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Suggested Citation:"6 Moving Forward." Institute of Medicine. 2014. Sustainable Diets: Food for Healthy People and a Healthy Planet: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18578.
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6


Moving Forward

Although much of the discussion about moving forward revolved around policy, one of the most important points in the sustainable diet debate, in Derek Yach’s opinion (from the Vitality Group®), is “the reality that none of the changes happen unless individuals at the point of purchase make a decision that can in fact have a big impact on their lives and their health and on the environment.” This raises the question: how can people at the point of purchase be coaxed into making decisions that support sustainable diets? This chapter begins with a summary of George Loewenstein’s (from Carnegie Mellon University and University of Pennsylvania) exploration of this question. Loewenstein discussed how behavioral economics can contribute to a greater understanding of the food environment and the choices that consumers make and how that understanding is providing policy makers with new approaches to managing the obesity epidemic. He discussed a variety of approaches to improving diet inspired by behavioral economics that have been successful to varying degrees, but concluded by expressing concern that many of the interventions that could be most beneficial, like taxing unhealthy foods, are unlikely to be implemented. Instead, he fears that “easier” behavioral economics solutions, which will have only a limited aggregate impact will substitute for real action.

The remainder of this chapter summarizes reflections by the workshop’s organizing committee chair, Erik Olson, moderator Derek Yach, and invited discussant Lisa Eakman (from The Chicago Council on Global Affairs) on major themes of the workshop presentations and discussions.

To reiterate, the goal of the workshop was not to reach consensus on

Suggested Citation:"6 Moving Forward." Institute of Medicine. 2014. Sustainable Diets: Food for Healthy People and a Healthy Planet: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18578.
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any issues or make any recommendations for future action. As is true of this entire workshop summary, any conclusions or suggestions for action put forth this chapter reflect the opinions of individual workshop participants.

Key Themes of This Chaptera

•    Behavioral economics provides a helpful framework for considering ways to increase the human health and environmental impact of consumer choice at the point of purchase. (Loewenstein)

•    A shared vision between the traditionally siloed nutrition and environmental resource research communities appears to be emerging around the notion of a sustainable diet. (Olson)

•    Plant-based protein sources are worth considering as an alternative to animal-based protein sources as a way to improve human, environmental, and economic health. (Eakman, Yach)

•    There are many opportunities for the public sector in the United States to become more active in sustainable diet policy development and research. (Eakman, Yach)

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a Key themes identified during discussions, presenter(s) attributed to statement indicated by parenthesis “( ).”

BEHAVIORAL ECONOMICS: IMPLICATIONS FOR THE FOOD ENVIRONMENT AND CHOICES1

While in town for a meeting in Orlando, Florida, Loewenstein took a jog and rewarded himself afterward with an ice cream. As he was walking into the ice cream store, he notices a couple exiting with monstrously large ice cream sundaes with whipped cream and cherries. He looked at the couple and thought, “These are not people who should be eating these large ice cream sundaes.” When he saw the menu board, he understood why they had probably chosen the large-sized option: $4.29 for a small cone, $5.29 for a regular cone, $6.29 for a large cone, and $6.99 for a large sundae. “If you like getting a bargain,” Loewenstein said, “you’re going to end up getting the large sundae.” Lower-income consumers, in his opinion, will probably be even more likely to get the large sundae because of their greater sensitivity to “getting a good deal.” That is behavioral economics: people like good deals. More generally, behavioral economics is the application

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1 This section summarizes information presented by George Loewenstein, Ph.D., Carnegie Mellon University, Pittsburgh, Pennsylvania.

Suggested Citation:"6 Moving Forward." Institute of Medicine. 2014. Sustainable Diets: Food for Healthy People and a Healthy Planet: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18578.
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of insights and research findings from psychology, economics, and related fields. Loewenstein explored the implications of behavioral economics for the food environment and the choices consumers make, with a focus on obesity.

What Is Responsible for the Obesity Epidemic?

The obesity epidemic is a new epidemic. “For a long time, we were a reasonably thin nation,” Loewenstein said. But in the 1980s, obesity rates suddenly accelerated (Finkelstein et al., 2005). Why? One of the reasons the obesity epidemic is so difficult to address is its many causes. In a speech at the Grocery Manufacturers Association Conference in March 2010, First Lady Michelle Obama discussed these multiple causes.

The first is sedentary lifestyle. As Ms. Obama said, “Back when many of us were growing up, we tended to be able to lead lives that kept us at a pretty healthy weight. Most of us walked to and from school every day, and then we ran around all day at recess … and for hours after school before dinner.… Our kids today lead a very different kind of life. Those walks to and from school have been replaced by car and bus rides” (Obama, 2010). According to Loewenstein, the evidence supports Ms. Obama’s claim. From 1950 to 2000, average daily television viewing increased from less than 5 hours per day to more than 7 hours per day (Brownson et al., 2005), and today recreational Internet use is close to equaling television viewing. Lack of physical recreation is much more severe for minorities, which probably explains, in part, why minorities have greater health problems (CDC, 2004). These increases in sedentary behavior have serious consequences for population health. Hu et al. (2003) showed that, for women, every 2-hour-per-day increment in television viewing is associated with a 23 percent increase in obesity and a 14 percent increase in risk of diabetes. On the other hand, 1 hour per day of brisk walking is associated with a 24 percent reduction in obesity and a 34 percent reduction in risk of diabetes.

A second contributing factor to the obesity epidemic is portion size. In her 2010 speech, Ms. Obama said, “Portion sizes have exploded. Food portions are two to five times bigger than they used to be. And beverage portions have grown as well” (Obama, 2010). Loewenstein explained that 20 years ago, a typical bagel measured 3 inches in diameter and contained 140 calories. Today, a typical bagel measures 6 inches in diameter and contains 350 calories. Twenty years ago, a typical cheeseburger contained 333 calories, compared to 590 today. Twenty years ago, a typical serving of french fries weighed 2.4 ounces and contained 210 calories, compared to 6.9 ounces and 610 calories today (personal communication, The NPD

Suggested Citation:"6 Moving Forward." Institute of Medicine. 2014. Sustainable Diets: Food for Healthy People and a Healthy Planet: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18578.
×

Group, September 6, 20132; see also Nielsen and Popkin, 2003; Young and Nestle, 2002).

Snacking also feeds into the obesity epidemic. Ms. Obama said, “Today, snacking between meals has become more the norm rather than the exception. While kids 30 years ago ate just one snack a day, we’re now trending toward three—so our kids are taking in an additional 200 calories a day just from snacks alone. And one in five school-age kids has up to six snacks a day” (Obama, 2010). Loewenstein commented on how his own daughter comes home and wants to take a walk. But where does she walk? She walks to the convenience store and comes home with a bag of chips. “As a parent,” he said, “it’s incredibly difficult to regulate that even if you are conscious of it.” One study in the Journal of Economic Perspectives argued that higher snack calories are responsible for the entire rise in energy intake among females between 1977 and 1978 and 1994 and 1996 and for 90 percent of the increase among males during that same time period (Cutler et al., 2003). Nielsen and Popkin (2003) found that 76 percent of the growth in calories between the same two time periods resulted from increased snacking.

A fourth contributing factor is time pressure. Ms. Obama said, “It wasn’t long ago that I was a working mom dashing from meetings and phone calls, ballet and soccer and whatever else. I felt like it was a miracle just to get through the day and get everybody where they were supposed to be. So the last thing I had time to do was to stand in a grocery store aisle squinting at ingredients that I couldn’t pronounce to figure out whether something was healthy or not” (Obama, 2010). Families are much more pressed for time today. Families today have what Loewenstein described as “an incredible shortage of time,” which discourages cooking and puts a premium on processed foods.

In Loewenstein’s opinion, prices are also important. The price of food relative to other goods rose about 1 percent during the period when obesity rates were constant (1960s-1970s) (Finkelstein et al., 2005). However, between 1980 and 2000—when the obesity epidemic went into full swing—the relative price of food fell about 14 percent, with the relative prices of processed foods dropping disproportionately. In fact, almost the entire decrease in food prices resulted from a decrease in the price of processed foods; fresh foods actually increased in price during that period (Finkelstein et al., 2005). According to Loewenstein, several economic analyses (e.g., Cutler et al., 2003; Finkelstein et al., 2005) attribute most of the increase in obesity to increases in calorie intake that resulted, in turn, from changes

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2 National Eating Trends (NET), Spring 1995 Release, The NPD Group. NET is a proprietary, syndicated data base made available courtesy of The NPD Group.

Suggested Citation:"6 Moving Forward." Institute of Medicine. 2014. Sustainable Diets: Food for Healthy People and a Healthy Planet: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18578.
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in relative prices, including those resulting from the reduced time-cost of processed foods for time-pressed families.

Finally, Loewenstein observed that changing social norms are also contributing to the obesity epidemic. When behavior changes, social norms change, and those new social norms, in turn, affect behavior. It becomes very difficult to break the cycle. As an example of changing social norms, according to consumer surveys conducted by The NPD Group,3 in 1985, 55 percent of homemakers surveyed completely agreed with the statement, “People who are thin look a lot more attractive.” In 2009 only 23 percent of homemakers surveyed completely agreed. As another example of changing social norms, other NPD Group data show that the percent of adults on any diet has been decreasing over time for both men and women. In 1991, more than 35 percent of women and more than 25 percent of men surveyed reported being on a diet. In 2009, 25 percent of women and fewer than 20 percent of men surveyed reported being on a diet.

What Can Behavioral Economics Contribute to the Discussion on Obesity?

Behavioral economics can lead to a better understanding of the underlying psychological mechanisms that explain many of these patterns. In addition to the desire to get a good deal, other behavioral mechanisms to consider include present-biased preferences, which is the human tendency to put a huge weight on immediate costs and benefits and to “discount” delayed costs and benefits; and the “drop-in-the-bucket effect,” which is the idea that a “drop” of food, such as a single potato chip, does not have any perceptible effect on weight; and lack of knowledge (see Rick and Loewenstein, 2008).

In addition to leading to a better understanding of the underlying psychology of many of the behaviors that contribute to obesity, behavioral economics can also help to develop new approaches to policy. Loewenstein highlighted three policy approaches informed by behavioral economics: (1) better ways to provide information, such that people will understand and respond to the information; (2) nudges, or “choice architecture,” which involve changing the environment to encourage people to eat better or less food (Thaler and Sunstein, 2008); and (3) better ways to deliver incentives.

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3 National Eating Trends (NET), Spring 1995 Release, The NPD Group. Data from NET, a proprietary, syndicated database made available courtesy of The NPD Group (personal communication, September 6, 2013).

Suggested Citation:"6 Moving Forward." Institute of Medicine. 2014. Sustainable Diets: Food for Healthy People and a Healthy Planet: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18578.
×

Better Ways to Provide Information

In 1994, the Nutrition Labeling and Education Act (NLEA) led to ubiquitous food labeling on packaged foods, but most research has shown that the labels have had very little impact on people’s diets. Using consumer survey data provided by The NPD Group, Loewenstein and colleague Mark Patterson have been tracking various attitudinal, behavior, and health variables over time. Loewenstein described some preliminary findings of this study. Introduction of the labels had an impact on one survey item: people’s responses to the statement “I check labels.” People reported checking labels more often after the labels were introduced in 1994. Loewenstein remarked that given that labeling was much more limited prior to the NLEA, if the survey did not show this impact, we would have little trust in the data. However, it was pointed out that the research shows that the NLEA had few other significant effects on attitudes or behaviors. Loewenstein points out that research also supports the conclusion that the NLEA did not lead to a reduction in fat or cholesterol, two attributes listed prominently on the new labels. For example, Variyam (2007) reported that the labels led to increased consumption of iron and fiber, but had very little impact on total fat, saturated fat, or cholesterol. Moreover, Variyam’s research suggests that the NLEA had very little impact on obesity, except among white females who used the labels. In Loewenstein’s opinion decreased obesity among women who use the labels is not very informative, as those women might very well have lost the weight even without the labels.

Calorie posting was supposed to be introduced into New York City (NYC) in 2007. But the food industry fought it, so it was not introduced until 2008. “I think if the food industry had realized how little the impact was,” Loewenstein said, “they wouldn’t have bothered to fight it.” The NYC calorie posting policy was motivated by what Loewenstein described as a “flawed” study: Bassett et al. (2008) found that people who reported looking at calorie information posted in Subway restaurants ate 50 fewer calories on average compared to people who did not look at calorie information. Lowenstein again pointed out that those who look at nutritional information are likely to be different from those who do not, including in regard to their motivation to lose weight. Subsequent research has confirmed suspicions that calorie posting has little if any impact (Dumanovsky et al., 2011; Elbel et al., 2009, 2011; Finkelstein et al., 2011). Elbel et al. (2009), for example, reported that people consumed 825 calories on average at 14 quick-service NYC restaurants before labeling, compared to 846 after labeling.

Loewenstein wondered if labeling could be effective if it were implemented in a more innovative fashion. For example, would traffic light labeling be more effective? The evidence is mixed. Levy et al. (2012) showed

Suggested Citation:"6 Moving Forward." Institute of Medicine. 2014. Sustainable Diets: Food for Healthy People and a Healthy Planet: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18578.
×

a reduction in purchase of red-light items and an increase in purchase of green-light items, especially beverages, in a hospital cafeteria in Boston. Ellison et al. (2013) showed a reduction in calorie intake among patrons at a sit-down restaurant. But Sacks et al. (2009) showed no effects of traffic light labeling on increased purchases of healthy “ready meals” and sandwiches in the United Kingdom. Furthermore, Sacks et al. (2011) showed no effects from traffic light labels on the relative healthiness of products purchased online in Australia.

Loewenstein and colleagues have done some preliminary research on traffic light labeling. Loewenstein found the effects from two of his studies “surprising.” In one of the studies, he and his colleagues gave some people entering a McDonald’s restaurant a menu with traffic light labels, while others received labels with calorie information or no nutritional information. People using the traffic light menus ordered more green items, but they ordered so many green items that they ended up ordering more total calories. Also, people ordering yellow items tended to order the most highly caloric yellow items, and the same was true for the red items. The effects are “perverse,” Loewenstein said. “It’s really a cautionary note. Traffic light labeling seems like a no-brainer, but you can’t assume that things that are no-brainers will work. You have to test things (obvious policies) before you roll them out.”

Based on the notion that posting calorie information does not work because people do not know how to interpret and use the information, NYC regulators in launched an educational campaign publicizing daily calorie recommendations. In the second study Loewenstein found “surprising” he and his colleagues assessed whether providing people with calorie recommendations makes a difference (Downs et al., 2013). The researchers stood outside two McDonald’s restaurants in NYC, both before and after calorie posting was introduced in 2008, and gave people either a “day” recommendation (the number of calories they should eat per day), a “meal” recommendation (the number of calories they should eat per meal), or no recommendation. The researchers expected the meal recommendation to be the most effective in terms of reducing calorie intake; consumers would be handed information on how many calories they should eat and then, inside the McDonald’s, they would see the posted calorie information and make a decision. Unexpectedly, the researchers found no effect from providing a calorie reference either before or after the calorie posting went into effect. In fact, the researchers observed what Loewenstein described as some “strange” effects, with calorie posting actually leading to an increased calorie intake among people who were overweight or obese. That finding might be explained by the way some people use labels; rather than using labels to limit calories, some people may use them to maximize calories per dollar.

Suggested Citation:"6 Moving Forward." Institute of Medicine. 2014. Sustainable Diets: Food for Healthy People and a Healthy Planet: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18578.
×

Nudges or “Choice Architecture”

Behavioral economists have analyzed different choice architecture approaches. Schwartz et al. (2012) reported that 14 to 33 percent of customers at Chinese fast-food restaurants voluntarily accepted a half-portion of a steamed or fried rice side dish and consumed 100 fewer calories as a result. Loewenstein opined that many people want smaller portion sizes, but they are not provided with that option. Hanks et al. (2012) found that displaying healthier foods in a cafeteria lunch line led to an increase in healthy food consumption (from 33 to 36 percent of total consumption). Just and Wansink (2009) found that giving children a choice between carrots and celery increased both sales and consumption of carrots compared to providing just carrots. “People like choices,” Loewenstein said. Just and Wansink (2009) also found that moving the salad bar to a more central location led to a sustained increase in salad sales. By contrast, they found that trayless cafeterias, where children take only a plate and therefore cannot load everything onto a tray, led to 26 percent fewer salads taken but only 8 percent fewer bowls of ice cream; and those trayless cafeterias also produce more waste.

Incentives

Traditional economics is based on the assumption that incentives matter. But behavioral economics research shows that, in fact, how incentives are delivered also matters. The same incentives can be extraordinarily effective when delivered in some ways, but completely ineffective when delivered in other ways. Loewenstein mentioned a study that he and his colleagues conducted in collaboration with a company in Pittsburgh that wanted to increase its Health Risk Assessment completion rates (Haisley et al., 2012). The company was already paying employees $25 for completing the assessment. Loewenstein’s team either increased the payment to $50 or increased it to $50 with a behavioral economics incentive and found that simply doubling the payment had no effect but that doubling the payment and adding a behavioral economics incentive led to a substantially increased completion rate.

In what Loewenstein described as a “very encouraging” study of 15 elementary school cafeterias, Just and Price (2011) introduced various incentives to eat fruits and veggies. Children received either 25 cents immediately, 5 cents immediately, a prize immediately (a raffle ticket), money at the end of the month, or a prize at the end of the month. All of the incentives were effective. Thus, for even a small amount of money, children can be incentivized to eat more fruits and vegetables. Loewenstein remarked that, although he considered the results impressive, he has some discomfort with

Suggested Citation:"6 Moving Forward." Institute of Medicine. 2014. Sustainable Diets: Food for Healthy People and a Healthy Planet: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18578.
×

the approach. He said, “I’m not convinced that the right way to get kids to eat healthy foods is to pay them.… My guess is that it would be a lot better to try to make healthy foods more attractive to them.”

Loewenstein himself has been testing various behavioral economics incentives to encourage weight loss. In a randomized controlled trial on financial incentives and weight loss, he and colleagues tested two incentive conditions: lottery and deposit contract (Volpp et al., 2008). All of the study participants were obese veterans, with body mass indexes between 30 and 40. At the beginning of the study, all subjects were given a 1-hour consultation with a dietician, a scale to take home, and the goal of losing 4 pounds per month for 4 months. In both conditions, subjects phoned in their daily weight and were sent daily text messages if they were achieving their goal to let them know how much they won that day in incentives.

Subjects in the lottery condition were enrolled in a daily lottery, with a 1 in 5 chance of winning $5 and a 1 in 100 chance of winning $100. They were entered into the lottery every day, but were paid only if they called in and their weight was below their target. So, even if they won, they would not get paid if they called in and were above their target or if they did not call in. The lottery condition was designed to play on people’s love of lotteries. According to Loewenstein, more than half of the U.S. population plays the lottery, with lower-income people spending a disproportionate amount of their income on it.

Loewenstein summarized the study methodology. Subjects in the deposit contract condition were allowed to put money down at the beginning of each month, from 1¢ to $3 per day. For every day that they met their weight loss goal, they kept their money and received a one-to-one match. So, if they put $3 down, they got their $3 back and received an additional $3 for staying below the line. If they went above the line, they lost their $3. The deposit contract condition played on loss aversion. People hate losing their own money, Lowenstein opinioned. He observed that the study also played on over-optimism. People are generally overly optimistic about things, especially about their likelihood of exerting self-control in the future, including their ability to lose weight. The intention was to create a “self-fulfilling optimism,” with subjects initially driven by optimism to put a lot of money down and then driven by loss aversion to lose weight in order to keep their money.

Subjects in both groups were asked to return to the lab at the end of each month for a weigh-in. They received their money at the end of the month if the study scale corroborated their self-reported weights.

The incentives proved to be very successful, with subjects in the two incentive conditions losing 13 and 14 pounds respectively during the 4-month study period. Interestingly, in Loewenstein’s opinion, successful weight loss was correlated with exercise, not diet, a finding he has observed in a num-

Suggested Citation:"6 Moving Forward." Institute of Medicine. 2014. Sustainable Diets: Food for Healthy People and a Healthy Planet: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18578.
×

ber of other studies as well. An unfortunate result of the study, however, was that, by the 7-month follow-up, most participants had regained most of the weight they had lost.

Loewenstein and colleagues conducted a second study to see if a longer incentive period 8 months instead of 4 months, would help participants develop a habit that would lead to extended weight loss (John et al., 2011). But although participants were able to keep weight off for 8 months while the incentives were in place, at the 17-month follow-up, most participants had regained their lost weight. Loewenstein and colleagues are continuing to study different type of incentives, for example social incentives, to help people not just lose weight but also keep the weight off.

What Would It Take to Reverse the Obesity Epidemic?

Piecemeal actions are not a solution. As First Lady Obama said to the Grocery Manufacturers Association, “We need you not to just tweak around the edges but entirely rethink the products you are offering, the information that you provide about these products, and how you market those products to our children” (Obama, 2010). Loewenstein cautioned, however, that the food industry answers to its shareholders, not its customers. Neither the food industry nor the schools, movie theaters, or other stakeholders directly bear the huge costs to society of the health consequences of unhealthy food. Real change is going to require realigning incentives by taxing the production and sale of unhealthy foods, subsidizing the production and sale of healthy foods, mandating proportionate pricing of junk food (e.g., ending super-sizing), and providing incentives to improve patrons’ diets. Realigning incentives will drive the food industry to devote its creativity to selling healthy foods and will encourage consumers, including low-income parents, to buy healthy foods because they are cheaper.

Loewenstein expressed concern that many interventions that could be most beneficial, such as taxing unhealthy foods, are unlikely to be implemented. Instead he is worried that some of the behavioral economics “easy solutions” will substitute for the steps that need to be taken to realign incentives. Not only might those “easy solutions” not add up to much, but also, as in the case of traffic light labels, they might have unintended consequences. He ended by noting that mid-level solutions, such as “Meatless Weekdays” (eating meat only on weekends) or spending more money on school lunches, might be the best approach.

REFLECTIONS OF DEREK YACH

At several different times during the workshop discussion, Yach offered some reflections on key topics. This section summarizes his remarks.

Suggested Citation:"6 Moving Forward." Institute of Medicine. 2014. Sustainable Diets: Food for Healthy People and a Healthy Planet: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18578.
×

Reducing Obesity: Doable Steps

In Yach’s opinion, the size of the energy gap that needs to be reduced in order to re-establish the population’s energy balance “is not huge.” Although calorie shifts per person per day would be substantially higher for individuals with high body mass indexes, shifts could be accomplished at a population level by applying some of the incentives mentioned by Loewenstein. Yach noted that interventions like “Meatless Mondays” have already been proposed and emphasized simple incentives can be very powerful. He recalled how pharmaceutical companies used to deliver pizzas to hospitals in the evening, which had a favorable impact on profitability. Even though the actual monetary value of the pizzas was small, the deliveries were so perfectly timed that physicians on the floor were willing to accept them and to support the companies that provided the pizzas. The cozy relationships that were established translated into billions of dollars of profitability for the pharmaceutical companies. Yach described that particular example as one with a “perverse” long-term effect, but other incentives could be aligned with common goals around sustainable diets. He encouraged full engagement of industry and government leaders and emphasized the role of government in setting broad policy frameworks and removing structural impediments that are either wasteful or driving systems in perverse ways.

The Need for a Broader Coalition

Similar debates on the human health and environmental synergies and trade-offs associated with food have been under way for some time now in the World Economic Forum’s sustainable agriculture groups. Yach observed that the broader investor community, including insurers, is taking the issue very seriously because of the long-term risks of climate change, mass famine, and hunger and encouraged the engagement of corporations that are not directly linked to particular products. He called for a broader coalition to move forward. By reaching out, he said, “we would find a lot more synergy than we suspect.”

Think Globally

Yach also called for a global perspective. No single country can do it alone. He expressed concern that local initiatives will not solve long-term needs, in particular, long-term water needs. He said that he gets “terribly fearful” when he hears that Sweden is beginning to develop its own self-sufficiency food program. “That would be a disaster for the planet,” he said. “It would be the height of selfishness.… Sweden is blessed with some of the best water resources now and for the next 50 years. Their responsibil-

Suggested Citation:"6 Moving Forward." Institute of Medicine. 2014. Sustainable Diets: Food for Healthy People and a Healthy Planet: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18578.
×

ity is not just to become sufficient, but to become a net exporter for food that is going to be required around the world as the water crisis gets worse [in many developing countries in Asia, Africa, and the Middle East].” (See the summary in Chapter 5 of Tim Lang’s discussion on various efforts in the European Union to develop sustainable diet public policy.)

Non-Meat Sources of Protein

Yach remarked that, although he found the workshop discussions on fish important, there was very little mention during the workshop of aquatic plants. He viewed aquatic plants as a serious potential source of long-term food and pointed to work under way in Saudi Arabia, in its Red Sea initiatives and partnerships with Eritrea and elsewhere, as an example of efforts to understand that potential. He also wondered whether there might be a future role for laboratory-generated amino acid that could be supplied in the “unthinkable” event that the human population runs out of enough land, water, and energy for animal protein production. He mentioned that start-ups in Boston were already exploring this possibility. (See the summaries in Chapter 2 and 4, respectively, of Cynthia Jones’s and Barton Seaver’s presentations on fish.)

Economic Incentives to Move from a Quantity-Based to Quality-Based Diet

In Yach’s opinion, tackling obesity in the long term will require thinking about financing as well as messaging and labeling. He asked what the right economic arguments and incentives would be to move from a quantity-based diet to a quality-based diet. Yach said that the clothes detergent business serves as an example. Tide has cornered a huge proportion of the detergent market with a product that uses less stuff; the entire detergent industry has followed suit by offering tiny packets of detergent that consumers can simply throw into their dishwashers. As a result, less detergent is being used and less environmental damage is being done. Yach highlighted the Tide story as an example of when the choice to sell less stuff can actually be tremendously profitable. He asked what the equivalent would be for obesity.

A workshop participant responded that the key is protein, because protein regulates appetite. Rather than talking about calories, the participant encouraged a greater focus on protein requirements. She opined that it is likely that people who eat cheap foods are eating a lot more of those foods because they are trying to acquire the protein that they need, but they are not getting it. Although the highest-quality sources of essential amino acids are animal foods, these sources are also the most expensive and most environmentally impactful.

Suggested Citation:"6 Moving Forward." Institute of Medicine. 2014. Sustainable Diets: Food for Healthy People and a Healthy Planet: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18578.
×

When Yach asked the participant whether laboratory-generated amino acids might provide a solution, the participant suggested instead considering ways to incorporate more plant-based protein into the diet. She mentioned the “thriving” aquatic plant-based food industry in Southeast Asia and the many ethnic stores across North America selling those aquatic plant products. The participant implied that it would also be worth considering the many fermented functional beverages being used in traditional cultures worldwide. Many of those beverages are combinations of different plants that have tremendous potential to be incorporated into a healthy U.S. diet.

What Is Food in the Public Policy Forum?

What should be classified as food in the public policy forum? Yach mentioned the many debates about whether coffee, tea, cocoa, and certain other products should be classified as food. The public sector and many development agencies are investing significantly in coffee, tea, and cocoa production as if those products are equivalent to nutritionally rich foods (e.g., federal dollars are being used for U.S. aid programs to support cocoa farmers in other parts of the world). Meanwhile, there has been very little discussion of palm oil, which Yach described as the “nexus of bads.” Palm oil production has enormously destructive effects on the environment. Yach expressed skepticism about claims that palm oil production is sustainable. He stated that the same companies and groups supporting sustainable palm oil production in parts of Asia are rapidly expanding and destroying rainforests across West Africa. Not only does palm oil have destructive effects on the environment, it also impacts human health. Specifically, it has a long-term impact on cardiovascular disease. In Yach’s opinion, palm oil should be reduced and ideally removed from the human diet. The Institute of Medicine, the World Health Organization, and others have made it very clear over the years that there are a range of healthier oils, although there is debate about the environmental consequences of those oils as well. Yet, again, there has been very little discussion of oil consumption in the public policy forum. So what constitutes food in the public policy forum?

REFLECTIONS OF ERIK OLSON4

The challenge at hand is that there are both nutritional issues that need to be addressed, including malnutrition and obesity at both the domestic

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4 Workshop organizing committee chair Erik D. Olson, J.D., identified several common themes among the presentations and discussions that took place on the first day of the workshop, that is, the information presented in Chapters 1-4 of this report. This section summarizes his remarks. They should not be interpreted to be the views of his employer or any other person.

Suggested Citation:"6 Moving Forward." Institute of Medicine. 2014. Sustainable Diets: Food for Healthy People and a Healthy Planet: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18578.
×

and global levels, and some very real environmental constraints. Olson was inspired by the seeming convergence between the nutrition and environment “silos” on several issues and the shared vision that is emerging. He identified five components of that shared vision:

(1)   Healthy food. Healthy food is needed to supply a U.S. Department of Agriculture MyPlate diet and to ensure that omega-3 fatty acid and other micronutrient needs are being met.

(2)   Economic return for U.S. farmers. Olson referred to keynote speaker Kathleen Merrigan’s “eloquent plea” to consider the economic needs of struggling small and medium-sized domestic farmers. (See Chapter 1 for a summary of Merrigan’s keynote presentation.)

(3)   Access to healthy foods, especially for lower income consumers. Olson noted several ways to encourage access encouraged by workshop participants, including through existing programs (e.g., Supplemental Nutrition Assistance Program [SNAP] and the Special Supplemental Nutrition Program for Women, Infants, and Children) and via new incentives that could be created.

(4)   Environmentally sustainable food supply. Olson called for clear agreement around how to move forward with respect to building an environmentally stable food supply, not just with respect to climate change and greenhouse gas emissions but also with respect to land protection and resource overuse. Olson noted that aquaculture might help solve overfishing problems and that improved approaches to domestic animal agricultural production might help to increase production efficiencies. In addition, he noted that different types of meat have enormously different efficiencies and profoundly different impacts on the environment. “So, you can have meat in your diet without necessarily having the same impact, depending on what your selections are,” he said. He also noted the clear need to embed crop biodiversity in the vision and referred to Barbara Burlingame’s descriptions of the varying nutritional values among different varieties of the same plant species. (See Chapter 2 for a summary of Burlingame’s presentation.)

(5)   Foods that people actually eat. What can be done to ensure that people are actually eating and not throwing away healthy food? Olson noted that several speakers had suggested ways to educate and encourage people to try new foods. For example, Kathleen Merrigan (see Chapter 1) discussed the Farm to School and SNAP Education programs, and Barton Seaver (see Chapter 4) described a program that introduced into the diet new types of fish that

Suggested Citation:"6 Moving Forward." Institute of Medicine. 2014. Sustainable Diets: Food for Healthy People and a Healthy Planet: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18578.
×

        consumers otherwise might not eat. (See Chapters 1 and 4 for a summary of Merrigan’s and Seaver’s presentations, respectively.)

This vision and its five components were supported by some interesting undergirding themes, in Olson’s view. In particular, he was struck by the notion that some situations are characterized by what Christian Peters (see Chapter 3) described as ethical synergy, where the opportunity exists to improve both improve human and environmental impact. Examples are eating more legumes and eating less sugar. But other situations create ethical dilemmas. Examples are the recommendations put forth by some nutritionists to eat more fish and to increase lean meat consumption. Realizing the shared vision will require answering a key question—how can those ethical dilemma recommendations be managed given the environmental challenges associated with them?

LISA EAKMAN’S TAKE-HOME MESSAGES5

On the topics of human and environmental synergies and trade-offs, methods for quantifying those synergies and trade-offs, and the economic context of those synergies and trade-offs (information summarized in Chapters 1-4 of this report), Eakman identified several take-home messages:

•   There is growing evidence of the nexus between the nutrition and environmental sectors. Eakman predicted that the nexus will become an increasingly important area of study over time. The demand for food is expected to grow by 60 percent by 2050 (Alexandratos and Bruinsma, 2012). Yet, already almost 870 million people worldwide are hungry (FAO, 2013). Not only are undernourishment rates expected to increase, so too are obesity rates as low- and middle-income economies go through nutrition transitions.

•    Many panelists placed a high value on policy-relevant data. As just one example, Martin Heller discussed gaps in data that need to be filled in order to use life-cycle analysis as a policy tool. Policy-relevant data will enable a more evidence-based discussion on the optimal way forward for human health and the environment. (See Chapter 3 for a summary of Heller’s presentation.)

•    Diet has an impact on the environment. There was a great deal of discussion on meat, beef in particular, and its impacts on land, water, and greenhouse gas emissions. Eakman cited what she referred to as

_________________

5 Twice during the workshop, Lisa Eakman, M.A., The Chicago Council on Global Affairs, Illinois, was invited to offer her reflections on the overall workshop discussion. This section summarizes her remarks.

Suggested Citation:"6 Moving Forward." Institute of Medicine. 2014. Sustainable Diets: Food for Healthy People and a Healthy Planet: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18578.
×

      Emily Cassidy’s “powerful” statistics, including the finding that 36 percent of all calories produced by agriculture are for animal feed and 44 percent of land used for agriculture is used for meat production. She reiterated, however, Frank Mitloehner’s concern that the environmental impacts of food production, especially those associated with livestock, vary depending on geography. Compared to its impact in the United States, livestock production has much greater environmental consequences in other parts of the world, especially in middle- and low-income countries. (See Chapters 2 and 3, respectively, for summaries of and references supporting Mitloehner’s and Cassidy’s presentations.)

•    The link between nutrition and the environment is bidirectional. Although most presenters focused on the impact that diet has on the environment, early on during the workshop Burlingame made a strong case that environmental biodiversity plays an important role in nutrition, with different varieties of crops carrying different nutritional values. (See Chapter 2 for a summary of Burlingame’s presentation.)

•    Many presenters and members of the audience touched on the impact of waste on the environment. Globally, as much as 30 to 40 percent of food is wasted. Waste could be used in a much more sustainable manner.

•    Shifting to the U.S. recommended dietary guidelines will have environmental impacts. Several speakers described the impacts. Cynthia Jones elaborated on the reality that there are literally not enough fish in the sea for people to consume the recommended portion of protein. This is true of both domestic and global fish consumption. Christian Peters described how meeting the U.S. recommended fruit and vegetable guidelines would require roughly doubling the amount of land currently being used to produce fruits and vegetables. Still, given how little land is currently used for that purpose, the impact would be minimal. Cassidy described how a decrease in U.S. meat consumption would yield significant savings in land and water and greenhouse gas emissions. Although most of the workshop discussion focused on the U.S. agricultural production system, Eakman suggested that it would be useful to consider the relationship between the U.S. system and the international agricultural production system. In addition, Eakman reiterated the need for more policy-relevant data to enable more evidence-based conversations. (See Chapters 2 and 3 for summaries of Jones’s, Peters’s, and Cassidy’s presentations.)

•    There was much discussion of decision making about what foods are produced and why consumers buy what they buy. Richard Volpe

Suggested Citation:"6 Moving Forward." Institute of Medicine. 2014. Sustainable Diets: Food for Healthy People and a Healthy Planet: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18578.
×

      reported that even though commodity prices have risen, food prices have remained relatively stable. But some food groups, such as fruits, vegetables, and eggs, are more volatile than others. Seaver argued that consumer familiarity with a product, largely as a result of marketing, may limit food choices. (See Chapters 3 and 4, respectively, for summaries of Seaver’s and Volpe’s presentations.)

•    There was a great deal of discussion around different types of policy approaches. Keynote speaker Kathleen Merrigan argued that connecting communities to food producers through farmers’ markets, school gardening programs, and other avenues could increase consumption of fruits and vegetables. She also argued for the use of creative solutions, such as mobile food trucks, to increase the purchase of fruits and vegetables in food deserts. Cassidy discussed work under way in South Africa, where discounts on healthy food have been shown to incentivize people to increase consumption of fruits and vegetables and decrease consumption of less-nutritious foods. Eakman mentioned some concern about the practicality in the United States of taxing less healthful foods and recalled Parke Wilde’s discussion of policy considerations that should be made when thinking about how to incentivize the purchase of healthful food or when thinking about the impact of food on the environment. Eakman encouraged more consideration and discussion of non-policy solutions to solving problems in the growing nexus between human health and the environment. (See Chapters 1, 3, and 4, respectively, for summaries of Merrigan’s, Cassidy’s, and Wilde’s presentations.)

Moving Forward

At the conclusion of the workshop, Eakman identified four major take-home messages from the Day Two workshop discussion on available options and approaches for developing a sustainable U.S. diet (i.e., information presented and discussed on Day Two of the workshop and summarized in Chapter 5 and in this chapter):

(1)   Further research on links between nutrition guidelines and environmental constraints must include social and economic dimensions. The nutrition guidelines–environment relationship is complicated and complex and cannot be examined without also considering those other dimensions.

(2)   Incentives to spur behavior change should be tested before being implemented. Eakman encouraged holistic thinking about the dif-

Suggested Citation:"6 Moving Forward." Institute of Medicine. 2014. Sustainable Diets: Food for Healthy People and a Healthy Planet: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18578.
×

         ferent types of prompts being considered and their accompanying implications. Will their combined effect be more than the sum of the parts? Or will the sum of the parts not be great enough to get us to where we need to be?

(3)   The public sector in the United States could play a significant role. However, public-sector action needs to be more collaborative across agencies, encompass a wider set of perspectives, and consider the full range of issues. Eakman referred to Katherine Clancy’s call for a greater consciousness about the priority of sustainable diets being a legitimate policy issue and Tim Lang’s suggestion to be more intentional about incorporating other perspectives when developing dietary guidelines.

Given that consumers are not using the information being provided to them, whether it be through labeling or other means, Eakman suggested that there might be new ways to present information so that people are better incentivized to change their behavior. In addition, she suggested that there might be some ways to incentivize farmers to better align their production with the goals of sustainable eating, for example through the Conservation Stewardship Program.

The public sector could also help to fill research gaps. Not only is there a need for more U.S. investment in agricultural and food research, there is also a need for a different kind of research than what has been done in the past. Specifically, Eakman echoed other workshop participants’ calls for more multidisciplinary research. Along with the U.S. Department of Agriculture, Eakman suggested that the National Science Foundation, the National Institutes of Health, the Department of Energy, and the Environmental Protection Agency become involved. By engaging all of these agencies, the health–environment nexus could be examined through the lens of economic and social constraints as well.

(4)   Although “we absolutely need this public voice,” Eakman said, other nongovernmental actors can help to engender change. Eakman referred to Lang’s suggestion that the United Nations could play a role by issuing a joint World Health Organization/Food and Agriculture Organization/United Nations Environmental Programme report or by establishing an intergovernmental panel on sustainable diets with the same stature as the Intergovernmental Panel on Climate Change. Lang also suggested establishing watchdog groups to monitor the implementation and impact of the dietary guidelines and serve as an information resource for policy makers. Private companies could also take action. For example, Derek Yach mentioned The World Economic Forum’s New Vision

Suggested Citation:"6 Moving Forward." Institute of Medicine. 2014. Sustainable Diets: Food for Healthy People and a Healthy Planet: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18578.
×

         for Agriculture group—there might be an opportunity to leverage that group. Finally, given the economic impact of sustainability, these may be issues to address in G8 or G20 forums.

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One of the many benefits of the U.S. food system is a safe, nutritious, and consistent food supply. However, the same system also places significant strain on land, water, air, and other natural resources. A better understanding of the food-environment synergies and trade-offs associated with the U.S. food system would help to reduce this strain. Many experts would like to use that knowledge to develop dietary recommendations on the basis of environmental as well as nutritional considerations. But identifying and quantifying those synergies and trade-offs, let alone acting on them, is a challenge in and of itself. The difficulty stems in part from the reality that experts in the fields of nutrition, agricultural science, and natural resource use often do not regularly collaborate with each other, with the exception of some international efforts.

Sustainable Diets is the summary of a workshop convened by The Institute of Medicine's Food Forum and Roundtable on Environmental Health Sciences, Research, and Medicine in May 2013 to engender dialogue between experts in nutrition and experts in agriculture and natural resource sustainability and to explore current and emerging knowledge on the food and nutrition policy implications of the increasing environmental constraints on the food system. Experts explored the relationship between human health and the environment, including the identification and quantification of the synergies and trade-offs of their impact. This report explores the role of the food price environment and how environmental sustainability can be incorporated into dietary guidance and considers research priorities, policy implications, and drivers of consumer behaviors that will enable sustainable food choices.

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