Plastic food packaging encourages obesity

Abstract

The United Kingdom is at the top of the European league table for obesity in women and is in second place for men. Worryingly, the UK has more obese young people than any European country.1 The plastic packaging that encases so much of the food we buy has fundamentally altered our relationship with food to the extent that we are now constrained by poor dietary choice, just as food is imprisoned in its cellophane. Over the past 10-20 years a slow, invisible, and insidious transition has occurred: from a time when food was handled and could be smelt to one when all we can feel and smell is odour free plastic. In our supermarkets, canteens, and cafes we …

Full text

BMJ | 9 JUNE 2012 | VOLUME 344 31
VIEWS AND REVIEWS
There is an absence of evidence
that early diagnosis of dementia
changes anything
Des Spence on bad medicine in
dementia, p 45
PERSONAL VIEW Clare Relton, Mark Strong, Michelle Holdsworth
Plastic food packaging encourages obesity
T
he United Kingdom is at
the top of the European
league table for obesity
in women and is in
second place for men.
Worryingly, the UK has more
obese young people than any
European country.1 The plastic
packaging that encases so much
of the food we buy has funda-
mentally altered our relationship
with food to the extent that we
are now constrained by poor
dietary choice, just as food is
imprisoned in its cellophane.
Over the past 10-20 years a slow,
invisible, and insidious transition
has occurred: from a time when
food was handled and could be
smelt to one when all we can feel
and smell is odour free plastic.
In our supermarkets, canteens,
and cafes we see row upon row of
edible products wrapped in plas-
tic, yet we are blind to its eects
on us. Plastic invisibly alienates
us from many important aspects
of food production, prepara-
tion, and consumption that once
enabled us to make safe and
sensible nutritional choices and
helped food retain its important
social and cultural role. We have
evolved to look at, touch, smell,
and taste food before we decide to
consume it.
Plastic wrapping performs
many practical functions in
today’s food environment: to
protect from shock, vibration,
and temperature; as a barrier
against air and water, thus
keeping the contents clean
and fresh and extending shelf
life; as containment for small
items; to give information
through labelling; to give
security through tamper evident
features; to aid convenience
in distribution, handling,
stacking, display, sale, and
transportation; and to enable
portion control.2
But the function of plastic
packaging goes beyond the
immediately practical. Goods
wrapped in plastic communicate
to us that the product is unsullied
and uncontaminated, that we
are the rst people to touch the
item, leading us to believe that
we are being oered a safe, clean
product.
Because preparing and
consuming food are inherently
messy and time consuming,
traditionally we have cooperated
in the task and have cooked and
eaten in groups at home or in
cafes, restaurants, and canteens.
But the “nutrition transition”
has changed the way we relate to
food. Plastic packaging facilitates
the consumption of food alone,
at the expense of conviviality.
We purchase food and drink
We purchase food and drink without talking to the
producers or vendors and then consume it while focusing
on other tasks: watching the television or surfing the web.
Plastic is integral to being able to eat quickly and on the
move with minimal mess—a recipe for overeating
without talking to the producers
or vendors and then consume it
while focusing on other tasks:
watching the television or surng
the web. Plastic is integral to
being able to eat quickly and on
the move with minimal mess—a
recipe for overeating.
France has a less plasticised
food environment, with
customers touching, smelling,
and tasting foods before they
buy them. Is it a coincidence
that France is near the bottom
of the European obesity league
table, with less than half the
UK’s prevalence?
Besides inciting us to
consume more energy dense
foods, plastic may also
have a physiological role in
contributing to obesity. A recent
review found that the endocrine
disrupting chemicals widely
used today as plasticisers and
stabilisers in the manufacture
of food packaging such as
cellophane may be involved in
the development of obesity.3
Tackling obesity will require
us to drastically change our food
purchasing and eating habits,
with intervention at societal and
individual levels. The causes
of the obesity epidemic are
complex—one piece in the jigsaw
is a proper understanding of
the eects of plastic on our food
environment.4
Clare Relton is research fellow
c.relton@sheffield.ac.uk
Mark Strong is clinical lecturer in public
health
Michelle Holdsworth is senior lecturer in
public health, Section of Public Health,
ScHARR (School of Health and Related
Research), Faculty of Medicine, University
of Sheffield
References are in the version on bmj.com.
Cite this as
: BMJ 2012;344:e3824
ROB WHITE

32 BMJ | 9 JUNE 2012 | VOLUME 344
VIEWS AND REVIEWS
MEDICAL CLASSICS
The Medicalization of Everyday Life
A book of essays by Thomas Szasz, dating from 1973
First published 2007
“Psychiatry is medicalization, through and through. Whatever
aspect of psychiatry psychiatrists claim is not medicalization, is
not medicalization only if it deals with proven disease, in which
case it belongs to neurology, neuroanatomy, neurophysiology,
neurochemistry, neuropharmacology, or neurosurgery, not
psychiatry.” The psychiatrist Thomas Szasz makes this claim
in this collection of essays, the first of which was published in
1973. The book is misnamed, however, because it deals almost
only with psychiatric illness. Szasz is one of the proponents of
the widespread so called anti-psychiatry movement, along with
R D Laing, Michel Foucault, and Franco Basaglia.
So called medicalisation occurs when human conditions
are redefined as diseases to be diagnosed and treated—these
essays describe an evolution of such thinking. Szasz accepts
that some medical phenomena (melanoma and
malaria, for example) are diseases, but he goes
on: “But people have to be told, and are told over
and over again, that alcoholism and depression
are diseases. Why? Because people know that
they are not diseases: that mental diseases are
not ‘like other illnesses,’ that mental hospitals
are not like other hospitals, that the business of
psychiatry is coercion, not care.”
Szasz has long been an anachronism, still
inhabiting the world of 19th century scientific medicine, where
clinicopathological correlation was in its heyday. Then, the
careful physician observed the patient, described symptoms
and signs, and prescribed treatment. When a patient died the
physician would locate the lesion on autopsy. Szasz holds that
neither depression nor schizophrenia is really a disease, given
that no macroscopic lesion has accounted for the symptoms.
He seems, however, to ignore all evidence that there may
be what we might call microscopic lesions—problems with
neurotransmitters, for example.
In the essay “Psychiatry’s war on criminal responsibility”
Szasz argues convincingly that the psychiatric defence
of murder is “the oldest and most obvious instance of
medicalization of the law.” However, surprisingly, given that
Szasz lives in the United States, he does not mention the first
successfully argued case of “temporary insanity,” involving
the US civil war veteran Daniel Sickles, who in a jealous rage
shot the man who had cuckolded him. Szasz pokes fun at
the liberal tendency to excuse crime by renaming it mental
illness, quoting a Harvard professor of psychiatry, “My
position is that extreme racism is a serious mental illness
because it represents a delusional disorder.”
Although Szasz can irritate, he has for decades challenged
conventional thinking about mental illness. We may not
agree with him, but he makes us think. It is hard, however, to
convince myself that patients who talk to themselves about
imaginary beings are not experiencing real pathology. Perhaps
we have still to find the lesion that would satisfy Szasz.
A Mark Clarfield, director, Medical School for International Health, and
Sidonie Hecht Professor of Geriatrics, Ben-Gurion University of the
Negev, Beer-Sheva, Israel markclar@bgu.ac.il
Cite this as: BMJ 2012;344:e3696
BETWEEN THE LINES Theodore Dalrymple
Nameless woe
More has been written about Shakespeare
and the law than about Shakespeare and
medicine, yet you could still ll a small
library with the second group; and it is my
contention that every play of his contains
much to interest doctors. To test this
hypothesis I took one play, Richard II, to
scan it for medical interest.
I chose Richard II because I found an edi-
tion for £1 in a nearby charity shop, which
I thought I could mark up without a sense
of guilt at the defacement. Annotations to
books are always ugly and disguring until
they are 100 years old, when they become
of historical interest. It is a curious trans-
formation.
The medical interest of Richard II falls
into three categories: the image of doc-
tors, the use of illness as metaphor, and
clinical observation. In the play Richard
II is depicted as spendthri and feckless,
in thrall to “the caterpillars of the com-
monwealth,” his greedy and thoughtless
courtiers. He is overthrown by his first
cousin Henry Bolingbroke, who becomes
Henry IV.
The play begins with the dispute
between Thomas Mowbray, Duke of Nor-
folk, and Henry Bolingbroke, Duke of
Hereford. They accuse each other of being
traitors and propose to ght to settle the
matter (an odd way, to our way of think-
ing, of deciding a matter of truth). Richard,
trying to arbitrate, says:
“Let’s purge this choler without letting
blood—
This we prescribe, though no physician;
Deep malice makes too deep incision.
Forget, forgive, conclude and be agreed:
Our doctors say this is no month to
bleed.”
This is odd, because the opening of the
play takes place in April, and spring was
generally deemed a favourable month for
therapeutic blood letting.
Although Richard speaks of physicians
in this passage with respect, he not long
aerwards suggests that they speed their
patients on their way to death. Richard
hears that John of Gaunt, “time-honoured
Lancaster,” is on his deathbed; and, ever
short of money, Richard intends aer his
death to help himself to all his possessions.
He exclaims:
“Now put it, God, in the physician’s
mind
To help him to his grave immediately!
Come, gentlemen, let’s all go visit him,
Pray God we may make haste and come
too late!”
The most pertinent clinical description
in the play is that of anxiety and depres-
sion, which Richard’s queen feels when
she is parted from him and has an intima-
tion of disaster. She suers from an anxiety
state:
“Some unborn sorrow ripe in Fortune’s
womb
Is coming towards me, and my inward
soul
With nothing trembles”
One of the “caterpillars of the common-
wealth,” Sir John Bushy, who is executed
before the play is over, tries to console her
by telling her that “with false sorrow’s
eye” she “weeps things imaginary,” but it
does not help her:
“For nothing hath begot my something
grief,
Or something hath the nothing that I
grieve –
But what it is that is not yet known
what,
I cannot name: ’tis nameless woe, I wot
[I know].”
This, surely, is an excellent descrip-
tion of her state of mind; and, as usual,
Shakespeare is able to convey subjective
experience in such a way that we almost
experience it for ourselves. How did he
do it? Did Shakespeare himself have anxi-
ety? Yes, if he had been ambitious, cau-
tious, reckless, prudent, drunken, sober,
brave, cowardly, licentious, puritanical,
hypocritical, honourable, foolish, wise,
romantic, cynical, and a thousand other
things as well.
Theodore Dalrymple is a writer and retired doctor
Cite this as: BMJ 2012;344:e3843
Shakespeare is able to convey subjective
experience in such a way that we almost
experience it for ourselves

BMJ | 9 JUNE 2012 | VOLUME 344 45
LAST WORDS
Drugs are not disease modifying, having
no impact on rates of institutionalisa-
tion and disability
9
; there is no so called
treatment gap. Screening and more test-
ing will only ensnare the anxious rather
than the aicted. There is an absence of
evidence that early diagnosis changes
anything.3 Predictably perhaps, big
pharma lurks behind those advocating
early diagnosis.10
There is much we can do, however.
Value the elderly and their carers. End
society’s vacuous obsession with youth
culture. Make advance directives the
norm, and tackle the thoughtless pro-
longation of life with the common use of
percutaneous endoscopic gastrostomy
and nasogastric feeding tubing. The pro-
motion of underdiagnosis of dementia
is without cognition and will lead to
widespread suering and overdiagnosis,
which is bad medicine indeed.
Des Spence is general practitioner, Glasgow
destwo@yahoo.co.uk
References are in the version on bmj.com.
Cite this as: BMJ 2012;344:e3859
As our physical bodies give out we look
in horror into the mirror. We comfort
ourselves that at least we have our own
personality, memories, and individual-
ity. But to lose these is to lose everything;
I fear dementia above all other illnesses.
Due to an ageing population there is talk
of a pending national crisis in dementia,
and this particular medical bandwagon
is beginning to play politically.1
There has been much talk of early
diagnosis, memory clinics, training,
screening, and criticism that 75% of
cases go unrecognised.2 3 Advocacy
groups use familiar rhetoric, demand-
ing the “right to a diagnosis” and talking
about a “treatment gap.” The internet is
spawning online testing questionnaires
to aid and promote self diagnosis.
4
The
National Institute for Health and Clinical
Excellence in turn suggests treatment
even for those with mild dementia.5
Underdiagnosis is presented as the
problem. Perhaps this is all fair and
reasonable, for such an important and
pressing illness.
But what about the potential for over-
diagnosis of dementia? A concern nei-
ther researched nor acknowledged. Mild
cognitive impairment (MCI), associated
with impaired memory, is reported in
22% of those over 75.
6
But MCI is clini-
cally dicult to distinguish from mild
dementia, even using the latest imag-
ing and testing. And clinicians stung by
media criticism will make the diagnosis
rather than be accused later of misdiag-
nosis. So here is the problem: dementia
is a devastating diagnosis, progressive,
untreatable, and leading to dependence
and institutionalisation. Overdiagnosis
of dementia risks misery and the the
of wellbeing from millions of old people
and their families. Like Terry Pratchett,
many people would vow to take their
own life with such a diagnosis.
What about the evidence for early
diagnosis? Drug treatments result in a
2.7 improvement out of 70 on the Alzhe-
imer’s disease assessment scale: cogni-
tion (ADAS-Cog) score,
7
a dierence so
small as to be clinically undetectable.
8
The theories of Sigmund Freud were
mostly unsound and damaged society
in general and psychiatry in particular.
When I rst started doing psychiatry in
the 1960s such criticism was unusual
and heretical, but by the 1990s it was
the norm, except, of course, among
a dwindling band of true believers.
NHS psychoanalysts ght to retain a
tiny enclave in a psychotherapeutic
territory populated largely by evidence
based practitioners. In the United
Kingdom, native born medical
recruitment to the psychoanalytical
sects has diminished.
The spread of the Freudian faith had
several causes but one was surely that
although Freud was the very devil, he
had therefore several attractive tunes,
while his opponents had none. Against
such baroque Freudian constructions
as the Oedipus complex, penis envy,
and the vagina dentata, cognitive
“traumatised” (derived from the Greek
for “a wound,” in which the letters
“au” should sound as in paw or core) as
if it were derived from the German for
“a dream”: traum. “Trowmatised,” he
said; as in cow or loud.
Freud believed so strongly in his
friend Wilhelm Fliess’s so called nasal
reex neurosis theory that, as is well
documented, he allowed Fliess to
operate on the nose of his (psychiatric)
patient, Emma Eckstein. When she
nearly exsanguinated in consequence,
Freud blamed the bleeding on hysteria.
It is bad enough that psychoanalysis
can seriously damage your turbinate
bones but when it damages the
language of Shakespeare, it is time to
usher it into the dustbin of history.
Colin Brewer is research director of the
Stapleford Centre, London SW1W 9NP
brewerismo@gmail.com
Cite this as: BMJ 2012;344:e3857
The spread of the
Freudian faith and
its doctrines had
several causes but
one was surely that
although Freud
was the very devil,
he had therefore
several attractive
tunes
behaviourists oered conditioned
reexes and stimulus responses.
These terms are neither memorable
nor shocking, which partly explains
why psychoanalysis and allied creeds
remain attractive to lazy journalists.
Sadly, Freud also attracts writers who
are not lazy but are ill-equipped by
training or temperament to evaluate
scientic (and especially therapeutic)
evidence. These are the sort of
people who wouldn’t recognise a null
hypothesis if they were tickled to death
with one.
I heard a shocking example of
probable Freudian inuence recently
on BBC Radio 4 during a literary
discussion programme. Among the
guests was a professor from one of
our better universities who talked
about Shakespeare. Yet such is
Freud’s corrupting inuence that this
language expert pronounced the word
FROM THE FRONTLINE Des Spence
Bad medicine: dementia
NOTHING’S SACRED Colin Brewer
Psychoanalysis can seriously damage your health
Twitter
ЖFollow Des Spence on
Twitter @des_spence1
Screening and
more testing will
only ensnare the
anxious rather than
the afflicted. There
is an absence of
evidence that early
diagnosis changes
anything