Sugar-Sweetened Beverages the Next Tobacco?

Image from the NY City Department of Health Anti-Obesity Campaign

In class this week, we discussed strategies for reducing the consumption of sugar-sweetened beverages at home. Sugar-sweetened beverages are exactly what they sound like: any drink sweetened with sugar (sodas, fruit juices, "vitamin" or flavored waters, sports drinks, energy drinks....etc.).

The larger question at hand was: Can we utilize the same strategies that brought down the tobacco industry for reducing the consumption and availability of sugary drinks?

The idea of a "soda tax" has come under scrutiny by conservatives who don't like the idea of taxing anything, as well as groups that are strongly supported (i.e. funded) by the food and beverage industry, like the Center for Consumer "Freedom." And, yes, the quotes are my doing...

However, many in public health believe that taxation will curb consumption of sugar-sweetened beverages, particularly among those who consume the most and are most likely to suffer poor health and overweight because of it. Nonetheless, soda is just the tip of the iceberg when it comes to liquid, non-nutritive calorie consumption, especially among kids. There are many other beverages that provide just as many calories and can contribute to weight gain. What will happen when the beverage industry just switches production (and all its marketing!) to these other sugary beverages? Another tax?

Taxation of tobacco has been a primary strategy in reducing its consumption and preventing people from starting to use it. Yet, taxation of tobacco has gone extremely high! Right now the federal tax on tobacco is $1.00 per 20-cigarette pack, and states can tax tobacco even higher ($3.46). Would a soda tax ever get that high? Not likely. Harvard researchers suggest that just a $0.01 per ounce of soda would be enough to change consumption patterns of consumers; a typical 20 oz. soda would be marked with a 20 cent tax.

However, the strategy that I am most excited about is social marketing -- advertising that promotes healthy behaviors and discourages unhealthy ones. If you haven't seen the sugar-sweetened beverage ads out of New York City, check out my other post on this topic. Marketing can't just tell you that something is bad, it must suggest alternatives.

If you are looking for alternatives to sugary drinks here are a couple promoted on the Harvard Nutrition Source website:

• Plain (or Infused) Water -- I think this means throwing some lemons or cucumbers in with the plain water to add flavor without the calories.
• Tea -- Go light on the sugar and honey, of course.
• Coffee -- Choose milk over cream, go sugar-free.
• Sparkling water -- add a splash of 100% fruit juice for flavor, without packing in the calories.

The website even has a recipe for a healthy "fresh fruit cooler," which is a great alternative to store-bought smoothies. Notice, drinks that are "sugar-free" because they utilize artificial sweeteners are NOT included in this list.

Right now there is a national movement to get junk foods and soft drinks out of schools. While I believe this needs to happen soon, most kids get unhealthy foods outside of schools. A 2006 study by Harvard researchers found that 60-80% of sugar-sweetened beverages were consumed by kids at home.

This suggests that we need a national movement, not just to change school environments to provide healthier beverages, like water and low-fat milk, but also change social norms around providing sugary drinks to kids in homes.

What would sway parents to pass up purchases in the beverage aisle and stick to **free** tap water and nutrient-rich milk for kids?

That's a tough question. The strategy needs to incorporate environmental change, excellent social marketing of the health dangers of daily consumption of sugary drinks, and grassroots/community efforts. If we can get sugar-sweetened beverages out of schools (where they have no right to be!), perhaps we can raise awareness about the issues so that we can get them out of homes, too!

Could the tobacco model work? Perhaps. It may be important to look to other public health campaigns; however, to get the most insight into what public health strategies will be most effective. How about alcohol control campaigns?

RP: Health Reform Jumps First Senate Hurdle

The Affordable Health Choices Act, legislation supported by the American Public Health Association, passed through the Senate Health, Education, Labor and Pensions (HELP) Committee this afternoon. Some of the most exciting aspects of the bill (...in terms of social determinants of health) are:

• Establish a program at the Centers for Disease Control and Prevention to "facilitate the use of health impact assessments to gauge the public health implications of major decisions regarding the built environment, including housing, transportation systems, waste disposal sites and other land-use planning decisions.

• Establish a grant program for state and local governmental and community-based organizations to implement evidence-based community preventive health activities to reduce chronic disease rates, address health disparities (including social determinants of health), and develop a stronger evidence base of effective prevention programs and interventions.

• Collect data and conduct research on the health and healthcare of populations that have traditionally experienced health disparities...in efforts to improve the quality and effectiveness of health services." (quotes are taken from an APHA e-mail blast)

I am excited that these components of the plan take a social determinants approach to some of the health system issues that are currently lacking. Additionally, it was wise to articulate the needed move toward an evidence-based health care system, not only in terms of medical treatment, but also prevention activities!

I had wished, however, that the creation of programs for a "public health workforce loan repayment program" would have been a grant or scholarship program for students entering graduate degrees at accredited public health schools (...am I bitter of the lack of funding for my master's degree? or the idea that I might have to fight for a stipend in a doctoral program?...)

While many health reform advocates are hopeful at this point, the slim (partisan) margin by which this bill was passed is worrisome (13-10). Next, the Senate Finance Committee holds a markup of its version of the legislation and later their version is merged with the recently passed HELP Committee bill.

Up next -- how do the House and Senate health reform legislation compare? Great question!

Research and Policymaking Merge in Public Health

How does a State know whether fluoridating its water supply will prove cost-effective in reducing tooth decay and its related health costs of their residents? Are mass media campaigns effective in discouraging smoking among young people?

These questions and others are posed in a Fall 2008 report by the Council of State Governments entitled "State Policy Guide: Using Research in Public Health Policymaking". 

The report indicates strong support for State governments to begin making public health decisions based on empirical evidence rather than the influence of lobbyists or in the interest of political expediency. The challenge of making evidence based decisions is directly addressed in the report, as is the need to distinguish public health policies directed at the population (i.e. community) level from medical care policies, which focus on treating or preventing disease in individual patients. 

Rating scales to evaluate the evidence for particular interventions are provided, as well as a step-by-step guide to drafting and reviewing proposed legislation on public health policy. 

I wonder how much attention to evidence-based policy making is currently happening at the local and State level. Have other sectors of government (apart from health) been making evidence-based policies or is this something new altogether?

It is imperative that we elect and promote individuals with a strong ability to identify and critique the public health literature so that informed public health policies can be implemented. At the least, we must expect our policymakers to surround themselves with people who are public health experts and can inform the content that goes in to the legislation. This guide is a good first step -- a call to action of sorts. 

Next Steps:

• Are evidence-based public health policies being made in your State? 
• What are the risks/rewards of being the first State to adopt a new public health policy? Can these decisions still be evidence-based?
• Who will keep local and State governments accountable for their public health policies?

Should Prevention Trump Treatment?

I remember when I first started thinking about entering the field of public health. One of my major concerns was whether I needed to become a doctor in order to be respected and influential in the field. I was grateful for the advice I received from faculty (mostly doctors and nurses) at school that the path to clinical practice should not be done if you aren't passionate about becoming a clinician! While that may seem obvious, I think my concern was getting at something much deeper than that -- the enormous tension in public health to work within the health care system (a medical-driven, treatment intensive environment) and to work without it. 

The public health approach to health promotion is fundamentally about prevention. Its goal is to collaborate with multiple sectors to create environments where people can make healthy choices, to develop policies that protect peoples health, and to disseminate new finds and raise awareness about health damaging practices and products. 

Conversely, a clinical approach to health is to screen, identify, and treat disease. These clinical activities are vital and important to improve health of individuals. Ask anyone with high blood pressure, diabetes, or cancer, and they will agree that medicine plays an important role in helping them live their healthiest life possible. 

Sometimes people forget that clinical medicine and public health practice must be work in tandem. For example, when HIV/AIDS work began, there were many who wanted to prevent the spread of HIV/AIDS, but forgot the need to improve access to treatment for those already affected. Expanding access to antiretroviral therapy is now a major part of HIV/AIDS activities. 

The era of public health as a competency only for those in clinical medicine has past. What remains is a (growing?) tension between a growing number of public health professionals with no clinical training who reject the treatment-oriented focus of health work in this country and clinicians who believe that advancements within the health care system will be vital to improving the health of our nation. While both may believe that prevention is necessary, it is unclear whether -- when it really it comes down to it -- both believe that money spent on prevention is worth more than money spent on treatment. 

Our health care system is broken. Training more OB-GYN and orthopedic surgeons is not going to fix it. We need to create incentives for family physicians, primary care practitioners, and midwives. We need to invest more in prevention, in early life care, in parenting support, and healthy community initiatives to reduce violence and increase social capital. 

What does this tension mean for public health? Will it promote dialogue and lead to sustainable change or will it prevent us from accomplishing all that needs to be done to turn our health care system into a health promotion system?