Do you eat five servings (400-500 grams) of fruits and vegetables or do 30 minutes of physical activity in a day? Chances are that you do not. Do not worry, you are not alone in not doing so. The 2017-18 National NCD monitoring survey reported that 98% of Indians do not take adequate fruits and vegetables and only 59% of adults do adequate physical activity.
So why are we not making the right choices? Often the reason given is that people do not pay enough importance to health and choose to eat unhealthy due to taste and cost considerations or are simply too lazy to take that walk or go to the gym. In other words, individuals fail in making the right choices and are at fault. But are these individual choices? I believe that these choices are heavily influenced by the environment we live in.
I can no longer eat a full thali in any of the restaurants and yet I am forced to do so as there is no choice. Restaurants find large portions to be more lucrative. Finding a snack which is neither fried nor salty in a restaurant is nearly impossible. We need more choices for people to be able to eat healthy without compromising the choices for others. We know that food choices in families are now driven by children who are heavily influenced by food marketing on television or by inducements like toys. Surveys have shown that unhealthier choices are available more, priced lower and displayed more prominently in grocery stores to promote their buying.
There are two main reasons that most of us do not eat sufficient fruits and vegetables—culturally our diet is so cereal/pulse—based (due to the historical need to address undernutrition) that scope for adding these is limited. More importantly, it is an affordability issue. So, our food environment is configured in a way that promotes unhealthy options and dissuades healthy choices.
Now, let us understand why our intention to walk or exercise does not convert into actual practice. It is always desirable to pursue physical activities that are integrated into our daily work, including household work, walking to the office, market, or bus top, taking stairs over lifts and morning walks. However, we do not do it as we have many barriers to walking in our environment—air pollution, weather (hot-cold-rains), unusable footpaths, lack of parks or, when available, often unsafe and poorly lit. Socio-cultural barriers are equally important, especially for women not being able to do physical activity—their role within the house.
Thus, physical, economic, and socio—cultural environments in which we make decisions about purchasing, preparing and consuming food or doing physical activity are unsupportive of healthy choices. Can these environments be shaped differently? Yes, there is sufficient evidence globally that there are many policy—level interventions that help create an enabling environment. These include regulatory, fiscal instruments as well as structural and educational interventions.
The regulatory approach is best exemplified by regulating the marketing of foods to children. Many countries have banned or restricted the advertising of food and beverages to children on television—food companies cannot advertise on children’s channels or at times when they watch television. Regulating salt content in butter, cheese, chips etc. is another area for regulation. India is currently exploring front—of—pack food labelling by self—regulation by industry. Self–regulation has not really worked globally and is just a delaying tactic by the industry.
Given that affordability is an important consideration for eating healthy, fiscal measures have an important role. Some examples are taxing junk food, incentivising healthier options and subsiding fruits and vegetables.
Laying more footpaths, making them walkable by having them low, keeping them clean, removing obstructions and maintaining parks etc. are doable interventions by municipalities.
Commercial interests like the food industry are powerful interest groups. They would oppose interventions aimed at labelling or reducing salt or sugar. While we need to engage with the industry, we must also learn to insulate these decisions from their influence.
Along with improving awareness of people about making healthy choices, we also need to educate relevant stakeholders. Working with restaurants to promote healthier preparation of food—preventing multiple reheating of oils, lower oil, salt, and sugar use during preparation, and making available small portions are some examples.
India has not really explored these multifaceted policy interventions to address issues of diet and physical activity choices. We have used similar approaches effectively in modifying other behaviours like promoting safer sex, use of toilets. Many best practices exist globally which need to be synthesised and shared with policymakers. Even within the public health fraternity, there is a need for building capacity in planning, implementing, and evaluating these interventions. Ultimately, to make healthier choices easier for people, policymakers must exercise difficult choices. Sufficient momentum needs to be built for these interventions to be part of policymakers’ weaponry. Also, if more people opt for healthy choices, then the industry will be forced to respond to keep its market share.
Anand Krishnan is Professor at Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi