As suggested by the experts in “The Skinny on Obesity: Drugs, Cigarettes, Alcohol..and Sugar?” public policy intervention is one possible tactic to put the brakes on America’s obesity epidemic. Whether you consider the regulation of sugar-enriched food products regrettable or a revelation, it helps to know what the research says. Lucky for us, UCSF Health Policy Professor Laura Schmidt offered up an overview.
WHAT DOESN’T WORK
So far, evidence shows that individually focused approaches, such as school-based interventions and warning labels on product packaging, demonstrate only salutary efficacy. Conversely, for both alcohol and tobacco, there is robust evidence that “supply side” control strategies —taxation, distribution controls, age limits –- lower both consumption of the product and accompanying health harms.
WHAT DOES WORK
Taxation
Successful interventions for alcohol, tobacco and sugar all share a common end-point: curbing availability. Taxation — in the form of special excise duties, value added taxes, and sales taxes — are the most popular and effective ways to reduce the overall volume of drinking, and in turn, substance abuse and related harms.
Taxes are easy to collect and cause little market distortion. We have robust evidence of their beneficial effects on both acute (e.g., injuries) and chronic (e.g., cirrhosis) alcohol-related health conditions. Moreover, alcohol taxes disproportionately impact youth – a group at particularly high risk for alcohol-related harms.
Soda taxation will likely prove an efficient, effective public health strategy. European experience with sugar taxation thus far strongly supports this conclusion. However, one problem is that the current U.S. soda tax debate centers on adding one penny per ounce, which would raise the price of a can of soda by only 10-12 cents. Statistical modeling suggests the price should double to significantly impact soda consumption. Another question is whether juice consumption would be similarly taxed, as it contains an even higher average fructose load than does soft drinks (1.8 vs. 1.7 gm/ounce).
Controls at the Point of Sales
Other successful tobacco and alcohol control strategies target limits on product availability through distribution controls on opening hours or days for retail sales, the controlled placement and location of retail markets, and density of sales outlets, as well as limits on who can legally purchase the products. Reducing the density of retail alcohol outlets, through stricter state licensing and local zoning ordinances, especially in lower income communities, has been shown to reduce alcohol-related problems in controlled studies.
A reasonable parallel for sugar would tighten licensing requirements on vending machines and snack bars that sell sugary products in schools and workplaces. States could apply zoning ordinances to control the number of fast food outlets and convenience stores in low-income communities, and especially around schools, while providing incentives for the establishment of grocery stores and farmer’s markets. Another option would be to limit sales during the time intervals of school operation, or to raise the age limit for purchase of soft drinks. Indeed, parents in South Philadelphia recently took this upon themselves by blocking children from entering convenience stores after school. Why couldn’t a public health directive do the same?
Controls on Advertising and Marketing
Advertising shapes children’s perceptions about alcohol and tobacco, encouraging pro-drinking attitudes and greater consumption. Voluntary agreements among manufacturers and distributors have rarely been enforced or monitored, and, naturally, sugar vendors favor voluntary policing.
In contrast, government-imposed regulations on the marketing and promotion of alcohol to youth have been quite effective. Thus far, the U.S. government has not imposed a ban or careful monitoring of the marketing of high-sugar content products to children. Some communities, such as Santa Clara and San Francisco, CA, have however instituted toy bans on Happy Meals.
Subsidization
Reduced fructose consumption could also be fostered through subsidization — by limiting access to soft drinks and promoting access and consumption of healthy alternatives in low-fructose, high-fiber foods. Promotion of such foods in U.S. low-income programs such as Women, Infants, and Children, and Food Stamps is an obvious place to start. Unfortunately, the petition by New York City to stop subsidization of soft drinks within the Food Stamp program was denied by the U.S. Dept. of Agriculture.
Recommended Actions for the FDA
Ultimately, food producers and distributors must reduce the amount of sugar added to foods. But sugar is cheap, sugar tastes good, and sugar sells, so companies have little incentive to change. The U.S. Food and Drug Administration already has the power to instigate change at every step in the production pipeline: from farmers, to food processors, to marketers, to suppliers, and ultimately, consumers. Although one institution alone can’t turn this juggernaut around, the FDA could “set the table” for change.
Since fructose acts as a chronic, dose-dependent liver toxin analogous to alcohol, the FDA should consider removing fructose from the Generally Regarded as Safe (GRAS) list, which currently allows food manufacturers to add unlimited amounts to any food. Opponents will argue that other nutrients on the GRAS list, such as iron and vitamins A and D, can also be toxic when over-consumed. However, these substances have no abuse potential, as does sugar. Removal from the GRAS list would send a powerful signal to the European Food Safety Administration and the rest of the world, now facing the same crisis of obesity-related illness that America has been struggling with for the past 30 years.
REFERENCES
Babor, T., Caetano, R., Casswell, S., Edwards, G. & Giesbreacht, N. Alcohol: no ordinary commodity: research and public policy. Oxford University Press (2003).
International Regulation of Alcohol: Room, R., Schmidt, L.A., Rehm, J. & Mäkela P. Br. Med. J. 337, a2364 (2008)
Soda Taxes, Soft Drink Consumption, and Children’s Body Mass Index: Sturm, R., Powell L.M., Chriqui, J.F. & Chaloupka, F.J. Health Aff. 29, 1052-1058 (2010).