Legal Political and Social Issues of Overweight and Obesity - The Global Politics Of Obesity

At the international level, the World Health Organization (WHO) has developed an aggressive plan to combat an escalating global epidemic of overweight and obesity—"globesity"—throughout the world. The WHO guidelines on diet and exercise, The Expert Consultation on Diet, Nutrition and the Prevention of Chronic Disease, released in 2003, advocate such actions as lowering intakes of sugar, salt, and saturated fats. They also recommend sharply limiting the marketing of food to children, and using tax and pricing policies to influence food consumption. The WHO asserts that these measures are necessary to reverse rising rates of the obesity-related illnesses—heart disease, diabetes, and cancer—forecast to account for nearly three-quarters of deaths worldwide by 2020.

The WHO plan was developed by an international team of experts using the best scientific evidence available and has been commended by public health officials throughout the world. It is not, however, favored by some food manufacturers because among its proposals are restrictions on advertising unhealthy foods to children and the imposition of taxes and farm subsidy changes aimed at increasing prices of sugary and high-fat foods. For example, the International Sugar Research Organization strenuously objects to the recommendation that sugar amount to no more than 10 percent of food and drink calories consumed per day, calling instead for a 25 percent cap. Table 1.11 in Chapter One shows how total U.S. per capita consumption of caloric sweeteners has increased from 1966 to 2002.

On January 15, 2004, the United States expressed its opposition to the plan, and demanded significant changes to the initiative. Director of the Office of Global Health Affairs and Special Assistant to the Secretary for International Affairs at the U.S. Department of Health and Human Services (HHS) William R. Steiger questioned the validity of some of the dietary recommendations. In a twenty-eight-page critique of the WHO plan Steiger wrote, "There is also an unsubstantiated focus on good and bad foods, and a conclusion that specific foods are linked to non-communicable diseases." Steiger put forth the U.S. position that all foods can be part of a healthy and balanced diet and called for "greater personal responsibility in battling obesity." According to WHO spokesperson David Porter, Steiger has been the only member of the international scientific community to contest the proposed population nutrient intake goals.

U.S. opposition to the WHO proposal has been criticized as a clear effort to appease U.S. food and sugar suppliers. Some WHO scientists and consumer advocacy groups say the U.S. objections—specifically those about the recommendations to limit sugar consumption and reconsider food advertising aimed at young children—aim to protect industries that have recently been under attack rather than to improve public health. However, the food industry itself has publicly pledged to support the WHO plan. The Grocery Manufacturers of America, the world's largest association of food and drink companies, which includes PepsiCo Inc. and Hershey Foods Corp., said it was committed to working with WHO to combat obesity.

Kelly Brownell of the Yale Center for Eating and Weight Disorders, and Marion Nestle, chair of the Department of Nutrition and Food Studies at New York University, compared the food industry's self-serving attempts to delay action on the WHO proposal to efforts made by the tobacco industry to defend the harmlessness of cigarettes. In "The Sweet and Lowdown on Sugar" (New York Times, TABLE 8.1
Monthly estimates of sugar supply and use, fiscal year 2004

	May 2003	June 2003	July 2003	Aug. 2003	Sept. 2003	Oct. 2003	Nov. 2003	Dec. 2003	Jan. 2004
Beginning stocks	1,601	1,563	1,604	1,603	1,691	1,756	1,305	1,305	1,304
Total production	8,595	8,595	8,495	8,885	8,812	8,848	8,895	8,969	8,948
Beet sugar	4,450	4,450	4,450	4,659	4,651	4,667	4,720	4,798	4,852
Cane sugar	4,145	4,145	4,045	4,226	4,161	4,181	4,175	4,171	4,096
Florida	2,100	2,100	2,000	2,135	2,135	2,125	2,125	2,137	2,166
Louisiana	1,600	1,600	1,600	1,628	1,558	1,585	1,578	1,566	1,472
Texas	165	165	165	182	182	182	182	182	182
Hawaii	280	280	280	281	286	288	290	286	276
Puerto Rico	0	0	0	0	0	0	0	0	0
Total imports	1,606	1,581	1,581	1,581	1,584	1,584	1,584	1,584	1,584
Tariff-rate quota imports	1,221	1,221	1,221	1,221	1,224	1,224	1,224	1,224	1,224
Other program imports	325	325	325	325	325	325	325	325	325
Non-program imports	60	35	35	35	35	35	35	35	35
Total supply	11,802	11,739	11,680	12,069	12,087	12,188	11,784	11,858	11,836
Exports	150	150	150	150	150	160	160	160	160
Adjustments	0	0	0	0	0	0	0	0	0
Total sales	10,050	10,050	10,050	10,060	9,925	9,925	9,675	9,675	9,675
Domestic food and beverage	9,850	9,850	9,850	9,850	9,700	9,700	9,450	9,450	9,450
Other use	200	200	200	210	225	225	225	225	225
Total use	10,200	10,200	10,200	10,210	10,075	10,085	9,835	9,835	9,835
Ending stocks	1,602	1,539	1,480	1,859	2,012	2,103	1,949	2,023	2,001
Stocks/use ratio	15.71	15.09	14.51	18.20	19.97	20.85	19.82	20.57	20.35
NA = Not available.
SOURCE: "Table 26. Monthly Estimates of Fiscal 2004 Sugar Supply and Use," in Sugar and Sweetener: Data Tables, Economic Research Service, U.S. Department of Agriculture (USDA), Washington, DC, 2003 [Online] http://www.ers.usda.gov/briefing/sugar/Data/data.htm [accessed February 2, 2004]

January 23, 2004), the nutrition experts asserted that "By making its position on the W.H.O. indistinguishable from that of the food industry, the Bush administration undermines the efforts of more forward-thinking food companies and threatens public health. Its action underscores the need for government to create a wall between itself and the food industry when establishing nutrition and public health policy. Recommendations to cut back on sugars may not please food companies, but it's time to stop trading calories for dollars."

The WHO global strategy does not become official until it is endorsed by member states at the U.N. summit in May 2004. While the plan is not binding, it is considered a guiding document for public health efforts on the issue worldwide. Although the draft has gained broad international support, in January 2004 the WHO agreed to U.S. demands for additional time to comment on the final resolution. Nutritionists, public health agencies, and medical professional associations responded with shock and dismay that the United States had succeeded in stalling the global obesity-control plan.

Is Sugar the New Tobacco?

The WHO named sugar as the principal culprit in the current epidemic of obesity and such obesity-related diseases as diabetes and cardiovascular heart disease. One controversial element of the WHO plan to combat obesity is a recommendation that sugar intake be limited to just 10 percent of total daily caloric consumption. U.S. Secretary of Health and Human Services Tommy Thompson countered the WHO recommendation with a guideline suggesting that a healthy diet could contain two-and-a-half times as much sugar—that refined sugar, as opposed to naturally occurring sugars in fruits, could comprise 25 percent of a healthy diet.

Americans crave sugar. Though the United States is just 5 percent of the world population, it accounts for a staggering 33 percent of total global sugar consumption, more than ten million tons annually. Table 8.1 shows monthly estimates of U.S. sugar supply and use during fiscal year 2004. Sugar is the most subsidized U.S. crop. At a rate of nearly $500 per acre annually, U.S. sugar producers receive $1.4 billion in federal subsidies each year. U.S. sugar prices are artificially inflated because of import restrictions that protect producers from competition. Americans pay as much as four times more for domestic sugar than they would if foreign competitors were permitted to market sugar in the United States. Critics of these subsidies observe that the sugar industry makes generous contributions to senators and members of congress of both parties.

Sugar—sucrose, dextrose, fructose, corn syrup, or maltodextrin—is a key ingredient of many processed food products. Table 8.2 lists the names of added sugars that may be principal ingredients of processed foods. A can of soda may contain the equivalent of eight teaspoons of refined sugar. Table 8.3 shows that Americans' sugar consumption has been steadily increasing since the mid-1980s. Although the health food industry has been warning the public about the perils of over-consumption of refined sugars for more than thirty years, mainstream nutritionists and public health professionals have joined the ranks of those calling for reduced sugar consumption. Along with ending sugar subsidies, they want to sharply limit advertising of sugary products to children, ban the sale of soft drinks in schools, and conduct widespread community public health education programs to inform Americans about the health risks of consuming excessive amounts of refined sugars.

The U.S. War on Obesity Gains Momentum

In addition to generating international debate, the issue of obesity is receiving considerable attention from lawmakers, public health officials, and politicians throughout the United States. Some legislators and policy makers have chastised the administration of U.S. President George W. Bush for allegedly yielding to the food industry and trying to dilute the WHO antiobesity plan. Among the many legislative initiatives being considered are proposals to mandate nutrition information on restaurant menus, improving school lunch programs, and the imposition of taxes on high-calorie, low-nutrition food items.

Along with Brownell, Nestle, and Secretary Thompson, some of the combatants on the frontlines and in the news are Richard Daynard, president of the Public Health Advocacy Institute, California state senator Deborah Ortiz, federal regulator John Graham, nutritionist Margo Wootan and executive director Michael Jacobson, both of the Center for Science in the Public Interest (CSPI), George Washington University law professor Richard Banzhaf, and Richard Berman, executive director of the Center for Consumer Freedom, an advocacy group supported by restaurant and food companies.

Skirmishes in the war on obesity do not center on whether there is a problem, but rather on how best to TABLE 8.2
Names for added sugars that appear on food labels

A food is likely to be high in sugars if one of these names appears first or second in the ingredient list or if several names are listed.
Brown sugar	Invert sugar
Corn sweetener	Lactose
Corn syrup	Malt syrup
Dextrose	Maltose
Fructose	Molasses
Fruit juice concentrate	Raw sugar
Glucose	Sucrose
High-fructose corn syrup	Syrup
Honey	Table sugar
SOURCE: "Names for Added Sugars That Appear on Food Labels," in Nutrition and Your Health: Dietary Guidelines for Americans, 5th ed., Home and Garden Bulletin No. 232, U.S. Department of Agriculture (USDA), Washington, DC, 2000 [Online] http://www.health.gov/dietaryguidelines/dga2000/document/choose.htm#sugars [accessed February 2, 2004]

TABLE 8.3
Average consumption of added sugars, 1970–74 to 2000

	Per capita annual averages
Item	1970–74	1975–79	1980–84	1985–89	1990–94	1995–99	2000	Change 1970–74 to 2000	2000 food supply added sugars per capita per day1
	Pounds, dry-weight equivalent2							Percent3	Teaspoons
Total caloric sweeteners	123.7	123.8	122.4	130.5	140.7	148.4	148.9	20	31.4
Refined cane and beet sugar	100.5	91.5	74.7	62.0	64.1	65.4	65.6	−35	13.8
Corn sweeteners	21.7	30.9	46.4	67.3	75.3	81.7	81.9	277	17.3
High fructose corn syrup	1.5	9.4	27.4	47.1	52.5	60.3	62.7	4,080	13.2
Glucose	15.7	17.5	15.6	16.5	19.0	17.6	15.8	1	3.3
Dextrose	4.6	3.9	3.4	3.6	3.9	3.8	3.4	−26	.7
Edible syrups	.5	.4	.4	.4	.4	.4	.4	−20	.1
Honey	.9	1.0	.9	.9	.9	1.0	1.1	22	.2
	Teaspoons per capita per day3
Total caloric sweeteners supply
Not adjusted for loss and waste	38.4	38.5	38.0	40.6	43.7	46.1	46.3	20	46.3
Adjusted for loss and waste1	26.1	26.1	25.8	27.5	29.6	31.3	31.4	20	31.4
The Food Guide Pyramid bulletin recommends that people limit their consumption of added sugars to no more than 12 teaspoons daily for a 2,200-calorie diet. In 2000, average consumption of added sugars was nearly three times this suggested upper limit.
Note: Totals may not add due to rounding.
1Adjusted for spoilage, plate waste, and other losses. The Economic Research Service makes a tentative assumption that approximately 29–30 percent of the total domestic human food supply of caloric sweeteners is wasted or otherwise lost and not ingested.
2Aggregate data, unadjusted for spoilage, plate waste, and other losses.
3One teaspoon of sugar equals 16 calories.
SOURCE: Judy Putnam, Jane Allshouse, and Linda Scott Kantor, "Table 3. Average Consumption of Added Sugars Increased 22 Percent from 1980–84 to 2000," in U.S. Per Capita Food Supply Trends: More Calories, Refined Carbohydrates, and Fats, Food and Rural Economics Division, Economic Research Service, U.S. Department of Agriculture (USDA), Washington, DC, 2002 [Online] http://www.ers.usda.gov/publications/FoodReview/dec2002/ [accessed February 3, 2004]

address it. Combatants on one side characterize the food industry, advertisers, and the media as complicit—coercing consumers with seductive advertising and sugary, high-calorie treats. The other camp espouses personal responsibility, and believes that consumers can and should make their own choices about food and exercise.

In "The Ironic Politics of Obesity" (Science, vol. 299, no. 781, February 7, 2003), Nestle asserted that the war on obesity is unlikely to be won because healthful eating is not in the best interest of U.S. industry, and government agencies are beset by conflicts of interest. Nestle has condemned the lack of government leadership, observing that the U.S. Department of Agriculture (USDA) offers confusing and conflicting advice to consumers. To fulfill its mission to promote U.S. agricultural products, the USDA simultaneously exhorts consumers to eat more, while issuing advice about diet, which for many overweight Americans means "eat less." This conflict of interest has produced vague federal dietary guidelines that advise Americans to "aim for a healthy weight, [and] choose beverages and foods to moderate your intake of sugars." Nestle has called for "small taxes on junk foods and soft drinks (to raise funds for antiobesity campaigns); restrictions on food marketing to children, especially in schools and on television; calorie labels on fast foods; and changes in farm subsidies to promote the consumption of fruits and vegetables."

Although Secretary Thompson has been criticized for delaying adoption of the WHO global plan for improving diet, physical activity, and health, the nation's highest ranking health official has championed weight loss, personally and professionally. Since taking office in 2001, Thompson has shed 15 pounds and wears a pedometer to monitor his physical activity. In July 2003 he commissioned research to determine the feasibility of offering health insurance that rewarded group health-plan members for maintaining healthy weights. He advocates diet and exercise but asserts that communities rather than the federal government should lead the fight against obesity.

The Public Health Advocacy Institute (PHAI) contends that food industry processing and marketing practices have encouraged excessive food consumption. The PHAI Law and Obesity Project considers the existing state of regulation, legislation, and litigation related to the food industry's contribution to obesity, and the potential for new legal strategies to effectively reduce that contribution. PHAI board member Richard Daynard has suggested that every fast-food receipt should include not only item costs, but also calorie and fat content information.

California Democratic state senator Deborah Ortiz spearheaded a legislative victory that will prohibit the state's public elementary and middle schools from selling soda from vending machines. John Graham, a Harvard University professor of public health who serves as administrator of the Office of Information and Regulatory Affairs, Office of Management and Budget, campaigned to require food manufacturers to disclose the trans-fat content of their products on nutrition labels. (Trans-fats are formed by the partial hydrogenation of vegetable oil—the process used to make vegetable oil more solid. Trans fats raise LDL cholesterol levels and may lower HDL cholesterol.) Richard Banzhaf, who campaigned forcefully against tobacco, advocates using the legal system to create change in Americans' diets. He exhorts attorneys to bring lawsuits against fast-food purveyors and manufacturers of junk food to increase consumer awareness of the role the food industry has played in promoting obesity.

Richard Berman, whose organization represents major corporations such as RJR Nabisco, has marshaled lawyers, publicists, and lobbyists to respond to antiobesity crusaders. The Center for Consumer Freedom identifies itself as a nonprofit coalition that stands for "common sense and personal choice." Its Web site derides lawsuits and legislation aimed at limiting consumers' rights to choose the foods they want to consume, and it pokes fun at CSPI mandates to offer consumers nutritional data, and the self-appointed "food police"—legislators, public health officials, and others—intent on modifying Americans' diets. The organization is credited with helping to defeat a measure introduced by Ortiz in 2003 that would have required chain restaurants to offer nutritional data about their products. It also endorsed Florida Republican Representative Ric Keller's Personal Responsibility in Food Consumption Act (H.R. 339), aimed at protecting restaurants from obesity-related lawsuits. On January 28, 2004, the U.S. House Judiciary Committee approved H.R. 339 and Republican Senator Mitch McConnell from Kentucky introduced a companion bill in the Senate, the Common Sense Consumption Act (S. 1428).

The Center for Consumer Freedom is not the only group to disparage antiobesity campaigns sponsored by the U.S. government. In an editorial entitled "Leave Out a Gym Certificate for Santa; Not Cookies" (Politics.com, December 2001), Matthew Edgar asserted that the government should focus on combating communicable diseases rather than using coercive methods to battle obesity, a condition he described as a "social vice." Edgar argues for personal responsibility as opposed to government intervention and asserted that intervention to create better health is acceptable when it affects others, such as efforts to prevent reckless driving, murder, or contagious diseases, but he believes that obesity only harms the individual who has chosen to become obese. Absent evidence that obesity harms anyone other than the affected individual, Edgar believed there is no reason for the government to declare war on obesity. Despite the fact that it has not effectively reduced obesity to date, Edgar believes that education, peer pressure, and media exhortations to maintain healthy weights are sufficient to address the problem.

Presidential Hopefuls Offer Approaches to Combat Obesity

During a January 6, 2004 debate between the Democratic presidential candidates that was broadcast on National Public Radio, all of the candidates participating agreed that obesity was a pressing health-care problem that merited presidential attention. Senator John Kerry, the Democratic hopeful from Massachusetts, proposed executive leadership for an ambitious national fitness program, reminiscent of President John F. Kennedy's Council on Physical Fitness. Senator Joseph Lieberman, the Democrat from Connecticut, reiterated his request that the government investigate food marketing and advertising aimed at children, since in an average year a child sees about 10,000 advertisements, and 95 percent are for candy, soft drinks, fast food, and sugary breakfast cereals. Former Ambassador and Senator Carol Moseley Braun, an Illinois Democrat, favored education to change Americans' eating habits, as well as a single-payer, comprehensive universal healthcare plan to pay for prevention and treatment. Ohio Congressman Dennis Kucinich also favored nutrition education and described the universal health-care plan he introduced in Congress, H.R. 676, as covering all medically necessary conditions including obesity.

The American Obesity Association Action Plan

The 2002 the American Obesity Association Action Plan put forth an agenda for the government that enumerated specific funding priorities, programs, and services to prevent, treat, and educate Americans. The plan called for:

• A national commitment to combating obesity comparable in scope and funding to those for cancer, HIV/AIDS, and smoking.
• Full implementation of the National Institutes of Health Guidelines for the treatment of obesity in federal health programs including Medicare, Medicaid, federal employee health plans, the Indian Health Service, and plans for the military and veterans.
• Allocation by Congress of at least $750 million to fund a comprehensive research program on obesity.
• Accelerated HHS-funded research specifically aimed at preventing and treating childhood and adolescent obesity.
• Assumption of a key leadership role by the education community to address the rise of obesity among students at all levels.
• A Medicare prescription benefit to enable older adults and disabled persons to gain access to antiobesity medications.
• Support for consumer protection agencies' efforts to identify and eliminate frauds and deceptive practices directed against persons with obesity.
• Collaboration between the federal government and private organizations to initiate a campaign to better inform employers of the issues of workplace discrimination and denial of access to obesity treatment.
• Enacting legislation introduced by Senators Patrick Leahy (Democrat of Vermont) and Richard Lugar (Republican of Indiana) to allow the Secretary of Agriculture to more effectively restrict the sale of soft drinks and other foods of minimal nutritional value in schools that participate in the federal school-lunch program.
• Concerted efforts of the HHS and the Department of Education to encourage states to screen students for diabetes and hypertension.