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By Matthew Rees

Food and Health Fact #169: Is more government regulation needed to improve the American diet?

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What’s the optimal approach to spurring improvements in the American diet?

That’s one of the pressing issues facing the United States and countries throughout the world – and perhaps the central issue being grappled with in this newsletter. 

To radically oversimplify, there are two approaches. One is to let the market work its magic. Under this logic, when companies see demand for healthier products, they will supply more of those products to the market, and this will help trigger wholesale dietary changes, which will contribute to people realizing better health.

At the other end of the spectrum is for government – federal, state, or local – to take an interventionist approach to food and beverage products, as well as the ingredients in them. This can include warning labels, so-called “sin” taxes, and limits – if not bans – on the use of select ingredients or even entire products.

There’s a lot of middle ground, of course, as well as other factors that contribute to dietary choices, including food prices, advertising, education, and the engineering of ingredients to make certain food products irresistible.

The U.S. approach has traditionally been biased toward the market – with relatively little government intervention. This is particularly true at the federal level, where there are several different diet-related initiatives, but there’s almost no coordination among them (as documented in a federal government report published last year).

Coincidence or not, the United States has an adult obesity rate exceeding 42 percent – the world’s highest, outside of Kuwait and a few small island nations.

But there is a fairly recent precedent for the federal government taking a strongly interventionist approach: in 2015, the Food and Drug Administration announced a ban on the use of artificial trans fat (with the ban to take effect three years later), saying that partially hydrogenated oils (PHOs) – the primary source of artificial trans fat in processed food – did not meet the government’s benchmark safety standard.

Getting to this point took a very long time. Research showing a link between PHOs and raised blood lipid levels dates back to the 1950s. More research followed, with studies in the 1980s and ‘90s showing a link between trans fat consumption and coronary heart disease.

In 1993, an advocacy group, the Center for Science in the Public Interest, petitioned the FDA to require trans fats to be listed on nutrition labels, and ten years later the FDA issued such a rule, to take effect in 2006. (Interestingly, the FDA was urged to act by a deregulation-focused Bush Administration official, John Graham.)

But disclosure is one thing; a ban is another. How did it happen? A big break came in 2006, with New York’s city council voting to forbid food service establishments from including artificial trans fat in their products. Over the next three years, 20 localities throughout the country took the same step – as did the entire state of California. The effect? According to the authors of a fabulous article on the history of the trans fat ban (alas, you’ll have to pay to access the article), published in The Milbank Quarterly, 

“Instead of reformulating foods specifically for California, New York City, and other jurisdictions, many restaurant chains replaced PHOs nationwide, leading to important reductions of trans fat in the food supply and demonstrating the feasibility of large-scale preparation of foods that did not contain PHOs.”  

Within three years of New York City and select New York counties banning PHOs, a study showed that hospital admissions for heart attacks and strokes declined in those jurisdictions by 6.2 percent more than in jurisdictions without the ban. Another study showed a 4.5 percent reduction in deaths from heart disease in the jurisdictions with the ban. (This progress came against the backdrop of a 2006 study showing that artificial trans fat in food caused 20 percent of all heart attacks in the United States and 50,000 deaths per year.)

This activity coincided with the FDA being petitioned to ban trans fat – a petition that required the agency to review the scientific literature and make a determination about the ingredient’s safety. Confronted with overwhelming evidence, the FDA eventually did what was sensible, but nonetheless unthinkable – it announced the trans fat ban.

Is the ban a model for addressing other public health challenges? The Milbank Quarterly article authors think so. They note, for example, that this “systems approach” – a perfumed way of referring to a ban – improves the health of entire population but does not depend on individuals making a healthier choice (since, in this case, they no longer have the option of consuming the unhealthy ingredient).

If you’re skeptical that Americans can make wholesale improvements to their dietary patterns – and there’s good reason for such skepticism – the systems approach is appealing.

Another advantage of this approach, write the Milbank Quarterly authors, is that it reaches the entire population and adherence doesn’t ebb and flow. That’s in contrast to other popular approaches, such as education campaigns, which must be crafted to reach different audiences, require ongoing funding, and may have a lower penetration rate among those with lower incomes.

It’s noteworthy, though, that intake of trans fat declined nationally by 78 percent from 2003-2012 – a change that was likely a product of local regulations, publicity about the ill effects of trans fat, and food companies reengineering their products to have little if any trans fat. (Food companies said their changes to processed foods led to an 86 percent reduction in trans fat use from 2003 to 2015.)

To those who advocate for more trans fat-style bans, the obvious rejoinder is that it creates a slippery slope. What products or ingredients are next? How many other ingredients would need to be banned (or restricted) for there to be a dramatic decline in diet-related disease and death?

Similarly, will one unhealthy product just be substituted for another? U.S. palm oil consumption has increased quite dramatically over the past two decades and it’s hardly a healthy substitute for trans fat.

Opponents will also cry “nanny state” and “big brother,” as always happens when there’s any proposed regulation of food and beverage products. The hostility to such regulation is sufficiently ingrained in the American psyche that even Barack Obama, as president, said, "People's attitude is that they don't necessarily want Big Brother telling them what to eat or drink, and I understand that.”

Regulation always involves see-saw battle between freedom and security. There are very good reasons to be fearful of government over-reach, particularly if there are market-based solutions that can deliver the rewards just as effectively.

But the hands-off mindset to food and beverage regulation overlooks that government regulates all sorts of things that are deemed to be in the public’s health interest – seat belts in cars being a perfect example, but also hygiene in restaurants to promote food safety. Precisely why food and beverages should be off limits to reasonable, evidence-based regulation that will advance human health is something of a mystery.

Can the market turn the tide against obesity? I hope so – and there’s a lot of innovation happening in the food space. But it could take many years – if not decades – for those innovations to trigger wholesale changes in American consumption patterns. In the meantime the United States is left with an adult obesity rate that is likely to tip past 50 percent in the next decade.

That suggests there’s room for government to take a more interventionist approach. The trans fat ban shows one way that intervention can be carried out.