Dec. 1, 2018

What's the real cost of cheap food? Nutrition, children, and the factors that shape our eating habits

A growing body of research suggests the amount of processed foods we eat is doing a great deal of harm, and that the more ingrained our eating habits get, the harder they are to change.

According to Statistics Canada, the average Canadian household spends $732 per month on food. Obviously, that's a variable figure — for some families, it's trivial, for others, it's simply unrealistic. Either way, for different reasons, a growing amount of that food budget is spent on processed foods. (StatsCan calls these fruit or vegetable "preparations," and "non-alcoholic beverages and other food products.")

The allure of processed foods is strong. For busy families who don't have time to cook, it's much easier to grab a pre-packaged meal on the go and get to the next hockey practice or band concert. For working-class families on a tighter budget, processed foods are often cheaper and more filling than fresh, whole foods. There's a wide array of other forces that shape our food choices as well, including public policy, socioeconomic status, marketing and upbringing.

However, a growing body of research suggests that the sheer amount of processed food we eat has lasting health impacts. From a public health perspective, the costs of poor diets are far higher than we realized before. And the eating habits children learn early on set the stage for lifelong relationships with food.

Plenty unhealthy

We tend to think of food issues in terms of scarcity or not having enough. But it's not that simple. The things we eat too much of also cause a good deal of harm, not just because they're full of ingredients that aren't good for us, but because they're deficient in the things that are.

"A healthy diet consists of a variety of nuts, seeds, whole grains, fruits and vegetables, limited amounts of low-fat dairy and lean, unprocessed meat, fish, and poultry," says Dr. Norman Campbell, MD, a professor in the Cumming School of Medicine's Departments of Medicine, Physiology and Pharmacology and Community Health Sciences. "The issue is that most of us are eating largely processed food diets, which are deficient in those things."

"The leading risk for death in Canada is now our unhealthy diets."

Processed foods are also full of salt, simple carbs (including sugar), and saturated fats. These fill us up, they last a long time, they're cheap, and we're conditioned to think they taste better. But they wreak havoc on our bodies, causing issues like obesity, diabetes and hypertension, or increased blood pressure.

According to Campbell, the burden on public health systems is reaching crisis proportions. "The leading risk for death in Canada is now our unhealthy diets," he says. "Globally, it's the second-leading risk."

Campbell, whose main area of research is in hypertension prevention, says the condition is responsible for more than 10 million deaths per year globally. Because hypertension attacks blood vessels, and blood vessels are found throughout the body, it can lead to a host of complications, including heart disease, kidney failure, even dementia. About 40 per cent of people over 25 in the world are affected by hypertension, says Campbell, and 80 per cent of those cases are due to unhealthy eating.

In Canada, the hypertension costs are staggering. "It's estimated to go up to $20 billion per year by 2020," says Campbell, who is also a member of the CSM’s Libin and O’Brien Institutes. The social costs are just as alarming. "Premature deaths from dietary risk in Canada now exceed tobacco, alcohol and drugs."

More processed food than ever

It isn't news that eating poorly is bad for us. Anyone who's ever overdone it in the Halloween candy bag or at the buffet table knows that. But it's only recently that we're realizing the severity of the problem, and that the science is starting to back up what we know intuitively.

"People have always thought of food as a source of health and enjoyment," says Campbell. "There was a sense that maybe too much saturated fat is bad for you, or sugar is bad for you. But the recognition that these are actually driving the epidemic of diet-related disease, and that our diets are the leading risk of death — that knowledge has only been evolving for 10 years or so."

Our eating habits have also been changing over the past few decades. Humans have been processing and preserving food since we first figured out that drying meat or pickling vegetables made them last much longer. But now, packaged food is the norm rather than the exception.

Think of the age-old axiom about product merchandising in grocery stores, where the "staples" are arranged around the perimeter and at the back, forcing customers to walk through aisles filled with impulse buys. Now think of that arrangement in terms of fresh, whole food versus packaged, processed food. There's a fresh produce section along one side of the store, and maybe a meat counter on the other. In between, aisle upon aisle of processed food in cans, jars, plastic bags, boxes, tubs, jugs, squeeze tubes and freezer cases.

It's the same with restaurants. In the age of corporatization and globalization, more and more of our restaurant choices are fast-food franchises, where food is standardized and prepackaged as much as possible for efficiency.

As the world has sped up and our lifestyles have become busier, so have our expectations of getting everything fast, cheap and easy. "If you can pick up a package and eat it, it tends to be a lot more convenient and fit into our current lifestyles than say, preparing a meal," says Campbell. "We're trying to do everything fast and efficiently and our diets have gone that way as well."

"People think moderation is not eating every meal at a fast-food restaurant."

Whether the food industry is responding to market demand or creating it, one thing is clear: how we eat is dramatically different now than it was even 20 years ago. "We're eating so much unhealthy processed food that our whole concept of moderation is way off spectrum," says Campbell. "Now, people think moderation is not eating every meal at a fast-food restaurant."

Worse, we're passing our bad eating habits on to our children. "Once children start on solid food, they're often fed processed foods," says Campbell. "As they grow up, they're heavily marketed to with unhealthy foods. They start down this pathway early on and by the time they're adolescents, they have very unhealthy food preferences."

Health is more than a choice

It's all well and good to say we should be eating more whole, unprocessed foods, but preparing those takes time and money. Whether we're part of a middle-class family with packed schedules and little time for cooking, or a low-income, single-parent household in a neighbourhood with limited grocery options, it takes effort to eat as well as we should.

"Telling people to eat more healthily doesn't do anything," says Dr. Dana Olstad, PhD, an assistant professor and registered dietitian in the Department of Community Health Sciences and member of the O’Brien Institute for Public Health. "Everybody knows what's healthy and what isn't. We eat based on our socioeconomic circumstances."

Olstad's research focuses on dietary inequities, or the study of the connections between socioeconomic status, diet and health. "People who are more disadvantaged in society, who have lower levels of education and income, or less prestigious occupations, tend to have poorer quality diets," she says. "That then feeds into their health as well."

According to Olstad, the way we eat is shaped by a complex set of circumstances that include how we grow up, where we live and work, our cultural and ethnic backgrounds, what challenges we face in our daily lives, and what marketing forces we're exposed to.

"If you're working multiple jobs, you don't have time to go home and cook," says Olstad. "To plan out a menu. You're probably getting fast food along the way, or just opening more processed foods, which cost less money, and preparing meals really quickly, not sitting down as a family and eating."

Logistics also play a role. If you don't have a car, for example, your food options are going to be restricted. "Think of carrying a four-litre jug of milk with you on the bus," says Olstad. "Along with fruits and vegetables. Those are all bulky, heavy things and processed foods are much more compact."

Difficult or busy life circumstances can also lead to choosing processed foods as a coping mechanism. "You might just want to eat these foods because it feels better," says Olstad. "You just got home after a really hard day. That stress causes us to want comfort foods. It's kind of like an evolutionary response, where you want filling foods that are going to last."

Eating what's available

Even if our daily circumstances aren't conspiring against us, says Olstad, what we learn as children programs how we eat later in life. "The habits that become ingrained in childhood are dependent on your socioeconomic circumstances as a child," she says. "Could your parents afford to feed you healthfully? And what were the habits you learned from them?"

"Our food environment is always pushing the unhealthy food."

Further complicating matters is what food options are available and which products the food industry chooses to put in front of us. "Regardless of our socioeconomic circumstances, we're all influenced by our food environments," says Olstad. "And our food environment is always pushing the unhealthy food because that's what's marketed, it's very convenient, it's cheap, and it's available everywhere we go."

Think of the recent trend where grocery chains partner with fast-food outlets or coffee shops, so that there's even more processed food being sold at the supermarket. "Now, you go to a grocery store and half of it's basically a restaurant," says Olstad. "It's not even a choice so much anymore because it's pushed at you in so many different ways. And given how busy we all are, we're all trying to save money, save time. So you naturally just go with what's there and it becomes part of your patterns of eating."

The foundations of eating

Picking up on our parents' food habits may begin a lot earlier than we realize — even in the womb. As a fetus develops, its hypothalamus — the part of the brain that reads our environments — can already read and react to what's going on around it.

"The hypothalamus is your body's thermostat," says Dr. Deborah Kurrasch, PhD, an associate professor in the Cumming School of Medicine's Departments of Medical Genetics and Biochemistry & Molecular Biology. "It constantly measures your body and says, 'am I hungry? Am I full? Am I hot? Am I cold?' and adjusts your metabolism to compensate."

Kurrasch, who researches hypothalamic development, says her findings show that a fetus's environment can change the hypothalamus. "We're finding that different maternal stressors affect how the hypothalamus develops, which then affects how it functions later in life." In other words, what's going on with mom is reflected in how a baby's brain develops in utero.

As an example, Kurrasch cites a study from the 1940s, when Nazi Germany occupied the Netherlands and many Dutch were on the brink of starvation. Children whose mothers were pregnant during the famine, but who were born shortly after the war ended and food restrictions were lifted, showed curious side effects. "Children that were in their mothers' bellies during this time were shown to have a high risk of metabolic type-2 diabetes and cardiovascular disease," says the member of the CSM’s Alberta Children’s Hospital Research Institute (ACHRI) and the Hotchkiss Brain Institute. "The question of why food restrictions caused these increased risks led to a field of study called fetal programming."

Kurrasch says the study found that because food was in short supply during these pregnancies, the fetuses programmed themselves to expect the same shortages once they were born. But that's not what happened. "When they were born and it turns out there was plenty of food, their hormones and signaling centres were ill-prepared to deal with it," says Kurrasch. "As a result, they developed metabolic syndromes and other problems."

Erasing maternal stigma

Kurrasch says understanding hypothalamic development is especially important in a time when mothers are scrutinized and judged over everything they do or don't do. The risks of pregnancy are well-known, but we don't necessarily know how certain circumstances lead to certain outcomes, and as a result, whether these changes are really mom’s fault.

"There are epidemiological studies that say, 'Mom did this and therefore the kids have a higher rate of that,'" says Kurrasch. "'Mom gained a lot of weight and therefore the developing child is at risk for metabolic disorders, diabetes, obesity, ADHD, take your pick.' I've always asked how? That's always jumped over. How does the developing brain know Mom is fat or stressed? How did those signals get passed to the developing brain and what did the developing brain do differently once they received them? We have no handle on that."

"We're slipping back into a period of blaming mothers."

Knowing that something happens without knowing why it happens can lead to blaming and shaming, says Kurrasch. "We're slipping back into a period of blaming mothers," she says. "We're being nicer about it, but when something happens in development, we're implying that Mom did something wrong and that led to this."

According to Kurrasch, having a better understanding of cause and effect will help make pregnancy easier for mothers, and perhaps reduce risks. "I want to understand on a more molecular level what's happening, and maybe take some pressure off Mom," she says. "Because moms are already under a lot of pressure. They can't eat this, they can't bathe with that. Some women get really stressed about this. So let's understand the process a little bit better so maybe Mom can understand, too."

Keep calm and carry on feeding

When it comes to looking down on mothers for their choices, breastfeeding is an area fraught with potential judgment and recriminations. Mothers who don't breastfeed, or don't breastfeed long enough, or breastfeed for too long, are all subject to having their parenting fitness questioned.

But some mothers can't breastfeed. Either their babies won't take the breast, or there's a physical circumstance that prevents breastfeeding, such as blocked ducts or a mastectomy. Or they simply choose not to. Yet the pressure to do so is so great, some mothers resort to drastic, risky measures, such as ordering breastmilk online from strangers.

The anxiety over doing the best we can for our babies is understandable. Babies grow at phenomenal rates before and after birth — growth rates humans never experience again in their lives — and they need good nutrition to do so. But according to Dr. Tanis Fenton, PhD, pressuring ourselves to be perfect isn't the best way to give our kids a head start, nor set them up with good habits for life.

"Breastfeeding is a great way to feed a baby," says Fenton, an associate professor and dietitian in the Department of Community Health Sciences, who specializes in neonatal infant nutrition. "But it doesn't work for everybody. So we need a plan 'B,' and the only safe and affordable plan 'B' is infant formula. But right now, infant formula is considered in some media to be pretty close to poison."

The stigma surrounding infant formula is indicative of the anxiety and mixed messaging around kids' nutrition in general. "The messaging people get makes nutrition at any age seem impossible," says Fenton. "And it's actually quite simple and straightforward."

Clean your plate (if you want to)

Paradoxically, parental concern over nutrition can lead to problematic relationships with food, says Fenton. For example, insisting that children finish everything on their plates forces them to ignore their bodies' natural responses to food.

"Even a newborn baby has appetite control," says Fenton, a member of the O’Brien Institute and ACHRI. "They know when they're hungry, they know when they're full. But as parents, we think we know better about how much they need, because we care about their health."

"Even a newborn baby has appetite control."

According to Fenton, the ideal parent-child-food interaction involves a concept called "the division of responsibilities," developed by dietitian Ellyn Satter. In this model, parents decide when to offer food and what food to offer, and children decide if and how much they will eat.

However, in many homes, some combination of the reverse happens: children decide what they want to eat, and parents decide how much they'll eat. This can lead not only to picky eaters and constant battles at the dinner table, but can also affect children's ability to self-regulate.

"If we're encouraged to ignore our hunger and satiety, then we probably won't be very good at using them well," says Fenton. This could become an issue later, when children start being exposed to food-related messaging. "So much is marketed to us about food. It's constant. Plus, everywhere you go, people are usually carrying a beverage or food with them. We're getting cues to respond to food constantly."

Stick to the basics

Food marketing can also undermine parents' confidence in their own abilities, says Fenton. "Unfortunately, the solutions that are being promoted to parents is that it has to be all ketogenic and kale and avocadoes," she says. "But it's not that tricky. You don't have to eat just a narrow list of foods to be healthy. Good nutrition is a whole variety of foods. Generally, what most North Americans need to do to improve their nutrition is to eat more vegetables."

A child sees junk food flying out of a screen

And it's more than nutrition. Taking a more relaxed approach to feeding children can have enormous benefits to the family's well-being. "The eating environment is important to the psychological health of the family," says Fenton. " We need to prepare some simple, basic food, then relax and enjoy our time at the table with the kids. We're busy and always jumping into the car for this or that, so the few minutes we get with our families is a time to improve quality of life. You can't enjoy your food if everyone's upset because it's not perfect or someone's not eating their vegetables."

Marketing food to children

As much as parents wish it weren't so, there comes a time when they realize that they aren't the only influence in their children's lives. Other relatives, friends, teachers and peers all play roles in shaping children's personalities and desires. As do the things they watch, read and listen to. And the forces of marketing are likely the biggest influence of all.

Any parent who's stood in a checkout line, with candy and chocolate on racks at children's eye level, trying desperately to withstand the onslaught of pestering and begging, knows just how powerful marketing to children can be.

Beyond sweets and junk food and the cereal aisle, however, the food industry has created an entire category of "kid's food." Virtually any type of food you can buy has a kid's version, from string cheese to yogurt squeeze tubes to animal-shaped chicken nuggets — all highly processed, the majority high in sugar, salt or fat.

"The entire category of children's food suggests that kids need special foods that are distinctly made for them," says Dr. Charlene Elliott, PhD, a professor in the Department of Communications, Media and Film in UCalgary's Faculty of Arts, and a member of the Cumming School of Medicine’s O’Brien and Alberta Children’s Hospital Research Institutes. "This category of food is almost entirely created by the food industry."

Not only do these artificial differences make it harder for parents to get kids to eat more nutritious food, they normalize poor eating habits. Elliott, who holds the Canada Research Chair in Food Marketing, Policy and Children’s Health, says once these habits are formed, they follow children into adulthood. "Taste preferences are formed early on, and persist over time," she says. "If you teach kids from a very young age to be accustomed to a high level of sweetness, and the majority of kids' foods are high in sugar, then when are they supposed to grow out of these preferences? Is it supposed to suddenly turn off? That's unlikely.”

While we would assume that tastes and palates evolve as we grow into adulthood, Elliott says the high levels of added sugars and salt in processed foods make it more difficult to change habits later.

And this just isn’t about taste. It is also about the way that foods are marketed to children as vehicles for fun and entertainment. As the kids who have been raised on these foods are growing up, Elliott says, food marketers are beginning to target adults in the same way they target children. "The appeals towards adults in the last decade or so have become increasingly infantilized," she says. "A dominant appeal in current marketing strategies is about the fun and entertainment of eating food, even for adults."

The evolution of marketing

Elliott, who has studied the progress of children's food marketing, says that as concerns over the nutritional value of kids' food have risen, marketers have adapted their messaging. "In 2005, when I did my first content analysis of children's packaged supermarket food, ‘kids’ food was marketed with reference to fun and, perhaps surprisingly, artificiality," she says. "FunCheez, Funshine biscuits, and packages that made verbatim claims to fun and play and the entertaining elements of the food. There were glow in the dark yogurt tubes, and drink crystals that ‘magically’ changed colour. Kids' food was designed as more playful than ‘regular’ food."

Over time, Elliott noted that there was "a pushback against the artificiality of foods," she says. "There was a jump in the number of products labelled 'made with real.' Made with real fruit. Made with real chocolate. Which is interesting, because one should assume that food is made with real food."

The latest step Elliott has noticed is a move from "made-with-real" to "free from." Free from artificial colours. Free from artificial flavours. Free from gluten. As parents become more concerned about feeding their children healthy food, the number of gluten-free products targeted toward children has skyrocketed.

In one recent study, Elliott compared the nutritional content of gluten-free processed kids' foods to "regular" processed kids' foods. The study was inspired by the research that shows that many consumers without gluten sensitivity are purchasing these foods because they believe that gluten-free products are healthier than their gluten-containing counterparts. Elliott’s study revealed that the

products labelled gluten-free were not nutritionally superior than ‘regular’ foods. "Parents are paying three times the price for these products because they believe there is a nutritional advantage, but there is none."

Teaching kids to see food for what it is

Part of the difficulty in telling good food from junk, particularly for children, is that they aren't equipped to read the cues and signs on food packaging. "I've done a whole series of focus groups with children, grades one to nine, getting them to look at food packaging," says Elliott. "How do they determine what's a healthy food?"

Elliott says the results were surprising. "Many grade nine students could not determine a healthy packaged food item — even when they were specifically looking for it," she says. "They were persuaded by the pictures on the front of the package, marketing claims like 'supergrains,' or even the colour of the box."

A child with a shopping cart

In response, Elliott and her team developed a series of fact sheets and lesson plans for teachers and public health practitioners to help kids navigate food packaging. They include information and tips about common marketing techniques including cartoon characters, the use of colours to persuade, front-of-package claims, marketing techniques and slogans, nutrition fact labels, and misspellings.

"It's getting them to think," says Elliott. "'No, I don't want to be manipulated, and this isn't healthy even though it pretends to be.'"

It's the drinks, too

It isn't just unhealthy food that is causing concerns for kids. One particularly alarming example of marketing an unhealthy product toward children is in energy drinks. Often packaged similarly to sports drinks, energy drinks are found next to sugary sodas and iced teas and vitamin waters in stores. With bright colours and claims of "extreme" athleticism and performance, these drinks have been growing in popularity with kids.

But the high levels of caffeine and sugar in energy drinks make them dangerous to children. Concern grew to the point that in 2010, Health Canada convened a panel of experts to make recommendations regarding legislation to govern energy drinks.

"At that time, there was little regulation," says Dr. Jane Shearer, PhD, an associate professor in UCalgary's Faculty of Kinesiology and in the Department of Biochemistry & Molecular Biology at the Cumming School of Medicine. "Any company could come to market with an energy drink containing as much caffeine as they wanted, with no regulation or warning labels."

Shearer and her colleagues made a series of recommendations which the government adopted. "We included a warning label, for example, that says they're not recommended for kids," she says. "Not recommended for breastfeeding women or pregnant women. Should be consumed in moderation. We limited the amount of caffeine you can have in each container. We limited the serving format, whether the container is resealable or not."

While the regulations were a good start, Shearer says they don't go far enough. The marketing of energy drinks is still very much targeted to children and adolescents, she says, in particular young males. "The marketing is very much aligned with sex appeal and high-risk sports," says Shearer, a member of ACHRI. "The logos are very masculine and evoke feelings of superiority, of partying, of extreme sport."

Shearer says that strong industry resistance is also a barrier. "People would say Canada already has some of the strictest regulations in the world," she says. "And lobbyists come out of the woodwork when new legislation is proposed. But we have to balance industry interests with the health of Canadians."

What's the answer?

For Dr. Campbell, regulation is a key component in making it easier for Canadians to choose healthy eating. "When we look at the major threats to our lives and well-being, we have regulations," he says. "We have speed limits and we have speeding tickets. We have regulations about how tobacco can be sold, and to whom, and how it can be marketed. Same with alcohol. So if unhealthy food is the leading risk for death in Canada, why would we not regulate that?"

In order to urge the federal government to ensure access to nutritious food for all Canadians, Campbell, Olstad and colleagues recently developed the Calgary Statement. Part online petition, part call to action, the Calgary Statement calls for "food environments through public policies that support Canadians in maintaining healthy diets where they live, learn, work, and play."

But laws and regulations about food can't be the only approach when we look at all the factors that lead to people's eating habits and choices. "A superficial approach would be to readjust the cost of these things to make the desirable things less expensive and the undesirable things more expensive," says Campbell. "But we're living in one of the richest countries in the world. Then we have vulnerable groups of Canadians who are below the poverty line and many of them include children. A much deeper approach would be to reduce that disparity."

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Dr. Norman R.C. Campbell, MD, is a professor of medicine, community health sciences, and physiology and pharmacology in UCalgary's Cumming School of Medicine. Norman is a member of the O'Brien Institute for Public Health and the Libin Cardiovascular Institute of Alberta. He seeks to improve hypertension control, unhealthy diets and physical inactivity, and is known around the world for his work in sodium reduction. Read more about Norm

Dr. Dana Olstad, PhD, is an associate professor in the Department of Community Health Sciences in UCalgary's Cumming School of Medicine. She holds Adjunct academic appointments in the Faculty of Kinesiology at the University of Calgary and in the School of Public Health at the University of Alberta. She is also a Registered Dietitian. Read more about Dana

Dr. Deborah Kurrasch, PhD, is an associate professor in the Cumming School of Medicine's Departments of Medical Genetics and Biochemistry & Molecular Biology. She is a member of the Alberta Children's Hospital Research Institute and principal investigator at the Kurrasch Lab. Read more about Deborah

Dr. Tanis Fenton, PhD, is an associate professor and dietitian in the Department of Community Health Sciences at UCalgary's Cumming School of Medicine. She is nutrition research lead for Alberta Health Services, and an evidence Analyst for Dietitians of Canada. Tanis is also the Invited Chair for the Working Group for the development of evidence-based nutrition practice guidelines for preterm infants, the US National Institutes of Health and the US Academy of Nutrition and Dietetics’ “Pre-B” Project. Read more about Tanis

Dr. Charlene Elliott, PhD, is a professor in the Department of Communications, Media and Film in UCalgary's Faculty of Arts, and a member of the Cumming School of Medicine’s O’Brien and Alberta Children’s Hospital Research Institutes. Her research focuses on food, policy and health, especially in the context of children’s health. Read more about Charlene

Dr. Jane Shearer, PhD, is an associate professor in the Faculty of Kinesiology and the Department of Biochemistry and Molecular Biology at the Cumming School of Medicine. She is a member of the Alberta Children’s Hospital Research Institute at the CSM. Her goal is to develop an interdisciplinary research program examining the interactions between nutrition, genes and the development of metabolic diseases including diabetes and cardiovascular disease. Read more about Jane

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