Yes, Food Portion Sizes and People Have Become Bigger and Bigger. What Is to Be Done?

The food supply in the United States is a catastrophe, from the public health and other points of view. Its most visible result is obesity: in two decades, the prevalence of obesity among US adults has risen by more than 30% (from 30.5% to 42.4%) and the prevalence of severe obesity has almost doubled (from 4.7% to 9.2%).¹ Even more alarming are the figures for children. From the periods 1971–1974 to 2017–2018, among those aged 2 to 19 years, the prevalence of obesity nearly quadrupled (from 5.2% to 19.3%), and the prevalence of severe obesity rose sixfold (from 1% to 6.1%).² These are great warning signs.

A recent US government report dryly notes: “The typical American dietary pattern is not currently nor has it ever been aligned with recommendations issued by the Dietary Guidelines for Americans since their inception in 1980.”³

THE GROWTH OF PORTION SIZES

One reason is the large portion sizes of many food products, as shown in important AJPH articles in 2002⁴ and in this issue (p. 2223). The findings of these articles have vital implications for the United States and for other countries.

In their 2002 report, Young and Nestle showed that what they then named “market-place foods” evaded US official guidance. “Portion sizes began to grow in the 1970s, rose sharply in the 1980s, and have continued in parallel with increasing body weights.”^4(p246) Thus, for “French fries, hamburgers, and soda, current sizes are 2–5 times larger than the originals.”^4(p246) More examples of the swelling portion sizes of foods and drinks sold in retail stores or fast-food outlets are given. Thus: “In the mid-1950s, McDonald’s offered only 1 size of French fries; that size is now considered ‘Small.’ . . . Today’s ‘Large’ weighs the same as the 1998 ‘Supersize.’ . . . Since 1999, a McDonald’s ‘Supersize’ soda is nearly one third larger than the ‘Large.’ ”^4(p248)

Little has changed since 2002. The 2021 article by Young and Nestle, accurately identifying “market-place foods” as ultra-processed,⁵ reports that since 2002 all companies in their sample “still sold portions of ultra processed foods in up to 5-times-larger sizes than when first introduced” (p. 2223). The authors also state that whereas the original size of a Coca Cola bottle was 6.5 ounces, it now has 6 sizes, from 7.5 to 24 ounces, all of which are marketed as single servings. They note that although McDonald’s has eliminated its “supersizes,” it still markets quart-sized sodas and double burgers. Generally, bigger sizes remain priced as better bargains than smaller sizes.

SO, WHAT TO DO?

Young and Nestle argue for policies designed to reduce portion sizes of ultra-processed foods and drinks. Such advice is understandable in the United States, where on average, for everybody aged older than two years, “Foods and beverages [such as] burgers and sandwiches, casseroles, pizza, snacks and sweets, and beverages (other than milk and 100% juice) contribute 50–60% of total energy intake.”³ Practically all these products, and others cited, are ultra-processed,⁵ purchased ready-made and ready to eat, drink, heat, or snack anywhere, anytime, often alone, sold at retail stores and fast-food outlets.

The two reports by Young and Nestle are based on data from the United States, where fast-food and snacking habits are ingrained, and where those most in need of dietary advice may rarely if ever eat freshly prepared meals. In this context, consuming smaller portions and servings of ultra-processed food could be sensible advice, even though smaller products would remain devoid of intact food matrices; would still be energy-dense with combinations of fat, sugar, or salt; would continue to induce mindless snacking; and would discourage switching to whole and minimally processed foods and freshly prepared dishes and meals.

What then about other countries? Ultra-processed foods are made by transnational corporations whose policies and practices are worldwide. Rates of overweight and obesity are rising globally, as is the increase in the manufacture, marketing, sale, and consumption of ultra-processed foods, most dramatically in middle- and low-income countries.⁶ But in many of these countries, long-evolved, established national and regional food systems and dietary patterns persist, although threatened by the incursion of transnationals. Regular freshly prepared meals enjoyed with family, friends, or colleagues, at home or in neighborhood restaurants, are still normal in countries such as Brazil, where we live.⁷

In such countries, reduced portion sizes of ultra-processed foods would at best have limited effect, and most likely would be counterproductive if they were marketed to promote their consumption. Generally, the most rational guideline, for global as well as personal health and well-being, is to protect and promote minimally processed foods and freshly prepared meals and to discourage the consumption of ultra-processed foods altogether,⁸ together with statutory measures including fiscal policies and actions. These measures should make fresh and minimally processed foods cheaper and more available. Ultra-processed foods should be made more expensive and less available, if at all, especially in canteens and hospitals, other health settings, and in and near schools. Cosmetic additives should be banned or highly taxed.

Another important reason to avoid ultra-processed foods in any country has become more evident. Many such products are designed by their manufacturers to induce craving. A substantial literature states that such effects amount to addiction. This is not surprising. Humans are not evolved or adapted to metabolize ultra-processed foods, which are artificial technical formulations. The common combination of fat and refined carbohydrates in ultra-processed foods does not exist in any naturally occurring food. According to a recent study, “As with addictive drugs, ultra-processed foods are the result of processing naturally occurring substances . . . and refining them into evolutionarily novel substances with unnaturally high levels of rewarding ingredients. They are then combined with additives that further amplify their effects and are quickly consumed [in ways that] rapidly and effectively activate reward/motivation systems in the brain.”⁹

As with tobacco, there is no need to consume ultra-processed food products. Avoidance is the prudent and healthiest guideline.

Transnational food corporations operate worldwide, their ultra-processed products are increasingly consumed everywhere, obesity is now pandemic, and in most countries related disorders and diseases are rapidly increasing. Therefore, global action coordinated by the United Nations is necessary.¹⁰ It is uncertain whether moves like those recommended here will gain traction after the UN Food Systems Summit held in September.¹¹ They should, because the declared purpose of the summit has been to transform food systems so as to achieve the UN Sustainable Development Goals by 2030.

In any case, recommended policies and actions for—and then issued by—the United Nations should not be limited to those that could be immediately feasible. The time for thorough change is needed, and will come. Foresight is needed, and the social, economic, political, and environmental contexts of the pandemic need to be included, as in any major public health initiative. Sometime in the future—perhaps, unfortunately, only when many millions more people have obesity and are suffering from diabetes or other related disabilities and diseases—there should be effective action.

Rudolf Virchow, the great 19th-century physician, pathologist, and social reformer, said of mass epidemics: “[P]alliatives will no longer do. If we wish to take remedial action, we must be radical.”¹² Indeed we must.