It’s Hard to Eat Healthy

“Ba da ba ba ba.” In 2003, faced with slumping sales, McDonald’s commissioned a jingle. The fast-food giant recruited the era’s biggest music producer, Pharrell Williams, and pop icon Justin Timberlake to create “I’m Lovin’ It.”  The catchy hook became the heart of McDonald’s first worldwide campaign. It was sung in 20 languages throughout 120 countries. An “I’m Lovin’ It” EP topped the charts in Belgium.

McDonald’s poured $1.37 billion into advertising that year, according to AdAge magazine.

The food and beverage industry spends almost $14 billion a year on advertising in the United States, using more than 80 percent of those dollars to endorse fast food, sugary drinks, candy and other high-calorie food, according to an analysis by the University of Connecticut Rudd Center of Food Policy and Obesity.

The sum dwarfs the $1 billion the U.S. Centers for Disease Control and Prevention (CDC) budgets for addressing chronic disease prevention and promoting health.

The cheery jingle and the comforting image of ketchup-dipped fries it conjures is part of a United States food environment that makes it hard to eat healthy. And factors ranging from junk food marketing that targets children to poor access to fresh produce in low-income neighborhoods are slowing the battle against obesity. 

More than 42 percent of adults in the United States have body mass indexes greater than 30—the threshold for obesity, according to 2019 CDC data. About 30 percent of adults in Allegheny County are obese.  The national rate has increased by 26 percent since 2008. Obesity increases the risk of heart disease, diabetes, infertility, cancers and other diseases. It reduces the odds of recovering from COVID-19. 

“We’ve seen obesity rates rise over time. To me, this is a reflection of our investment in community and population health,” said Tamara Dubowitz, senior policy researcher at RAND Corporation. “This is about a society that is not creating a solid [food] infrastructure for all people.”

In the mid-1970s, less than 6 percent of young people had obesity. Today, about 19 percent of children do, according to CDC data. Obese children are likely to continue the struggle into adulthood. And diseases such as hypertension, high cholesterol and diabetes—once thought of as adult conditions—are increasing in obese children.

“We know that the gene pool hasn’t changed in this time frame,” said Marlene Jarlenski, associate professor of health policy and management at the University of Pittsburgh. “The evidence suggests that the food environment has changed in a way that makes it easier for people to consume calorie-dense food, and food that contributes to weight gain and obesity.”

Processed, pre-packaged foods and the spread of chain restaurants have dominated the U.S. food landscape over the past 50 years.

Numerous studies show that food advertising increases children’s preferences and requests for the foods advertised and that fast-food advertising correlates with youth obesity. A 2009 study in the European Journal of Public Health concluded that up to one in three obese U.S. children might not have become obese if they weren’t exposed to unhealthy TV food advertising.

“Once a person becomes obese it’s really difficult to go back to being a healthy weight,” Jarlenski said. “To have a child become obese has lifelong health consequences. That’s why the obesity epidemic has been hard to do anything about. The real answers lie in the prevention side.” She recently published a study in JAMA Network Open showing that chain restaurant advertising spending alone is associated with an increase in obesity concentrated in low-income communities. Other research suggests marketing unhealthy foods targets low-income communities.

“In the United States, it’s really hard to intervene on the advertising side. We don’t believe that restaurants are in the same category as big tobacco companies. The tobacco industry was successful at knowingly marketing a product to make it maximally addictive. Do these large food corporations have the incentive to get people to maximally consume in order to maximize their profits?”

Public policy has contributed to the obesity epidemic. Government subsidies for large, export-oriented crops, such as soybeans and corn, have helped make the raw ingredients for starchy and sugary foods less expensive than fruits and vegetables. But some policymakers are slowly coming around. A Chilean government campaign that warns of excessive salt, sugar, calories and fat has helped change eating habits. Sugar-sweetened beverage consumption declined almost 25 percent in the 18 months after regulations were in place, according to a study published in PLOS Medicine. In the United States, former first lady Michelle Obama’s Healthy Hunger-Free Kids Act of 2010 set meal standards for K–12 students, increasing vegetables, fruits and whole grains. Five years later, USDA measures of the quality of students’ diet had improved by nearly 20 points.

Obesity is particularly acute among African Americans. Black adults have the highest level of adult obesity in the United States at 50 percent, according to 2019 CDC data. The obesity rate among black women is 57 percent.

“The food environment is part of a much larger socioeconomic picture,” said RAND’s Dubowitz. “It’s often an indicator of many other components of an environment that play into the obesity epidemic. Is there social cohesion in your neighborhood? Is there a commercial district that adds to the vibrancy of your neighborhood? What retail services are available? What is the housing availability and housing quality? Quality of schools? These are critical to your access to health and opportunity. Obesity is a product of access to opportunity and access to health.”

Dubowitz was part of a RAND team that studied the impact of opening a Shop ’n Save in 2013 in the Hill District to provide healthy foods to poorly served neighborhoods. In 2014, researchers saw dietary improvements among residents—whether or not they used the new store. “The grocery store did something within this neighborhood, but we don’t understand why we saw the changes. Was it investment in the neighborhood? Exposure to the message? Was it a sense of hope?” The store closed last year.

In September, the Pittsburgh Food Policy Council, a nonprofit coalition of business, government and nonprofit leaders, released the Greater Pittsburgh Food Action Plan, which offers an agenda for regional food systems. Its solutions range from zoning changes and capital supporting urban agriculture to incentives for establishing healthy corner stores, increasing funding to mobile markets that provide fresh produce, and expanding programs that give school children backpacks of food on Friday afternoons.

“We need to gain some ground in terms of how we’re supporting the smaller, more regional food systems,” said the council’s director, Dawn Plummer. “The work that’s being done bottom-up on community food systems is where you can connect a place’s culture to the business environment, its eating culture and food environment.”

Pennsylvania has the 44th lowest per capita state-level public health spending, according to an analysis by State Health Access Data Assistance Center, a health policy research center. But policy is slowly shifting toward healthier eating. Last year, Pennsylvania adopted a farm bill that included support for farm-to-school initiatives, urban agriculture infrastructure, small-scale meat production and other programs for building out regional food systems.

COVID-19 hasn’t helped. Dubowitz said almost 40 percent of the Hill District residents who participated in the RAND study struggled with food insecurity last summer.

Some policies have been adjusted to improve food access for lower-income people during the pandemic. In May, the Pennsylvania Department of Human Services allowed Supplemental Nutrition Assistance Program households to use benefits online, expanding their food options. But purchases are limited to a handful of online merchants. The benefits are accepted at local farmers markets.

“We can’t just hope that grocery store chains and food distributors are going to figure it all out for us,” Plummer said. “Food needs to be seen as public infrastructure instead of leaving it up to market forces to determine solutions. Food policy is public policy and the food system is critical infrastructure.”