Reducing Fast Food Outlets through Zoning

Over the last three decades, obesity rates in the United States have doubled in adults and tripled in children and adolescents, and reports now indicate that approximately one-third of children and adolescents and two-thirds of adults are either overweight or obese (1). Obesity has increased among all racial, ethnic, and income groups, but the highest rates occur among minorities and the poor (2, 3). This is particularly concerning given obesity’s link with numerous chronic health conditions, including diabetes, stroke, heart disease, high blood pressure, and some cancers (4).

While advocates correctly emphasize the importance of making healthy food more available to reduce obesity and other health problems, some researchers believe that such measures can only be effective if they are coupled with efforts to limit unhealthy foods as well (5). After all, eating a few more fruits and vegetables daily is unlikely to improve health if one is also consuming a Big Mac, fries and 32 ounces of soda a day. These researchers note that the policy rationale for reducing access to unhealthy foods is to make healthy choices the easier path.

In particular, fast food companies may play a key role in the obesity epidemic because of their large and inexpensive portion sizes, the high levels of calories, fat, and sodium contained in fast food, and the frequency with which those most affected by obesity (especially poor populations and children) consume fast food (6). Americans rely on fast food outlets for a substantial amount of their food, with almost half of food spending going to meals consumed outside the home (7). And not surprisingly, studies have found an association between eating fast food and higher fat consumption and weight (8, 9).

In considering how access to unhealthy foods might be reduced, municipal zoning codes may hold unique potential. Zoning laws determine how city land may be used and where these different uses may occur. As a police power, through which states are obligated to protect the public’s health, welfare, and safety, zoning laws may be a powerful tool for improving food environments (10). To help advocates better understand how zoning might be used to reduce access to unhealthy foods, this article provides information about how zoning has been used to influence fast food outlets, describes how various jurisdictions have approached the regulation of fast food, discusses potential arguments for and against the zoning of fast food, and describes some of the ways that the food industry has opposed efforts to zone fast food.

How has zoning been used to regulate fast food outlets?

City governments have developed a variety of ways of reducing fast food outlets through zoning. These typically fall into two categories: bans or restrictions (10). The most common types of zoning bans and restrictions to reduce fast food outlets are described briefly below (11). (For more detailed descriptions of these approaches, see Mair et al., 2005)

  1. Banning fast food outlets and/or drive-through service. Banning fast food outlets has been done via complete bans on new fast food outlets throughout a city or town, or less restrictively, as bans in which new fast food and/or drive-through service can only be allowed via conditional or special use permits.
  2. Banning “formula” restaurants. Formula businesses have been defined as those “that have standardized services, décor, methods of operation, and other features that make them virtually identical to businesses elsewhere.” Formula restaurants typically refer to large national chains, but in some cases have been interpreted to mean very small, local chains.
  3. Banning fast food in certain parts of a city. Often when fast food has been banned only from certain areas within a city, it is banned from areas that have a “unique character” that the city wants to preserve and fast food restaurants are banned for aesthetic reasons.
  4. Restricting the number of fast food outlets. This involves a cap on the number of fast food outlets that can exist in a given area or an entire city.
  5. Restricting the density of fast food outlets. Density of fast food outlets has been regulated per unit space (eg. one fast food outlet for every 400 feet of lot frontage along the street, as in the Westwood Village area of Los Angeles, California) and via space between fast food outlets.
  6. Regulating the distance between fast food outlets and other sites. These other sites have included schools, churches, hospitals, nursing homes, public recreation areas, and residentially zoned property.

Several municipalities have sought to ban fast food in the areas around schools.

Where has zoning been used to reduce fast food outlets?

South Los Angeles, California

In July 2008, the Los Angeles City Council approved a measure to place a one-year moratorium on the opening of new fast food establishments in several south Los Angeles neighborhoods with high fast food density and high obesity. The measure defined fast food as, “[a]ny establishment which dispenses food for consumption on or off the premises, and which has the following characteristics: a limited menu, items prepared in advance or prepared or heated quickly, no table orders, and food served in disposable wrapping or containers” (12). The new law only applied to stand-alone restaurants, not to those located inside malls or shopping centers (13). The rationale for implementing the measure as a moratorium was to give city planners time to assess the best use of minimal remaining land in these neighborhoods for the creation of a healthier food environment, and to attempt to draw grocery stores and sit-down restaurants to the area (13). The moratorium has now been extended to two years, and no evaluation data has yet been published regarding the measure’s effectiveness, though one analysis has suggested that the ban is not the best approach for addressing obesity in these areas (14).

Concord, Massachusetts

Concord, Massachusetts, a town of approximately 17,000 that is located within commuting distance of Boston, implemented a complete ban on drive-in and fast food restaurants in 1981 (11, 15). The rationale for the ordinance was two-fold: “to lessen congestion in the streets” and “to preserve and enhance the development of the natural, scenic and aesthetic qualities of the community” (11). City officials indicate that no one seems to miss the fast food outlets banned via the ordinance (15), however, to our knowledge, no health-related assessments of the ban’s effects have been conducted to date.

Detroit, Michigan

In Detroit, for close to two decades, the zoning code has prohibited most fast food restaurants from being built within 500 feet of all elementary, junior, and senior high schools (11, 15). The code’s language includes both “standard” restaurants and “carry-out or fast food” restaurants. As in Concord, no health-related evaluation data of this fast food restriction exists.

What kinds of arguments have been made for the zoning of fast food outlets?

Historically, the arguments used most commonly to reduce fast food outlets through zoning have been related to the increases fast food outlets can cause in traffic, pollution, and trash around the site (11), as well as the threat they may pose to pedestrian safety (16). Many have also successfully argued that fast food outlets be banned in specific areas in order to preserve a certain aesthetic to which fast food outlets do not conform (11).

A measure passed to ban new fast food outlets in South Los Angeles in 2008 (described above) marks the first time that health has been used as the explicit rationale for a change in the zoning of restaurants. The language of this ordinance reads that it was intended to “provide a strong and competitive commercial sector which best serves the needs of the community, attract uses which strengthen the economic base and expand market opportunities for existing and new businesses, enhance the appearance of commercial districts, and identify and address the over-concentration of uses which are detrimental to the health and welfare of the people of the community” (12).

What are the arguments against zoning fast food and potential responses to these arguments?

Argument 1: Reducing access to fast food in places considered “food deserts” could make residents vulnerable to not getting enough to eat.

Response: Fast food bans via zoning do not typically remove all fast food restaurants in a given area; they merely restrict the opening of new fast food outlets. The effect of such bans is to arrest the growth in fast food outlets and to make room for healthier food options. Stopping the growth of fast food outlets in areas considered “food deserts” may thus be an important first step in changing the overall food landscape in these neighborhoods, especially when banning fast food is implemented in conjunction with proactive efforts to increase healthy food options. Additionally, research indicates that hunger and obesity may be paradoxically intertwined. Insufficient income and food stamp benefits often force food choices based on economics rather than nutrition and health, and may encourage some people to overeat when they have money and go hungry when it runs out (5). If what people are overeating is fast food because that is what is most accessible, then the risks of obesity—even among populations that suffer from hunger—can be high.

Argument 2: Since zoning typically only affects new fast food outlets, it is not useful in reducing access to existing fast food restaurants.

Response: It’s true that eliminating or limiting the operation of existing fast food outlets through zoning is difficult and costly to implement. To address existing outlets, municipalities usually do one of three things: allow the business to continue, without changes or expansion; allow the business to continue operation for a specified period of time (amortization); or use eminent domain to provide the business owner with “just compensation” for the value of the business (17). This last route is the rarest of the three. Thus, in areas with a very high density of existing fast food outlets, the reduction that zoning could provide might be a legitimate concern. However, in most places, a prohibition or restriction of new fast food restaurants would likely substantially alter the food environment over time.

A poster exemplifying the “nanny state” argument.

Argument 3: It’s wrong for government to tell people what kinds of food they can have access to.

Response: This “nanny state” argument falls short when we recognize the extraordinary influence the fast food industry has on what we eat, as compared with government. Through the location of their outlets, as well as their prices, portion sizes, and advertising, fast food restaurants have made themselves an integral part of American life, just as they play an integral role in the obesity epidemic. Advocates suggest that we ask ourselves, “Who do we trust more to tell us what kinds of foods to eat: corporate executives with a financial bottom line or public health officials?”

Argument 4: There are other, better targets than fast food if we want to reduce obesity.

Response: The reduction of fast food outlets is rarely if ever intended as the sole approach to improving food environments. Rather, policies to reduce fast food are intended play a single but nonetheless critical role in a larger array of efforts to improve food environments.

How do food and restaurant industries oppose zoning changes?

The food and restaurant industries have opposed the zoning of fast food primarily through strong media responses to efforts to zone fast food and through lobbying. Media responses typically use the “nanny state” claim (Argument 3 above), and come from organizations like the Center for Consumer Freedom (CCF), which is a food and restaurant industry front group. For instance, in response to a report released by Institute of Medicine in 2009 that recommended zoning of fast food in areas near schools to reduce childhood obesity, CCF’s director of research said, “The big picture is [activists] want to control what everybody is eating. The theory is that we’re too stupid to make our own eating choices, so let’s make sure the restaurants are far away from you.” The president and executive director of CCF is Rick Berman, a food and tobacco industry lobbyist who also runs Berman & Co., a restaurant and tobacco industry public affairs group that is estimated to earn $10 million annually.

The National Restaurant Association also opposes zoning changes that would limit fast food outlets, and has developed a well-oiled machine for lobbying state and local legislators. In a 2005 CorpWatch article, Michele Simon wrote, “The National Restaurant Association has 60,000 member companies representing more than 300,000 outlets. NRA works quite effectively in tandem with each state’s restaurant association, providing model legislation, talking points, and additional technical assistance.”

By Emma Tsui, Postdoctoral Fellow at the City University of New York School of Public Health at Hunter College and editor at Corporations and Health Watch.


  1. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, and Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295:1549-1555.
  2. Black J and Macinko J. Neighborhoods and obesity. Nutr Rev. 2008;66:2-20.
  3. Drewnowski A. Obesity, diets, and social inequalities. Nutr Rev. 2009;67(Suppl 1):S36-S39.
  4. Visscher TL, Seidell JC. The public health impact of obesity. Annual Review of Public Health 2001;22:355-75
  5. Dinour, L, Fuentes L, Freudenberg N. Reversing Obesity in New York City: An Action Plan for Reducing the Promotion and Accessibility of Unhealthy Food, CUNY Campaign Against Diabetes and Public Health Association of New York City, October 2008.
  6. Brownell KD. Fast food and obesity in children. Pediatrics 2004;113(1 Pt 1):132.
  7. Clauson A. Share of food spending for eating out reaches 47 percent. Food Rev. 1999;22:20–22.
  8. Bowman SA and Vinyard BT. Fast food consumption of U.S. adults: impact on energy and nutrient intakes and overweight status. J Am Coll Nutr. 2004 Apr;23(2):163-8.
  9. Bowman SA, Gortmaker SL, Ebbeling CB, Pereira MA, and Ludwig DS. Effects of fast-food consumption on energy intake and diet quality among children in a national household survey. Pediatrics. 2004 Jan;113(1 Pt 1):112-8.
  10. Hodge J. The Use of Zoning to Restrict Access to Fast Food Outlets: A Potential Strategy to Reduce Obesity. Presentation to the CDC Diabetes and Obesity Conference, May 2006.
  11. Mair JS, Pierce MW, and Teret SP. The use of zoning to restrict fast food outlets: A potential strategy to combat obesity. The Center for Law and the Public’s Health at Johns Hopkins & Georgetown Universities, October 2005.
  12. Los Angeles City Council. Los Angeles, California Ordinance 180103 (July 29, 2008).
  13. Hoag, C. “Los Angeles to vote on fast food ban.” The Huffington Post. July 29, 2008.
  14. Sturm R and Cohen DA. Zoning for health? The year-old ban on new fast-food restaurants in South LA. Health Aff (Millwood). 2009 Nov-Dec;28(6):w1088-97. Epub 2009 Oct 6.
  15. Fernandez, M. Pros and Cons of a Zoning Diet: Fighting Obesity by Limiting Fast-Food Restaurants. The New York Times, September 24, 2006.
  16. Spacht AC. The zoning diet: Using restrictive zoning to shrink American waistlinesNotre Dame Law Review. 2009 85(1): 391-418.
  17. National Policy and Legal Analysis Network to Prevent Childhood Obesity (NPLAN). Model Healthy Food Zone Ordinance. October 2009.

Photo credits:

  1. StudioGabe
  2. Mirsasha
  3. DonnaGrayson
  4. DR000
  5. swilkes

Beverage Industry Uses Old and New Strategies to Block Soda Taxes

The battle over soda taxation at the state level rages on, as more and more cash-strapped states seek to close budget shortfalls and avoid cuts to critical services such as public safety and transportation. Officials in at least 20 cities and states have proposed new excise taxes or to remove existing sales tax exemptions on non-alcoholic drinks. The beverage industry has responded by spending millions of dollars on lobbying and advertising against the proposed beverage “sin taxes” since 2009.

In a recent twist, the beverage industry has offered the city of Philadelphia what it calls a $10 million “good-will-gesture donation” to fund health initiatives in the city if the city agrees to abandon its proposed excise tax on soda. As noted by a food industry analyst, the move “demonstrates just how much the soda industry fears any attempt to tax its product.” Although the $10 million may seem like a generous offer, Philadelphia’s tax proposal, in contrast, would have raised $77 million in revenues, with $20 million going toward obesity prevention.

In this article, we review the strategies the beverage industry has used to try to block efforts to tax soda and sugar-sweetened beverages at the federal level, and in several key localities, including New York State, Washington State, Maine, Philadelphia, and Washington D.C. We also present evidence that clearly demonstrates how the proposed taxes and presumed increase in the price of soda would help Americans lower obesity rates by reducing our per capita soda consumption.

Beverage industry blocks proposals to tax soda at federal level

A federal excise tax on soda was first proposed in September 2009 as one means of offsetting the cost of healthcare reform and reducing the nation’s high rates of obesity. Although the proposals did not get very far, several high-level talks did take place, including a Senate Finance Committee hearing and closed-door talks with members of the House Ways and Means Committee (1). In response, the beverage industry immediately mobilized a broad-based lobbying effort to quash any such proposal. The coalition operated under the name Americans Against Food Taxes, and included soft drink manufacturers, suppliers, and mass-marketers such as McDonald’s.

In Washington D.C., corporations such as Coca-Cola Co., Pepsi Co., and numerous fast food companies spent $18 million in lobbying activities, and several million more in campaign donations to officials (2). Television commercials, such as this one, which appealed to concerns of everyday families about affording groceries, cost over $10 million to produce and air in key districts (2).

The American Beverage Association also went on the offensive in response to the increasing scientific evidence on the link between increased soda consumption and weight gain. The industry group attacked the findings of nutrition researchers, and funded studies of their own that were more favorable to the beverage industry’s interest in keeping soda consumption high. Kevin Keane, senior vice president of public affairs for the American Beverage Association, claimed that researchers “pick and choose the facts that support their view and attack anyone who disagrees. It’s scientific McCarthyism” (2). The industry’s well-funded efforts to silence any talk of a federal tax on soda were ultimately successful.

New York State fails to pass revised soda tax proposal

Corporations and Health Watch previously reported on the failed campaign to implement a “penny per ounce” excise tax as part of an effort to help close some of New York’s 2009-2010 budget shortfall. After Governor Patterson first announced the proposal in December 2008, the beverage industry poured massive amounts of funding (over $3 million) into lobbying and other efforts to oppose the measure, often working under the coalition called New Yorkers Against Unfair Taxes. The American Beverage Association spent nearly $900,000 lobbying in New York State in 2009, up from zero dollars in 2008. This influx of money appears to have worked, as original supporters of the tax like Senator Jeffrey Klein (D-Bronx/Westchester) became instrumental in getting the proposal off the table. Senator Klein accepted $36,000 in campaign contributions from the beverage industry and related groups since the tax was proposed in December 2008, actions that coincided with his decision to reverse his position on the soda tax.

Given New York State’s unrelenting fiscal troubles and multibillion-dollar shortfall, Governor Patterson tried to revive his soda tax proposal for the 2010-2011 budget, this time with a “carrot and stick” approach that would have allowed for an exemption for diet drinks and bottled water. At the present time, soda, diet soda, and bottled water are subject to a sales tax, but Governor Paterson wanted to add on an additional excise tax of “a penny per ounce” which would be levied on the beverage bottler for sugary sodas, with a “carrot” of sales tax exemptions for water and diet sodas. Governor Paterson maintained that the public would support the proposal as long as “we can justify where the taxes are going” (3). However, the revised proposal failed as well, owing in large part to the American Beverage Association’s ability to dominate discourse on the issue by spending $9.4 million in New York State in the first four months of 2010.

Philadelphia forced to raise property taxes and slash public safety programs rather than tax soda

Another locality where proposals to tax soda have recently failed is Philadelphia, where an estimated 70 percent of children in the city’s poorest neighborhoods are considered to be overweight or obese, according to city data. There, the City Council has recently refused to vote on the proposal to tax soda and other drinks with added sugar. Had the original proposal by Mayor Nutter been successful, Philadelphia would have levied a 2-cent per ounce excise tax on sugary drinks as part of an effort to balance the city’s 2010-2011 fiscal budget. The proposed tax was eventually reduced to a working number of between ½ to ¾ cents per ounce, which would have raised an estimated $9 million to $14 million in 2010-2011. The proposed tax wasintended to avoid cuts to libraries, recreation and public safety.

In Philadelphia, area retailers, teamsters and beverage corporations came together to oppose the tax, claiming that it would lead to the loss of nearly 1,000 of an estimated 13,000 food store jobs, as well as 2,000 jobs in distribution and bottling. The beverage industry has been criticized for the role that it played in the defeat of this soda tax. Harold Honickman, a “beverage mogul” who owns Canada Dry Delaware Valley Bottling Co., and whose net worth is estimated at up to $850 million, became the face of the anti-soda tax coalition, when he stepped up to offer $10 million on behalf of the beverage industry for city health and recreation programs just weeks before the scheduled vote. Mayor Nutter commented that, “It seemed a little strange in the middle of this fiscal and public health issue, that out of nowhere an offer of money was made, essentially to make this go away. I don’t operate like that, and our government does not operate like that.”

With City Council members deciding not to vote on the soda tax, the Mayor was forced to find other means of closing the budget gap. In order to close the budget shortfall, Philadelphia will be forced to shed 339 city positions, in addition to slashing police and fire companies’ budgets, reducing libraries to four-day weeks, cutting $500,000 from shelters and supportive housing programs, and raising property taxes 9.9 percent.

Washington D.C. fails to pass soda tax to fund Healthy Schools Act

In Washington D.C., penny per ounce soda taxes were considered as a means of funding healthy school foods programs earlier this year. The bill would have mandated more physical education and that low-calorie and low-fat meals be served to the area’s approximately 70,000 students. In a preliminary vote in April of this year, the 13-member D.C. Council unanimously voted to back the Healthy Schools Act, without a soda excise tax attached. However, once the soda tax was attached to the bill, several weeks of intensive lobbying followed by groups such as the Maryland-Delaware-D.C. Beverage Association, and support for the penny per ounce tax quickly dwindled. Instead, the city decided to apply its 6 percent sales tax to soda and other sweetened beverages to fund the $6 million cost of the program.

Industry works to repeal taxes in States that have passed excise taxes

It is noteworthy that a few states – Washington, Maine and Colorado – were recently successful in passing excise taxes on soda, but the beverage industry has now stepped up efforts to overturn these taxes. In April, the Washington state legislature passed a tax of 2 cents for every 12 ounces of soda and other sugary beverage, with a 2012 expiration date. According to theWashington Post, the American Beverage Association soon began funneling money to its Washington State branch. The beverage industry coalition, operating under the name Stop Grocery Taxes, had has collected over 395,000 signatures which will place Initiative I-1107 “to stop the tax hikes on food and beverages” on the state ballot in November. A similar approach has already been successful in Maine, where two years ago the legislature passed a soda tax of 42 cents per gallon. Last November, the beverage industry spent over $4 million on its Fed Up With Taxes Campaign, which was successful in putting the tax on the ballot and encouraging voters to reject the tax.

The case for a soda tax

While industry groups claim that soda taxes are nothing more than a money grab from taxpayers struggling to support families, there is substantial evidence that increases in price will in fact reduce soda consumption. In a recent report by the USDA, it was estimated that a ten percent price increase would decrease purchases by 12.6%. Cathy Nonas, head of nutrition programs for the New York City Department of Health, has noted, “If the consumer sees the price difference when they’re about ready to buy the product, we do see a reduction in consumption of an unhealthy food.”

With Americans currently consuming approximately 50 gallons of soda per year (4), and nearly two thirds of American adults who are overweight or obese, a reduction in consumption of sodas and other high calorie beverages will translate to better health.

Note: The proposals described above deal mainly with excise taxes, which would be levied on the beverage bottler. Sales taxes, on the other hand, are levied directly on the consumer at checkout. Sales taxes are generally a percentage of the total cost, whereas excise taxes tend to be levied per unit or quantity (e.g., per ounce, or per a given quantity of syrup used). In addition, sales taxes apply to a range of products, whereas excise taxes are usually associated with a particular product category, such as alcohol or tobacco.

Excise taxes are generally considered preferable by health advocates in terms of their likely effect on price and consumption patterns, although few states currently have excise taxes on soda (exceptions include Arkansas and West Virginia). Soda and other sugar-sweetened beverages, despite their low nutrient content, are exempt from sales tax in many localities because they are considered “grocery items.”

By Lauren Evans, writer for Corporations and Health Watch and student in the Doctor of Public Health program at the City University of New York.


  1. Hamburger T, Geiger K. Soda tax fizzles; Targeting lawmakers and nutritionists, beverage firms put a stopper in the plan. Los Angeles Times. February 7, 2010.
  2. Geiger K, Hamburger T. States poised to become new battleground in soda tax wars; Lawmakers in California and elsewhere seek levies on sweetened drinks. Los Angeles Times. February 21, 2010.
  3. Madore JT. Proposal could be pain in the wallet; Paterson unveils new taxes, big cuts in budget plan; says $7.4B hole calls for difficult, necessary moves. Newsday. January 10, 2010.
  4. Bittman M. A sin we sip instead of smoke? The New York Times. February 14, 2010.

Recommended reading on relationship between taxes and soda consumption:

Merging Medicine and Marketing: An Interview with Ray Moynihan, Author of Sex, Lies, and Pharmaceuticals

Ray Moynihan is an award-winning health journalist and researcher, and co-author of the bestselling book Selling Sickness: How the World’s Biggest Drug Companies Are Turning Us All Into Patients, which was published in 2006. His latest book, Sex, Lies, and Pharmaceuticals: How Drug Companies Plan to Profit From Female Sexual Dysfunction, written with Dr. Barbara Mintzes, will be released this October. The book builds on his past work and explores how pharmaceutical companies are helping to define and construct women’s sexual difficulties as symptoms of a new disorder. In August, medical anthropologist S.D. Gottlieb interviewed Ray Moynihan for Corporations and Health Watch about the role of the pharmaceutical industry in defining pathology and his new book. What follows is an edited version of that interview.

CHW: Can you explain to the readers of Corporations and Health Watch what it means for pharmaceutical companies to be creating diseases and disorder?

RM: I don’t normally say that companies create diseases. What the evidence suggests is that companies have helped to sponsor the creation of diseases, to create the scientific building blocks of disorders. This can happen in a range of ways. The boundaries that define conditions can slowly be widened. We’ve seen this happen with depression, with Attention Deficit Disorder, we’re seeing it now with female sexual dysfunction. Some of the ordinary ups and downs of life become blurred with the symptoms of medical conditions. This has become one of the elements of contemporary pharmaceutical company marketing because the more people who can be labeled as requiring a pill, the bigger the markets for the drugs. It’s often a subtle process. You’ve got to follow the money to look at the relationships between the companies and the medical profession. When you do that what we see is a merging of marketing and medical science. In the United States particularly, pharmaceutical marketing is off the leash. A key aspect of that marketing is telling as many people as possible that they need not just one drug but a range of drugs. The marketing is insidiously trying to make us feel as if the ups and downs of life are the symptoms of conditions that require drugs. Anyone living in the United States with a television will recognize these: overactive bladder, stomach problems, mild depression, or a bit of unusual busyness in children. Now we have adult ADD as well. This insidious process is largely unregulated because the regulators focus on drugs, not on the science that defines the conditions.

CHW: That’s a great point. Can you speak more about the problem of the difference between regulation and actual oversight of how pharmaceutical companies develop these notions of pathology?

RM: When you look at the specific panels of doctors who sit down and define illnesses, conditions, and the boundaries of high cholesterol, higher blood pressure, type 2 diabetes, or depression—the doctors actually sit down around a table and decide who is sick and who is healthy—you’ll find that many of those doctors are extremely close financially to the drug companies, and will clearly profit if those boundaries are set as widely as possible. Now this is a crude analysis because it comes out of investigative journalism, not a long history of academic research. Certainly there’s been wider debate about medicalization for a long time, but what I’m trying to do is throw the spotlight on the process by which conditions, diseases, dysfunctions, and disorders are being generated and promoted, The closer you look at that process, the more that it smells.

CHW: So to probe a little deeper, you have a book coming out about the idea of female sexual dysfunction. Can you tell us about this category—how is it constructed and what does it mean?

RM: Female sexual dysfunction does have a technical definition in the pages of the Diagnostic and Statistical Manual of Mental Disorders, but I won’t bore your readers with those details. But there are technical definitions. DSM-4 defines four sub-disorders: disorders of desire, arousal, pain and intercourse, and orgasm.

CHW: And do they all have to be present in order to diagnose FSD?

RM: No, they don’t. They are four separate sub-disorders. But that formal definition is constantly in play and is extremely controversial. For the last decade, there has been a cogent, well organized, and small but effective campaign to criticize those formal definitions and promote an alternative view. That’s an incredibly important part of this story. But back to the definitions themselves. For the last decade or so, there’s been an attempt to portray female sexual dysfunction as being a widespread and treatable medical condition that could affect up to 43% of women. That figure sounds absurd, but it is still widely used by people within the medical profession. It comes from a 1999 article in the Journal of the American Medical Association. It somehow has a degree of scientific credibility, despite the fact that many people have criticized the figure and now that figure has largely been discredited. So the simplistic narrative that has been promoted is that 43% of women have this condition, that it can be severe, under-diagnosed, and it can respond to treatment. And anyone who questions this narrative must be trying to disrespect or delegitimize the genuine suffering of women.

CHW: Isn’t that a slippery slope, to be critical of this diagnosis because it could suggest a lack of recognition of the plight of women?

RM: Absolutely. Almost everyone who is critical of the way in which this condition has been promoted acknowledges that sexual difficulties are widespread and that sometimes those difficulties are so debilitating that a medical angle and a medication may be the best strategy. I don’t think there’s any denying that. The controversy is about the extent of those treatable medical problems. And I think that estimates like 43% are clearly such vast exaggerations that they themselves have sparked a backlash of rationality. When you drill behind that 43% figure and look at the surveys from which it comes, you realize that it in no way represents the proportion of women with treatable medical problems. It represents the proportion of women who say yes to having experienced very common ups and downs in their sex lives. People who have had lack of interest in sex for a few months, people who have had problems with pain, people who have had problems with orgasm. Very common aspects of sexuality that have been categorized as the symptoms of a treatable medical condition.

CHW: Can you clarify why you think these experiences might not require medical intervention?

RM: Sure. In 2000, the New View Campaign was co-created by a New York psychologist called Dr. Leonore Tiefer. This is a global campaign that has a totally different way of framing sexual difficulties. They talk about sexual problems and why women might suffer sexual difficulties. In their view, a passing lack of interest in sex is not something that should be pathologized, not something that should be seen as a symptom of a disorder called Hypoactive Sexual Desire Disorder. It’s an aspect of ordinary life that sometimes is so serious and severe that professional help may be necessary and valuable, but in many cases is not.

CHW: To bring it back to the production of the disorder, a lot of readers probably know about the successful—and profitable—male sexual dysfunction drugs on the market, the most familiar version of which is Viagra. In your view, how has the development and marketing of female sexual dysfunction drugs differed from or paralleled the drug for erectile dysfunction?

RM: The biggest difference is that despite ten years or more of trying a whole range of different drug therapies, nothing has yet been successful in terms of female drugs, whereas my understanding is that the trials of Viagra showed fairly good evidence of effects. But when it’s come to trials of drugs for female sexual dysfunction, so far the FDA has approved nothing. To date, there have been three main waves of potential drugs to treat this condition. First, there was Viagra. The trials of that showed that for women it didn’t work any differently from a placebo. Secondly, there was testosterone, and that failed at the FDA because of fairly negligible benefits but serious risks of harm. And then thirdly we’ve just had this drug called flibanserin which affects the neurotransmitters in the brain, and that just recently failed as well. So I think in all these trials we have seen the power of the placebo.

What is similar is that as the drug companies approach the FDA approval for these drugs, they put a lot of energy into what’s called preparing the market, trying to cultivate the market so that as soon as their drug is approved, a lot of doctors are ready to prescribe. And we saw this most beautifully this year, 2010, when the German drug company Boehringer Inglheim were seeking approval for their drug flibanserin in June. For the last couple of years, behind the scenes, very quietly, Boehringer has been developing links with senior researchers within the world of sexual research. It’s been holding forums, it’s been starting to prepare the market, it’s been funding medical education, things like that. In May 2010, they sponsored a very aggressive media assault that rolled out across the United States and the world, trying to frame sexual difficulties in women as a problem in the brain. They claimed that their drug, which was about to go up for approval, could then be the white knight that rode in on a horse to fix the problem. Things didn’t go according to plan. The FDA rejected the drug. So in a sense there are very similar marketing strategies at play here, but one of the big differences is there’s been no drug approved yet in the United States.

CHW: My understanding of Viagra’s history is that it was more or less coincidence that its indication for erectile dysfunction was discovered. From what you’re saying, it sounds like the female sexual dysfunction pill has been much more directed in its intentions than the discovery of Viagra.

RM: You’re right. Viagra was being tested for something else and this was discovered as a serendipitous side effect and that then became the main indication. And I think that the discovery of Viagra’s sexual benefits for men in the 1990s immediately sparked enormous interest on the part of Pfizer and other companies in the possibility of a market among women. So a lot of energy is going into trying to find a drug that may get approval here. And of course testosterone is used in men and so it was a natural idea to try it in women. The German drug company that has brought us flibanserin also has a similar narrative to the Viagra narrative. Boehringer Inglheim says that flibanserin’s sexual benefits were only discovered accidentally, because the drug was originally tested as an antidepressant. And as it happened, it failed as an antidepressant and now it looks like it may have failed as a sexual dysfunction drug as well.

CHW: Let’s go back to the ideas of companies framing and structuring the marketplace, instead of creating markets. I’m wondering about the innovation-oriented conferences. I read one of your 2003 articles about female sexual dysfunction and you mention in that article the idea of innovation-oriented conferences where so-called “knowledge and opinion leaders” in the pharmaceutical world are coming together to educate other clinicians, to create a community of experts, and to use clinicians as emissaries to other clinicians.

RM: Yes, that’s exactly right. There really is a very frightening merging of marketing and medical science going on, often behind closed doors at these so-called scientific gatherings. The extent of involvement of drug companies in these so-called scientific gatherings has really gotten out of control. Particularly in the early 2000s when this disorder was being developed as a widespread epidemic, the extent of involvement of Pharma was extreme. So not only did companies fund, sponsor, place their booths, and have their marketing people interact with doctors and researchers at these events, the company representatives were actually inside the educational lecture halls taking part in all of the debates, and these debates were actually defining what is human pathology and what is normal life. So drug companies help to define their own markets. I was at a conference in Paris just last year and to my dismay, the senior drug company marketing staff were not just there flogging their drugs, they were in the mainstream so-called scientific discussions, going on about how to define and treat these conditions.

Let me briefly describe three of the building blocks where this merging of medicine and marketing is happening. One is the studies of prevalence. So when we hear studies that say one in ten women have Hypoactive Sexual Desire Disorder, sometimes these surveys are being designed and executed by drug companies. So if you look closely at the fine print of the journal articles that produce these prevalence estimates, these big surveys, companies are actually explicitly involved in them. The next thing is the measurement tools – the tools that are used to measure whether or not a woman suffers from this so-called condition, and whether or not a drug helps. Drug companies have actually created those measurement tools. They’re not being done independently outside the companies, they’re being specifically created by company staff. The third area, and this is perhaps the most shocking, is the diagnostic questionnaires that are used to determine whether or not someone has Hypoactive Sexual Desire Disorder are actually being created by the staff from the companies who are making the drugs for the same condition. In the book Sex, Lies, and Pharmaceuticals I present this evidence. It’s referenced and fact-checked within an inch of its life.

CHW: How would you say that pharmaceutical companies defend this practice when they’re called to task?

RM: I think that we’ve all slowly slipped into these processes. The closeness between the pharmaceutical industry and the medical profession is at least a century old. Recently, the relationship has gotten closer, and in the last decades of the 20th century, without knowing it, we’ve seen a frightening merging of the profession and the industry. In the first decade of the 21st century, the world is starting to wake up to this and we’re seeing widespread concern about this overly cozy relationship between doctors and drug companies. In America, there are now new laws that will force companies to reveal every single payment to every doctor that they put on the payroll. These are unprecedented levels of transparency, and ultimately they’ll produce a new independence in the relationship between industry and the profession.

What’s flown under the radar in all of this is the way in which this closeness has actually started to affect how we define illness. And direct-to-consumer advertising in America has been the vehicle by which the industry has helped to pathologize vast swaths of the healthy population. So far, industry has not really been called to account for this, because this analysis is still not widely understood. On the rare occasions that the industry does have to answer the criticism that it is widening the boundaries of illness, companies simply say that they are responding to legitimate areas of unmet need, legitimately funding science to help bring an end to suffering and improve the health of people and populations, and that its relationships with professionals are entirely appropriate and legitimate, and legal and acceptable. That is their standard approach.

They can’t really deny any of the evidence that we’re discussing, because all the evidence is there. In this new environment, it will be interesting to watch where there is a genuine push for more independence between health professionals and industry and what effect that will have on the way in which we define illness. If we bring a whole fresh bunch of people, good people, and ask them to put their minds to this problem of how to define an illness without that conversation being in the shadows of the pharmaceutical companies, I think we might come up with some very different sorts of answers. We may not find that diseases and definitions keep being broadened.

CHW: The United States FDA advisory panel recently issued a recommendation against the Boehringer Inglheim oral drug for sexual dysfunction that’s pending FDA approval. Many people don’t recognize that there’s an advisory panel that’s separate from the FDA regulatory panel. In 2000, the FDA issued preliminary guidelines to help companies plan human studies of drugs for female sexual dysfunction complaints. Can you talk about government involvement in promoting companies’ developments of new categories of illness?

RM: The FDA has its hands full trying to understand the risks and benefits of pharmaceuticals and other products. I would argue that it is not qualified to critique and evaluate the science behind the actual conditions. The regulators, like almost everyone else, take on good faith the disease definitions that are handed to them by groups of experts within the medical profession. But we can no longer take those definitions on good faith. We must look closely at them, who has defined them, who has funded them, and at the relationships between the people doing the defining and the drug companies. And really, I think, we need to start again.

Even this year, I don’t think the advisors to the FDA were well enough aware of the deep controversy surrounding this thing called HSDD, Hypoactive Sexual Desire Disorder. You have a bizarre situation occur where the FDA’s advisors and the FDA are assessing a drug for a condition called HSDD, while at the same time, a panel that is rewriting the DSM, the manual of diseases, has proposed abandoning HSDD as a disease entity. So, in fact, HSDD may no longer exist within a couple of years, and yet the FDA is happily and enthusiastically assessing a drug for this condition. This is just one example where I think the FDA regulators generally need to be a lot more rigorous in their analysis of claims about the nature of conditions. The other important thing to say is that the FDA has actually explicitly encouraged companies to design the instruments that measure the success of their drugs. I find that bizarre but I think it flows from something deeper. Increasingly, health care and medicine are not seen just as something that helps prevent disease and augments human health. Rather they are seen as industries, very large industries, and the FDA sees its role as facilitating that industry. Don’t forget that the FDA itself is funded in a very big way by industry.

CHW: And populated with people who have a lot of industry experience as well. It’s self-contained in some way.

RM: That’s right, and there are often debates within the FDA itself about the extent to which it is too close to industry. At least one bill has been proposed to end industry funding for the FDA. I suppose these are deeper and bigger debates for another day, but they’re certainly relevant to this debate about how conditions are constructed and promoted.

CHW: As our final question, I wanted to ask about one of the things that prompted my interest in this most recently, which is the Boehringer Inglheim website called It’s one of many drug company educational content websites that precede FDA approval. What do you think are the benefits or challenges that websites might provide for patients?

RM: The pharmaceutical industry and their allies are asking us to believe that their promotion and marketing is actually information and education. This is a deep assault on our sense of reason and I really don’t understand how the assertion can even be made. That’s the big picture answer to your question. The smaller answer is that consumers need to be extremely skeptical of any sources of information that are sponsored by the drug companies or other industries with vested interests in the outcome of that information. I think that the sexbrainbody website was a crude attempt by Boehringer to help build the market for its drug. These promotional exercises, even though there may be independent people involved in running them, need to be heavily labeled. There should be laws that mandate that the sponsorship should be front and center on the front page of such websites. The sad thing is that there are not easily, readily accessible websites that offer truly independent information and education. The few sources that are around don’t have the firepower behind them that a drug company hungry for a new market can bring.

This question of who educates consumers about drugs is raging in Europe at the moment, as the drug companies are attempting to introduce direct-to- consumer advertising into Europe under the guise of providing information to people. And we’re living through a very strange epoch where the belief that knowledge can be generated independently of corporate interests is under threat. Somehow we have come to believe that corporate involvement in the generation of information of knowledge or education is acceptable, actually something to encourage. It’s a blurring of categories.

CHW: Thank you so much.

Ray Moynihan was interviewed by S.D. Gottlieb, MHS, PhD, anthropologist and author of the recent dissertation entitled, “Manufactured Uncertainty: the Human Papillomavirus and the Object Multiple.”

For other related CHW posts, see:

Image credits:

  1. Bashed
  2. Feggy Art

Teaching about Corporations and Health

As the influence of corporations on population health grows, it will be necessary to prepare researchers, practitioners, and advocates who have the knowledge and skills to analyze and contribute to changing harmful corporate practices. One place to do that is in training programs for public health professionals. In this ongoing series, Corporations and Health Watch offers readers materials about courses on business and health.

William H. Wiist is Professor of Health Sciences at Northern Arizona University and the editor of The Bottom Line or Public Health: Tactics Corporations Use to Influence Health and Health Policy, and What We Can Do to Counter Them (Oxford University Press, 2010). In the past two years, he has taught courses on globalization and health at the University of Chile School of Public Health and at Northern Arizona University.

At the University of Chile, the “Economic Globalization and Health” course was co-taught by Dr. Wiist and Dr. Ron Labonte (from the University of Ottawa, Canada) in January 2009 and 2010. In 2010, 35 students enrolled in the course, including seven from the United States. The topics included:

  • Economic Globalization and the Social Determinants of Health
  • Global Trade and Health Equity
  • Transnational Corporations: Protagonists of Economic Globalization and Their Impact on Health
  • The Tobacco Industry
  • The Pharmaceutical Industry
  • Global Financial System: external debt, international cooperation and development
  • Chile Facing Economic Globalization
  • The Economic Crisis and its Effects on Public Health
  • Globalization from Below: Civil Society Actions to Counter the Adverse Effects of Globalization.

A syllabus provides additional details. [click here to download]

The online course at Northern Arizona is also called “Economic Globalization and Health,” though is less focused on Chile as a case study. Course requirements include reading scientific reports and political analyses, viewing popular films on corporate power, and writing an analysis of the economic determinants of a health problem that students choose. A syllabus [click here to download] gives further details.

CHW readers with other relevant syllabi or teaching materials are encouraged to submit them for posting.

Previous CHW reports on teaching about business practices include:


Vaccine Promotion in the Hands of a Corporation: The Missed Opportunity of Merck’s Marketing of Gardasil

Over the last several years, human papillomavirus (HPV), one of the most common sexually transmitted infections in the United States, has gone from relative obscurity to a source of heated debate and, for some, a new cause for fear. Casting a new spin on an old infection, Merck Pharmaceuticals single-handedly produced more widespread familiarity with the virus and manufactured the catalyst for conversations about HPV and cervical cancer. In June 2006, Merck received FDA approval for a new vaccine that protects against four of the more than thirty types of sexually transmitted HPV, Gardasil. Even before its approval, Merck advertised the coming vaccine indirectly with the teaser “Tell Someone.” In doing so, Merck began the process of using marketing to position a vaccine that protects primarily against a common sexually transmitted infection instead as a powerful vaccine against cancer.

The HPV vaccine debuted on the market with an advertisement campaign explicitly acknowledging women’s lack of familiarity with the virus and its consequences. The television ads featured women talking directly to the camera, exclaiming, “Cancer caused by a virus…I didn’t know that!”

As the “Tell someone” campaign encouraged its viewers, sharing this knowledge with other women was critical. Concurrent with its direct-to-consumer advertising, Merck also launched an “Educate the educators” session to inform physicians about the new vaccine, anticipating a fair amount of public resistance to vaccinating girls (ages 9-26) with a vaccine that might minimize the consequences of sexual activity. The importance of this education also stemmed from the fact that HPV is not well understood even among many physicians, likely as a result of the many types of HPV that exist. In a physician education session targeting gynecologists that I attended, the majority of the session focused on the epidemiology of the virus, and session leaders failed to discuss any of the existing treatment options, which most attendees would be using in their everyday practice. In other words, Merck seemed to expect that even physicians had vague knowledge about one of the most common STIs.

At its FDA hearing, Merck explicitly focused on the vaccine as a response to a variety of working groups that sought to reduce mortality due to cervical cancer. The promotion of the vaccine and the management of the trial data stressed that the “need” was for a cancer vaccine, not for a vaccine to prevent a highly transmissible and very prevalent STI. Some of this focus may reflect the company’s desire to minimize parental resistance to the vaccine. In the months leading up to the vaccine’s distribution, a variety of popular press articles questioned whether a vaccine for an STI could really gain acceptance in the United States, with its recent history of abstinence only programs in lieu of sexual health education. The reactions from a number of conservative family organizations, like Focus on the Family, and these groups’ public acceptance of the vaccine also suggest that Merck packaged its campaign to address their concerns. Once the FDA approved the vaccine, these groups acknowledged that they were not against a vaccine that protected against cancer, but they were against government requirements of the vaccine. This carefully worded response played into Merck’s own positioning perfectly. While the vaccine does prevent the infection with some types of HPV that can cause cancer, cancer is not, in fact, an inevitable outcome of an HPV infection. This point, though small, is rather critical. Merck’s entire advertising campaign has focused on HPV’s cancer potential; a recent advertisement that leads the viewer to visit Merck-owned portrayed a young woman’s (heteronormative) life dreams (college, travel, boyfriend, marriage) as pre-empted by her health decline into a cancer that could be prevented. directs the viewer to learn more about preventing the STI by sending her to the Gardasil website. The tagline for this promotion is quite simple: HPV. Why risk it?

Once Merck received its FDA approval, the campaign progressed from the vague and non-specific “Tell Someone,” into “One Less” (woman/girl with cervical cancer) and then to “I Chose.”

In addition to its advertisements, Merck created a program initially called “Make the Connection,” which was renamed “Make the Commitment,” that offered make your own bracelet kits for free that would donate money to a cancer research organization. A number of celebrities participated in the purported “public service announcement” promotions, which have since been discontinued.

The Gardasil campaign, which included non-transparent lobbying of state legislatures to require the vaccine for school-entry, revealed that the pharmaceutical company’s message and the everyday experience of/practice around HPV infection were not completely coherent with each other. Merck’s education campaign pushed the vaccine as an unquestionable necessity, neglecting to mention how highly effective other technologies of gynecological care can be to reduce cervical cancer. The Pap smear, for example, has been used in the U.S. since the 1940s, and while it is an imperfect science, its institutionalization through gynecological guidelines have reduced American women’s deaths from cervical cancer to about 3,400 a year from more than 70,000 annually in the 1970s. Still, the consequences of HPV morbidity are not insignificant and reducing the spread of the disease is not inconsequential. What causes concern, however, is Merck’s positioning of Gardasil as a cervical cancer vaccine (not an STI vaccine), which in fact complicates how women may understand the benefits and limitations of the vaccine. What remains problematic about Merck’s campaign is that even with the HPV vaccine, women will need to have the same gynecological screening and treatment that women experienced before the vaccine. Women’s experiences with gynecological care may not change radically.

Merck’s vaccine (and now GlaxoSmithKline’s recently approved vaccine) is not intrinsically bad; such a position is uncomplicated and fails to take into account the fact that HPV can be a serious infection, regardless of whether it develops into cancer or not. However, the company’s willingness to use fear to incite parents and young women to vaccinate casts doubt on the insistent message that the vaccine will liberate women from traumatic health care experiences. Gynecological care is not without its limitations. Technicians read hundreds and hundreds of Pap smear slides in a day. Human errors can contribute to the progression of HPV to cervical cancer, and clinicians’ and patients’ continued uncertainty about the most appropriate interventions and even prevention make the vaccine a very powerful prophylactic.

Merck invested a lot of time and money in “educating” people — public health officials and providers in particular — about HPV and cervical cancer as the vaccine became available and widely disseminated. Tracking exactly how and where the money has gone is difficult because, like the program for Make the Connection/Commitment, Merck’s strategies appear to have included supporting a number of non-profits, such as Women in Government, an organization that lobbied in various states for the vaccine requirements in schools. But all its investment in education stressed the necessity of the vaccine, rather than focusing on preventive health as a more comprehensive strategy. Because a more comprehensive cervical health education focus might obviate the urgency of the vaccine, the emphasis in all the educational materials was on the ubiquity of HPV and the challenges of preventing its spread.

Throughout Merck’s HPV and Gardasil advertisements, little has been said about the treatability of cervical cancer or the success at preventing HPV from progressing to cancer. Much like other pharmaceutical interventions designed to make life easier, when available solutions exist to address the same problem, Gardasil offered an alternative but is not a panacea. Many of the screening techniques and preventive health services are less expensive (per use) than the high cost (and incomplete levels of protection) that the vaccine presents. Though Merck has set up programs to allow low-income women (and presumably now men, since its FDA approval in boys and men in September 2009) to receive financial assistance to get the vaccine, Gardasil debuted on the market as the most expensive vaccine. Costing nearly $350 for the three shot series, the vaccine initially was a big money maker for Merck with $1.4 billion sales worldwide in 2007. Its first quarter report in 2010, however, showed an 11% decrease in sales from the same time last year. Sales of the vaccine, however, are harder to track than other treatments, because governments fuel much of the purchasing, with programs like the United States’ Vaccines for Children program and county public health programs’ acquisition of the vaccine. Current research suggests that there are still significant disparities between women/girls who receive the vaccine and those who don’t. Much like the disparities in cervical cancer rates (and deaths), class and race seem to be the distinguishing factors in terms of who gets the vaccine. With further approval to market the vaccine to older women, Merck is capturing a large market share of people who may not benefit from the vaccine.

Because Gardasil only protects against some and not all types of HPV, promoting a more comprehensive education scheme would have not compromised Merck’s campaign. Merck’s rush to lobby state legislatures to require the vaccine for school entry, for example, seriously undermined the public’s trust in their motives. Instead of transparently lobbying (though perhaps an unrealistic expectation in American government), Merck used a number of indirect channels to promote state laws (for instance, Women in Government) that subsequently failed almost nationwide. Merck publicly announced it would no longer lobby state legislatures after the Texas governor overrode the state legislature debate. This sort of aggressive push devalues the real potential benefits the vaccine might offer young women.

It seems clear that there was an incredible opportunity available at the moment of Gardasil’s debut. A vaccine that protects against an STI that can slowly progress into cancer is a significant accomplishment. Offering women the opportunity to reduce their health risks and preempt an often painful and stressful set of morbidities associated with HPV infection was also a significant coup. Raising awareness about HPV, the difficulty in preventing it, and reducing cervical cancer mortality globally are all meaningful developments. But Merck did not manage any of these well and used its advertising campaign to manipulate women by playing on their ignorance or confusion about their health care. While the campaigns framed the decision to use the HPV vaccine as women’s own proactive involvement in their health care, the messages have been frightening and unsettling unnecessarily. Merck has handled its campaign irresponsibly, choosing not to frame the message simply and with straightforward information, perpetuating the notion that HPV and cervical cancer are a mysterious threat that can only be stemmed through vaccination. Since this is not true, and women will still get HPV and may still get cervical cancer, the message remains deeply problematic and even paternalistic.

By S.D. Gottlieb, MHS, PhD, anthropologist and author of the recent dissertation entitled, “Manufactured Uncertainty: the Human Papillomavirus and the Object Multiple.”

Photo Credit:

  1. neofedex

Corporations and the Food Movement: The Case of the KFC Double Down

In the June 10 edition of the New York Review of Books, Michael Pollan writes that while the diverse interest groups of the American food movement are starting to pull together, “It’s a big, lumpy tent, and sometimes the various factions beneath it work at cross-purposes.”

Under this tent, Pollan includes those people interested in:

school lunch reform; the campaign for animal rights and welfare; the campaign against genetically modified crops; the rise of organic and locally produced food; efforts to combat obesity and type 2 diabetes; “food sovereignty” (the principle that nations should be allowed to decide their agricultural policies rather than submit to free trade regimes); farm bill reform; food safety regulation; farmland preservation; student organizing around food issues on campus; efforts to promote urban agriculture and ensure that communities have access to healthy food; initiatives to create gardens and cooking classes in schools; farm worker rights; nutrition labeling; feedlot pollution; and the various efforts to regulate food ingredients and marketing, especially to kids.


This article explores what a new and much-discussed sandwich from KFC, the Double Down, can tell us about ways that corporations might try to use the lumpiness of the food movement tent to their advantage. KFC introduced the Double Down on April 12th, describing it as a “one-of-a-kind sandwich” that “features two thick and juicy boneless white meat chicken filets, two pieces of bacon, two melted slices of Monterey Jack and pepper jack cheese and Colonel’s Sauce.” KFC gushed, “This product is so meaty, there’s no room for a bun!” Advertisements for the sandwich sparked a lively debate on the Internet and beyond. This response has translated into sales, and while initially the sandwich was to be offered for just a few weeks, KFC recently announced that its availability would be extended through the summer and perhaps for as long as demand remains high.

At first, commentators repeatedly noted the blow to health that the Double Down appeared to pose for anyone who consumed it. As a reporter for the Baltimore Sun quipped, “I’d call it murder on a bun, except there is no bun.” But others argued that KFC was not alone in promoting unhealthy fare. Pop culture analyst Greg Beato wrote, “Positioning KFC as a culinary terrorist that coerces chicken-hearted consumers into eating against their best interests makes for a savory sound bite, but it’s based on faulty intelligence.”

As it turns out, the Double Down’s 540 calories, 32 grams of fat, and 1,380 milligrams of salt make for a pretty average nutritional profile as compared with that of other fast food items. The Double Down is considerably less unhealthy, for instance, than Wendy’s Triple Baconator (1,350 calories, 90 grams of fat, and 2780 mg of salt) or Burger King’s Triple Whopper (1160 calories, 76 grams of fat, and 1170 mg of salt). According to one of the more sophisticated analyses, even Burger King’s regular Whopper with cheese is slightly nutritionally worse than a Double Down. And the Double Down appears almost light next to items from restaurants like The Cheesecake Factory and California Pizza Kitchen, whose products were recently featured in the Center for Science in the Public Interest’s Xtreme Eating 2010 report.

So, miraculously, the notion of the Double Down as a nutrition disaster is morphing into an understanding of it as fast food business as usual. In their efforts to target young men, KFC has joined Hardee’s, Burger King, and Jack in the Box in launching marketing campaigns designed to increase product recognition, brand loyalty, and sales to a population characterized by rapid increases in obesity and escalating cardiovascular risk.

In conjunction with these nutritional concerns, it is interesting to note that KFC has engaged a somewhat surprising branch of the food movement—hunger activists and food banks—in its promotion of the sandwich. In their online newsroom, the corporation has written,

When introducing a bunless sandwich, the obvious question is: what happens to all the buns? To celebrate the launch of the Double Down, KFC will do some good by donating the “unneeded” sandwich buns to feed the hungry. The brand will donate both buns and funds to food banks across the country, starting with the Dare to Care Food Bank in KFC’s hometown of Louisville, Ky.

Some, like NYU Professor Marion Nestle, have wondered what purpose this aspect of the Double Down marketing serves. Nestle speculates that perhaps it is merely desperation on the part of KFC, which saw its market share fall precipitously in the latter half of the 2000s. However, even desperate acts are driven by strategy. Might bun donation have functioned as a preemptive offering to one branch of the food movement—in this case, hunger activists—to quell the anticipated outrage of other branches, like those concerned with obesity and nutrition?

Though the complex tensions between hunger and obesity are at the heart of the food movement, the mobilization around food is not just political. As Pollan puts it,

What is attracting so many people to the movement today (and young people in particular) is a much less conventional kind of politics, one that is about something more than food. The food movement is also about community, identity, pleasure, and, most notably, about carving out a new social and economic space removed from the influence of big corporations on the one side and government on the other.

Except for this last clause about corporations and government, Pollan might well be describing the soaring interest in popular food culture, through which many people now identify as “foodies” or “chowhounds.” Foodies are people who take a collector-like interest in food and restaurants. Not all foodies care about where food comes from and how it’s produced, but many do, especially those who have followed renowned and socially-minded chefs like Alice Waters and Bill Telepan into the food movement.

Chowhounds represent what some regard as the more adventurous, less high-brow end of the foodie spectrum. The name stems from an online message board started by Jim Leff and Bob Okumura in 1996. As Leff described in an interview in 2005, a chowhound is:

Someone who seeks out deliciousness in any situation and loves to discover new culinary treasures. The one who, on the way to work each morning, walks blocks out of the way to try a different muffin and isn’t satisfied until the most delectable one is found. They are people who hate to settle. In a world where titanic engines of marketing influence people’s opinions and taste, there are the guys who opt out and make their own decisions. You know how there’s adventure travel? Well, we’re adventure eaters. Which doesn’t mean that we won’t go to the obvious places if they’re great. If McDonald’s made great hamburgers, I would be there every day.

Leff’s last sentence highlights the idea that when a movement is, as Pollan writes, about “community, identity, and pleasure,” there are many possible forms that communities can take, and many (possibly conflicting) values that these communities can hold. Like the food movement, the foodie movement has gained its steam online as much as anywhere else, and many of the related communities are online ones. This is relevant to the Double Down’s success, which has been fueled by online interest. At the end of April, KFC’s spokesperson Richard Maynard was quoted as saying, “For the demographic it is intended for, primarily young males, [the Double Down] has received an unprecedented response following launch. […] We’ve never seen so many people post YouTube videos and social-media reviews of one of our products.”

However, the response to the Double Down is not limited to young men posting YouTube videos. According to KFC’s post-test marketing research, the Double Down has received high scores for “uniqueness,” precisely one of the food characteristics that chowhounds and many other foodies seek. And sure enough, many chowhounds couldn’t resist a jaunt to KFC to try the Double Down. Posts about the Double Down on (the current incarnation of the chowhound message board) have received more than 100 replies (an examplehere), often weighing in with first-hand knowledge of the sandwich.

Further evidence of the curiosity that the Double Down has produced among studied eaters and those outside of the usual fast food target audience is apparent in the unprecedented reviews (examples herehere, and here) of the fast food item, not only by numerous food and other blogs, but also by the dining sections of several major newspapers. Mina Kimes of writes that the Double Down is a “turning point for the fast food industry as a whole–proof that customers will now flock to product innovation, not just pricing promotions.”

While Pollan notes that the food movement’s diverse subgroups are beginning to converge, KFC seems to see another path. Using its awareness of tensions in the movement, KFC hopes to fuel sales of what appears to be a very successful product. The marketing of the Double Down should provoke us to ask two basic questions. First, how can a food movement resist corporate efforts to undermine people’s capacity to make healthier food choices? And second, what roles can foodies play in the food movement and what interests do they share with other reformers?

By Emma Tsui, Postdoctoral Fellow at the City University of New York School of Public Health at Hunter College and editor at Corporations and Health Watch.


Photo Credit:


The Health Impact of Targeted Marketing: An Interview with Sonya Grier

Sonya A. Grier is an Associate Professor of Marketing at the Kogod School of Business at American University. She was previously on the faculty at the Stanford University Graduate School of Business and was a Visiting Scholar at the Federal Trade Commission, where she provided consumer research expertise as part of a presidentially mandated team examining the target marketing of violent movies, music, and video games to American youth. She also spent a semester at the University of Cape Town in South Africa conducting research on social influences on consumer responses to targeted advertising.

In March 2010, Sonya Grier and her collaborator Shiriki Kumanyika published an article in the Annual Review of Public Health entitled, “Targeted Marketing and Public Health,” which explores the complex concerns raised for public health by the use of targeted marketing. In May, Corporations and Health Watch staff person Marissa Anto interviewed Dr. Grier about her interest in targeted marketing, recent trends in the field, and how public health advocates might better harness targeted marketing for their own purposes. What follows is an edited version of the interview.

CHW: How did you become interested in targeted marketing?

SG: I’ve always been interested in the different types of strategies that marketers use to reach specific groups and how they determine what different types of strategies are necessary. My first job out of college in the late 80s was as a market research analyst at Kraft and I remember asking why there wasn’t an ethnically targeted marketing campaign for barbecue sauce. Based on my personal knowledge, it seemed like there was heavy usage in the African American community and I didn’t see that reflected in the ad campaigns that were developed. That led me to understand, especially being a research analyst, how they were using data and information and putting it together to develop these types of strategies and that really started to drive my interest in targeted marketing. I also volunteered in a corporate program for non-profits, and I was assigned to help a Women of Color Theatre Group with audience development. The marketing issue there—this is again in the 80’s—was how to market something that might be perceived as an ethnic product to the core audience, as well to others who might be interested. So these are my first experiences in the professional field of marketing as a practitioner that really drove my interest specifically in targeted marketing.

CHW: In your Annual Review article, you define targeted marketing as “the identification of a group of people who share common needs or characteristics that an organization decides to serve” (p. 350). Can you explain what that means?

SG: My definition is based on the notion that if you speak to consumers in a way that resonates with the way they think, the way they talk, their attitudes, beliefs and values, they’re going to respond favorably to targeted marketing. That’s really the crux and most important part of it. Identifying when and how to do that is the challenging and creative part.

CHW: Why do you think this issue is important for public health professionals?

SG: Well, targeted marketing strategies influence behavior, which is a key goal of many health professionals. More specifically, targeted marketing can be used to influence commercial behavior such as getting people to buy a certain product, to influence health-related behavior such as increasing fruit and vegetable consumption, or some combination of the two. Targeted marketing often influences attitudes and reinforces people’s beliefs about what they think is normal. From a commercial perspective, it attempts to increase consumption of products or services. And this is the environmental context that people face daily as they try to listen to any type of public health message, so this is significant “competition” for public health efforts and that’s why it becomes very important. Think about obesity where people talk about food marketing being a negative influence. If the majority of the messages that come to you based on food marketing strategies encourage overconsumption of less healthy food or discourage physical activity; then this is a reality that people face and public health professionals need to understand the real day-to-day experiences of people in order to change their behaviors.

CHW: That leads into my next question: Are there ways that public health researchers can learn from industries that use targeted approaches to marketing? What do you think are some of the most important concepts we can learn?

SG: Definitely. One specific area is customer orientation, which is generally the basis of all marketing efforts and especially targeted marketing efforts. Marketers work to develop a profile of their target consumers, learning everything they can about the consumer from their perspective. This includes not only how people make choices about buying one specific product—and from a public health perspective, it’s not about just engaging in one specific behavior— but it’s also about how the desired behaviors fit into their lives and the kind of constraints people face, or believe they face. Everything is viewed from the perspective of the target audience. And this may not always be the same as what the professional ‘knows.’ Industry marketers also try to speak to target audiences in their own language, which is something that often doesn’t happen in public health. What I often see in public health is that specific actions are seen as right or wrong from a health perspective. So for public health researchers, a customer orientation might be letting go of preconceived notions of what is right and what is wrong and instead focusing on the person’s perspective, understanding how they make choices and what factors are influential to them.

CHW: What role do you think targeted marketing plays in maintaining or exacerbating disparities in health?

SG: I will use an example from the area I am currently working in which is obesity. The prevalence of obesity in African American and Hispanic children and adults is significantly higher than in White populations. We know this disparity is due not only to differences in income and education, although those factors might play a role. Social marketing programs aimed at obesity prevention often promote increasing the consumption of healthy foods and decreasing that of less healthy foods. So we have to think about what the role of targeted marketing of these less healthy foods is. As I noted, commercial marketing can be in competition with desired behaviors from a public health perspective. So commercial marketing can serve to hinder or prevent prevention. Say there’s a billboard that says, ‘Don’t let your children eat unhealthy foods’ and then right next to it is a billboard for fast food, advertising this very appetizing thing for $1. Which one is going to have the most sway and persuasiveness? Which one is a person going to see a lot more of? Understanding that context becomes really important because it can serve to prevent prevention.

I did a paper with Shiriki Kumanyika in 2008 called “The context for choice: health implications of targeted food and beverage marketing to African Americans” where we conducted a systematic review of the marketing environment for African Americans and we looked at the literature on food and beverage products, promotion, accessibility and prices targeted at African Americans as compared to White consumers. We found that targeted marketing strategies may challenge the ability of African Americans to eat healthfully. The strategies that were directed towards African Americans emphasized low-cost, low-nutrient food products like candy, soda, and snacks, and they were less likely to contain health-oriented messages. We also found that distribution and pricing strategies constrain the ability of African American consumers to purchase healthy food. It’s a challenge for any consumer to eat healthfully when their choices are constrained and they don’t have access, and prices are a lot higher or they are not made aware of these other products.

CHW: Can targeted marketing ever promote health or reduce disparities?

SG: Yes. Targeted marketing is a strategy, it’s a tool, it’s a set of practices and procedures that you put together to reach a particular goal; it’s not necessarily for good or for bad, it’s just a strategy someone uses and it can definitely be used to promote health. Health is a large component of the field of social marketing which has focused on using marketing to promote health, including the reduction of disparities as a goal. [Editor’s note: For more on social marketing and public health, see an article on this topic that Dr. Grier co-authored.]

CHW: Can you discuss some of the most compelling examples where targeted marketing has promoted health and reduced disparities?

SG: One example is the VERB campaign, which was created to increase physical activity in tweens. It was targeted at tweens but it also put particular focus on ethnic minority tweens, especially Hispanic tweens and African American tweens. Some of the research shows that it was effective in improving behaviors.

CHW: How do you think targeted marketing strategies have changed over time? You’ve been in this field since the late ‘80s. What are some of the shifts you’ve seen in the use of targeted marketing to get consumers to use different products?

SG: I think that strategies have moved from relying on one demographic variable like age, race, or gender to thinking about combinations of variables. So advertisers are now getting more into lifestyle and other variables to target a market. They’re not going to target me as a Black person or as a woman or as a baby boomer, but rather, perhaps, as a person who likes live music, buys health foods, and shops at Trader Joe’s, and all these others types of variables. Because there is so much more known now, and this is driven by technology. You also have the micro-targeting of media outlets which has created all these vehicles where you can reach particular groups of people. People can now live in their own marketing worlds without really knowing what’s going on in other worlds. What one group sees may be systematically patterned relative to what another group sees. And we can only to expect this to increase as marketers look for ways to be successful in increasingly competitive marketplaces.

CHW: How has the public health community sought to modify the harmful aspects of targeted marketing? What do you think of counter-marketing?

SG: Counter-marketing is really emerging as an important strategy to modify corporate practices that harm health. By counter-marketing, I’m assuming that we’re talking about the use of marketing techniques to try to un-sell a product or to destroy demand for a product. Research suggests that counter-marketing can be effective. The Truth campaign, for example, exposed the marketing practices used by the tobacco industry and then positioned this information in a way that spoke to youths. They did this by focusing on some of the core values for young people, like a desire for independence and individuality. This is a clear case of the consumer orientation that I was talking about earlier. The Truth message was also marketed just like a commercial brand and it had money behind it and it looked like what the teens wanted to see. Research on the effectiveness showed that it influenced attitudes toward the tobacco industry and tobacco use, and contributed to a decline of smoking prevalence. Research also shows that it was cost-effective because it recouped its cost and averted future medical costs. But at the same time, counter marketing is not really a one-size-fits-all strategy, and would need to be adapted to the particular domain you’re going to use it in.

For example, the success you see in tobacco may not transfer to products like food and beverages. Cigarettes are harmful and it’s illegal to sell them to minors but that’s not the case for food and non-alcoholic beverages. And the foods that may be the least healthy, like fried foods and soft drinks, taste good, are inexpensive, convenient, and they’re the norm. Research has also shown that counter-marketing can contribute to boomerang effects. In terms of alcohol and illicit drugs, some research that shows that attempts at counter-marketing increased positive attitudes towards alcohol and drugs. There’s also research that shows that the industry may pursue efforts to undermine counter-marketing strategies such as forming partnerships or other strategies. I think the big picture is that commercial marketers face few counter-marketing campaigns relative to the messages that are out there that counter health. So that’s an area where research is needed to really understand how do you develop counter-marketing strategies that won’t have boomerang effects and be insulated from things that industry might try to do and that can be effective across different domains.

CHW: In your opinion, what are some of the most important research questions on targeted marketing?

SG: One would be research on counter-marketing. Another is the targeted marketing of healthy products. You often hear store owners say that they won’t carry healthy products because people won’t buy them. Is this because people aren’t aware of those products? Or haven’t received the same type of repetitive messages about the value of those products in a way that speaks to them as they have for less healthy products? Another question related to this is: How do some consumers maintain healthy eating although they might encounter the same marketing strategies that encourage overconsumption? Understanding ‘positive deviance’ may lend important insights. I’d also say at a broad level there is a need for research to understand the extent of corporate consciousness about the aggregate effects of the market strategies they use among particular segments. Do they know that following the basic tenets of marketing they may be providing different messages to different groups about what constitutes a normal and healthy diet? We don’t know. Sometimes there is a discussion of whether targeted marketing on the part of corporations is intentional or not. I know from my experience with corporations that they’re following basic marketing strategy. It’s not like they’re saying, “We’re going to go out and make African Americans and Hispanics fat.” But there is a whole complex web of things that work together and the question is, are they aware of and conscious of those aggregate effects?

Additionally, I think a very important area is digital targeted marketing, especially with regard to the potential negative health effects for ethnic minority youth. Digital media really supports the basic goal of targeted marketing, which is to resonate with consumer characteristics. These strategies may rely on, for example, identity-related concerns of adolescents. Marketers are recognizing both that ethnic minority youth are leaders in the use of a lot of digital media and also that they are fast becoming the majority of the U.S. population, so marketers are putting a lot of money and effort into marketing to ethnic minority youth. And these same youth are dealing with not only basic identity concerns but also ethnic minority concerns. Think about some of the location-based strategies that involve digital marketing. Through these kinds of strategies, marketers might give teens a coupon when they’re near a fast food restaurant via a mobile phone. Research shows that minority youth are frequent mobile phone users, and they’re more likely to live near a fast food restaurant or have one near their school. For these reasons, they are more likely to get a coupon and perhaps will buy something that is affordable and good-tasting but that may contribute to more weight gain in this population. This interaction between technology, health, personal characteristics, and marketing strategies in the digital realm seems like an area where much research is needed from across disciplines and paradigms, within public health as well as from the social sciences, economics, and business.

CHW: What are some current targeted marketing research questions you’re now working on?

SG: I am looking to identify the specific characteristics of African American and Hispanic youth that may make them more responsive to digital targeting, and examining the effectiveness of strategies that might harm their health. I’m also working with the African American Obesity Research Collaborative (AACORN) on a five-year grant from the Robert Wood Johnson Foundation. We’re using community-based participatory research (CBPR) to investigate how targeted marketing strategies encourage healthy eating at the community level.

CHW: What’s your opinion of the use of terms like “organic” and “green” to denote products as being healthy? Do you think it brings these products to a wider audience by making it more mainstream?

SG: I think it can confuse consumers because if there aren’t specific standards to say what it means to be “green”, what it means to be “organic”, what means to be ”all natural,” etc., people may not have an understanding of how these relate to their goals of eating healthier. And I think that’s really what’s needed: Information and knowledge that helps people understand how they can be healthier within the context of the environments that they face and the lifestyles they lead.

CHW: Do you think that corporations and commercial entities can be more responsible in their use of targeted marketing?

SG: Yes, definitely. That’s why one of my current research questions examines consumers’ consciousness of the effect of corporate strategies on specific target markets. Eventually, I want to look specifically at corporate consciousness. I mean, honestly, I’m not even sure they realize this. Companies may read in the newspapers that there’s more targeted marketing of soda to African American youth, but do they know that these are their strategies, that their strategies play a role in that? It’s such a contentious and controversial issue that it’s not like there is an open dialogue typically between companies and public health advocates in this domain.

CHW: Do you think there should be a more open dialogue and greater consciousness surrounding these issues?

SG: You see so much about targeted marketing to kids, but within targeting to kids, you have the sub-groups of African American and Hispanic children who are significantly overweight. A basic marketing principle is that you focus on the heavier users, because those are the people who will keep buying your products. In public health, you would think the focus should be on protecting those with the greatest need. So with all this concern about food marketing to children, there should be a heavy emphasis on looking more carefully at food marketing to ethnic minority youth and you don’t see that. You see lots of discussion of obesity disparities and the horrific statistics, but very little focused effort, especially effort that takes the community perspective as fundamental. From a political or policy perspective, perhaps you don’t get things done if you only focus on one group. At the same time, I don’t think public health can afford to play that policy game and ignore the need to understand these minority groups because if you look at what’s going on with the census, eventually these groups are going to be the majority. So you can ignore this at the peril that in ten years we still have very limited research on groups that by then will be the majority of the marketplace and at highest public health risk.

CHW: Thank you very much for your time and insight.

SG: Thank you for your interest in targeted marketing!

For other related CHW posts see:

Tracking the Effects of Corporate Practices on Health