The Fund supports networks of state health policy decision makers to help identify, inspire, and inform policy leaders.
The Milbank Memorial Fund supports two state leadership programs for legislative and executive branch state government officials committed to improving population health.
The Fund identifies and shares policy ideas and analysis to advance state health leadership, strong primary care, and sustainable health care costs.
Keep up with news and updates from the Milbank Memorial Fund. And read the latest blogs from our thought leaders, including Fund President Christopher F. Koller.
The Fund publishes The Milbank Quarterly, as well as reports, issues briefs, and case studies on topics important to health policy leaders.
The Milbank Memorial Fund is is a foundation that works to improve population health and health equity.
June 2015 (Volume 93)
Quarterly Article
Lawrence O. Gostin
Nov 5, 2024
Oct 30, 2024
Oct 23, 2024
Back to The Milbank Quarterly
Science informs us that nutritious dietary patterns and physical activity improve prospects for health and well-being. Yet pursuing a healthy lifestyle is incredibly difficult in a society designed to incentivize the opposite set of behaviors.
For example, individuals may know the value of physical activity, but there may be few parks, playgrounds, fields, and walking paths for exercising their bodies. In inner-city neighborhoods with hazardous, unlit physical environments, for example, parents, fearful of the dangers of firearms and illicit drugs, may not want to send their children out to play.
When it comes to our diet, we are constantly pushed toward unhealthy eating. Food manufacturers aggressively market hyperprocessed foods laden with saturated fat, salt, sugar, and refined carbohydrates. These companies put these unhealthy ingredients even in basic “healthy” foods, such as bread, granola, and yogurt. Advertisements for sugar-filled cereals and sodas are targeted to children. Fast-food chains collude with Hollywood and entertainment venues to give away toys in “meals” marketed for kids. It is little better for their parents. Consumers seeking whole, nutritious foods often find them inaccessible or unaffordable, driving many to buy convenient and cheap options.
Even the most informed consumer faces a confusing shell game—“low-fat” foods often contain high amounts of sugar and salt, while “low-sugar” foods often are filled with high amounts of saturated fats and calories. Serving sizes are not uniform, stymieing even the most mathematically gifted consumer when comparing products.
How can we structure society to make health the easier choice?
Four simple ideas could make healthy behaviors the “default” choice for most consumers. To be sure, the evidence for these interventions is mixed, mainly because they are rarely enacted, let alone rigorously evaluated. Although evidence for a given intervention is important, tobacco control has taught us that a suite of measures, working in combination over time, has the best chance of success.
Taxes/Pricing: Lower Demand/More Revenue
Higher prices for unhealthy products reduce demand, especially among youth and low-income groups, while generating revenue to increase access to and affordability of healthier alternatives. Of all the interventions to control tobacco, raising excise taxes on cigarettes translated into the greatest reduction in smoking. Modeling this success, Mexico levied a tax of 1 peso per liter on sugary beverages in 2013, resulting in a price increase of 10%. Modeling showed that the price increase would reduce consumption by 15%, thereby preventing 630,000 cases of diabetes by 2030, with early evidence demonstrating a 10% drop in soda purchases and a 13% rise in bottled water purchases.1
In 2014, Berkeley, California, became the first US jurisdiction to adopt a soda tax, levying a penny-per-ounce tax on sugar-sweetened drinks. A recent European Commission Report lent support, concluding that taxes on sugar, salt, and fat reduce consumption, although consumers often switch to nontaxable foods, which might be equally unhealthy.2 Berkeley added the soda tax revenue to its general budget, but states could instead earmark food tax revenues to subsidize fruits, vegetables, and legumes, or for nutrition education campaigns.
Product Reformulation: Direct and Co-regulation
Industry adds copious amounts of fats, sugars, and sodium to foods, and consumer tastes have evolved to crave these additives. If companies gradually reduced these unhealthy ingredients, consumer tastes would adjust as well. For example, no one today misses artificial trans fatty acids (TFA) in their fried and baked goods. In March 2003, Denmark established a maximum of 2% TFA content in oils and fats; New York and other cities followed this model; and the US Food and Drug Administration (FDA) has proposed a national ban.
Co-regulatory strategies—voluntary industry compliance with government-set standards—can be a politically palatable alternative to mandatory bans. The United Kingdom, for example, set progressive targets for reducing sodium in 85 food categories and supported them through education campaigns. Companies voluntarily agree to both the targets and to front-of-pack labeling to alert consumers to high-salt products. Over a 7-year period, the program achieved a 15% reduction in the population’s salt intake.3
Disclosures/Advertising: The Informational Environment
Altering the informational environment shifts the political dialogue because few dispute the value of consumer awareness. In 2014, the FDA proposed rules for redesigning food-packet labeling, notably adding a separate line for added sugars and standardizing serving sizes. The United Kingdom’s Food Standards Agency developed a voluntary “traffic light” system, with prominent green, yellow, or red lights for major nutritional groups like saturated fats, sodium, and sugar.
California could go further, with a proposed bill that requires warning labels on sugary drinks, including sodas, sweet teas, and sports and energy drinks. Sugar now has an air of comfort, but imagine the effect of this admonition on your beverage:
STATE OF CALIFORNIA SAFETY WARNING: Drinking beverages with added sugar contributes to obesity, diabetes, and tooth decay.
Junk-food advertisements are even more ubiquitous than tobacco advertisements were in the years before tobacco control. In 1980, Quebec banned all commercial advertising aimed at children. The ban significantly reduced French-speaking children’s exposure to food and beverage advertising.4 In the United States, the First Amendment poses a major obstacle to advertising bans. Nevertheless, in 2007 Maine became the first state to prohibit brand advertising of unhealthy foods and beverages in schools. The US Supreme Court is more deferential to government restrictions on advertisements targeting children, so regulating commercial messages in K-12 public schools remains a prime target.
Built Environment: Healthy Food Accessibility
Visit any inner city in the world and witness food market globalization, with the same global “fast-food” brands populating the streets. What often is missing are supermarkets, farmers’ markets, and greengrocers. Most urban settings are structured through market forces, but government can use zoning and licensing laws to limit fast-food outlets, while incentivizing vendors and stores to sell healthy products.
In July 2008, for example, the Los Angeles City Council passed a moratorium on new or expanded fast-food establishments in south central Los Angeles, with plans to attract dining establishments and grocery stores.
That same year, New York City began its “Green Carts Scheme,” creating 1,000 licenses for street vendors selling fresh fruits and vegetables in “food deserts.” A 1-year evaluation found higher access to and more consumption of fruits and vegetables in low-income neighborhoods, with Green Carts being “a powerful tool . . . to combat obesity and poor nutrition.”5 Minneapolis requires grocery stores to stock ample supplies of “staple foods” such as fruits and vegetables, while Philadelphia’s Healthy Corner Store Initiative provides training and incentives for stores operating in food deserts.
The food industry lobbies hard to block these reform strategies, even though obesity is at epidemic levels. Tobacco control overcame key political obstacles—paternalism, the “nanny state,” and personal responsibility—by demonstrating the harm of secondhand smoke and revealing industry deceit and recalcitrance. Certainly, the outcomes of unhealthy living (diabetes, cancer, and heart disease) pose real harms to families, the health system, and productivity.What is not as well understood is that the food industry behaves much like Big Tobacco, denying the health impacts and aggressively blocking taxes and regulations.
Choosing what to eat is not an unfettered personal choice. Poor diets have become the “default” behavior in a perversely structured society. Alas, in America, and throughout the world, living well is hard to do.
References
Author(s): Lawrence O. Gostin
Read on Wiley Online Library
Volume 93, Issue 2 (pages 242–246) DOI: 10.1111/1468-0009.12117 Published in 2015
Lawrence O. Gostin is University Professor in Global Health Law at Georgetown University, faculty director of the O’Neill Institute for National and Global Health Law, and director of the World Health Organization (WHO) Collaborating Center on Public Health Law and Human Rights. He has chaired numerous National Academy of Sciences committees, proposed a Framework Convention on Global Health endorsed by the United Nations Secretary General, served on the WHO Director’s Ad Hoc Advisory Committee on Reforming the WHO, drafted a Model Public Health Law for the WHO and the Centers for Disease Control and Prevention, and directed the National Council of Civil Liberties and the National Association for Mental Health in the United Kingdom, where he wrote the Mental Health Act and brought landmark cases before the European Court of Human Rights. In the United Kingdom, he was awarded the Rosemary Delbridge Prize for the person “who has most influenced Parliament and government to act for the welfare of society.”
