Challenging Dogma - Fall 2009

Thursday, May 20, 2010

The Scapegoating of Trans Fats: the Newest Fad of the Anti-Obesity Campaign and Why it Won’t Work – Emily Benjamin

I. Introduction
America, as has become abundantly clear, is in the midst of a nutritional crisis. Three in every ten American adults are clinically obese (BMI>=30), and the rate is higher for those clinically overweight (BMI 25-29.9)(1). Overall, upwards of two-thirds of American adults are overweight or obese. In addition, 16.3% of American children are clinically obese.(1) As of 2000, there were up to nine million morbidly obese Americans (BMI >=40)(2).

Given that obesity is strongly associated with diabetes, various forms of cancer, cardiovascular disease, stroke, and hypertension, calls for action to stop the epidemic have intensified as obesity continues to spread (2,3,4). Further support for curbing the epidemic is the enormous cost that obesity is exacting on America’s health industry. More than 25% of the nation’s health care spending is related to obesity, and upwards of $61 billion are spent each year directly because of obesity (1).

Due to the increased health risks and striking economic costs of obesity, many domestic public health interventions have been implemented with the goal of controlling the spread of the epidemic. These have taken various forms, from requiring restaurants to post calorie counts, to sending elementary-school children home with BMI ‘report cards’, to airing educational media campaigns (5-8). These interventions have seen varied levels of success, but many have been misguided, and have ultimately failed to achieve their goals (9).

One such recent and ineffective form of intervention has been the regulation of trans fats, which have recently been labeled a main contributor to the spread of obesity. The premise of the regulations is that by removing the option of consuming trans fats, we will not consume them, and thus, overall, we will be healthier (4).

Trans fat regulations have taken two primary forms. Trans fats have been banned in restaurants in some cities, states and countries, and the labeling requirements for packaged foods that contain trans fats have become more explicit (4). Over the past several years, a number of countries and cities worldwide, including Denmark, New York City, Philadelphia, and Boston, have mandated that all food sold in restaurants must be free of trans fats (4,12). In general, the media and general public have reacted to these regulations positively. Supporters view these bans as promising methods through which the morbidity and mortality associated with obesity will decrease (4).

Despite the generally positive reception that these regulations have received, opposition does exist. Some challenge that saturated fats are equally culpable in the obesity epidemic; others contend that government does not hold the power to limit personal choice in this manner (4). However, the strongest argument against focusing on trans fat as the perpetrator is the fact that these policies ignore the actual causes of the obesity epidemic (15-17). We are not all fat because we consume too many grams of trans fats; regulating trans fats, as is becoming more and more popular, is not going to make us all thin on its own. Obesity is spreading because of the lifestyle that has pervaded America, that of eating too much and not being active enough (9). Obesity is allowed to arise when energy expenditure is surpassed by energy consumption (9). Given the practices that have become normalized in our society – the prioritizing of sedentary activities over physical activity, and having access to many, and inexpensive, food options – energy consumption has continually increased nationwide while energy expenditure has decreased (9).

II. A Critique of the Trans Fat Regulations
There are two overarching shortcomings of the trans fat regulations that explain why the regulations will ultimately fail in their goal to control the obesity epidemic. Firstly, trans fats are not the problem. This issue can be analyzed from two separate perspectives: one, the regulations inappropriately and misleadingly frame the problem; and two, through fundamental attribution error, the character of trans fats have been identified as the culprit, thereby ignoring entirely the context of the obesity epidemic. The second main problem with the trans fats regulations as they stand presently is that the government, by taking away an individual’s right to choose what s/he eats, risks reactance by these citizens in the form of eating more unhealthily in an attempt to reclaim that freedom.

A. Trans Fats Regulations Incorrectly Frame the Issue of Obesity
By focusing so strongly and singly on trans fats, government is telling its citizens that trans fats are the cause of the obesity epidemic. The regulations further imply that by not consuming trans fats, we, as both individuals and a general population, will immediately become healthier. This is not entirely incorrect – studies have confirmed that consumption of trans fats can increase risk for coronary artery disease and Type II diabetes, and increase HDL (‘bad’ cholesterol) and decrease LDL (‘good’ cholesterol) (10). However, french fries are not a healthy food, regardless of what kind of oil they are fried in and whether that oil contains trans fats. By policing restaurants and not allowing them to cook with trans fats, these regulations are, in effect, telling potential patrons that the foods available to them at these restaurants are now healthy enough for consumption. This could lead unwitting consumers to continue eating these foods, believing that they are eating healthier, when in fact their health may only be marginally improved, if at all, by eating french fries cooked in oils without trans fats (13).

The focus on trans fats has also allowed the food industry to portray itself as contributing to a healthier America. In 2006, Wendy’s International made news headlines across North America when it instituted a new company policy that regulated all stores to begin cooking with more healthful oils. Shortly afterwards, Kentucky Fried Chicken Corporation, McDonald’s Corporation, and Burger King Brands, Inc. all announced the same intention (11). These changes have been heralded as positive responses to consumer demand (11). However, not nearly enough research has been done to examine the actual healthiness of these replacement oils. A similar dearth of research in the 1970s led to the replacement of palm oil with trans fats in many processed foods, as it was then believed that trans fats were healthier than palm oil, which has a high saturated fat content (10). Now, two decades later, trans fats are being held responsible for the obesity epidemic. If we do not start examining with what food corporations are replacing trans fats, we could be consuming foods made with equally or more unhealthy ingredients (10).
By continuing to frame the issue in this way – by focusing on trans fats only – we as public health practitioners are effectively putting on blinders, not allowing ourselves to consider the larger, stronger causes behind obesity that we can affect. If we are to be successful in the fight against obesity, we as public health practitioners need to take a broader approach how we view obesity and its causes.

B. Trans Fat Regulations Incorrectly Assign the Causes of Obesity
Public health practitioners’ failure to take a step back and view the larger causes of obesity is a classic example of fundamental attribution error. By focusing on the character of trans fats as our culprit, we miss the larger picture – the context in which the obesity epidemic is blossoming. There are multiple and varied causes of obesity’s spread throughout a population, beyond simply what foods individuals are consuming and if they are exercising.

The environment in which we live plays a profound role in the spread of obesity in America, where inexpensive food is readily available, and physical activity is being actively replaced with sedentary behavior (14). This shift away from physical activity towards more inactive behavior has stemmed in large part from changes in the workplace. Technological advances precipitated movement away from manual labor, leading to a dramatic decrease in physical activity required at work (15).

Further, the spread of increasing portion sizes at restaurants (including ‘supersizing’ at fast food outlets), has drastically increased consumption (16). The proportion of food consumed away from home, as compared to that prepared in-home, has increased from 18% from 1977-1978 to 32% from 1994-1996 (16). The combination of more frequently eating food prepared outside of the food with larger portions being offered outside of the home has led to an increase of an average of 1854 calories per person per day to 2002 calories per person per day, which results in weight gain of 15 pounds per person per year (16).

In developed countries, socio-economic status (SES) is a major component in the obesity epidemic. As SES increases, obesity tends to decrease (17). This is due to low-nutrient foods being most affordable, and gym membership and healthy foods, including fruits and vegetables, being more, at times prohibitively, expensive (17). Furthermore, poorer areas can be less likely to have sidewalks, thereby further discouraging physical activity (17).

By focusing as the public has done on a molecule as slight as trans fats, we are ignoring the comparatively enormous societal contexts in which obesity exists. It is far easier to devise ways to moderate consumption of trans fats than it would be to moderate the environmental causes contributing to the spread of obesity. Perhaps this is why trans fats have become the latest offender in the anti-obesity movement.

By ignoring the more distal causes of the spreading obesity epidemic, we as public health practitioners are severely limiting the impact we can exert on the epidemic. Our efforts will prove futile if we continue to target this proximal and arguably insignificant factor contributing to the spread.

C. Trans Fat Regulations Draw Reactance
Psychological reactance theory states that, upon perception of a threat to one’s freedom, an individual may adopt one of three reactant behaviors: ignoring the threat, disparaging the source of the threat, or demonstrating their freedom from the threat by deliberately performing the behavior being threatened (18,20).

These reactions could quickly incapacitate an intervention if it is perceived to be presenting such a threat. Although the bans already instituted have overall been deemed ‘successes’, based on the fact that high percentages of restaurants have complied with the bans and increasing numbers of food producers are decreasing the amount of trans fats in their products, these regulations have led to significant concern across the country (4,11,19).

There are many Americans who believe that government oversteps its bounds in a number of ways (18,19). We as Americans are accustomed to being able to purchase what we want when we want, including decisions about what foods we are going to eat (4). Many individuals see the trans fats regulations as the government overstepping its bounds for purely paternalistic reasons in dictating what we can and cannot put into our bodies (4,18,19). Further claims have been leveraged against the regulations on the grounds that they impede the free speech of restaurants and food producers (19).

The measurement of success discussed above, which is being used to determine how effective the bans and labeling requirements, is an incomplete measurement. If we measure the effectiveness of the bans solely by decreasing trans fat consumptions, then the bans will obviously be successful: if there is no trans fat in foods available at restaurants, then patrons cannot consume trans fats at restaurants. Similarly, food producers are facing pressure to decrease the trans fats in their products, as industry leaders such as Oreo’s are now trans fat free and consumers are demanding a healthier product. The amount of trans fat that could possibly be consumed is continually decreasing nationwide (21).

However, the larger goal of the trans fat regulations is to help lead to an overall healthier America. Thus, this should be the scale by which the success of these regulations is measured. Further, the success of the regulations needs also to be considered in the context of reactance. If individuals feel that their ability to consume the foods they want to consume, regardless of their fat content, is being threatened, those individuals, according to reactance theory, are likely to go out and consume more high fat-content foods to display their continued control over their freedom to eat what they like. Data on actual levels of reactance to trans fat regulations are deficient (22); however, it can be assumed that reactance theory would play a similar role in these regulations as it has in others (23-25), given that the threat to an individual’s freedom is present.

The creators of the trans fat regulations do not appear to have considered reactance to the regulations when they were creating them. Given the influence that reactance has played in the past on various interventions, including interventions aimed at decreasing alcohol consumption, increasing patient compliance, and increasing anti-pollution measures (23-25), it is likely that the trans fat regulations will be severely hindered by individual’s reactance to the threat of their freedom to eat what they want to eat.

III. The Trans Fat Regulations Reshaped
By examining the shortcomings of the regulations surrounding trans fat, there are a number of possible alternative solutions to America’s obesity crisis. These alternative solutions will be far more effective if they examine obesity from the lens that the trans fat regulations are lacking. Successful solutions to enable the halting of the spread of obesity will need to approach the epidemic from an environmental and social context, rather than from an individual behavior model.
The proposed intervention incorporates solutions to the three shortcomings of the current trans fats regulations, as detailed above. By providing incentives coupled with education to individuals, public health practitioners put the adoption of healthier lifestyle choices back in the hands of the individuals themselves, rather than removing the control of such decisions altogether.

A. A Brief Description of the Intervention
The use of incentives has been shown to change individuals’ behaviors regarding HIV prevention (26) and reducing household waste (27), and to change firm behavior in promoting pollution control (28). Several interventions have examined the effect that financial or material incentives can have on behavior change, and most have found that such incentives can in fact successfully change an individual’s behavior to reflect healthier decisions (29,30). Indeed, in one literature review, nearly 75% of randomized trials aiming to increase healthy behavior through financial incentives achieved successful outcomes (30). However, another study found that though these financial and material incentives led successfully to behavior change, they had no impact on the attitudes of the participants – individuals were purchasing healthier foods simply because they were more affordable, not because of the increased nutritional value that they offered (29).
The proposed reformulation of the trans fat regulations involves the provision of differential financial incentives to individuals who not only reduce their consumption of trans fats, but who consume healthier foods overall and/or who increase the regularity with which they are physically active. One arm of this incentive will focus on trans fats, due to their recognized detrimental and deleterious health effects (10,31), by providing incentives to those individuals who can prove that they have purchased trans fat free foods in both supermarkets and restaurants. However, similar incentives will be provided for similar restrictions of saturated fat consumption and overall caloric consumption, on a graduated scale: saturated and trans fats consumption reductions will be linked to a smaller incentive than will overall caloric consumption. Further, individuals who can prove that they are increasing the regularity with which they are physically active will receive a financial incentive on the scale of the overall caloric consumption. Insurance companies, the government, and the anti-obesity movement will together finance the incentives provided, at percentages to be determined.

B. Support for the Proposed Intervention
1. The Proposed Intervention Frames the Obesity Epidemic Correctly
As described above, the proposed intervention is far more likely to be successful in combating the spreading obesity epidemic than are the trans fats regulations currently in existence because it frames the obesity epidemic more appropriately. By including not only provisions directed at reducing consumption of specific and proximal causes of obesity (trans fat and saturated fat), but also specifications for broader, more distal individual causes (consuming too much food, not exercising enough), the proposed intervention includes a more precise frame from which we can examine the problem of obesity.

The proposed intervention will not directly affect the broader environmental causes of the spread of obesity, but if the intervention is successful, it can be expected to have later indirect and more residual affects on these most distal causes. As people adopt these healthier behaviors, we can expect, through the application of network theory, that these healthier behaviors will spread through the individuals’ networks as has been seen with the spread of obesity and cessation of smoking (32,33). As these behaviors become adopted by more individuals, we can expect that these individuals’ new behavior decisions will put collective pressure on various industries, forcing provision of healthier options for consumption. Therefore, though the proposed intervention will lead to behavior change on an individual level most immediately, it can be expected to lead to greater change on a social level with time.

2.The Proposed Intervention Accurately Attributes the Causes of the Obesity Epidemic
Through its provision of financial incentives for much broader behaviors than those simply surrounding trans fat consumption, the proposed intervention offers a more comprehensive and accurate recognition of the broader causes associated with the spread of obesity. Rather than focusing on the consumption of trans fats as the primary cause of the obesity epidemic, the proposed intervention encompasses recognition of a far broader set of origins of the spread of obesity. By focusing on two singular nutrients – trans fats and saturated fats – the proposed intervention recognizes the significance of the role of consumption of these two nutrients on obesity in America. However, by recognizing the larger and stronger individual factors at play – notably, consuming too much food and not being physically active enough – the intervention promises to be more successful, given the higher incentives for these broader causal identifications.

Again, as discussed above, the intervention will likely not affect the more socially and economically ingrained distal causes of the epidemic at first. However, it promises, through promoting individual behavior change across an entire society, to lead to greater change on a social and economic level in the future. Further, since it will be the consumers themselves driving this broader change, as discussed above, it is more likely that the changes that occur on a social level will remain in place for longer than they would be if forcibly imposed, as the trans fat regulations do.

3. The Proposed Intervention Avoids the Issue of Reactance
Thirdly, the proposed intervention entirely removes the issue of reactance, which promises to plague the trans fats regulations as they stand currently, as discussed above. Because the intervention allows for individuals to create the behavior changes that they themselves want, this intervention will lead to the intended and desired adoption of new behaviors, rather than the imposed and potentially unwanted adoption of such behaviors that the trans fats regulations enforce. This will allow for those who do not want to make such changes to continue with the same behavioral profile as they had before, but will also make it possible for those who do indeed want to change to be able to. Since no behavior is being threatened, only encouraged, we can expect that reactance will not pose a problem for this proposed intervention. Further, since these behavior changes are being implemented on an as-wanted basis, by the individuals themselves who want to make the changes, it is likely that these changes will be more long-lasting than those imposed by an outside force, as discussed above.

In addition, the proposed intervention will help to encourage those who have been thinking of making these changes through increasing their sense of self-efficacy, a crucial component of behavior change as stipulated in Bandura’s Social Cognitive Theory (34). Self-efficacy must be present in this model for individual behavior change to take place and to be continued, and the proposed intervention increases individuals’ self-efficacy by making healthy lifestyle changes more affordable and more achievable.

IV. Conclusion
The current trend of imposing trans fats regulations in cities, states, and countries worldwide will likely fail in their efforts to stop the spread of obesity. There are several reasons for this future failure, including the improper framing of the obesity epidemic, inaccurate attribution of the causes of the obesity epidemic, and the likelihood of inciting reactance against the regulations. A newly proposed intervention that encompasses encouragement of reducing the consumption of trans fats in a larger scheme intended to incentive healthier lifestyles in a broader sense will likely be more successful in combating obesity. This new intervention correctly and accurately frames the obesity epidemic and its causal factors, and also decreases the likelihood of reactance to such encouraged behavior changes, and for these reasons it is likely that the proposed intervention will be more successful than the current imposition of regulations.

1. Levi J, Vinter S, St. Laurent R, Segal LM. F as in Fat: How Obesity Policies are Failing in America. Washington, DC: Trust for America’s Health, 2008.
2. Peskin GW. Obesity in America. Archives of Surgery. 2003; 138:354-355.
3. Ogden CL, Carroll M, McDowell M, Flegal K. Obesity Among Adults in the United States-No Statistically Significant Change Since 2003-2004. Atlanta: CDC, 2007.
4. Gostin LO. Law as a Tool to Facilitate Healthier Lifestyles and Prevent Obesity. Journal of the American Medical Association. 2007; 297:87-90.
5. Kuo T, Jarosz CJ, Simon P, Fielding JE. Menu Labeling as a Potential Strategy for Combating the Obesity Epidemic: A Health Impact Assessment. American Journal of Public Health. 2009; 99;1680-1687.
6. Berman M, Lavizzo-Mourey R. Obesity Prevention in the Information Age: Caloric Information at the Point of Purchase. Journal of the American Medical Association. 2008; 300;433-435.
7. Scheier, LM. School health report cards attempt to address the obesity epidemic. Journal of the American Dietetic Association. 2004; 104;341-344.
8. Beaudoin CE, Fernandez C, Wall JL, Farley TA. Promoting Healthy Eating and Physical Activity: Short-Term Effects of a Mass Media Campaign. American Journal of Preventive Medicine. 2007; 32;217-223.
9. Hill JO, Peters JC, Wyatt HR. The Role of Public Policy in Treating the Epidemic of Global Obesity. Clinical Pharmacology and Therapeutics. 2007; 1-4
10. Unnevehr LJ, Jagmanaite E. Getting rid of trans fats in the US diet: Policies, incentives, and progress. Food Policy. 2008; 33:497-503.
11. Stein K. Many Companies making More Healthful Choices for Consumers. Journal of the American Dietetic Association. 2007; 107:550-552.
12. Niederdeppe J, Frosch D. News Coverage and Sales of Products with Trans Fat: Effects Before and After Changes in Federal Labeling Policy. American Journal of Preventive Medicine. 2009; 36:395-401.
13. Borra S, Kris-Etherton PM, Dausch JG, Yin-Piazza S. An Update of Trans-Fat Reduction in the American Diet. Journal of the American Dietetic Association. 2007; 107:2048-2050.
14. Brownell KD. The Chronicling of Obesity: Growing Awareness of Its Social, Economic, and Political Contexts. Journal of Health Politics, Policy and Law. 2005; 30:955-964.
15. Finkelstein EA, Ruhm CJ, Kosa KM. Economic Causes and Consequences of Obesity. Annual Review of Public Health. 2005; 26:239-257.
16. Wellman N, Friedberg B. Causes and consequences of adult obesity: health, social and economic impacts in the United States. Asia Pacific Journal of Clinical Nutrition. 2002; 11:S705-709.
17. Poston WSC, Foreyt JP. Obesity is an environmental issue. Atherosclerosis. 1999; 146:201-209.
18. Clee MA, Wicklund RA. Consumer Behavior and Psychological Reactance. Journal of Consumer Research. 1980; 6:389-405.
19. Mello MM. New York City’s War on Fat. New England Journal of Medicine. 2009; 360:2015-2020.
20. Burgoon M, Alvaro E, Grandpre J, Voulodakis M. Revisiting the Theory of Psychological Reactance: Communicating Threats to Attitudinal Freedom (pp. 213-232). In: Dillard JP, Pfau M, ed. The persuasion handbook: developments in theory and practice. Thousand Oaks, CA: Sage Publications, 2002.
21. Frank TH. A Taxonomy of Obesity Litigation. ULAR Law Revew. 2006; 28:427-441.
22. Faith MS, Fontaine KR, Baskin ML, Allison DB. Toward the reduction of population obesity: Macrolevel environmental approaches to the problems of food, eating, and obesity. Psychological Bulletin. 2007; 133:205-226.
23. Allen DN, Sprenkel DG, Vitale PA. Reactance theory and alcohol consumption laws: Further confirmation among collegiate alcohol consumers. Journal of Studies on Alcohol. 1994; 55:34-40.
24. Fogarty JS. Reactance theory and patient noncompliance. Social Science and Medicine. 1997; 45: 1277-1288.
25. Mazis, MB. Antipollution measures and psychological reactance theory: A field experiment. Journal of Personality and Social Psychology. 1975; 31:654-660.
26. Lamb ML, Rhodes F, Hoxworth T, Rogers J, Lentz A, Kent C et al. What about money? Effect of small monetary incentives on enrollment, retention, and motivation to change behavior in an HIV/STD prevention counseling intervention. Sexually Transmitted Infections. 1998; 74:253-255.
27. Thogerson J. Monetary Incentives and Recycling: Behavioural and Psychological Reactions to a Performance-Dependent Garbage Fee. Journal of Consumer Policy. 2003; 26:197-228.
28. Milliman SR, Prince R. Firm incentives to promote technological change in pollution control. Journal of Environmental Economics and Management. 1989; 17: 247-265.
29. Anderson JV, Bybee DI, Brown RM, McLean DF, Garcia EM, Breer ML et al. 5 a day fruit and vegetable intervention improves consumption in a low income population. Journal of the American Dietetic Association. 2001; 101:195-202.
30. Kane RL, Johnson PE, Town RJ, Butler M. A structured review of the effect of economic incentives on consumers’ preventive behavior. American Journal of Preventive Medicine. 2004; 27:327-352.
31. Ascherio A, Willett WC. Health effects of trans fatty acids. American Journal of Clinical Nutrition. 1997; 66:1006S-1010S.
32. Christakis NA, Fowler JH. The collective dynamics of smoking in a large social network. New England Journal of Medicine. 2007; 358:2249-2258.
33. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. New England Journal of Medicine. 2007; 357:370-379.
34. Bandura A. Human Agency in Social Cognitive Theory. American Psychologist. 1989; 44:1175-1184.

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