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Policy Options for Increasing Whole Grain Consumption as a Target for Obesity Intervention
- Tamar Roomian
This policy brief will focus on whole-grain consumption in the United States population as a target for obesity intervention. Over one-third of U.S. adults are obese, and can contribute to heart disease, stroke, type 2 diabetes, and some cancers. The estimated annual cost of obesity was $147 billion (in 2008 dollars) (Centers for Disease Control and Prevention, 2014). Recent scientific evidence has associated refined grain consumption and lack of whole grain consumption with obesity and its complications. According to the National Health and Nutrition Examination Survey (NHANES), a majority of adults are deficient in whole grains and fiber. Given the widespread scope of the obesity epidemic, this is problematic, as it has been demonstrated by epidemiological evidence that whole grain consumption is inversely associated with abdominal fat and weight gain. Currently, there are no policies regarding whole grain consumption beyond Food and Drug Administration (FDA) regulations for labeling number of whole grain grams per serving. Therefore, a policy to increase population-wide whole grain consumption may reduce population-wide weight gain, associated health outcomes, and economic impact.
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This policy brief will discuss three policy options. The first option is to impose a labeling requirement for manufactured products to report percentage whole grain, in conjunction with dietary guidelines to limit refined grain consumption, in order to encourage food manufacturers to voluntarily reformulate their products consistent with consumer demand. The second option is to require that whole grains be the default option at restaurants by taking advantage of the “default effect,” or the phenomenon that individuals tend to stick with the default choice. However, testing would be required to ensure that the nudge is indeed effective. The third option is to impose a refined grain tax to disincentivize purchase. A tax would generate government revenue, but would meet heavy resistance from the food manufacturing industry.
Context and Importance of Problem
According to the Centers for Disease Control and Prevention (CDC), over one-third of U.S. adults are obese, and can contribute to heart disease, stroke, type 2 diabetes, and some cancers. The CDC estimates that the annual cost of obesity was $147 billion in 2008 (Centers for Disease Control and Prevention, 2014). Obesity is a complex problem requiring many solutions at multiple levels. Recent scientific evidence has associated refined grain consumption and lack of whole grain consumption with obesity and its complications. This policy brief will therefore focus on whole-grain consumption in the United States population.
Whole grains are defined as “grains that still have the endosperm, germ, and bran present in the same proportion of the intact grain.” The outer bran and inner germ are a source of dietary fiber, b-vitamins, iron, magnesium, vitamin E, as well as other potential unmeasured nutrients that are lost in processing when manufactured as refined grains (McKeown, Troy, Jacques, Hoffmann, O’Donnell, & Fox, 2010). Processing whole grain to white flour increases caloric density by 10% and decreases fiber content by 80% (Gross, Li, Ford, & Liu, 2004).
Gross et al. examined trends in refined grain consumption over the twentieth century using the National Nutrient Data Bank to obtain nutrient content of the U.S. food supply, and food availability data from the Economic Research Service and Nutrient Data Laboratory of the Agricultural Research Service. They concluded that since 1963, consumption for carbohydrates increased from 374 g/day to 500 g/day, but fiber intake did not increase proportionally, indicating that refined-grain consumption increased (Gross et al., 2004).
According to the National Health and Nutrition Examination Survey (NHANES), a dataset from a nationally represented nutrition questionnaire, only 4.9% of adults 19-50 years of age and 6.6% of adults 51 years and over consume the government recommended three or more whole grain servings. Approximately 72% of adults 19-50 and 66% of adults 51 and over consumed less than .6 servings of whole grains. Mean dietary fiber intake was 16.1 grams, below the government recommended 25-30 grams per day (O’Neil, Zanovec, Cho, & Nicklas, 2010).
This is problematic, as whole grain and fiber consumption is associated with lower body weight in the NHANES (O’Neil et al., 2010). Moreover, in a study using the Framingham Heart Study cohort, whole grain consumption was inversely associated with waist circumference and abdominal fat after controlling for confounders. Abdominal fat is strongly associated to metabolic risk factors including glucose intolerance, hypertension, dyslipidemia, and insulin resistance (McKeown et al., 2010). Using the Nurses’ Health Study and Health Professionals Follow-up Study, a very large longitudinal cohort of female nurses and male health professionals, whole grain consumption was inversely associated with long-term weight gain, while consumption of refined grains was positively associated with weight gain, after controlling for physical activity, television use, alcohol use, sleep duration, smoking and diet. The authors suggest that increased consumption of whole grains is therefore associated with a greater reduction of intake of other foods, because fiber slows digestion and increases satiety. (Mozaffarian, Hao, Rimm, Willett, & Hu, 2011).
Therefore, based on the above scientific evidence, the goal of policy is to increase consumption of whole grains while decreasing consumption of refined grains. Even if the reduction to the individual is small, because most Americans are exposed (i. e. consumers of refined grains), a modest reduction in the entire population could therefore make a large impact (Rose, 2008). While whole grain requirements have already been added to the national school lunch program, this does not address the majority of U.S. adults, as they do not attend public school (Grain requirements for the National School Lunch Program and School Breakfast Program, 2012).
Evidence for policy options can be derived from previous policy regarding trans fat, sodium, and sugar-sweetened beverages, as there has been strong scientific evidence to associate their consumption with poorer health outcomes, and subsequent policies have followed.
The first option is to institute a labeling requirement so that manufacturers must clearly label the percentage of whole grain in the product, as recommended by the Center for Science in the Public Interest (CSPI). Current FDA regulations only prohibit false or misleading labeling. However, according to the CSPI, even with FDA regulations, current whole-grain labeling by manufacturers based is still misleading, as items accurately labeled as ‘made with whole grains” can still be primarily comprised of refined grains (CSPI, 2012)
Requiring labeling may cause manufacturers to change formulations on their own volition. For example, In the United States, mandatory trans fat labeling decreased trans fatty acid content in manufactured foods, even without substantially increasing saturated fat (Uauy et al., 2009). In a study of 5000 chip and cookie products before and after the mandatory labeling requirement, led to a reduction of 45% and 42% respectively (Van Camp, Hooker, & Lin, 2012). Bakery products reduced their trans fat level by 73% after the labeling requirement (United States Department of Agriculture (USDA), 2013).
It is important to note that the labeling requirement was in conjunction with the USDA’s 2005 dietary recommendations to “limit trans fatty acid consumption as low as possible.” (USDA, 2008). In contrast, the current 2010 dietary recommendations for whole grains state that at least half of servings eaten each day should be whole, rather than an explicit limit on refined grains. Labeling and the USDA requirement would therefore need to be concurrent to be most effective. In addition, changes in labeling assumes consumers will be able to understand the new labels, and therefore influence their choice of item. If the labels indeed drive consumer demand, this can provide a motivating force for manufacturers to change formulations in conjunction with the labels. The advantage is minimal government intervention beyond dietary guidelines and labeling requirements. The manufacturers would voluntarily change their product formulations because of consumer demand. Consumers would still have autonomy over their choices. Consumers would likely support this policy as it could increase access to information and better inform consumer choice. Food manufacturers would likely oppose this policy, as it would require testing, new labeling, and possible product reformulations, which would increase costs, unless the food manufacturers are highly motivated by consumer demand for the reformulations.
A second option is to require that whole grains be the “default” option at restaurants. The default effect is defined as “the tendency for decision makers to stick with the default or the option that takes effect if one does make an explicit choice.” (Li and Chapman, 2013). Previous evidence for the default effect is with regards to the McDonald’s Happy Meal, which changed to reduce the French fry serving size, include apples without caramel dipping sauce, and low fat or fat-free chocolate milk in place of soda. Analysis of item-level transaction data that included the children’s meals pre and post meal changes showed that the average meal after changes were initiated reduced calories by 18% (although it is worth noting that the study was partially funded by McDonald’s) (Wansink & Hanks, 2014). However, despite success with the Happy Meal, “nudges” are not always successful, and testing should be conducted before any policy enacting.
The third option is to impose a tax on refined grain foods to discourage purchase. The government may benefit by using the revenue generated by the tax towards health prevention programs. Currently, taxes on harmful substances such as cigarettes can be more easily justified due to their addictive nature, strong evidence towards poorer health outcomes, and their lack of requirement for survival. However, taxes on food items can be unpopular and difficult to enact. Political climates may eventually change, easing passage of this type of policy. For example, New York City’s soda tax was unpopular at the time, but as evidence against sugar-sweetened beverages increased, the idea has become trendy and the political climate has changed. Mexico recently adopted a 10% soda tax which has resulted in a 5% decline in Coca Cola sales (Guthrie, 2014). San Francisco and Berkley, California, are now imposing a soda tax. Past efforts in United States cities have failed due to heavy lobbying by the food manufacturing industry, as the PepsiCo Inc, Coca Cola Co., and the American Beverage Association have spent $70 million on lobbying and issue ads (Stanford, 2012).
Centers for Disease Control and Prevention. (2014f). Obesity and Overweight for Professionals: Data and Statistics: Adult Obesity – DNPAO – CDC. Retrieved October 13, 2014, from http://www.cdc.gov/obesity/data/adult.html
Center for Science in the Public Interest (2012). Misleading “whole grain” claims rampant on store shelves. Retrieved from http://wholegrainscouncil.org/files/CSPI_wgclaimsPR.pdf.
Gross, L. S., Li, L., Ford, E. S., & Liu, S. (2004). Increased consumption of refined carbohydrates and the epidemic of type 2 diabetes in the United States: an ecologic assessment. The American Journal of Clinical Nutrition, 79(5), 774–779.
Guthrie, A. (2014, February 26). Mexico Soda Tax Dents Coke Bottler’s Sales. Wall Street Journal. Retrieved from http://online.wsj.com/news/articles/SB10001424052702303801304579407322914779400
Li, Meng, & Chapman, G. B. (2013). Nudge to health: Harnessing decision research to promote healthy behavior. Social and Personality Psychology Compass 7(3), 187-198. Retrieved from http://ruccs.rutgers.edu/faculty/pylyshyn/Proseminar13/NudgeToHealth.pdf.
McKeown, N. M., Troy, L. M., Jacques, P. F., Hoffmann, U., O’Donnell, C. J., & Fox, C. S. (2010). Whole- and refined-grain intakes are differentially associated with abdominal visceral and subcutaneous adiposity in healthy adults: the Framingham Heart Study. The American Journal of Clinical Nutrition, 92(5), 1165–1171. doi:10.3945/ajcn.2009.29106
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Mozaffarian, D., Hao, T., Rimm, E. B., Willett, W. C., & Hu, F. B. (2011). Changes in Diet and Lifestyle and Long-Term Weight Gain in Women and Men. The New England Journal of Medicine, 364(25), 2392–2404. doi:10.1056/NEJMoa1014296
O’Neil, C. E., Zanovec, M., Cho, S. S., & Nicklas, T. A. (2010). Whole grain and fiber consumption are associated with lower body weight measures in US adults: National Health and Nutrition Examination Survey 1999-2004. Nutrition Research (New York, N.Y.), 30(12), 815–822. doi:10.1016/j.nutres.2010.10.013
Rose, G. (2008). Rose’s Strategy of Preventive Medicine. Oxford University Press.
Stanford, D. D. (2012, March 13). Anti-Obesity Soda Tax Fails as Lobbyists Spend Millions: Retail. Retrieved October 18, 2014, from http://www.bloomberg.com/news/2012-03-13/anti-obesity-soda-tax-fails-as-lobbyists-spend-millions-retail.html
Uauy, R., Aro, A., Clarke, R., L’Abbé, M. R., Mozaffarian, D., Skeaff, C. M., … Tavella, M. (2009). WHO Scientific Update on trans fatty acids: summary and conclusions. European Journal of Clinical Nutrition, 63, S68–S75. doi:10.1038/ejcn.2009.15
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Van Camp, D., Hooker, N. H., & Lin, C.-T. J. (2012). Changes in fat contents of US snack foods in response to mandatory trans fat labelling. Public Health Nutrition, 15(06), 1130–1137. doi:10.1017/S1368980012000079
Wansink, B., & Hanks, A. S. (2014). Calorie reductions and within-meal calorie compensation in children’s meal combos. Obesity, 22(3), 630–632. doi:10.1002/oby.20668
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