A Big Fat Crisis (25 page)

A hybrid supermarket/consumer behavior laboratory would have two main goals: first, to identify marketing techniques that can help people choose foods for a healthy diet; and second, to determine whether promoting healthy foods and discouraging the consumption of discretionary calories can be economically sustainable and/or profitable. By documenting the arrangements and presentation of foods and keeping track of the nutrient value of the purchases made through cash register receipts, it will be possible to track not only how changing store factors might influence diet, but also how profits can be maximized without sacrificing health.

What Will the Supermarket of the Future Look Like?

I believe the best size for a Supermarket of the Future would be relatively small, less than ten thousand square feet, and considerably smaller than the fifty thousand square feet of today’s average supermarket. The Supermarket of the Future will carry a limited number of items, a fraction of the 40,000–50,000 items that major supermarkets typically carry. The arrangement of displays and shelf space will be considerably different from those of traditional markets.

Because most Americans need to cut down on salt by nearly 50 percent, a supermarket that promotes a healthy and tasty diet should have a special spice and herb section. Here, customers could learn how to flavor foods and make them delicious without adding too much salt. Store employees would encourage customers to taste foods with different flavors. Spices could be provided in small quantities for sampling, as well as in bulk.

Indeed, tasting and sampling would be a primary strategy for introducing new foods. Offering free samples has been successful because it provides the consumer with valuable experiential information and an implicit obligation to return the favor as a result of having been given a taste. Arizona State University Professor Robert Cialdini calls this phenomenon the principle of reciprocity.
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The Supermarket of the Future will also carry some foods that are not entirely healthy, like sweets and other desserts, but the relative amount of shelf space devoted to items whose consumption we have to moderate would be sharply curtailed in contrast to that of the typical supermarket. These items won’t be displayed as impulse buys at the cash register or at the end of an aisle, but reached only after the shoppers have made all their other purchases.

The experimental supermarket can study how changing prices and promotions affect purchases. Just using words like “sale” and “discount” often leads to buying because people think they are getting a bargain, whether or not they are. Many supermarkets have now adopted “ten for $10” specials, which may not in fact represent a price break but is perceived as a discount. In addition, by tying a quantity to the sales price, the terminology also provides a benchmark against which people might decide how many of an item they should buy and serves the purpose of what behavioral economists call an “anchor.”
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It will be fascinating to see whether these techniques can be effective in promoting healthier choices.

Measuring Economic Impact

Would the Supermarket of the Future be affordable? Would it make a profit, or at least break even? Practically speaking, this is the most important question. To answer this question, it will be critical to keep detailed financial records of the entire process, from conception to implementation. If the store helps improve diet, doesn’t lose money, and is sustainable, we could build one in every neighborhood on a nonprofit basis.

Another experiment might investigate how a supermarket would fare if the business model was like that of a health maintenance organization (HMO), in which the food cost for customers was capitated.
For example, for the cost of $50 per person per week, the supermarket would have to provide all the food a person needs to stay healthy, but not more than that. This would help people who don’t have the time or energy to figure out how to find the right amount of food for a reasonable price. I know I would love such a service, especially if it came with recipes that were both easy to prepare and flavorful.

For several years I participated in a type of consumer-supported agriculture (CSA) that selected bags of fruits and vegetables from a farmers’ market and delivered them to my office on a weekly basis. Each bag was designed to include at least 31.5 cups of fruits and vegetables—the recommended amount the average person should consume in a week. Those bags of groceries formed the basis of my family’s diet for the week and helped me figure out what to prepare. If I managed to finish all the bags, I knew my family had gotten enough fruits and vegetables that week. If the leadership of the organization hadn’t changed and canceled the program, I would still be using that fabulous service.

The work of helping people achieve a healthy diet is so important that we should open several supermarket-based consumer laboratories simultaneously in many parts of the country. With multiple working laboratories, marketing strategies can take into account regional, cultural, and racial/ethnic differences and preferences while accelerating progress in addressing obesity and diet-related chronic diseases.

What If Promoting a Healthy Diet Is Not Profitable?

Even if selling food that doesn’t make people sick turns out to be a losing proposition financially, as a society, we may still want to figure out ways to support these outlets. Compare the need for a healthy diet to our need for clean water, clean air, or even police and fire protection. Do these services make money? No, they are subsidized because they are essential. Without clean air, water, and safe communities, we would be more sick and less productive. Although there is widespread agreement that everyone should have access to healthy food, we also need to protect people from being exposed to too much unhealthy food. Learning how to do that is an effort that I believe society should underwrite.

Certifying Restaurants and Supermarkets

Once we identify the features of restaurants and supermarkets that contribute to healthier choices and healthier diets, we can develop a rating system to grade how well these businesses comply with the standards. In 1998, Los Angeles County introduced a restaurant rating system using the grades A, B, and C to indicate the quality of hygienic practices, and it mandated that the results of kitchen inspections be posted within five feet of the restaurant’s entrance.
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Restaurants fought this regulation, complaining they would lose business if they got less than an A. Because the county supervisors agreed that knowing whether a restaurant met hygienic standards was a critical right-to-know issue, the health department prevailed. Food establishments that score below C (70 percent) twice within a twelve-month period are now subject to closure until all the violations are corrected. A low grade remains posted until the inspector returns to confirm that conditions have improved.

This rating system has changed both restaurant and consumer behavior.
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Within one year of the program’s initiation, restaurants improved their preparation standards, and the number of those performing at an A level (above 90 percent) on the inspection scores increased from about 25 percent to more than 50 percent. Improved scores were generally maintained on subsequent inspections. Restaurants with low grades reported a loss in revenue and customer patronage. Sales at restaurants receiving an A grade rose 5.7 percent, or about $15,000 a year, whereas B-level restaurant sales increased 0.7 percent, and sales at C-level establishments decreased 1 percent. The system also focused efforts on restaurants with lower ratings, which were inspected more frequently than establishments with higher scores. The rate of closures decreased.

In the year after the restaurant rating system was introduced, the number of patients admitted to hospitals in Los Angeles for food-related illnesses dropped by 13 percent.
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When restaurant ratings are posted or published, consumers become aware of how well outlets meet standards and can avoid outlets with lower ratings.
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Grades serve as a heuristic—or shortcut—that will help people automatically
make a better choice, but they do not prevent anyone from eating what they want.

If the inspection standards included assessing the quality of prepared foods, menus in restaurants, the design of food stores, and their use of promotional strategies, with the goal of limiting the risk of nutrition-related chronic diseases, it would help people choose healthier restaurants and eat a healthier diet. Food-borne infectious diseases are now relatively rare because hygienic standards are rigorous and compulsory. Just think of what similar regulations could do to reduce chronic diseases.

Making Regulation of Restaurants and Supermarkets for Chronic Disease Prevention a Reality

Politically, adding regulations is always difficult because it upsets the status quo. Historically, change is always accompanied by protest, even for such changes that we now consider as common sense, like requiring adherence to sanitary codes. Yet we need to demand that the government initiate a process to move a chronic-disease-prevention agenda forward. This includes building a consensus on feasible standards, developing product labels and marketing practices that allow people to make healthy decisions rapidly and that delay impulse purchases, allowing them only after thoughtful deliberation, creating certification and incentive programs, and instituting evaluation and monitoring protocols.

It would be the government’s job to establish a set of minimum performance standards and facilitate compliance among stakeholders, including food industry and nutrition experts. To help disseminate the standards, the adoption of tried-and-true marketing techniques like branding would be useful. A symbol identifying adherence to the performance standards (e.g., like a LEED
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standard for a green building) must become widely recognized and easily understood by consumers.
In addition, local governments should certify restaurants whose practices conform to the performance standards; provide incentives (e.g., tax credits, fee rebates, marketing) to outlets that meet or exceed performance standards; and sponsor industry learning and dissemination of best practices.

Labeling for away-from-home food could borrow from the clear successes of eco-labeling programs for consumer products.
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For example, eco-labels provide a simple signal to consumers that products have met environmental, social, and other sustainability standards of verifying agencies. The US federal government has a great deal of experience in developing and managing label programs. The Environmental Protection Agency’s Design for the Environment (DfE) logo helps consumers choose household cleaners that meet standards for minimal toxicity, the EPA’s Energy Star label identifies energy-efficient electronics and appliances, and the USDA’s certified organic label identifies food grown without chemicals or hormones. In each of these cases, eco-labeling and certification by an authoritative agency have contributed to the growth of markets for sustainable products.

Whatever changes are made to foods, food labels, and the food environment, we should evaluate their impact. Surveillance systems can be established to see whether people indeed order healthier options and whether, in the long term, that change has an impact on their diet and health. If evaluations show the changes don’t work, then we should go back to the drawing board and try something else.

Would Restaurant and Supermarket Performance Standards Interfere with Individual Choice?

Some may argue that performance standards are a threat to individual freedom and choice. The claim is that constraining how foods are sold will prevent people from getting what they want. Yet the regulations I am proposing are directed at food establishments (not individuals) and don’t ban any particular foods. Regulations might make getting unhealthy foods less convenient, but they would not reduce consumers’ freedom to eat what they want. Performance standards are intended to change industry behavior and thus the range of choices offered to
individuals. Furthermore, the ability to make informed choices would be enhanced rather than diminished by clear, understandable designations of the health risks or benefits.

Ultimately, adopting and enforcing stricter guidelines regulating food outlets will not preclude people from choosing what they prefer. Instead, they will guide food outlets to routinely offer foods that promote long-term health.

Professionalizing the Food Industry

We require all health professionals to attend accredited schools, pass comprehensive exams, and be licensed in order to ensure that they will not perform at a substandard level and potentially put their patients at risk. We monitor their performance, investigate consumer complaints, require continuing education, and often mandate recertification to make sure they stay up-to-date with scientific advances.

We now know that food providers are in many respects also health-care providers. The food we eat can reduce or increase our risk for both infectious and chronic diseases, yet restaurateurs and their employees are not required to have any formal training in nutrition or chronic disease prevention.

Just as other professions have raised their images by undergoing training and professionalization, the food industry should do the same. Food service employees should understand the consequences of eating the food they serve, and take some responsibility for their role in their customers’ health. Developing standards and requiring food providers to receive nutrition training are necessary so they can properly prepare, label, serve, and promote foods that won’t increase the risk of or exacerbate chronic diseases.