Four Types of Killjoy: #3 Anti-obesity

Food control: the new kids on the block

In this series of posts, the IEA’s Christopher Snowdon explains the background and beliefs of the anti-smoking, anti-alcohol, anti-obesity and anti-gambling movements in the UK.

This is part 3 on anti-obesity. Part 4 is available now to paid Insider subscribers.

Read part 2 on anti-alcohol here, and part 1 on anti-smoking here.

Food policy has historically been focused on safety, nutrition and on ensuring that people have enough to eat. In the twenty-first century, the issue has been increasingly seen through the lens of obesity, with tobacco-style regulation of the food supply proposed as part of the remedy. Obesity is a far more complex issue than smoking, but food and soft drinks - particularly mass produced ‘ultra-processed’ food - lend themselves to top-down regulation more easily than other contributing factors to obesity, such as physical activity and genetics.

Food differs from alcohol and tobacco in several important ways. Firstly, it is essential to life. Total abstinence is obviously not an option. Secondly, there is no clear connection between specific types of food and specific diseases comparable to the links between smoking and lung cancer or alcohol and liver cirrhosis. Thirdly, whilst some people have compulsive eating disorders, no particular type of food is ‘addictive’ per se. Fourthly, there are no obvious negative externalities associated with excessive food consumption that are equivalent to secondhand smoke, drunk driving or alcohol-fuelled violence.

This deprives campaigners of four arguments used to advocate for policies against tobacco and alcohol; that the products are unnecessary, inherently dangerous, addictive, and harmful to others. Some of them have, however, been applied in a modified form. For example, it can certainly be argued that certain types of food and soft drink are inessential (e.g. sugary drinks) and there is some evidence that certain products are more closely associated with obesity than others. The absence of negative externalities can be partially overcome by pointing to healthcare costs associated with obesity which often fall on taxpayers.

And yet the evidence on diet and disease is less compelling and more contestable than the main health findings that condemn smoking and heavy drinking. While questions remain about what constitutes a ‘safe level’ of alcohol consumption, it is beyond doubt that excessive alcohol consumption can lead to acute and chronic health problems. The key questions about smoking were answered definitively decades ago. The tools of observational epidemiology have been less effective in finding clear associations between food consumption and disease. Researchers require accurate information about what thousands of individuals eat over a period of many years before they can hope to find statistical associations, and these associations are muddied by a raft of confounding factors. As a result of these and other issues, nutritional epidemiology has become something of a laughing stock. Although nutritional studies garner a great deal of media attention, it sometimes seems as if a foodstuff causes cancer one minute and cures it the next. Academic research shows that this perception accurately reflects the state of the literature, which is a mass of contradictions.

Unlike the modern literature on tobacco, the dietary literature allows room for those who legitimately question the prevailing narrative on both science and policy. For example, Archer and Arjmandi (2020) have complained that ‘anti-sugar rhetoric is divorced from established scientific facts and has led to politically expedient but ill-informed policies’ while Campos et al. (2006) argued in a leading epidemiology journal that the ‘“obesity epidemic” is largely an illusion’. It is difficult to imagine such dissent appearing in medical journals in relation to smoking or, increasingly, alcohol.

Notwithstanding the food adulteration scandals of the nineteenth century and modern disquiet about factory farming, the food industry does not have the toxic legacy of the tobacco industry. It is a natural employer of nutritional scientists and, traditionally, nothing untoward has been seen in this. But as the issues of tobacco and food have begun to be framed in a similar way, attempts have been made to equate ‘Big Food’ (and ‘Big Soda’) with ‘Big Tobacco’. A notable example is a study by Stanton Glantz, an American anti-smoking campaigner who received and published leaked tobacco industry documents in the 1990s. In 2016, Glantz and his colleagues published an article in JAMA Internal Medicine showing that one of the authors of a relatively obscure evidence review from the 1960s about the relationship between sugar consumption and heart disease had undisclosed financial links to the sugar industry. The review had concluded that fat was a bigger risk factor than sugar and the implication of Glantz’s study was that the sugar industry had somehow bought this finding. A more thorough historical review published in Science in 2018 dismissed this theory and warned that ‘conspiratorial narratives in science can distort the past in the service of contemporary causes’, but the original article succeeded in generating such headlines as ‘Drafter of U.S. Dietary Goals was Bribed by Big Sugar to Demonize Fat’ (Reason), ‘The sugar industry used Big Tobacco-techniques’ (San Francisco Chronicle) and ‘How the sugar industry has distorted health science for more than 50 years’ (Vox).

Despite recent attempts to portray the food industry (and other ‘unhealthy commodity industries’) as following the ‘tobacco playbook’, there is little evidence that the controversies about nutrition that regularly appear in the media have been driven by food manufacturers. On the contrary, those who question the mainstream view accuse the food industry of profiting from what they see as flawed science. In contrast to the ‘smoking controversy’ of the mid-twentieth century, the public debate about food and food policy tends to be led by passionate amateurs. Notable figures include journalists, such as Gary Taubes and Nina Teicholz, and medics such as Michael Mosley, Chris van Tulleken and Aseem Malhotra, as well as an assortment of bloggers, authors and YouTubers. In Britain, the most influential figure in the obesity debate in the last two decades has not been a scientist, dietitian or academic but a celebrity chef, Jamie Oliver. Perhaps unsurprisingly, restaurateurs have been particularly prominent in the debate about food policy, including Henry Dimbleby, Hugh Fearnley-Whittingstall and Prue Leith.

Debates about nutrition have always attracted their share of faddists, zealots and entrepreneurs. There is significant public demand for quick dietary fixes and there is an audience for those who simplify the issue. Most nutritional scientists understand that obesity is complex and the science uncertain but are not accustomed to battling it out in the media. As a consequence, noisier and often less qualified voices have tended to dominate the public debate and their messages have filtered into the political debate.

The stigmatisation of ‘Big Food’ and ‘Big Sugar’ has a long way to go before it competes with Big Tobacco, but it is moving in that direction. Like a growing number of industries, the food industry is portrayed by ‘public health’ activist-academics as one of the ‘commercial determinants of health’. They are dismissive of all research funded by industry and claim that ‘Big Food’ is following a ‘corporate playbook’ created by the tobacco industry. For example, Mialon et al. (2021) assert that:

‘Similar to the tobacco industry, the food industry also shapes science, through the funding and dissemination of research and information serving its interests and criticises evidence that may thwart these interests’.

The authors of that article express clear disapproval when they discuss ‘a state of affairs where the food industry is seen as a legitimate actor in science and policy and where academics see no problem in working with industry actors’.

The idea that it is inappropriate for food companies to commission scientific research into the products they make is a relatively new development, but is now widespread. A survey of 335 ‘health researchers, advocates and policymakers’ in 40 countries found that 93 per cent of them believed there was a ‘fundamental and irreconcilable conflict’ between public health objectives and the objectives of the tobacco industry, and 85 per cent felt similarly about the alcohol industry. The figure for the food industry was lower at 67 per cent, but is nevertheless a large proportion. The survey also found that 73 per cent of respondents felt that public health researchers, advocates and practitioners should not accept funding from the food industry.

Most academics in the field of nutrition are not directly involved with policy and the literature on food policy-making is much smaller than that on alcohol and tobacco, although now growing rapidly. Considering the differences between the issues of obesity and smoking, it is striking how similar the ‘public health’ approach to food has been to that of tobacco, both in terms of how activists have organised themselves and how the issue is framed. To some extent this represents ‘mission creep’ in which political coalitions formed to tackle one problem seek new dragons to slay, but it also reflects a degree of availability bias; anti-smoking policies are familiar to public health campaigners and parallels can be drawn between smoking and obesity as health issues.

Organised lobbying for ‘anti-obesity’ policies is a relatively recent development. The National Obesity Forum, a small charity partly funded by pharmaceutical companies, was the leading voice on the issue until 2014 when the small but effective pressure group Action on Sugar was set up as an adjunct to Consensus Action on Salt and Health (they have since formally merged to become Consensus Action on Salt, Sugar and Health). Along with the Children’s Food Campaign - an off-shoot of the charity Sustain - Action on Sugar successfully lobbied for the Soft Drinks Industry Levy announced by George Osborne in 2016. Since then, Bite Back 2030 has been founded by Jamie Oliver, purporting to represent the voice of young people and lobbying against ‘junk food’ advertising. The Obesity Health Alliance, an umbrella group of like-minded organisations, was formed in 2015, and an All-Party Parliamentary Group on Obesity was founded in 2016. Strategically, there are clear parallels with the anti-smoking and anti-alcohol interest groups, both of whom have formal coalitions and All-Party Groups.

Food policy interest groups have diverse and sometimes conflicting goals. Clinical dietitians are used to dealing with patients who need to eat more, not less. Charities concerned with poverty are focused on preventing families going hungry and have reservations about paternalist taxes on food and soft drinks. Advocates of the low carb diet approve of the public health establishment’s attack on refined sugar but not its attitude towards red meat and fat. Some academics feel that the issue of obesity has overshadowed more important issues of physical inactivity, poor nutrition and malnutrition.

Despite the differing goals and viewpoints of these interest groups, many of them were able to coalesce around the issue of sugar-sweetened beverages in the 2010s, just as the disparate policy entrepreneurs in the field of alcohol coalesced around minimum pricing. There was a general consensus in the public health literature that obesity was a growing health problem, that the average Briton consumed too many calories and that the government should do something about it. Sugary drinks represented low-hanging fruit insofar as they are ‘non-essential’, high in sugar and contain ‘empty calories’ (i.e. do not satisfy hunger). There was seen to be no downside to portraying sugary drinks as unhealthy and getting people to reduce their consumption of them. To that end, sugary drink taxes - usually called sugar taxes or soda taxes - were proposed in a number of countries as a way to both highlight the issue and to deter consumption through the price effect.

The anti-sugar crusade has since been eclipsed by the campaign against ultra-processed food, a concept popularised by the virologist and children’s entertainer Chris van Tulleken. It is an extraordinarily broad category, encompassing everything from boiled sweets to sliced bread, and it remains to be seen whether it has the legs to be seen and regulated as ‘the new tobacco’. History suggests that a new dietary villain will emerge in a few years. Since food per se cannot be regulated like cigarettes, there is a desire among anti-obesity activists to find a discrete category of food than can be subject to advertising bans, taxation, health warnings, plain packaging etc. (recent legislation has used an ad hoc defintion of ‘less healthy’ food). Once they have found an appropriate scapegoat somewhere in the food supply, the ‘public health’ lobby has a full set of policies ready to deploy.