A recent report released by the McKinsey Global Institute highlighted the global financial cost of obesity to be around $2 trillion, about the same cost as war and smoking. In the United States alone, we pay $344 billion to manage the healthcare cost of diabetes, a cost that is projected to only increase. By 2050, the Center For Disease Control predicts that 1 out of 3 adults will have type 2 diabetes. An article entitled The State of US Health (1990-2010), also demonstrated that an unhealthy diet is now the single leading cause of poor health, death, and disability in America.
During the month of January, millions of Americans will begin the process of trying to improve their health and avoid becoming one of these statics. People will join gyms, buy diet plans advertised on television, or drink coffee made with butter that is promoted as a nutritional powerhouse by celebrities. These well-intentioned people are looking for help and want to change. But in the end, these plans and goals usually do not stick and people will lose the focus of health from their daily lives. Thankfully, this does not have to be the case.
Wouldn't it be great that instead of having millions of individuals changing their own environments, society could be more efficient with changing the focus to our larger food environment and cultural beliefs around food?
Restaurants could make healthy food convenient and as easy as take out pizza. Grocery stores could be redesigned to make customers be more deliberate with buying unhealthy foods like soda, refined carbohydrates and chips; instead of using checkout lanes filled with impulse purchases at the end of your visit.
These nutritional improvements are beginning to become a reality, but restaurants and grocery stores need standards to strive for. Researchers have started to evaluate our food environment and help stores and restaurants improve their offerings. Karen Glanz and her University of Pennsylvania research team are pioneers in the field and were the first to create a tool to measure the nutritional quality of our food environment.
In 2007, their efforts culminated in the creation of the seminal Nutrition Environment Measures Survey (NEMS). The tool was created to measure food availability, price and nutritional quality differences between food products at retail outlets. The survey is unique because it includes well-defined measurements and is reliable across different venues. NEMS has been modified since its inception, and measurements are now in place to evaluate grocery stores, convenience stores, restaurants, vending machines and even national park food venues. Since 2008, over 50 research studies have been published using the surveys to assess domestic and international food environments.
NEMS has been an influential tool, but it is in need of several updates to accurately assess our access to healthy and unhealthy food. Currently, NEMS emphasizes the outdated nutritional science method of focusing only on total calories and fat intake as the defining characteristics of individual food products. Dr. Mozaffarian, the Dean of Tufts Friedman School of Nutrition and Policy, has stated that our nutrition research needs to shift from simply emphasizing fat content and calories to recommending actual food and consumption patterns. When applying the NEMS evaluation tools to assess grocery stores, vending machines, and conveniences stores, several shortcomings become clear.
When assessing the food environment of grocery stores, the survey instructs the observer to check availability and pricing of baked vs. regular potato chips and fat-free vs. full-fat hotdogs. A store will be considered healthier if they have the baked and fat-free varieties available and at a lower price point. Additionally, frozen dinners are part of the survey and solely assessed using only fat content and calories. If the product has 9 grams of total fat or fewer it is considered healthy; the product is considered unhealthy if it has 10 grams of total fat or more. Nothing else is evaluated, overlooking important factors such as sodium content or if the product is made with whole grains, vegetables, or healthy choices of protein.
Baked goods are similarly compared only on overall fat grams and calories. If bagels and muffins are fat-free or have fewer than 3 grams of total fat, they are considered healthy. Again, no other criteria about how processed the product may be is required. A store is also considered to be healthier simply by offering more 90 percent lean ground beef compared to 80 percent standard ground beef.
A singular focus on fat grams and calories also dominates the restaurant and vending machine evaluations. Fat-free or low-fat salad dressings are considered the healthiest option for salads at restaurants. When assessing nutrition of restaurant entrees, the observer only documents total calories, total fat and saturated fat. A salad in the vending machine measurements is also deemed unhealthy if it contains more than two high-fat ingredients. If a salad has ingredients like nuts, avocado and an oil-based dressing, it is considered unhealthy.
Although researchers who created the Nutrition Environment Measures Surveys in 2007 used contemporary nutritional science from reputable sources such as the National Institutes of Health and the USDA, the issues with NEMS as a modern tool are clear. Nutrition is constantly progressing and we should embrace the evolution of the field. It is important, therefore, that the tools we use to assess food environments are similarly updated.
NEMS should keep some key existing measurements, such as produce quality and availability. Comparison and availability of whole grain breads is also a beneficial component of the current survey. But research should include more behavioral factors and a more food based approach in the assessments of food outlets.
Some grocery store environmental factors that should be measured include: do locations sell soda and candy at the registers? Do they only sell fresh fruit, nuts and non-caloric beverages at registers? What percentage of aisle end-caps are comprised of junk food? Are sugary cereals eye level for children to see? When your receipt prints does it come with a healthy or unhealthy food item coupon? What percentage of the items advertised by store sales fliers are for fruits, vegetables, whole grains, or nuts? Does the store have a dietitian on staff? What percentage of their prepared food is healthy?
As you read through these food environment checkpoints you probably thought that almost no stores would meet the standards, a point that further cements the need for revision. Shouldn't stores have access to a set of standards to enable the provision of a healthy food environment? Healthy choices are available in most grocery stores, but they are currently not promoted or convenient enough to be a regular part of shoppers' purchasing habits. Stores can use simple 'nudges' to make products containing items such as nuts, vegetables, fish, whole fruit and actual whole grains more prominent in their layout. Additionally, stores can use these items to prepare healthy convenience foods to meet the preferences of consumers.
An updated NEMS can be a tool to encourage retailers to improve. Research takes time and developing valid measurement tools is not easy. However, the food environment research field cannot rely on a outdated protocol simply because of its legacy. For the field of nutrition, researchers can and should move beyond including baked chips, fat-free hot dogs, fat-free salad dressing and low-fat baked goods as a positive nutritional measurement of our food environment.