The magazine of the American Heart Association published an article a few days ago in which it estimated the benefits of complying with the recommendations of the World Health Organization (WHO) in salt consumption. In Australia alone, where the study was conducted, reducing sodium intake with salt by 30% by 2025 would prevent 1,700 premature deaths each year and 7,000 diagnoses of heart disease, kidney disease, and stomach cancer. Another 2021 analysis, published in the journal Circulation, estimated that meeting the goals of the US Salt and Sugar Reduction Initiative, which calls for a 20% drop in packaged foods and a 40% drop in beverages sweetened, would mean a reduction of 490,000 deaths from cardiovascular disease and 750,000 cases of diabetes over several decades.
The benefits of reducing sugar, salt, fat and ultra-processed foods in general would be clear and many social transformations show what can be achieved with determined public policies. The improvement of roads and vehicles, together with awareness campaigns and the promotion of the use of safety measures such as seat belts, made it possible to reduce road mortality in Spain by 80% in 30 years. If the harms of a poor diet are just as clear, would it be possible to achieve the goals predicted by the studies by forcing people to eat well?
Manuel Franco, epidemiologist at the University of Alcalá and professor at Johns Hopkins University (USA), points out that these types of changes in the reduction of salt or sugar have to be population-based. “It must occur in the environment, so that I do not have to make the decision to choose between a food with a lot of salt and one with little every time I go to eat, because that will not work. People, and especially those with fewer resources, have little time to cook and choose healthy food, so there needs to be policies that make the decision already taken”, he explains.
The success of these population measurements was studied by Franco together with several collaborators in a drastic historical experience. After the fall of the Soviet Union in 1991, the US tightened the embargo against Cuba and that combination of misfortunes caused an intense economic crisis on the island known as the Special Period. Cubans went from consuming 3,000 calories a day to around 2,200 and the scarcity of fuel forced them to walk everywhere or use their bicycles. In a study published in the British Medical Journal, Franco showed that the radical change in lifestyle, which the islanders remember as a miserable period, produced benefits for their health. The combination of diet and exercise led to a widespread loss of ten pounds per person across the country that improved many important indicators of health. Analysis of the health of Cubans between 1980 and 2010 showed that this weight loss would cut deaths from diabetes by half, those caused by coronary disease by a third, and would reduce the number of strokes.
Despite the positive results of that involuntary experiment, it is unlikely that any society would support a government that would subject it to a special period, no matter how much it promised improvements to health, nor that any government would dare to raise such a project. In addition, according to nutritionist Juan Revenga, “there is a very powerful industry around these products that harm our health, on which many jobs depend, and that exists because the products are bought and they are bought because we like them”.
In recent years, driven by a social and political awareness of the impact of diet on health, some measures have been taken that have reduced the consumption of elements such as salt or sugar that, along with fat, make them so attractive processed foods. The Spanish Association of Refreshing Drinks (ANFABRA) has promised a cumulative reduction of 53% in the sugar content of its products between 2020 and 2025. Last year the Government placed a limit on the amount of salt in bread, which is estimated to , will reduce the average consumption of this ingredient by Spaniards by 20%, which is slightly more than nine grams per day. Even with the reduction, the amount would remain above the two to five grams per day recommended by the WHO.
Regarding sugar, in 2021, the Government increased the VAT on sugary and sweetened beverages from 10% to 21%. An analysis of the effects of the measure by ESADE’s Center for Economic Policies showed that, although it did not have an impact on medium- and high-income households, it meant a reduction in the consumption of 11 liters of sugary drinks per household, by 13%, between the third of households with the lowest economic level, and 10.5% less in the consumption of snacks. The value of taxes to change behavior has also shown its usefulness with tobacco, with examples such as Colombia, where after tripling the rate for each pack there was a 34% drop in consumption.
Beatriz Blasco Marzal, general director of Anfabra, considers that self-regulation “has shown that progress can be made” without staying at “partial measures”, as he qualifies taxes on soft drinks. Blasco assures that in his sector, which accounts for 2.1% of the caloric intake of Spaniards, they are “committed to reducing the consumption of sugar in the population”, and recalls that drinks with little or no sugar are already 60% of your business. In addition, she mentions other measures taken by the industry on its own initiative that, at least in part, recognize that their products are not completely healthy. “We have the commitment not to direct advertising of our products to children under 13 years old, not to sell any type of soft drink in primary education centers and only low-calorie or no-calorie drinks in secondary schools”, she says.
Ramón Ortega, professor of Bioethics, Anthropology of Health and Human Communication, has explored other techniques to condition the behavior of groups of people regarding food without restricting their freedom, classified as libertarian paternalism. “Paternalism is very present in our lives. One case is the seat belt, which they force us to use for our own good, but without leaving us the freedom to choose, or the prohibition of certain substances such as heroin”, explains Ortega. Libertarian paternalism would fall somewhere in the middle, which would consist of exploiting the cognitive biases of the population in order to increase the probability that people make a decision that is considered beneficial to them without directly forcing them.
“An example is what was done in the Google dining rooms. There, to reduce the consumption of soft drinks and other sugary drinks available in their vending machines, they placed them in a less visible place than the water”, says Ortega. “With this measure, they managed to increase water consumption by 47%”, he adds. Other examples of these pushes for our good, described by Ortega in a recent article in The Conversation, are offering meat and fish with salad by default in school canteens, but also giving the possibility of ordering chips, or, as he did in Argentina, remove the salt shakers from restaurant tables and let the customer ask for it if they want.
The Nebrija University researcher acknowledges that these pushes “are done from a certain manipulation, without seeking rational acceptance of a measure”. However, he sees it as an alternative to more restrictive public health measures when the health of the community is seen as a higher goal than the autonomy of the individual. In addition, remember that the food industry also uses these cognitive biases to guide our behavior, “such as when basic foods such as meat or fish are placed at the back of the supermarket to make us pass before other products such as sweets or chips”.
When the possibility of removing temptations in the form of unhealthy foods from citizens is raised, appeal is frequently made to the freedom of choice of consumers and companies to offer their products. However, freedom is already conditioned. The large amounts of sugar, salt, and fat in processed foods, often in combinations not found in nature, produce powerful effects on our brains that make a meal without much salt taste like nothing afterward or water we find it bland compared to sugar-flavored drinks. Some researchers like Ashley Gearhardt, from the University of Michigan (USA) and addictive of some foods.
Gearhardt suggests that certain products, such as pizza, French fries or hamburgers, share some characteristics with addictive substances that make it difficult to control their intake, even though we know that they are not good for us. Among other things, the food industry has modified foods found in nature so that they absorb more quickly and generate a more intense sensation of pleasure, similar to what happens with the coca leaf when it is processed to produce cocaine. Hebebrand, who disagrees on the term food addiction, believes that excessive consumption of certain products is due to their omnipresence in places like supermarkets and the wide variety, which maintains consumer interest in these unhealthy products.
Manuel Franco believes that once again enjoying foods with less salt and sugar and less processed will be a long road: “We are not all going to become flexitarians overnight, nor are we going to suddenly enjoy bread without salt or we are going to be able to dedicate 3 hours a day to shopping and cooking, because that would require a brutal change in the economy and society”. In addition, the industry, which in some cases has manipulated science as it did that of tobacco to cover up its harmful effects, “is not only very powerful but also feeds us”, continues Franco. “We can live without tobacco, but not without the food industry, so we have to live together while we promote changes”, he acknowledges. Revenga, who even questions the value of measures such as reducing salt in processed foods, “because they can give the feeling that it is safe to consume a product that is still unhealthy”, believes that one of the important steps to change at a social level is “That they begin to teach in school what our mothers knew so well: to buy and to cook, which no one knows anymore”.