeted health program.

We have significantly more food and beverage choices than ever before, yet we also have an obesity epidemic.¹⁵ The argument for increasing the number of options available to consumers rests on the assumption that providing more choice increases the likelihood that healthier options will be chosen, at least in an educated population. Research on decision-making suggests that this is not the case.¹⁶ Humans have a limited capacity to process and remember information, and as the number of choices increases, it becomes increasingly difficult to evaluate attributes and select the best option.¹⁷ As more and more foods become available, it becomes nearly impossible to perform a full evaluation of the up to 15 nutritional attributes listed on packaged foods.

When faced with a bewildering variety of options, most people engage a simplified method of decision-making by choosing a primary attribute and evaluating only that attribute in a given food.¹⁸ Even with this strategy, however, examining the side of every box to identify levels of the desired attribute is onerous—particularly when there may be up to 100 similar products on display. In these situations consumers are likely to rely heavily on front-of-package claims (e.g., low salt, high fiber, no added sugar). Even with the regulation of these claims, health-conscious consumers are likely to be confused if not misled.

In Australia we are witnessing a push to address the lack of a legal requirement that nutritional claims on packaged foods and drinks reflect the product's overall healthiness. Food Standards Australia New Zealand recently considered a proposal to prohibit health claims on products that fell below an overall level of healthiness.¹⁹ Such a proposal, if made law, would prevent confectionary companies, for example, from advertising that a product is 99% fat free if it is also high in sugar. Traffic light food labeling (red, amber, green) is another method of influencing the nutritional quality of shoppers’ food, through a simplification of the numerous nutritional attributes of a product. This method is applied to four nutritional areas of common concern—fat, saturated fat, sugar, and salt. The more green lights displayed, the healthier the product.²⁰ However, the traffic light method does not entirely alleviate the problem of choosing between multiple items with multiple attributes.

Both of these labeling measures focus on micronutrients: they rely on the belief that our diets can be improved by quantitative tinkering with the nutrient profile of foods, rather than by making more qualitative changes (such as switching from processed convenience foods to unprocessed whole foods).²¹ Regardless, many of us are more or less aware of the relative healthiness of many foods but still regularly purchase products we know are unhealthy.

If more food options and additional education about nutrition will not substantially improve consumers’ ability to identify and select healthy food, what are the alternatives? Measures that affect the accessibility, overwhelming ubiquity, and desirability of unhealthy food are essential. If we are serious about addressing the obesity epidemic, we could, to use an analogy from interventions to increase smoking cessation, ban the sale of all food designated as unhealthy (an appropriate definition would need to be developed), particularly in government venues and to children. However, less controversial options are also available, such as limiting the proportion of unhealthy products a food outlet can stock, increasing the price of unhealthy food (the so-called fat tax), and reducing the price of healthy food (through subsidies). Similarly interesting are proposals to establish calorie caps (a limit on the maximum number of calories a meal or snack can contain) and to reduce the density of fast-food outlets, particularly in disadvantaged areas.

Governments and public health researchers who are serious about tackling obesity must consider the toxic environment that has led to the current epidemic. Proposals for reform that focus solely on individuals—be it on their knowledge, willpower, or decision-making ability—will not be successful in reversing our society's body weight trajectory. We need measures aimed at changing the context, not the individual. Rather than simply encouraging consumers to make healthier choices, we must recast the environment so that healthy options are far more accessible, available, and desirable than unhealthy alternatives. A fruitful area for further exploration is corporate practice, because it is so influential in shaping consumption patterns and because it must be carefully regulated in new ways if we are to achieve any change in the epidemiology of obesity.