Public health measures like cleaner water, public sanitation systems, cleaner air and barriers to cigarette smoking have been major contributing to longevity in the last 200 years. These measures have contributed significantly to the average lifespan in the US more than doubling during that period. High-tech end-of-life medical developments have had only minor impacts on overall longevity compared to these public initiatives. How do such public health longevity-enhancing interventions get put into place? There is usually first a long period of scientific awareness and then growing public awareness that something can and should be done. After that, what typically follows are initial efforts that are only partially effective, an example being small warnings that were first placed on cigarette boxes. Finally, as a result of innovative leadership, effective action steps are taken, often steps that are controversial like outright smoking bans. In the final phases, the public health issue is often characterized as an economic one where the cost of proposed public health measures are very small compared to the costs of inaction. Here, I review several news items that appeared only during the last week describing the states of public health initiatives related to mass-distributed foods.
Dangerous foods, diet, obesity, disease and shortened lifespans
Research over decades has established the life-shortening impacts of obesity(ref) (ref)(ref) and the roles of saturated fats, trans-fats and excess sugar in soft drinks and processed foods in promoting obesity, cardiovascular diseases, diabetes and cancers, and leading to shorter lives(ref)(ref)(ref)(ref)(ref)(ref). Countless blogs and websites are devoted to these issues and to dietary advice(ref). My focus in this blog entry is not to review that research, but rather to discuss what is being done about these issues from a public health viewpoint. Major public health focus has been on foods likely to lead to an alarming increase in childhood obesity including sweetened sodas, fast foods containing saturated and trans-fats, and on unhealthy school lunches.
One of the ways of dealing with public health problems associated with marketed substances is to impose “sin taxes” on products that generate public health problems. The idea is that raising the cost of an unhealthy item will result in lesser consumption of that item. The two primary current examples are high taxes on tobacco products and on alcoholic beverages.
The this-week article Tax sugar-sweetened beverages in a British Columbia newspapers is one on a many that have called for an extra tax on sugary soda pop.
But sin taxes tend not to work unless they are set painfully high. An April 2010 Science Daily article Small Soda Taxes Insufficient to Curb onsumption Among Children, Study Finds reports “Small sales taxes on soft drinks in the range currently in force in some states are insufficient to reduce consumption of soda or curb obesity among children, according to a new RAND Corporation study. — Such small taxes may reduce consumption in some subgroups such as children at greater risk for obesity, but reducing consumption for all children would require larger taxes, according to the study published by the journal Health Affairs. — “If the goal is to noticeably reduce soda consumption among children, then it would have to be a very substantial tax” said Roland Sturm, the study’s lead author and a senior economist at RAND, a nonprofit research organization. “A small sales tax on soda does not appear to lead to a noticeable drop in consumption, led alone reduction in obesity.” — Taxes on soft drinks and other sugar-sweetened beverages have been proposed as part of many anti-obesity efforts, with the goal being to discourage consumption of the high-calorie drinks in order to curb excess weight gain. — Researchers estimated the potential effect of soft drink taxes on children’s consumption and weight by examining differences in existing sales taxes on soft drinks between states. Details about state soda taxes were compared to information about weight and soda consumption among 7,300 children enrolled in the Early Childhood Longitudinal Study, which has been gathering information about a national group of children for many years. — Children studied reported drinking an average of six sodas per week, but there was wide variation among the group. Fifteen percent reported drinking no sodas in the prior week, while 10 percent consumed two or more sodas per day. The amount of soda purchased at school was small. — The analysis could find no significant link between the consumption of soda or weight gain among children and differential taxes on sodas versus other foods. Existing differential taxes (taxes that are imposed on sodas and not other food items sold in grocery stores) are small, averaging 3.5 percent and none are larger than 7 percent.”
Nutrition labels do not necessarily affect eating patterns and can be misleading
Another approach favored by the food industry and the US government up to this point has been nutritional labeling. The logic seems very reasonable: “Tell consumers what they are getting and let them make their own choices.” This approach may be good for a few people who have the knowledge, eyesight and patience to read labels. But the approach tends to be relatively ineffective when it comes to the general public. Just like cigarette warning labels did not initially scare off many smokers, last week’s news reports indicate that calorie listing on restaurant menus have virtually no impact.
A publication appearing in the February 2011 issue of American Journal of Preventative Medicine is Mandatory menu labeling in one fast-food chain in King County, Washington: “As part of a comprehensive effort to stem the rise in obesity, King County, Washington, enforced a mandatory menu-labeling regulation requiring all restaurant chains with 15 or more locations to disclose calorie information at the point of purchase beginning in January 2009. The purpose of this study is to quantify the impact of the King County regulation on transactions and purchasing behavior at one Mexican fast-food chain with locations within and adjacent to King County. To examine the effect of the King County regulation, a difference-in-difference approach was used to compare total transactions and average calories per transaction between seven King County restaurants and seven control locations focusing on two time periods: one period immediately following the law until the posting of drive-through menu boards (January 2009 to July 2009) and a second period following the drive-through postings (August 2009 through January 2010). Analyses were conducted in 2010. No impact of the regulation on purchasing behavior was found. Trends in transactions and calories per transaction did not vary between control and intervention locations after the law was enacted. In this setting, mandatory menu labeling did not promote healthier food-purchasing behavior.”
A number of newspaper articles picked up on this research in the last few days. Here is an excerpt from one in the Daily Mail, Nutrition labels on fast food ‘won’t stop you eating unhealthily: “Making fast food chains print nutritional facts on the packaging of burgers, fries and other fat laden products does not make an ounce of difference to diners’ choices, according to new research. — A 13-month study of restaurants after mandatory labelling legislation was brought in found customer tastes remained just the same. — Professor Eric Finkelstein, of Duke-National University of Singapore, said: ‘Given the results of prior studies, we had expected the results to be small, but we were surprised we could not detect even the slightest hint of changes in purchasing behaviour as a result of the legislation. — Right choice? Mandatory labelling of fast food products did not stop consumers eating them, a survey found ‘The results suggest mandatory menu labelling, unless combined with other interventions, may be unlikely to significantly influence the obesity epidemic.’ — As part of a comprehensive effort to stem the rise in obesity King County in Washington, which includes Seattle and surrounding areas, brought in the regulation on all restaurant chains with 15 or more outlets from January, 2009. Restaurants had to disclose calorie information at the point of purchase. Some companies in the UK, including McDonald’s, now print facts including the fat, salt, calorie and carbohydrate content of its foods to help people make healthy choices. — But Prof Finkelstein and his colleagues monitored a chain of Mexican restaurants called Taco Time for just over a year and found there was no difference in the eating habits of diners at those situated in King County and those who used ones outside the area where the rule was introduced. — No difference: ‘Traffic light’ health label on a pizza. The total number of sales and average calories per transaction were unaffected by the menu labelling, reports the American Journal for Preventive Medicine. — As part of health care reform, the US
government is planning a nationwide launch of mandatory nutrition information
at the point of purchase for fast-food chains with twenty or more outlets.”
Besides confusing fine-print nutrition labeling on supermarket foods, products often feature pseudo-health claims in much larger print on the fronts of packages. A “low fat” desert product may be taken as healthy when in fact it contains a large amount of sugar. An “all natural” product may contain an unhealthily large amount of fructose sugar. And a number of toxins are perfectly natural. Another news story this week was Front-of-Package Labels Hide Truth: 8-of-10 kids’ foods flunk nutrition standards. “Parents want healthy food for their kids, and they want accurate information to guide them. — But parents are being fundamentally misled, says Prevention Institute’s new study, released today through Strategic Alliance. Claiming Health: Front-of-Package Labeling of Children’s Food examined products with front-of-package labeling–those products that food companies choose to identify as healthier. Claiming Health found that 84% of products studied failed to meet basic nutritional standards. — Contrary to the claims on the labels, study findings reveal: – More than half (57%) of the study products qualified as high sugar, and 95% of products contained added sugar. – More than half (53%) were low in fiber. – More than half (53%) of products did not contain any fruits or vegetables; of the fruits and vegetables found, half came from just 2 ingredients – tomatoes and corn. – 24% of prepared foods were high in saturated fats. – More than 1/3 (36%) of prepared foods & meals were high in sodium.”
Banning junk foods in schools and playgrounds
A news story that appeared last week was WHO calls for junk food ban in schools, playgrounds, as reported by AFP: “GENEVA — Junk food should not be sold in schools and playgrounds, the World Health Organization said Friday in a series of recommendations aimed at promoting a healthy diet and cutting child obesity. — However it fell short of calling for a ban on advertising directed at children for foods high in saturated fats, sugars or salt, opting instead to ask member states to “consider the most effective approach to reduce” such marketing. — The non-binding recommendations will be put to a high-level meeting on the prevention and control of non-communicable diseases during September’s General Assembly in New York, WHO officials said. — “Settings where children gather should be free from all forms of marketing of foods high in saturated fats, trans-fatty acids, free sugars or salt,” said the UN health agency. — “Such settings include, but are not limited to, nurseries, schools, school grounds and pre-school centres, playgrounds, family and child clinics and paediatric services and during any sporting and cultural activities that are held on these premises,” it added . — Some 43 million pre-school children are obese or overweight, according to WHO data. — “Children throughout the world are exposed to marketing of foods high in fat, sugar or salt, which increases the potential of younger generations developing noncommunicable diseases during their lives,” it said. — Six out of ten deaths every year are due to cardiovascular diseases, cancers, diabetes and chronic lung diseases, the WHO warned, pointing out that a common factor of the four main diseases is poor diet.”
Another headline this week was USDA Proposes Cutting Fatty Foods From School Lunches. “According to government data, almost a third of all kids under 19 are obese. In an effort to curb the trend, the USDA is proposing new guidelines on the nutritional content of school lunches. — The plan would place a limit on calories, saturated fat content, and sodium on school meals. It would also ban trans-fats entirely. — Servings for starchy foods, like French fries or tater tots would be limited to one per week. — “I probably wouldn’t have school lunches anymore,” said Kya, a student at Turtle Bay School. “I would kind of eat a little bit.” — Other students say they already enjoy the vegetables. — “Really, I wouldn’t care because they’re still good,” said Cloe, another Turtle Bay student. — The school already offers fresh fruits and a salad bar, something Turtle Bay principal Linda Lawhon should make the transition easier. — “For our students, they already have the choices of greens and fruits that are available to them and they usually choose to take from the salad bar almost daily,” said Lawhon. “I don’t think it’ll be much of a change for them.” — Before the guidelines are finalized, the USDA is requesting input from the public on how to make school lunches both healthier and appealing to kids. Those interested in providing input can do so at Regulations.gov.”
A related headline was School nutrition-guideline changes sought to fight obesity. “Calling it not only a national health issue but also a military one, Agriculture Secretary Tom Vilsack on Thursday proposed to overhaul the nutrition guidelines for public school meals for public school meals for the first time since 1995, when Americans were mostly alarmed by the fat content of food. — The proposed rules are far more wide-ranging and would gradually reduce sodium, limit starchy vegetables, ban most trans fats, require fat-free or lowfat milk, increase whole grains, add more fruits and vegetables, and, for the first time, limit the number of calories children consume daily. The guidelines are consistent, Vilsack said, with first lady Michelle Obama‘s Let’s Move initiative, which promotes healthier eating for children. — “The numbers are rather troubling. We have today nearly a third of our youngsters at risk of being obese or, in fact, are obese in our schools,” he said in a conference call Thursday. He added: “If we do not get our hands around the obesity epidemic in the United States by the year 2018, we will face nearly $344 billion of additional health-care costs. That’s money we won’t be able to spend on innovation and creating jobs and improving our education system.”
Another related story was USDA unveils new school lunch rules “– U.S. Department of Agriculture Secretary Tom Vilsack unveiled Thursday what he called a series of “fundamental changes” his agency plans to make to the country’s school nutrition program. The changes are designed to stem the effects of childhood obesity. — Recognizing the financial burden the nutrition guidelines can place on a school system, in terms of increased equipment, personnel and ingredient costs, Vilsack said his agency has set aside more than $380 million of additional nutrition program funding each year for schools that comply with the new rules. — That funding increase mainly comes in the form of a 6 cent per meal increase in the amount of money the government pays schools through its free- and reduced-price lunch program, which helps students from low-income families across the country eat the meals served in their cafeteria. The government currently pays schools in the 48 contiguous states between $2.32 and $2.89 for each lunch they serve through the program and $1.18 and $1.76 for each breakfast.” It is not clear to me whether this program will be funded by congress.
The guidelines are just guidelines and are not necessarily followed. The Boston Globe in a January 23 2011 Sunday editorial School lunches get healthier commented “While the USDA deserves a pat on the back for updating its guidelines for the first time in 15 years, it should consider further updates, including restrictions on the amount of sugar and processed foods a school can serve. Increasing the number of apples kids consume is beneficial, but not if they are covered in caramel sauce. In short, the USDA should create incentives, and provide encouragement, for schools to provide healthy meals with fresh ingredients, without tilting too far toward food-police tastelessness. — That may be harder than it would appear. According to the USDA’s own estimates, up to 35 percent of schools are out of compliance with even current federal regulations. While schools that follow the new guidelines will get an extra 6 cents per meal from the agriculture department, some school-lunch advocates doubt this rate will cover the extra cost of healthier lunch options. Schools that already meet national standards will surely adapt to the new guidelines, and their students will be healthier for it. But those struggling to keep up with even the outdated regulations may need more help — and a stronger nudge — to stop dishing out so many fries.”
I suspect that these approaches related to school lunches are likely to have a slow but growing effect. Already a number of school districts have moved to better diets and some have even thrown out their soft drink machines. On the other hand, needed change is slow and partial and it may take 20-30 more years for a full effect to be felt. The food industry has traditionally been very effective in blunting USDA regulations they don’t like.
Banning junk food advertising
Another approach involves banning advertising of junk foods, advertising that appears in vast quantities on TV programs viewed by children. One headline that appeared in the press last week was World leaders to discuss junk food ad ban at UN. “The U.N. health agency says world leaders will discuss efforts to clamp down on junk food marketing to children when they meet in New York on Sept 19-20. — The World Health Organization says heads of state will use the U.N. General Assembly meeting to talk about limiting the number and type of ads that children are exposed to. — WHO says 43 million preschool children around the world are overweight or obese. Experts talk of a “fat tsunami” that is already causing millions of premature deaths each year. –Bjorn-Inge Larsen of the Norwegian Directorate of Health told reporters Friday that he expects voluntary measures limiting junk food advertising to eventually evolve into laws banning the practice in the same way that has occurred with tobacco.”
Another headline was Health officials eye junk food ad ban. “It may be time to ban ads for foods high in salt, sugar and trans fats that target children, international health officials say. — Voluntary measures to limit junk food ads eventually could evolve into legislated bans just as tobacco bans did, Bjorn-Inge Larsen of the Norwegian Directorate of Health told reporters Friday in Geneva. — Domestic laws might not work since so many ads reach children through international TV channels, Larsen said. — Non-communicable diseases such as cancer, diabetes and heart and lung disease will top the agenda when heads of state meet at the United Nations General Assembly in New York on Sept. 19 to 20. — About 43 million children aged five and under around the world are overweight or obese, according to the UN health agency. — WHO officials are consulting with food makers such as Coca-Cola, General Mills, Kellogg, Kraft, McDonald’s, Mars, Nestle, Pepsico, Unilever and the World Federation of Advertisers on drawing up a code of conduct that restricts marketing of unhealthy products to children under the age of 12.”
Despite the horrors of the situation involved for 43 million children, I suspect this approach of banning advertising will not get very far. That is because the advertising at stake is worth billions of dollars to gigantic media companies and because the product sales are worth many tens (or hundreds) of billion dollars to the food giants involved. Do I think these companies are more influential in political circles than the World Health Organization and all the nutritional do-gooders in the world combined? Yes, I do.
Wal-Mart move to healthier foods
It takes a giant to influence other giants like food packagers, and Wal-Mart is definitely a giant, the world’s largest retailer with about half of its sales in foods. “Retailing behemoth Wal-Mart Stores, Inc., operates 4404 stores in the U.S. (including Sam’s Club) and 8838 worldwide, at last count(ref).” The news was all over the world’s press three mornings ago. From a Bloomberg news report Wal-Mart to Stock Healthier, More Affordable Foods to Help Fight Obesity: “Wal-Mart Stores Inc., the world’s largest retailer, said it is joining first lady Michelle Obama’s anti-obesity campaign by stocking healthier foods. — The company said it will reformulate thousands of packaged food items by 2015, reducing the salt content by 25 percent and sugar content by 10 percent, and will remove all remaining industrially produced trans fats and partially hydrogenated oils. — “No family should have to choose between food that is healthier for them and food they can afford,” Bill Simon, chief executive officer of U.S. stores for Bentonville, Arkansas-based Wal-Mart, said in a statement. — With more than 140 million customer visits each week, Wal- Mart “is uniquely positioned to make a difference” by making healthy foods more affordable, said Simon, who joined Mrs. Obama for an event today in Washington. — The first lady said Wal-Mart’s initiative is a victory for parents and children that will give families more information and more opportunities to eat more healthy foods. She said that because of company’s size, the move “has the potential to transform the marketplace.” — Wal-Mart said it plans to reduce prices to save customers about $1 billion a year on fresh fruits and vegetables. The company said it would develop “strong criteria” for simple front-of-package seals that would help consumers identify healthier foods, including whole-grain cereals, whole-wheat pastas or unsweetened canned fruit. — Andrea Thomas, Wal-Mart’s senior vice president of sustainability, said lower costs will come in part from planned efforts to make the entire supply chain more efficient, including steps to stock more produce from local farmers to reduce shipping costs.”
I am not claiming the step will make all or even most of Wall Mart foods healthier. For example, it appears the company is doing nothing about sugar-infused soft drinks. But I believe it is an important step that is likely to have immense impact. Wal-Mart suppliers will have to modify their manufacturing processes and product mixes to meet Wal-Mart’s criteria. Once they do this to produce healthier products they will want to sell those products through other retailers as well. Everybody will benefit from more efficient supply chains for healthier food. And other retailers are likely to want to sell foods even healthier than Wal-Mart’s. A health-positive feedback loop is likely to be set off.
Wrapping it up
Almost all the above-quoted news stories appeared in the course of only one week, last week. So my take is on the whole optimistic:
– Obesity is now recognized as a major public health issue and there is good general awareness of what has to be done to address the situation. It seems displacing unhealthy foods is the next big public health issue after slowing tobacco smoking.
– A vital and growing health food industry offers affluent consumers many choices (over $3 billion in 2011 for the health food and supplement store sector alone(ref)). The public-health crosshairs are now on low-cost mass-distributed foods and on the fast food and school lunch sectors.
– The public health issue of foods is being tied to economic issues like future health care costs and national defense, and to the emotional issue of wellbeing of our children.
– Public health measures for providing healthier foods for children and adults are in the advanced planning and initial action phases involving all levels of government, giant corporations and tiny businesses, school systems of every size and households such as my own.
– Even fast-food companies are opting into the push for better nutrition. Three weeks ago McDonalds added oatmeal to their breakfast menu. “But now the stakes are much higher. The government is beating on their door, telling them that it is no longer politically correct to serve greasy, high in fat foods to the general public(ref).”
– For now, dietary suggestions are contained in the anti-aging anti-aging lifestyle regimen in my treatise. Also, for comments on a number of healthy as well as unhealthy foods, see my blog entry Diabetes Part 2: Lifestyle, dietary and supplement interventions
– The food industry is likely to play a mixed role, progressive as well as regressive. Providers of more healthy foods will exercise influence counterbalancing the influence of providers of unhealthy and junk foods. And, big food companies do not want to find themselves facing gigantic lawsuits in the future like cigarette companies are facing now.
– While we are seeing the start concerted action there is a long way to go. Further measures are likely to identified and implemented throughout the century as our science and knowledge and public awareness related to nutrition improves. The point is, the healthier-food train has already left the station.
Public health measures like cleaner water, public sanitation systems etc.The public health issue of foods is being tied to economic issues like future health care costs and national defense, and to the emotional issue of wellbeing of our children.Thanks.
Thanks GPCR and Hormone Replacement Therapy. The dialog goes on.
A Nov 24 opinion piece in the New York times weighs in further “‘Realistic’ Is Not Good Enough
Updated January 24, 2011, 12:57 PM — Tom Laskawy blogs on food policy for Grist.org and Beyond Green.
The question we need to consider isnâ€™t if Wal-Martâ€™s new healthy food policies will make a difference in the fight against obesity. It’s whether they will make a meaningful difference. The answer is far from clear.
Remember: Wal-Mart’s primary responsibility is to its shareholders, not to public health..Itâ€™s difficult to deny that Wal-Mart’s initiative will bring greater attention to the issue of healthy eating, especially in the many low-income and rural communities that it serves. But its proposals, while broad, are relatively shallow. Does the largest, most influential, most ruthless retailer in the world really need five years to enact a 10 percent reduction in added sugar in its products?
— As for the likely impact of Wal-Martâ€™s policies, you need only walk into one of its stores and scan shelf after shelf of soda, sports drinks, sweetened breakfast cereals, cookies, candy, salty snacks and microwaveable dinners to realize that small percentage reductions in a few ingredients could easily be overwhelmed by slight shifts in consumer buying practices.
The first lady is now learning the limits of industry cooperation as a means to addressing obesity. The head of Wal-Mart referred to his company’s â€œrealistic targetâ€ for reductions in sugar, salt and fat. Realistic, that is, for Wal-Mart. Its primary responsibility, after all, is to its shareholders, not to the public health.
Safeguarding public health is the governmentâ€™s responsibility. And if the government wants to bring down the obesity rate in this country quickly, itâ€™s going to take aggressive policies with far more bite. These policies will necessarily be less â€œrealisticâ€ than what the head of Wal-Mart could ever willingly stomach.”
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