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Public health policies to encourage healthy eating

habits: recent perspectives

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Journal of Healthcare Leadership
23 September 2015
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Mary T Gorski 1 Abstract: There is an urgent need to address unhealthy dietary patterns at the population level.
Christina A Roberto 2,3 Poor diet and physical inactivity are key drivers of the obesity pandemic, and they are among
1
Interfaculty Initiative in Health
the leading causes of preventable death and disability in nearly every country in the world. As
Policy, Harvard University, Cambridge, countries grapple with the growing obesity prevalence, many innovative policy options to reduce
2
Department of Social and Behavioral overeating and improve diet quality remain largely unexplored. We describe recent trends in
Sciences, 3Department of Nutrition,
Harvard TH Chan School of Public eating habits and consequences for public health, vulnerabilities to unhealthy eating, and the role
Health, Boston, MA, USA for public health policies. We reviewed recent public health policies to promote healthier diet
patterns, including mandates, restrictions, economic incentives, marketing limits, information
provision, and environmental defaults.
Keywords: food policy, diet, obesity, public health

Introduction
Over the last 40 years global eating patterns have changed in significant ways.
Population diets have shifted toward a greater consumption of processed and ultra-
processed foods that are low in nutrients and high in energy.1 There has been an increase
in consumption of foods prepared outside the home (eg, fast food) and many of these
foods have increased in portion size, which promotes overconsumption.2 There has also
been an increase in foods from animal sources, as well as a greater intake of oils and
caloric sweeteners.1 In many countries, the general population consumes amounts of
sodium, unhealthy fats, and added sugars that greatly exceeds recommended levels.3–5
The overconsumption of unhealthy foods and beverages have also been coupled with
a lower intake of healthier dietary components, including high-nutrient, low energy
foods such as legumes, coarse grains, and other vegetables.1
The past few decades has also seen an enormous increase in consumption of sugar-
sweetened beverages (SSBs).6 Intake of these beverages – including soda, sports drinks,
fruit drinks, and energy drinks – increased 3-fold from 1970 to 2001 in the USA alone,
and almost half of Americans (48%) report drinking soda every day.7,8 Recent trends
in the USA show that soda intake is falling, but intake of other SSBs, such as sports
and energy drinks, is on the rise with SSBs remaining the greatest contributor to added
sugar intake in the American diet.6,9,10 Countries such as the People’s Republic of China,
India, Vietnam, Thailand, and other Southeast Asian countries are also experiencing
Correspondence: Mary T Gorski
Interfaculty Initiative in Health Policy, rapid increases in SSB intake.11
14 Story Street, 4th Floor, These dietary shifts have major consequences on the public’s health. Diet and physi-
Cambridge, MA 02138, USA
Fax +1 617 432 0092
cal inactivity are now among the leading causes of preventable death and disability
Email mgorski@[Link] in nearly every country in the world.12,13 More than two billion people worldwide are

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now overweight or obese, while maternal and child under- substances like drugs or alcohol.26,30 Neuroimaging research
nutrition is responsible for 11% of the total global disease in both rats and humans suggests that intake of ultra-
burden.14,15 Unhealthy diet patterns, including high intake processed foods high in added sugar, fat, and salt generate
of added sugars, trans fats, and excess sodium intake, are responses akin to other addictive substances.31,32 In particular,
linked with obesity, heart disease, type 2 diabetes, cancer, children are biologically vulnerable to developing preferences
high blood pressure, and stroke.16–19 Furthermore, diet-related for highly processed foods because they have a stronger
risk factors (including low fruit consumption and high sodium preference for sweet foods compared to adults.33–35 Finally,
intake), account for 10% of disability-adjusted life years humans’ complex biological reactions make it difficult to
worldwide.20 SSBs alone are linked with obesity, weight lose weight and maintain weight loss.36,37 This often traps
gain, dental caries, increased energy intake, type 2 diabetes, people in a vicious cycle where weight is initially lost, but
and heart disease.6,17,21–23 regained over time. The difficulty in sustaining weight loss
In this paper, we discuss the ways in which current food can contribute to feelings of failure, which in turn can push
environments exploit biological, psychological, social, and people to cyclical diets and related products that falsely
economic vulnerabilities to overeat. We then discuss public promise quick, lasting change.
health policies designed to accelerate progress in promoting
healthier eating habits. We group these policy strategies into Psychological vulnerabilities
the following categories: mandates, restrictions, economic Research suggests that more than half of consumers’ gro-
incentives, marketing limits, information provision, and cery store purchase decisions are unplanned and made in
environmental defaults. Although the causes of obesity the store.38 This leaves consumers vulnerable to subtle
are multifactorial (and include growing rates of physical environmental influences that promote intake of less healthy
inactivity), this review is only focused on strategies to alter foods in places like supermarkets or restaurants. Examples
the food environment. of such environmental influences include large portion sizes
at restaurants, which encourage overeating through chang-
Vulnerabilities to unhealthy eating ing consumption norms; highly visible placement of sugary
Biological vulnerabilities drinks on supermarket end caps and candy in the check-out
As discussed by Roberto et al in a recent Lancet series on aisles, which makes these items salient and increases impulse
Obesity,24 although individuals have some control over their purchases; and child-targeted marketing using athletes or
diet, the modern food environment has introduced an influx of licensed characters, which can shape taste and snack prefer-
hyper-palatable foods high in sugar, fat, and salt, that appear ences, and form brand loyalty at early ages.24,34,39,40 Part of the
to surpass the rewarding properties of non-processed foods.25 problem is that incentives are misaligned. Food companies
These ingredients, along with flavor enhancers, food addi- are under immense pressures to maximize profits over maxi-
tives, and caffeine, are manipulated in ways that maximize mizing the health outcomes of consumers. Thus, they create
the reward value of foods, making it difficult for the body to and promote foods that take advantage of the aforementioned
regulate food intake and weight.26 Many processed foods biological vulnerabilities to help sell more products.
are engineered to increase the concentration of refined car-
bohydrates, such as white flour and sugar. In addition, fiber, Social and economic vulnerabilities
water, and protein – ingredients which help with satiety and Modern environments also exploit social and economic
slowing the absorption of sugar into the bloodstream – are vulnerabilities toward consuming unhealthy diets. In many
frequently stripped from these foods.27 The result of this pro- low- and middle-income countries, rising household incomes,
cessing is an increased rate at which refined carbohydrates are rapid urbanization, and increasing female labor force partici-
absorbed into the body, causing rapid spikes in blood sugar. pation have driven a higher demand for unhealthy processed
Previous research has demonstrated that highly processed convenience foods.1,41 For example, from 1999–2012 total
foods with a high glycemic index rapidly raise blood sugar per capita processed food consumption increased 3.2-fold in
and can lead to excessive hunger, overeating, and a biological the People’s Republic of China, and 3.6-fold in Vietnam. In
preference for high glycemic index foods, propagating cycles high-income countries, unhealthy foods tend to be relatively
of overeating.28,29 inexpensive compared to healthier options, and lower-income
There is also emerging evidence that certain foods may neighborhoods are saturated with unhealthy options.42,43 For
trigger brain responses that mimic reactions to addictive example, restaurants and other ready-to-eat foods are quick

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Dovepress Policies to encourage healthy eating habits

and convenient, making them especially appealing to families to an unhealthy substance or environment, but makes it
with limited time and resources. However, these foods tend easier for them to avoid it.
to be less healthy than home-cooked meals.44 In addition, In the next section, we review government policies
research on low-income populations in the USA has found to promote healthier diets that fit into the six categories
that black and Latino Americans are often disproportion- described above.
ately the targets of aggressive marketing tactics by the food
industry.45,46 Mandates
As the most restrictive policy tool available, government
Policies to accelerate progress mandates tend to be effective at changing both industry and
on healthy eating individual behaviors. However, they may be harder to enact
Our understanding of these biological, psychological, social, than less restrictive policies because they limit freedom. An
and economic vulnerabilities has shed light on the ways in example of an effective government mandate was the New
which food environments undermine people’s ability to make York City (NYC) Board of Health’s 2006 ordinance that
responsible food choices that reflect their long-term goals prohibited restaurants from cooking with trans fats. The
to be healthy. Therefore, policies may play an important ordinance was passed based on scientific literature demon-
role to better align people’s food choices with their desires strating an association between the consumption of trans
to live healthy lives. Traditional evidence-based population fats and cardiovascular disease and concerns that trans fats
approaches for improving public health focus on identifying presented a greater risk to health than other kinds of “bad”
exposures in the environment that can lead to negative health fats such as saturated fats.47 Restaurants were able to switch
outcomes, and designing interventions or policies that limit to other cooking fats without complaint from customers.48
exposure to hazards. Current evidence-based policies typi- NYC could have pursued other options for behavior change,
cally fall into one of six categories that vary in effectiveness such as encouraging restaurants to voluntarily stop using
and feasibility: trans fats or requiring trans fat to be labeled on restaurant
1. Mandates (eg, vaccinations required for children in order menus. However, these strategies would not have entirely
to attend school, smoke-free air laws) – these required removed trans fats from restaurant food as effectively as the
policies for industries or individuals are designed to pro- legal mandate.
tect against the adverse effects of an unhealthy substance
or environment Restrictions
2. Restrictions (eg, prohibit the sale of alcohol to minors) – Governments can enact policies that do not impose mandates
these policies are designed to limit access to an unhealthy on everyone, but only restrict products in publicly-funded
substance or environment spaces (including government departments, schools, hospi-
3. Economic incentives (eg, excise tax on cigarettes) – tals, and prisons). For example, they may require that these
these policies aim to better align price incentives with places only offer food that follows national dietary guide-
health outcomes, encouraging higher consumption of lines, or limit the sale of certain products (such as alcohol or
healthy products and lower consumption of unhealthy SSBs).49 Recent policy examples include a 2011 ban on the
products sale of SSBs from city property in Boston, Massachusetts,
4. Marketing limits (eg, regulation of tobacco advertising) – as well as a SSB ban in all food establishments within a
these policies try to limit advertising and promotion of children’s hospital in Ohio (USA). The latter was linked with
an unhealthy substance or environment a decrease in carbonated beverage sales and an increase in
5. Information provision (eg, education campaigns to milk, juice, water, and coffee sales, without a revenue loss
promote fruits and vegetables, requiring warning labels at non-vending locations.50
on tobacco products) – these policies provide the public Policies may also restrict sales of unhealthy items or ingre-
with important health information, including encouraging dients to particularly vulnerable populations, such as children.
healthy behaviors and warning about the dangers of an The most common examples are implementing a minimum
unhealthy substance or environment legal age to purchase alcohol and tobacco.51 Within the food
6. Environmental defaults (eg, changing the default restau- arena, in 2014 Lithuania became the first country in the
rant side dish from French fries to salad) – these policies European Union to ban energy drink sales to anyone under
preserve the freedom of individuals to expose themselves the age of 18 years, a measure that is being pursued at the

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state and local levels in the USA.52 Some scholars have vending machines than grocery stores. In addition to sales
suggested policies that would place a per-capita limit on taxes, the city of Berkeley, California, passed an excise tax
the amount of a product one can purchase (eg, only one on SSBs (US$0.01 per ounce [~30mL]) in 2014, the first of
500 mL SSB container per purchase), or restrict sales its kind in the USA.71 In 2014, Mexico enacted a one peso
to certain locations or hours within a given purchasing (US$0.08) per liter excise tax on SSBs and an 8% sales tax
location.53 on junk food (energy-dense, non-staple foods), prompting
Policies have also been enacted to influence school food similar proposals in other Latin American countries. 59,72
environments. Children spend more time in schools than any When Denmark enacted a saturated fat tax in 2012, pre-tax
other environment away from home,54 and school practices simulations estimated that it could reduce saturated fat con-
affect children’s diets,55,56 and weight status.57 In 2010, the sumption by 8% in the population.70 Despite its later repeal
USA enacted a policy to update the federal nutrition standards due to pressures from retailers and consumers, the tax raised
for all foods and beverages in schools, requiring more serv- US$216 million in revenue.73
ings of fruits and vegetables, limiting kilocalories (calories), Together, these findings suggest that small taxes or sub-
saturated fat, and sodium, and restricting access to candy and sidies are not likely to produce significant changes in obesity
SSBs.58 Peru, Uruguay, and Costa Rica have all banned “junk prevalence, although small taxes may generate substantial
food” in public schools since 2012, and programs in countries government revenue. However, non-trivial pricing interven-
such as Brazil, Ethiopia, Malawi, and Senegal have changed tions have shown measurable effects on weight outcomes,
procurement policies to increase the amount of school foods particularly in price-sensitive populations such as children
sourced by local producers.24,59 In 2014, the UK released new and low-income adults.13,62,74 More research is needed to
school food standards, limiting fried foods and desserts, and understand how specific policy changes – including the size
emphasizing water, whole grains, fruits and vegetables.60 of taxes/subsidies, specific items taxed/subsidized, and the
Although research has documented links between school tax/subsidy design – alter behavior and impact weight and
food policies and improvements in diet quality and lower other health outcomes.62 Research is also needed to better
weight gain among children,61 more evidence is needed to understand substitution effects, compensatory eating, and
better elucidate how these changes impact children’s overall longer-term changes in behavior in response to pricing
diet quality (both in and outside of school), as well as their interventions.
weight over time.
Marketing limits
Economic incentives Currently, most child-targeted food and beverage mar-
Spurred on by successful pricing policies for tobacco control, keting is for products which are high in sugar, fat, or
there has been a growing interest in the role of economic sodium.75 Previous research has documented that advertis-
incentives (taxes and subsidies), to shift food and beverage ing shapes children’s food preferences, purchase requests,
consumption patterns toward more healthy diets.13,62 Most beliefs, and dietary intake. 76–78 Because of this, many
research evidence to-date has focused on price data. Findings countries have restrictions on marketing to youth. More
suggest that changing prices of specific foods and beverages than 60 countries around the world currently have some
alters consumption, where larger price changes are associated regulations on food and beverage television advertising
with more meaningful changes in consumption.13,62–65 to children.79 Some countries have also begun banning
Several recent studies have also focused on the association television advertising to children, but the effect of such
between state-level soda taxes and individual data, showing bans is difficult to evaluate. Australia has banned televi-
that small sales taxes (1%–7%) have had a minimal impact sion advertisements aimed at children 13 years old and
on overall soda consumption or on weight/obesity.66–68 Many younger, while Sweden, Norway, and Quebec now ban all
places have implemented special taxes on foods of low television advertising aimed at children, regardless of the
nutritional value, including soda, junk food such as potato product involved.13 After South Korea restricted televi-
chips and candy, and high-fat items.69,70 In the USA, 29 states sion advertising of energy-dense and nutrient-poor foods
have a sales tax on candy, while 34 states have a sales tax on targeting children in 2010, Korean food companies placed
soda, although none of the funds generated from these taxes significantly fewer television advertisements of these foods
are used for obesity prevention efforts.62 Sales taxes vary targeted to children.80 Previous studies have estimated
widely across and within the USA, with higher taxes in that banning television food advertisements to children

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in the USA could reduce the prevalence of obesity, 81,82 traffic light labeling system on packaged food and bever-
although estimating the magnitude of such effects requires age products to signal whether products have low (green),
better accounting for the non-linear relationship between moderate (yellow), or high (red) levels of sodium, sugar, and
calorie reduction and weight loss.83 Food industry pledges to unhealthy fats.95 One study of a single traffic light labeling
limit television advertising to children are also widespread, intervention in a USA hospital cafeteria found that sales of
although evidence suggests that further efforts are needed to red items decreased and green items increased over a two-
reduce the exposure and power of marketing to children.84 year period and results were maintained after two years.96,97
Other policies to limit food marketing to children include Another study found that translating calorie labeling into
curbing advertising and marketing of less healthful foods and physical activity equivalents on SSBs (eg, displaying the
beverages in schools and removing toys in children’s fast food number of minutes of exercise required to burn the equivalent
meals (eg, Chile and Peru have banned Happy Meal toys).59,76 amount of calories in a product) may reduce SSB purchases
Most ongoing policy efforts to address food marketing in among adolescents.98 These results suggest that certain label-
high income countries focus on television advertising and ing schemes may be an easy, cost-effective way to encourage
in-school product marketing. In the USA, issues of free healthier purchases. The Netherlands, along with several
commercial speech present a major barrier to enacting laws other countries, have implemented the “Choices” checkmark
that would limit food advertising. Most research on food symbol, which is used as a supermarket shelf tag to flag
marketing to-date has focused on television advertising, products that meet dietary guidelines for healthfulness as
but further research is needed to understand the scope and established by an independent international scientific com-
impact of other marketing strategies and marketing efforts mittee.99 Although more research is needed on the influence of
directed at specific sub-populations such as low-income front-of-package or shelf-tag labeling systems, some studies
groups or children. have found that they can encourage purchasing of healthier
products.93 It is important for future research to evaluate the
Information provision optimal design of nutrition labels and how they influence
Policies that inform the public are often met with less resis- purchasing habits and food intake.
tance than some of the more restrictive interventions we Although the primary goal of nutrition and menu label-
previously described. A variety of mandatory and voluntary ing policies is to inform consumers, their largest effects on
efforts are underway to include calorie labeling on restau- public health may occur through providing incentives for
rant menus and labels on the front of packaged foods that manufacturers to reformulate products (eg, calorie reduction,
would provide consumers with key nutrition information. For lower portion sizes).27 For example, trans fats were reduced
example, the USA has passed a law requiring menu labeling in some packaged foods following their mandatory inclusion
in large chain restaurants.85 The research on the influence of on the nutrition facts label in the USA.100–102 More research is
calorie labeling in restaurants on consumer food choices and needed to understand how labeling spurs product reformula-
intake is mixed,86–93 with some studies finding that labeling tion among food manufacturers.
encouraged lower calorie choices and others observing no In addition to nutrition labels, an emerging area of future
effect on food choices. The current state of the evidence research and policy interest is in placing warning labels on
suggests that calorie labeling promotes lower calorie food certain beverages with added sugar. State legislation has
choices for some consumers, some of the time, at some res- recently been introduced in New York and California,103,104
taurants.94 Longer-term studies, particularly after the USA with a goal of educating consumers on the scientific evidence
implements calorie labeling nationally, will be needed to linking SSB consumption with weight gain, diabetes, and
determine its long-term impact. tooth decay.
There has also been a growing interest in placing labels Governments can also inform the public through national
on the front of packaged foods to improve consumer under- dietary guidance. Although both sugar and caffeine – the two
standing of the nutritional profile of foods and/or improve main ingredients of SSBs – are recognized as potential health
the healthfulness of their dietary choices. In 2014, Ecuador concerns,105–107 few governments worldwide have strong or
passed a mandatory traffic light labeling policy for packaged quantitative recommendations to reduce their consumption.108
foods, while voluntary labeling schemes are used in countries Including limits on added sugar in national dietary guidance
such as Denmark, Norway, Sweden, and Singapore.24,59 In to reflect current scientific evidence would be a first step
the UK, some food manufacturers have adopted a multiple toward addressing this issue.109

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Powerful interest groups have traditionally slowed the pre-committing to healthier food choices by ordering food
actions of governmental and non-governmental organizations ahead of time, have shown some potential to reduce calorie
(such as the World Health Organization) in addressing consumption.121 However, these types of strategies typi-
reductions in added sugar.110,111 However, in 2014, the World cally represent small “p” policies that must be undertaken
Health Organization issued draft guidelines to limit sugars voluntarily by companies or institutions. One example of a
to 5% of total daily energy intake, while in 2015, the USA government policy designed to change the large portion size
Dietary Guidelines Advisory Committee issued a scientific that is default in restaurants was a 2012 proposal in NYC to
report recommending that the federal government limit added limit the portion size of sugary drinks sold in food service
sugars to below 10% of total daily energy intake.112,113 Both establishments to 16 ounces (~500 mL). This policy was
sets of recommendations are currently in draft format. struck down because the NYC Board of Health did not have
Another way to inform the public is through mass media the legal authority to enact it, but it remains a viable policy
campaigns, which can raise awareness, increase knowledge, option. Although there are no shortage of creative ideas to
and prompt healthier behavioral intentions.114 Several govern- use nudges to improve the food environment,122 a recent
ment initiatives have launched such campaigns to inform the randomized controlled trial found no long-term effects for
public about diet-related chronic diseases. In 2008 the Austra- a school-based nudge intervention, and there have been few
lian government launched the ‘Measure-Up’ campaign to link other evaluations of such interventions in the long-term.123,124
waist circumference with chronic disease risk. An evaluation More longer-term experiments are needed.
showed increased public awareness of the link between waist
circumference and chronic disease, but did not result in changes Future prospects
in fruit and vegetable intake or physical activity.115 Similarly, the Most food environments across the globe make it difficult
Los Angeles County Department of Public Health (California) to eat a healthy diet. Given the magnitude of the obesity
launched the “Sugar Pack” health marketing campaign in 2011 to pandemic and the rapid, global changes in unhealthy diet
educate the public on reducing excess calorie intake from SSBs. patterns, it is unlikely that general population eating habits
An evaluation showed increased knowledge and self-reported will improve without major policy interventions. Echoing
intention to reduce SSB consumption, potentially complement- previous findings,24 we see a need for systematic, large-scale
ing a comprehensive obesity prevention strategy.116 efforts to address unhealthy diets. Policymakers must also
recognize the double burden of under nutrition and obesity,
Environmental defaults particularly in low- and middle-income countries, and design
Mandatory or voluntary “nudge” strategies – behavioral policies with both issues in mind. Further, funding levels to
science approaches involving small, usually unnoticed evaluate the impact of major food policies in high-income
environmental changes – can complement traditional pub- countries are very low, and there is essentially no funding
lic health policies and inform the design of new policies to for evaluation in low- and middle-income countries.1,13 New
increase effectiveness.117,118 One advantage of these types efforts are needed to establish more comprehensive and
of interventions is that they are designed to be simple and rigorous approaches to evaluating programs and policies
cost-effective. Part of the reason such interventions are aimed to improve diet, coupled with feedback to improve
appealing is that they do not rely on people making effortful the effectiveness and efficiency of implemented policies.
changes or comprehending complex health information.119 Examining long-term effects of policies in different locations
For example, in 2015 major fast-food chains McDonald’s, and among different populations, as well as best practices for
Wendy’s, and Burger King all dropped soft drinks from implementation, are urgently needed to increase the evidence
their children’s menus,120 shifting the default beverage to a base in this field. Reversing the obesity epidemic will require
healthier option. In conjunction with major policy efforts, a demand for change from civil society, actions and innova-
these types of voluntary nudges have the potential to reduce tions from the food industry, and most importantly, policy
soft drink consumption among children. implementation from governments and institutions.
Policies may also change the default food environment
by increasing access to healthy foods through farmers’ Acknowledgment
markets and mobile vendors of healthful foods.24 Attempts This project was supported by grant number T32HS000055
to nudge consumers to make healthier food choices through from the Agency for Healthcare Research and Quality. The
subtle environmental cues such as smaller plate size and content is solely the responsibility of the authors and does

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Dovepress Policies to encourage healthy eating habits

not necessarily represent the official views of the Agency for 19. Mozaffarian D, Aro A, Willett WC. Health effects of trans-fatty acids:
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Disclosure of burden of disease and injury attributable to 67 risk factors and risk
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