Tuesday, April 18, 2017

Public Health Strategies Part 4C: Bans

Bans on Unhealthy Foods

In earlier blog posts I discussed taxes and subsidies as public health strategies, mainly related to the current more popular calls to tax sugar sweetened beverages (SSBs) and subsidise fruit and vegetables.  In researching those posts I came to the conclusion that both strategies have some potential to influence consumer choices and therefore population health when implemented broadly (e.g. tax ‘extra’ foods instead of just SSBs) and strongly (e.g. 50-100% tax rather than 10-20% tax).  However, the narrow range of targets combined with the weak tax/subsidy is unlikely to substantially improve population health.  In addition, assuming consumption wouldn’t be affected, a 100% tax on SSBs would only increase the average household budget of low income earners by 1% [1], which is something that even most low income earners in an affluent country like Australia could shrug off (not to mention those on higher incomes).  This raises the question of whether more aggressive market controls such as bans on the marketing, sales and/or possession (the latter has actually been proposed [2]) of foods like SSBs are required to truly reduce the prevalence of obesity and metabolic disease

Bans can apply to the ability of producers to market a product or sell a product and the ability of consumers to possess a product.  Bans are not necessarily universal, it may only apply to certain times (such as advertising on TV when children are most likely to be watching and bands on selling alcohol after a certain hour of the night), places (such as bans on selling SSBs in schools) and very specific products (such as the proposed New York City ban on big gulps).  Non-universal bans on selling products are intended to lower consumption by reducing convenience, while universal bans on selling products or being in possession of them (such as illicit drugs) are intended to eliminate consumption

Like any other policy, putting a ban on unhealthy foods is likely to have unintended consequences and these will depend on what kind of ban is implemented.  A universal ban on unhealthy foods with little to no redeeming qualities like SSBs is unlikely to happen, and it could result in unintended consequences similar to the war on drugs and the American prohibition on alcohol, in addition to losing an opportunity for tax revenue.  Alternatively, a non-universal ban that reduces convenience can be easily circumvented by a determined consumer who can plan in advance to take extra drinks with them to consume late at night, to take SSBs with them to a school/university campus and to simply order to small size drinks instead of the big gulp.  Of course, not everyone will be the determined consumer and the point is that small changes in convenience can have large impacts in behaviour.

The rationale of banning something like SSBs (as opposed to TFA, asbestos, etc) is to save people from themselves, but is it the government’s job to do this?  Some people would object to the nanny-statism and demand the freedom to eat/drink what they choose, although if you’re asking the government to pay for your healthcare one could argue that you are implicitly trading some liberty for security.

Bans to reduce the consumption of unhealthy foods by children are another story.  Unlike adults, we do not hold children completely legally responsible for their actions (which scales with age of course), and so there is an argument to be made to protect children from themselves, or from their parents*.  With health issues like obesity and tooth decay being an issue among some young children, perhaps banning the sale of SSBs for children or to children (SSBs would be an 18+ substance like cigarettes and alcohol) would be help to reduce these issues.  Unfortunately, my look at the research at the moment suggests that just banning sodas at high schools results in an increased consumption of other SSBs [3], while banning the sale of all SSBs at middle schools only seems to reduce consumption at school and doesn’t appear to reduce overall consumption [4].  Perhaps there would be more success at primary schools, but also it seems people will get their sugar fix no matter what, and so the narrower the ban, the less likely it is to be effective at all

* Bit of a rant: sorry Guardian author, if a 2 year old needs 20 teeth removed due to tooth decay, that’s not an issue with oral health prevention [5], that’s child abuse from parents who don’t sufficiently care.  This is similar to issue that sometimes comes up where children fed a vegan diet are malnourished, leading to an Italian proposal to jail parents feeding young children a vegan diet [6].  I don’t want to necessarily jail vegan parents or vilify parents who give their children SSBs, just when there is evidence of harm, because it’s about the outcome (in the absence of losing the genetic lottery), not the methods to get there.  Vilifying ‘wrong’ methods regardless of any feedback from outcomes could lead to a hideously broad application of that Italian proposal (‘oh, you’re feeding your child a low carb diet?  That’s against the dietary guidelines.  It doesn’t matter that there’s nothing wrong with your child, you’re going to jail’) and leads to dogmatically sticking with the ‘right’ method, such as the dietary guidelines, rather than updating your methods based on the feedback from outcomes in research and clinical practice (outcome based medicine > evidence based medicine).  If you think I’m being harsh, consider how you would feel if you had your teeth removed, got type 2 diabetes or suffered developmental issues before you had the chance to make your own choices or because your mother smoked and drank heavily while pregnant with you.  The right as a parent to bring your child up their own way should not trump their responsibilities to bring them up well.

** The Torba province of Vanuatu is aiming to impose strong restrictions on junk food while promoting locally grown, organic food [7].  It will be interesting to see how that goes.  They have a fairly special advantage from being isolated and a small community which might lead to it working out very well (but good luck trying to implement the same in Australia, etc)

*** Alternatively if you see obesity and lifestyle diseases as an product of market failure, you could just ban capitalism and adopt socialism or communism, which is proving to be a really effective policy at reducing obesity in Venezuela at the moment :p

Ban on Trans Fats

This leads me to the FDA ban on partially hydrogenated oils (PHOs).  In the US, the FDA has ruled that PHOs are not generally recognised as safe for use in human food.  The response to this seems to generally be positive, with a small number of doubts and concerns coming from some libertarians.  I agree that banning PHOs won’t have much effect as consumption of PHOs is quite low and they aren’t actually that bad.  In Australia in 2009, the average intake of TFA is 0.5% of total energy intake, with 60-75% coming from animal foods, so only 0.125-0.2% from PHOs, though intakes in the US seem to be quite a bit higher [8].  A recent study using the Nurses’ Health Study and the Health Professionals Follow-up Study found that each 1% increment of total energy intake from TFA was associated with just a 10% increase in total mortality (the effect would be diluted as TFAs from animal foods are pretty neutral, but still) [9]

Even though at current intakes, PHOs aren’t that bad, they are still a great example of something that should be banned.  (1) PHOs are really only convenient for the food industry and consumers don’t seek them out (copha is disgusting) (no black market).  (2) They will likely just be replaced with SFA rich fats/oils (no negative unintended consequence for consumers, just a drop in sanity from the Heart Foundation).  (3) It’s unlikely that this will translate to regulation on ‘unhealthy’ foods like red meat because PHOs don’t have any nutritionally redeeming qualities, whereas red meat certainly does (particularly when most people could use more protein, iron and zinc, etc) (so the libertarian concern of increasing government regulation is unlikely)

Some objections to a ban on PHOs is the false dichotomy that SFA is a larger issue [10], concerns that the PHOs would be replaced with SFA rich fats/oils, and concerns that that enforcing a ban would be too hard [11].  The ban would be hard to enforce 100%, but would be just as hard to enforce accurate labelling [12] which seems to be the Australian Heart Foundation’s preferred method, at least initially.  Mandatory labelling hasn’t been implemented because TFA intake in Australia is less than the WHO target of 1% [13], but I still think consumers should still have a right to know

Down the Conspiracy Theory Rabbit Hole

Given that the FDA is banning PHOs due to their adverse health effects and having no redeeming qualities, why aren’t cigarettes also going to be banned?  Cigarette smoking is associated with far worse health outcomes than PHOs and also results in second-hand smoke and more litter.  About 15% of Australians still smoke despite decades of health messaging stating the adverse effects of smoking, cigarettes been heavily taxed, advertisements for cigarettes been banned, plain packaging laws, and graphic imagery depicting some potential consequences of smoking.  Surely banning the sale and possession of cigarettes entirely would be one of the most productive policies for public health (and even poverty), and potentially a popular policy for the vast majority who don’t smoke (cleaner air and environment) and especially for ex-smokers.  One could speculate that the reason why governments haven’t banned the sale and possession of cigarettes is that the tax revenue they get from them exceeds the healthcare costs from smoking.  When looking at the costs of smoking, you see stats along the line of ‘smoking costs $X’, but these stats are probably irrelevant if not compared with the costs of not smoking.  I came across a study from the Netherlands (so could be different elsewhere) that predicted that the healthcare costs of smokers and of people with obesity are actually lower per person because they live shorter lives [14], and haven’t yet seen another study with a similar type of analysis.  Another consequence of smokers and people with obesity or diet and lifestyle diseases tending to die younger is that on average you would expect them to cost the government less money on pensions.  I wonder if these reason are a factor why many governments aren’t aggressively addressing diet and lifestyle diseases.  After all, even if the average life expectancy suddenly increased by 10 years because the government implemented rigourous public health policies, people will still want their pension at 65 and moving the pension age up to 75 might be more politically unpalatable than getting people to stop having pizza and coke for dinner.  (That might be a bit of a stretch, but I think you could make a reasonable case for pensions being a factor (alongside more major ones like debt) behind the constant drive for economic and therefore population growth and for the migrant crisis in Europe, but that’s getting quite off topic).  But this is hardly a flawless conspiracy theory given that government had a major role in the reduction in smoking, the investment governments make in medical research, and the demographics that receive most of the healthcare expenditure (i.e. not working)

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