Sunday, February 26, 2017

Public Health Strategies Part 4B: Subsidies

In an earlier blog post I discussed taxation as a public health strategy, particularly related to the proposed tax on sugar sweetened beverages (SSBs) in Australia.  In this post I’m going to look at the opposite of taxation: subsidies.

Putting a tax on unhealthy foods would generate extra tax revenue and so the question becomes whether the government should reduce taxes in other areas (or use it to help pay off national debt) or put that extra revenue into something, and if so, what?  Generally I have seen calls to tax unhealthy foods being coupled to calls to subsidise health foods, like fruit and vegetables (F&V).  There are a few rationales for subsidising healthy foods like fruit and vegetables:

  • Reducing the cost of fruit and vegetables would increase the consumption of them and displace unhealthy foods, which will ultimately improve population health and reduce healthcare costs
  • Coupling a fruit and vegetable subsidy to a tax on unhealthy foods (like sugar sweetened beverages) is also a means to reduce the increase to cost of living as a result of the tax, provided people purchase fruit and vegetables 

However, there may be a few problems if a health food subsidy was put in practice

  • A recently published Australian modelling study estimated that a F&V subsidy ($0.14 per 100g of fresh and preserved F&V*) would increase F&V consumption by 42g (a serving of fruit and vegetables is considered 150g and 75g respectively).  However, it was estimated that the subsidy would also increase sodium consumption by 48mg and energy consumption by 236kJ (56.6 calories), because “however, using price subsidies or discounts as an incentive to purchase more fruits and vegetables may have the effect of increasing real income available to buy food, including unhealthy products, and could therefore lead to an overall increase in dietary measures such as saturated fat, sodium, or total energy intake”**.  As a result, their model predicted that a F&V subsidy would actually have adverse health outcomes [1].  The major benefit of food taxes is that they generate revenue [2].  This revenue should go towards initiatives that are at least cost effective, but with a F&V subsidy there’s this study says there’s a 89% chance that it wouldn’t be.  Not a great policy
  • A subsidy on F&V isn’t likely to offset the increase in cost of living from a tax on unhealthy foods such as SSBs.  The estimates show that there isn’t going to be much change in behaviour.  So the people who are already low SSB consumers and high F&V consumers are the ones who will benefit.  This got me thinking if the promotion of taxes + subsidies in some people (not all) may at least partly driven by financial self-interest, but you can defend this motivation in countries with socialised healthcare.  (By the way, my diet is very rich in F&V, with no SSBs and low added sugar, so I would benefit a lot from such policies) 

In my opinion as a stingy student currently on an unflattering income, many F&V are already very cheap as there’s a lot you purchase for < $4-5 per kg or much less.  I think the reason why so many people don’t consume the recommended intake of F&V [3] is because other foods simply taste better, the structure of their habitual meals is not conducive to eating many F&V (cereal for breakfast, sandwiches for lunch, etc), and they don’t value/are empowered about their health enough to change.  When people say cost is important, they are comparing apples with apples, and not apples with muffins.  The apple wins easily on cost, but the café bought muffin wins on palatability and reward, and because most Australians have that money to spend, that’s what most people choose

A tax on unhealthy foods should be coupled with a subsidy or health initiative that is actually cost effective in itself.  An idea circulating around AHSNZ is that a tax on SSBs could be coupled to subsidy on dental health or free dental for children.  This would disproportionately benefit lower income families who are less likely to have private health insurance, see the dentist less often and more likely to have worse diets.  It is also likely to be more cost effective as healthcare spent in younger people has a greater return on investment, and dental health is one of the major health issues for children, and one (rampant tooth decay) that is potentially not reversible unlike obesity and type 2 diabetes.  Some people may be against the government using taxes and subsidies to save people from themselves, but may concede that something should be done as tooth decay is so common in children [4].  I would still like to see an estimate of the cost effectiveness of any policy, as good intentions are not a guarantee of good policies

* For example, if a fruit or vegetable was priced at $4 per kg, this subsidy would cover 35% of the costs.  This method of subsidising has a greater effect on cheaper F&Vs such that it wouldn’t be practical as very cheap F&Vs like carrots would be almost free.  In fact, at the time of writing this Coles has a special on carrots at $1.20 per kg, so they would be paying the customer to purchase them, pretty crazy! (but don’t forget that F&V are expensive and cost of healthy foods is a limiting factor in population health…)

** I think this point is debatable.  Paying less for F&V would result in consuming more F&V and this may have the opposite effect on calorie intake as F&V are more satiating than most foods per calorie.  In addition, the sodium > blood pressure data they used was based on a large effect from observational studies [5] rather than the small effect in RCTs [6], although sodium could be a surrogate marker for highly processed foods and such foods are unhealthy for other reasons besides sodium.  That being said, if the estimates on calorie and sodium intake were ignored, increasing F&V intake by 42g alone isn’t going to have that much impact on population health

*** The study also modelled the effect of taxes on SSBs, sugar, saturated fat and sodium.  The study estimated that all these taxes combined, plus the F&V subsidy, would reduce 470,000 disability adjusted life years (DALYs, or years with chronic disease) and would reduce health healthcare expenditure by $3.4 billion.  These figures seem impressive, but need to be put in context.  The study used a population of 22 million, so this works out to average reduction of 0.0214 DALYs per person (7.8 days) and average reduction in healthcare costs of $155.55 per person across their lifetime (or a few dollars per year, depending on how long you think the average person will live for (e.g. 40 years = $3.86 per person per year)).  This magnitude of response is consistent with another Australian study I discussed previously.  Modest taxes on unhealthy foods are somewhat useful at generating revenue for the diseases they increase the risk of, and will very marginally improve population health, but they won’t come close to solving the obesity/chronic disease epidemic

Sunday, February 5, 2017

Health Associations and Censorship

In an earlier post I discussed education as a public health strategy.  In that post I levelled some criticisms against health associations, particularly that they should revise some of their content and offer more detail, depth and complexity than the bare minimum to sufficiently inform and empower the early majority.

I care about health associations because they strongly influence health policy and what the public thinks on health.  And I think they should.  The purpose of health associations is for a large number of experts to come together and arrive, and arrive at a consensus and publish their collective ideas in a centralised place.  As a result, statistically speaking, the average person is more likely to find information from health associations and this information is more likely to be accurate.

However, the rise of the Internet has resulted in increasingly more information that is decentralised, crowd-sourced, and diverse than ever before, the opposite form of information from health associations.  Much of this kind of information is likely to be of a lower quality than the former, but due to the great diversity of ideas in the latter, some of those ideas may be better.  The hope is that this crowd-sourced information undergoes a process akin to evolution wherein in the free marketplace of ideas, good ideas are generally promoted and bad ideas are generally discarded, and that the average person is able to discern this

This dichotomy was described by Tom Naughton as the vision of the anointed vs the wisdom of crowds (also see his four part series on the anointed and free speech regarding the call for retraction by the ironically named Centre for Science in the Public Interest (CSPI) on Nina Teicholz's BMJ article criticising the dietary guidelines)  And health associations, much like the 'anointed' that Thomas Sowell discusses in his book, are generally pretty dismissive of ideas that challenge their consensus, particularly when coming from non-experts.  Perhaps more importantly, there are few notable instances where health associations have attempted to censor people who promote opposing ideas:

Tim Noakes is a highly regarded South African emeritus professor in exercise science and recent advocate for LCHF diets.  After providing rather general and unindivdualised advice on Twitter, the dietitian Claire Strydom, president of the Association for Dietetics in South Africa, said it was “Dangerous to wean an infant onto #LCHF diet” (evidence for that claim?) and reported Tim Noakes to the Health Professional Council of South Africa (HPCSA) for unprofessional conduct [1], which lead to the HPCSA setting up a hearing.  Tim Noakes doesn’t practice medicine, so could easily give up his license, but wanted to put both conventional dietary advice on trial and defend LCHF.  If you want to learn more about the Tim Noakes trial I would highly recommend Marika Sboros’ coverage of the trial and the following article.  Meanwhile, veganism actually has a history of failure to thrive and (rare) child deaths [2], but you don’t hear about people promoting veganism in children being taken to court

Gary Fettke is an Australian orthopedic surgeon who had been advising his diabetic patients to eat a LCHF diet until a complaint led to an investigation by the Australian Health Practitioner Regulation Agency (AHPRA), where APHRA found he was not qualified to give nutritional advice and told him to stop doing so.  The case led to senate inquiry into the AHPRA (see link) [3] [4] [5] [6] [7] [8]

Jennifer Elliot is an Australian dietician who was giving advising people with metabolic syndrome and type 2 diabetes to eat a LCHF diet.  When an anonymous complaint was lodged with the Dietitians Association of Australia (DAA) the DAA deregistered her and then her employer fired her and stated that “Nutritional advice to clients must not include a low carbohydrate diet. Jennifer will be advised on the information that she may provide to clients…” [9] [10].  If dieticians are told what advice to give, then what’s the point, is their function just a meal plan generator?

Steve Cooksey was a type 2 diabetic who decided to manage/treat his condition with a low carb Paleo diet.  He started a blog, which included dietary advice in an advice column that the North Carolina Board of Dietetics/Nutrition deemed was illegal (giving dietary advice without a licence).  Steve Cooksey and the Institute for Justice, filed a free speech lawsuit against the board [11].  Fortunately, the case was successful [12]

Even if you disagree with some or all their ideas you should still defend their right to express them both on principle and in self-interest (taking away one person’s rights sets a precedent to take away everyone’s).  When someone aims to censor speech, they are communicating that they aren’t interested in having a conversation or that they are in the pursuit of truth.

There are a perhaps two broad motivations for censorship.  The first is a concern that they won’t win in the free marketplace of ideas and so resort to censorship to protect the public from ‘dangerous’ ideas.  However, this motivation is based on a patronising belief that the public is too stupid to hear both sides of an argument and come to the right conclusion.  In addition, it may reveal some anxiety in how well they can express their ideas, how convinced they are of them and how convincing the ideas are to others.  You may be able to draw a parallel here between the political correct authoritarianism, which aims to censor ‘hate speech’ (which these days basically means anything someone finds offensive) and is associated with low verbal cognitive ability, high interpersonal disgust sensitivity, mood or anxiety disorder, and intolerance of nuance and the unknown [13].  As an unintended consequence, the act of censorship signals to others that they have something to hide or that their arguments are weak, and so the idea they are trying to censor gains more visibility and credibility than otherwise (the Streisand effect)

Secondly, the individual or organisation doing the censorship may have a conflict of interest.  Dietetic associations are particularly suspect here.  They function more like a trade union in that their primary function to benefit dieticians collectively rather than the health of the public [14].  They have an incentive to pass anti-competition laws to give them have a monopoly over dietary advice (Steve Cooksey’s case + other evidence [14]).  Also, dietetic associations receive sponsorship from the food industry (see ‘And Now a Word From Our Sponsors’ US [15] and Australia [16] + the conflicts of interest in the Tim Noakes trial [17]),  and the food industry also employs many individual dieticians.  Finally, and this applies to many organisations, they have an incentive to shut down opposing ideas so that the public perceives them to be the ultimate gate-keepers of knowledge, and that acknowledging other ideas or previous errors will cede the monopoly and make them appear less relevant, rather than more honest

With the internet providing increasingly more diverse ideas and information, the increasing partisan bias of the media and the rise of fake news, the solution cannot be to silence everyone you disagree with, as this will be both logistically challenging and counterproductive.  Instead the solution must be to teach people how to think, not what to think.  And instead of presenting an uninspiring version of conventional wisdom and dismissing/censoring opposing ideas, I would like to see health associations hosting debates similar to the Sugar and the State debate hosted by the Cato Institute The Protein Debate hosted by the Performance Menu