Is There the Courage to Change the American Diet?

Kelly D. Brownell, MD
Professor of Psychology,
Yale University Director: Yale Center for Eating & Weight Disorders

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Q: Please tell us about your background. How did you become interested in obesity and eating disorders?

A:I worked with an inspirational mentor in graduate school at Rutgers, G. Terence Wilson. He was doing work on obesity and I found it to be a fascinating issue where psychology, biology, and the environment are all important players.

Q:  Where are we in the field of obesity? 

A:We have reframed the same results over time to convince ourselves we are doing better than we actually are. The percentage of people getting the right amount of physical activity has not changed since 1986! By 2030 the United States is projected to have a 37% increase in the prevalence of diabetes. In China this percentage is expected to be 76%, and in India the rate will be triple that of the U.S., a 134% increase. The field needs a rallying theme and we must correct the overemphasis on treatment and relative lack of attention to prevention. 

Q Is there a relationship between television-watching and obesity?

A:Yes and the evidence is robust. Children who have a television in their room are more sedentary and receive the most exposure to food marketing. However,  “screen time” includes not only television, but time on the internet, playing video games and general computer use. 

Q:  What role does the food industry play in the obesity problem?

A:The food industry has reeducated us. We are trained to choose certain foods in certain forms e.g., bottled water, a 20 oz bottle of soda instead of the 8 oz used before. Americans have come to value the quantity of food over its quality, believe that a serving is whatever is in a bottle, box or bag, and for the most part, do not care where food comes from, who grows it, or what is done in its processing.  We are disconnected with food, treating it as a commodity and as a nutrient delivery vehicle rather than the key to health and well-being it is.

Q:  What do we do now?

A:We must change the optimal defaults:

1. Decrease food marketing:  The types of marketing strategies used today (guerilla, viral, stealth) offer us insight. Sadly, everyone believes they are not influenced by marketing, but of course they are. Inappropriate marketing occurs, like having fast food restaurants in the lobby of a children’s hospital.  We let industry establish its own definitions of good nutrition and then splash self-serving symbols on their packages. Products such as sugared cereals and beverages are touted as being high in one nutrient or another, making consumers vulnerable.
2. Change relative costs:  Since 1983 the cost of fresh fruits and vegetables has increased approximately 117% while sweets have only increased about 46% and soda, only about 20%. Agriculture subsidies make fast food and processed food artificially cheap.  The most stark fact is that it is cheaper to buy foods that contribute to obesity than foods that would help prevent it. This problem must be addressed.
3. Address the possibility that food triggers an addictive process:  There is a growing body of evidence that food may have the capacity to trigger an addictive process. It is important that this be studied in more detail because of the relevance of this issue to understanding the genesis of obesity, its treatment, and how prevention policy might be used.

Q: Is high-fructose corn syrup more addictive than pure cane sugar?

A:  There were early papers suggesting that high fructose corn syrup provokes satiety less than sugar, but more recent papers do not support this claim. Other health effects are now being studied. The Corn Refiners Association has launched a major public relations campaign to reassure people that high fructose corn syrup is safe and has effects no different from those of sugar.  We should know the answers soon. 

Q:  Can we put restrictions on food marketing as was done with tobacco?

A:Possibly. Tobacco is illegal to sell to children and the companies cannot advertise on television. Actually, the tobacco companies found many years ago that television advertising had become cost-ineffective because anti-smoking ads were required and were damaging business. So the industry voluntarily stopped advertising on television, which seemed a victory at the time, but the companies just spent their money in more cost-effective ways by advertising elsewhere. The tax on tobacco has been the most effective measure to curb smoking, so a food tax makes sense to explore. Several countries are considering a tax. If there was a tax, the monies generated could be used to fund nutrition programs. The question is, what do we tax?  *NOTE: If we did a penny tax on soda, there would be a billion dollar profit.

Q:  What about the public school system? Can we intervene there?

A:Getting rid of the vending machines is a good place to start, followed by improvements in school lunches and getting physical education reinstated.  It may be beneficial to incorporate the planting of gardens so that children can raise some of the foods they eat and learn more about them. We need improved federal nutrition guidelines for school lunch programs.

Q:  What types of treatment do you recommend for obesity?

A:There is a lot of emphasis on treatment rather than prevention and unfortunately, available treatments have modest or disappointing results (except for surgery).  Surgery is reserved for those who are most obese, so much of the overweight population would not qualify. A Swedish cost-benefit analysis showed that the surgery actually pays for itself quite quickly, hence more insurance companies now cover it. Meridia (sibutramine) and Alli (orlistat) are drugs that have shown some promise, but with these, the results are modest as well.  

Q What has been your experience with eating disorders?

A:Bulimia has proven more readily treatable than anorexia. The treatment can be protocol-driven and there are several helpful books, focusing mainly on the two treatments that have been studied most thoroughly - cognitive behavioral  therapy and interpersonal therapy. Anorexia is more difficult - there is earlier onset and usually considerable accompanying psychopathology. Treatments have been less successful, and even after a good outcome such as restoration of normal weight, patients are sometimes plagued for years by issues pertaining to weight and shape. 

Q: Is anorexia more of a problem now or simply that we pay more attention to it? 

A:Good question. It appears there are more cases now than before, but reporting could help explain this at least in part.  There is a ‘normative discontent’ – most people finding something lacking in the way they look, and people assume that if there is something “wrong” with your body – there is something wrong with you. Thus, we see at least two extremes – those with anorexia nervosa and those with obesity. The unhealthy relationship our culture has with food contributes to both.

Q:  Are there certain environments within our society that draw anorexics?

A:Modeling, some sports, and even perverse “support” groups (pro-anorexia sites) which teach people how to perfect the disease. The science is not clear on whether people with eating concerns are drawn there or if participation in the sport triggers eating concerns.

Q Which of your publications would you recommend to physicians?

A:I would recommend:

1)  Fairburn, C.G., & Brownell, K.D. (Eds.) (2002).  Eating Disorders and Obesity: A Comprehensive Handbook (Second Edition).  New York: Guilford Press.
2) Brownell, K.D., & Horgen, K.B. (2004). Food Fight: The Inside Story of the Food Industry, America’s Obesity Crisis, and What We Can Do About It. New York: McGraw-Hill/Contemporary Books.