The Tribune

By LARRY SMITH

THERE is a move afoot to make welfare in the Bahamas conditional on taking steps to reduce obesity, eat better, get regular health checkups, and improve education results. You may not think that is terribly important in the overall scheme of things, but you would be dead wrong.

The statistics are telling. Eleven per cent of Bahamian pre-schoolers are overweight or obese, together with almost 10 per cent of Grade 1 students, 18 per cent of Grade 6 students, and a quarter of Grade 10 students. In fact, surveys show that 70 per cent of Bahamians between the ages of 21 and 60 are overweight or obese.

As a direct result, chronic non-communicable diseases account for three quarters of all deaths in The Bahamas these days. The biggest contributors (40 per cent) are heart disease and diabetes. And obesity has also been linked to psychosocial disorders and poor education results.

Education outcomes are closely connected to poverty in the Bahamas. While most youngsters eventually reach grade 12, about half of all public students leave school every year with only an attendance certificate. And one of the consequences of that is 30 per cent youth unemployment. It is also true that poorer and less educated folks are also more likely to be obese.

Conditional cash transfers – as they are known in the trade – are an attempt to break this vicious circle.

The Ministry of Social Services currently administers several cash and in-kind transfer programmes for low-income Bahamians. They include subsidies for food, rent, water, electricity, cooking gas, clothing, building repairs, burials, and school uniforms, as well as an allowance for disabilities.

Plans are now underway to reform this safety net in collaboration with the Inter American Development Bank. The goal is to consolidate all assistance into a conditional cash transfer with transparent criteria that can be objectively evaluated. These reforms will be about two years in the making.

According to the IDB, the new system will focus on promoting healthier lifestyles in poor households. “In the case of education it is expected that the conditionalities will focus on early entry into school and secondary completion rates. In the case of health it is expected that incentives will focus on the prevention and management of obesity and chronic conditions.”

Similar policies have worked well in Mexico and Brazil, helping to reduce poverty by getting families to invest more in their children. In fact, over 30 countries have implemented some form of conditional cash transfer in recent years, and both the World Bank and the IDB are working with governments to spread these programmes around the globe. Studies show that they do keep people healthier, and keep kids in school.

Obesity is one of the major social health problems of our time, with the number of overweight people rivalling the number of underweight people globally for the first time in human history.

In fact, doctors now consider obesity to be a major medical problem, because overweight people are at much greater risk of developing a range of serious, life-threatening conditions – from heart disease to diabetes and cancer. But nutritional and health improvements face an uphill battle against junk food.

A groundbreaking recent book by the former head of the US Food and Drug Administration reveals that food is now a top public health issue.

The unfortunate fact is, says Dr David Kessler in The End of Overeating, is that we have all become addicts – hooked by overstimulated brain chemicals on huge portions of food layered and loaded with sugar, fat and salt, and offering little or no nutritional value.

Kessler, a Harvard-educated paediatrician, argues that until we fundamentally alter our eating behaviour, we will continue to run the risk of all those deadly medical conditions that are caused by obesity.

His book focuses on the American food industry in particular. But Bahamians are in the same overloaded boat. And since most of our prepared foods and chain restaurants are American, Kessler’s facts about overeating and poor nutrition are just as applicable here.

Kessler is perhaps best known for his efforts to investigate and regulate the tobacco industry, and his accusation that cigarette makers intentionally manipulated nicotine content to make their products more addictive. His new book compares the food industry to big tobacco, and shows how our responses to food need to change.

“The attitudes that created the social acceptability of smoking shifted, and many of us began to see smoking as deviant, even repulsive behaviour. A consensus emerged that the cigarette, and the industry that manufactured it, was abhorrent. We moved from glorification to demonisation.”

So we need to change our thinking about big food in the same way. As Kessler says, “Its ubiquitous presence, large portion sizes, incessant marketing, and the cultural assumption that its acceptable to eat anywhere at any time (are you listening civil servants?) puts us at risk...And people need to hear repeatedly, from many sources, that selling, serving, and eating food layered and loaded with sugar, fat and salt has negative, unhealthy consequences.”

The back story is that for thousands of years human body weight stayed remarkably stable, so that people who were overweight stood apart from the general population. A perfect biological system seemed to be at work, until something happened in the 1980s.

When researchers surveyed government health and nutrition data collected from 1988 to 1991 it became apparent that fully one-third of the entire American adult population was overweight – an abrupt increase. The landmark study showing that the rate of obesity in America had exploded was published in the July 1994 issue of the Journal of the American Medical Association. Kessler’s book is the result of the years of thinking and study he went through to try to make sense of those results. As he points out, food had become more readily available in the 1970s and 80s, along with larger portion sizes, more chain restaurants, more neighbourhood food outlets, and a culture that promoted more out-of-home eating. But there had to be something more driving us to overeat.

His conclusion - in a nutshell - is that sugar, fat and salt cause us to eat more sugar fat and salt. It’s all about “palatability”, a term scientists use to refer to food that has the capacity to stimulate the appetite and drive us to eat more. “It’s the stimulation, rather than general hunger,” he says, “that makes us put food into our mouths long after our caloric needs are satisfied.”

Decades of research into human taste, food preferences and dietary choices, have confirmed that what stimulates us most is a combination of sugar and fat. Mix the same amount of sugar into low fat and high fat products and people always choose the higher-fat mixtures.

Kessler cites one experiment with two groups of rats. One group was allowed to eat freely while the diet of another group was restricted. Both then headed towards a chocolate-flavoured cereal high in sugar and fat at almost the same speed. The absence of hunger made no difference to the appeal of the reward.

But it is Kessler’s insights into the food industry that are most interesting. He reports inside information from a variety of food consultants who confirmed that the industry creates dishes specifically to hit the three points of the compass – sugar, fat and salt.

“Chicken tenders,” he writes, “are so loaded with batter and fat that my source jokes that they’re a UFO - an unidentified fried object.”

Eating high-sugar, high-fat foods produces opioids in our brains that help calm us down and make us feel better - at least in the short term. That’s why infants cry less when given sugar water and animals feel less pain when administered opioid-like drugs. “Eating highly palatable food activates the opioid circuits...The more rewarding the food, the greater the attention we direct toward it and the more vigorously we pursue it.”

In addition to that, the conditions under which we encounter foods switch on powerful brain chemicals that compel us to eat. We learn to want a food or some other substance we once liked. Putting all this together gives the following picture, he says:

“A cue triggers a dopamine-fueled urge...dopamine leads us to food...eating food leads to opioid release...and the production of both dopamine and opioids stimulates further eating...The more rewarding the food, the stronger the learning experience that creates the automatic behaviour.”

And the goal of food design is to make products as rewarding as possible. The result is hyper-palatable food that goes down easily, is readily available and inexpensive – a sort of adult baby food.

And according to US figures we are eating more of everything these days. Per capita consumption of fats and oils jumped 63 per cent over the past 30-odd years. Use of sugars and sweeteners was up 19 per cent. We ate 43 per cent more grain and 7 per cent more meat, eggs, and nuts over the same period. We are also eating 24 per cent more vegetables - but most of those are deep-fried potatoes, otherwise known as french fries.

Then there are the portion sizes. Food designers say that if you make plates bigger and fill them more, everyone makes more money. Supersize options and all-you-can-eat specials give consumers access to a bottomless well of food for a fractional increase in cost. It’s cheap and its always available.

“Based on these findings,” Kessler says, “an argument can be made that conditioned overeating is a syndrome, or a condition characterised by a cluster of symptoms...These patterns almost certainly contribute significantly to the exploding obesity epidemic...A conducive environment is necessary to trigger hypereating. That’s exactly what we have today.”

The bad news is that there’s no quick fix - it’s simply impossible to avoid the temptation of highly palatable foods all the time in today’s world. The good news is that we can begin to train ourselves to alter the reactions that are generated by stimulation. And awareness of the problem is the first step along this road, Kessler says.

Of course, these findings apply to everyone, but lower income families are more at risk because of lack of awareness and lack of cash, with cascading consequences as noted above. So in future the idea is to make welfare payments conditional on nutritional training, use of nutritional supplements and other related behaviours.

It may be one of the best things we can do to alleviate poverty. According to Nancy Birdsall of the Centre for Global Development, cash transfers to poor families that are conditional on their participation in education, health, and nutrition services may be “as close as you can come to a magic bullet in development.”

• What do you think? Send comments to larry@tribunemedia.net or visit www.bahamapundit.com.