Time to Regulate the Food Industry

I am reproducing below an Op-Ed I had in today's Kingston Whig-Standard, our local paper.

You might not be a big fan of New York City’s mayor Michael Bloomberg, but he was on to something when he tried to limit the size of soft drink containers. The stuff that’s in there is both terribly unhealthy, and delightfully addictive.

Let’s face it: we do have an obesity problem. The World Health Organization has identified obesity and being overweight as the fifth-leading cause of death worldwide. The cost to our economy comes in at a whopping $4.6 billion to $7.1 billion every year.

Academics love to argue about the question of whether obesity is a disease or – for most people – just a result of an unhealthy lifestyle. There are also legitimate arguments to be had about the question of what constitutes “unhealthy” obesity. It turns out that being a tad bit overweight might actually confer a survival benefit to those of us who are in my age bracket and older. However, it is beyond reasonable doubt that people who are significantly overweight run a higher risk for diabetes, heart disease and a host of other serious and expensive-to-treat medical conditions.

If you look at the comments sections under newspaper articles focusing on the growing obesity problem, you will find out quickly that there are plenty of weight Nazis among us. “Charge them by weight when they board planes so that the really big ones sit in the business class section and don’t squeeze me out of my seat in the back of the bus,” “make them feel crappy about how out-of-shape they look,” and any number of other punitive or stigmatizing proposals are generously bandied around by those of us who typically are at the lighter end of the weight scale.

Then there is the well-meaning type on the back of packages telling us everything we actually don’t want to know about carbs, salt content and whatnot. Frankly, I doubt that they have any significant impact on most people’s purchasing decisions.

A lot of obesity research that is undertaken discovers, to some extent, the obvious: kids who are subjected to junk food by their parents grow bigger faster than kids who are not subjected to junk food. Kids who experience a sedentary lifestyle courtesy of their parents’ way of life are more likely to live like their parents do, with predictable outcomes in terms of their girth.

Of course, public health people are quick to come up with their own predictable suggestions: nudge kids into the right behaviour, offer healthy foods in school, etc. It’s not that we aren’t trying, it’s just that we haven’t been terribly successful while at it.

There have also been more strident suggestions, such as stigmatizing big people as we stigmatize (well, ostracize) smokers. To be fair, the combination of high taxes, public health information on the effects of smoking on our life expectancy and stigmatization of cigarette use has worked. The number of smokers in Canada is significantly down from what it was 15 or 20 years ago. The same isn’t as straightforward for our eating habits, unfortunately. There are some parallels, though.

Believe it or not, but a lot of the stuff that we eat has been designed specifically to make us addicted to it. They have gone so far as to ensure that we crave more after we have had our fair share already, thereby increasing sales and wrecking our health in the medium- to long term.

Billions of food industry research and development dollars go into ensuring the addictive nature of the unhealthy foods that we eat. The research efforts include the right combination of that terrible trio of sugar, salt and fat, the consistency of the food while it melts in our mouths, the sounds the food makes when we eat it, the packaging, and who knows what else.

You might assume that a baker would the one to determine how the cookies you buy in the supermarket look, taste and feel. Think again. The cookies were likely created by highly sophisticated chemists, aided by psychologists or neuroscientists, all colluding to ensure that we eat many more of those cookies than we otherwise would if the baker down the road had created them. All this is an attempt to ensure that we come back for more once we are hooked on them.

You would think a government response that forces companies to include data on the amount of addictive content that they put into our foods would properly prevent us from making obviously bad choices, but the evidence suggests otherwise. We know it is bad, but we cannot quite help it because we are hooked already, courtesy of the refined product and marketing research and development that food manufacturers engage in.

The food labelling activity makes typically liberal assumptions whereby an autonomous individual makes informed choices about what is best for them. The thing is, many of us do not make informed choices - a situation not unique to food. Worse, many of us make choices that actually are comparable to those of other addicts. As with other addicts, the products we are addicted to are objectively not good for us.

We have little choice, of course, other than to purchase a significant amount of processed foods. What is problematic is that food producers are currently permitted to deliberately create addictive foods that are objectively bad for us and there is no warning label about that on the packages. There are no gruesome photos of obese people unable to move their bodies without assistance, or other physiological manifestations of obesity.

Worse, the nature of an economic system where more is always better forces companies to compete against each other by making us eat more than we should, and eat more unhealthy products than we should.

Typically, solutions to this issue are individualized. (“Eat responsibly?” Nice try!) Then there is plenty of talk about voluntary, public-private partnerships (the food industry cannot possibly be “responsible,” because producing healthy foods would reduce its sales and profits), and, last but not least, it has been suggested that we should levy taxes on unhealthy foods that are commensurate with the health care costs they cause.

Some of these features ignore that the poorest among us are also much more likely to be obese. Sadly, this is especially true for Canada’s aboriginal peoples. They also happen to be frequently stuck in so-called “food deserts” where access to healthy foods is hard to come by.

Isn’t it high time our regulators had a serious look at the food-producing industry with a view to regulating it in much in the same way that cigarette manufacturers are regulated? Considering the cost to our health and economy of so many of our food products, why not tax them as we tax cigarettes? That might be a good start! Just make sure that the money generated that way is diverted right back toward subsidizing healthy foods.

Udo Schuklenk is a Professor of Bioethics and Public Policy at Queen’s University. He’s on twitter @schuklenk

Poverty and Health

Here was an interesting piece of research that is being reported on the website of the Canadian Broadcasting Corporation. It links into debates on the social determinants of health. It has been argued (and shown) on many occasions that folks lower down the socio-economic pecking order are more likely to suffer from a whole host of chronic (as well as sometimes even infectious) diseases. It turns out, they're more likely to suffer from ' increased rates of death and illness including diabetes, mental illness, stroke, cardiovascular disease, gastrointestinal disease, central nervous system disease and injuries.' Indeed, kids brought up in situation subjecting them to what professionals refer to as 'toxic stress', that includes substandard housing, living with adults who are also stressed due to their socioeconomic circumstances, experience stunted brain development according to a technical report published in 2013 in the journal Pediatrics. The American Academy of Pediatrics issued a large-scale technical report in the end of 2012 that reaches similar conclusions.

No wonder a family medicine specialist in Toronto, Gary Bloch, is quoted in the CBC article as follows, 'Treating people at low income with a higher income will have at least as big an impact on their health as any other drugs that I could prescribe them.'

Such findings must have an impact on ongoing ethics debates among public health ethics experts on how to deal with illnesses such as obesity. Would nudging or stigmatising people who have already lost out on much of what constitutes a good life due to the poverty they experiencing be truly fair? Or would it place additional unfair burdens on those already struggling to live a decent life? Perhaps campaigning for better education and jobs for all would be a better placed priority than figuring out what drugs best control obesity? Difficult one.

The Junk 'Food' Wars Continue

Belatedly policy makers have woken up to the fact that the largest disease burden in the world is caused by chronic diseases. They have begun to zoom in on 'food' products known to contribute to obesity. The thing about obesity is that it is linked to a whole gaggle of expensive-to-treat diseases, including diabetes, heart disease and so on and so forth. It is also linked to lower life expectancy and other such niceties. It turns out, soft drinks are a known significant contributor to obesity. Politicians such as New York City's mayor Michael Bloomberg have come up with a plan to reduce the maximum size of the containers that soft drink products are delivered in. They clearly hope that that might reduce soft drink consumption, to some extent at least. Public health experts have lauded Bloomberg's initiative. Others have suggested limiting advertisements for such products to times when children and teenagers ain't watching TV any longer.

When you think about it, Bloomberg's policy proposition isn't that different to what we do with regard to other known health hazards such as smoking and alcohol. If anything his policies are probably not far reaching enough. However, it is reassuring that voluntariness on part of the soft drink producing industry isn't relied on any longer. It cannot possibly deliver the required results, simply because these companies must be interested to sell as much of their products as is feasible in order to satisfy their owners' (ie their shareholders) financial interests, lest they will be punished by the financial markets.

Here are some fun facts related to the issue, 'Several studies have shown that the rate of type-2 diabetes has soared at just the same rate as intake of high-fructose corn syrup -- the favored sweetener in many soft drinks -- has risen. Soft drinks such as Coca-Cola were sold in 6.5-ounce bottles in the 1920s. Now the 12-ounce can is standard but fountain drinks are sold in sizes up to 64 ounces -- or the equivalent of eight of these cans of soda. One 64-ounce drink carries more than 800 calories.'

Well, yesterday Bloomberg's new regulations for New York City were halted in their tracks in court. Nothing new on that front either, cigarette companies also dragged the inevitable out by means of seemingly never-ending court proceedings. Even the arguments deployed during the cigarette wars and those deployed now are eerily similar. One would hope Bloomberg and - more importantly - his successor will keep their nerves on this. I saw Bloomberg last night on the Letterman show (yep, guilty as charged, I watch the Late Show) and he mentioned some staggering figure like 5,000 New Yorkers die every year as a result of obesity related complications. The cost of treating - just in that city - obese people's avoidable health problems reaches multi billion $$ each year.

Here comes the inevitably Onion style response from US Republicans. NPR reported that in Mississippi, a state where 1 out of every 3 adults is about 30 pounds (!) heavier than what would be a healthy weight, state Republicans are moving to legislate that counties and towns must not enact rules like those proposed by Michael Bloomberg, including rules that require calorie counts of meals and drinks to be posted, that cap portion sizes, or that keep toys out of kids' meals. It goes without saying that the restaurant, beverage and chicken producing industry was behind this initiative. Which arguably supports again the point that it ain't public-private partnerships and voluntary industry action that is called for, but government regulation. That industry should lobby to withhold basic information from its customers, in order to prevent them from making informed choices at least about the food products they digest, tells you truly all that you need to know.

Bizarre Canadian court ruling on airfares - celebrating your obesity!

The Globe and Mail reported a day or two ago that a Canadian court has ruled that Air Canada (the yuk factor outfit still operating as Canada's flag carrier) and Westjet (another Canadian airline), can't charge disabled people two airfares if they require their carers to fly with them. I think one can argue about this, but at least I can see how the court could reach the conclusion that charging such passengers two airfares is probably unjust.

What bugs me is that the same ruling is also seen to apply to seriously overweight people. The judgment is basically this: if you are too big for one regular seat, the airline must provide you free of charge with two seats. This is the most bizarre judgment I have ever seen (I'd love to know the judge's weight on this one ...). Here's the problem: for most overweight people (if not for all of them), the decision to eat too much or too many fattie things has resulted into them being overweight. They are by and large responsible for their predicament. Disabled people cannot usually be held responsible for their disability.

So, what would be unjust about charging the overweight crowd for the extra space that they need, and possibly even for the extra fuel needed to transport their fat around the world in an aeroplane? At the end of the day what we are doing as airline passengers is to purchase SPACE on a plane going from A to B (frequently via C, D, and E), as well as the right to truly horrendous 'service', food for purchase, the right to look at armrests and similarly amazing goodies.

My view on this issue would be that if you need more space than the average passenger you ought to be charged for the extra space. Some accommodation is frequently rightly made for very tall people (they didn't choose to grow that tall), so we often find them sitting in emergency exit rows. All that is sensible, but why people's wrong eating habits should be beneficial to them in terms of the space airlines must now provide to them without being permitted to charge them extra, completely escapes me.

Wrong verdict, and wrong message sent out to society. I need to reconsider, obviously. Perhaps I should aim to gain quite a bit of weight before I board my next intercontinental flight, so that even in economy an airlines must provide me with plenty of space. All that this means, in the real world, is that people of average size must subsidize the space overweight people require (free of charge). That is unjust. It is so evidently unjust that one wonders in which dreamworld the judges reside that passed this judgment. If anything, as a society we have a strong public health interest in encouraging people to lose weight. It's good for them and it's good for our health care bill. Perhaps uncomfortable plane seats could be a good start!

Help your country! Smoke, drink... and die faster.

I am sure you will agree with me that public health promotion programs designed to reduce smoking, drinking and obesity are a good thing. After all, we live longer, and our quality of life is higher. Well, both of these claims are correct. There is just one problem that economists have been aware of for some time. The problem is this: People that eat too much, drink too much and smoke big-time have a habit of dying in the average about 7 or so years earlier than comparable people who do not over-eat, drink and smoke. Now, it's possible to parcel out what does more damage, but this isn't the point I am going to make. From a public interest perspective those of us who don't smoke, drink crazily and eat as if there's no tomorrow, should be grateful to those behaving differently. After all, these people kindly pay into our welfare system, pension schemes and so on and so forth, but thankfully they die sooner than those of us who happen to choose a healthier life-style. So, they're subsidising our old-age care, because they usually don't reach old age to begin with. Not only that, overall their health care comes cheaper, too, because us healthier-living characters, while we also get sick, have a habit of escaping death time and again, while the live fast and die young crowd actually achieves at least the dying younger objective, and so, overall turns out to be even cheaper (over a life-time) in terms of health care costs.

Dutch scientists published in PlosMedicine their main finding: 'Until age 56 y, annual health expenditure was highest for obese people. At older ages, smokers incurred higher costs. Because of differences in life expectancy, however, lifetime health expenditure was highest among healthy-living people and lowest for smokers. Obese individuals held an intermediate position. Alternative values of epidemiologic parameters and cost definitions did not alter these conclusions.' They conclude: 'Although effective obesity prevention leads to a decrease in costs of obesity-related diseases, this decrease is offset by cost increases due to diseases unrelated to obesity in life-years gained. Obesity prevention may be an important and cost-effective way of improving public health, but it is not a cure for increasing health expenditures.'

This strongly suggests that people like the Scots and US Americans (mind you, the Germans are catching up rapidly) may have got it right after all: Live fast (and unhealthy) and die young. It seems our current pension systems are not designed to handle our longevity anyway, so why not make the best of it.

I am kind of kidding, of course, but there is an important lesson in this: If we succeed in getting people to live healthier and live quite a bit longer, we got to find a way to pay for that, too. An average of another 7 years added to our lives adds huge burdens to any pension system.

Pretty scary things - comfort food among them

I went with a colleague to a place called Dallas BBQ in Brooklyn. I can recommend it to you as a true local experience. It's usually jam packed with mostly substantially obese folks of all ages - I take that back, not all ages, there are only few elderly people, because obesity leads to the premature death of far too many people. Anyway, Dallas BBQ is a steak, ribs, fried onion rings, fries, margarita type place that serves gigantically oversized portions of essentially junk 'food' at fairly low/reasonable prices. I got to be honest, I greatly enjoyed the atmosphere in this place. The staff were friendly and the folks feasting themselves to death were remarkably cheerful. I particularly 'enjoyed' parents ensuring that their newborns get addicted to the same type of food so that they can also die premature deaths. I mean, if the idea of 'child abuse' makes any sense at all, it needs to incorporate such stuff, too.