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Towards a New Norm

By Lindsey Shultz

The entirety of the time I have lived in New York, Michael Bloomberg has been the mayor.  That means 7 years of getting accustomed to the seasonally renewed battles of paternalism in the name of public health and libertarianism in the name of freedom to (in this particular case) drink tub-sized cups of soda at the movies or ballpark.  The city has been among the most aggressive in the country in putting into place innovative public health measures.  The range of proposals has reiterated how the role of public health has evolved beyond its historic roots to take a much more encompassing look at the importance of social determinants of health in public life.  Mayor Bloomberg’s administration has among other programs: banned smoking in restaurants and bars, as well as public parks and beaches, banned trans fat in restaurant foods, and required restaurants to post health inspection grades and those with over 15 locations to post calorie counts on their menus.  In addition to the regulatory agenda, health initiatives have sprouted all over the city, from increasing public green space and more environmentally efficient public transportation, to the bike share program that will be unveiled later this summer.  But things have not always come without a fight. After an unsuccessful attempt at the state level to implement a sugary beverage tax and at the federal level after a proposal to restrict the purchase of these drinks with food stamps, the Mayor’s office seemed to settle for a new ban on sugary drinks over 16 ounces.  


Polling suggests that a majority of the public opposes the ban and criticism has come in from across the political spectrum (when is the last time you can remember Jon Stewart and John Boehner agreeing on anything?).  However, Bloomberg stands by his support of the ban, framing it in terms of refashioning norms, rather than prohibiting a behavior.  A person will still have every freedom to purchase 2 16-ounce drinks, but now choosing higher levels of consumption will be an active choice, rather than the default.  Summed up nicely by economist Justin Wolfers on twitter, “Portion sizes shape norms, and norms shape behavior. So shouldn't we choose sensible norms?”  Furthering support for the proposal, NYC Health Commissioner Thomas Farley takes issue with the idea that such regulations should be subject to popular opinion: "You wouldn't respond to a cholera outbreak, by putting it to a vote, and obesity is a crisis."  


But before engaging in a political skirmish- how strongly does the science speak to this as being a battle worth fighting?


The science behind this part of the justification for revising sizes and options seems promising.  Average soda sizes have gone up a remarkable 7 times since the 1950’s, and portion size has been consistently shown to influence what we consider a “normal” amount to consume.  In one often cited study, Philadelphia movie patrons were given either a medium or large popcorn bucket, filled with old,  stale popcorn.  The people who got the large bucket ate around 35% more despite the popcorn being kind of terrible.[1] Dr. Brian Wansink, who has studied the ins and outs of unconscious influences on consumption for decades, aptly puts why something as seemingly arbitrary as Bloomberg’s proposed soda ban are a lot more important that most people realize:


People are often surprised at how much they consume, and this indicates their consumption may be influenced at a basic level of which they are not aware or do not monitor. This is why simply knowing these environmental traps exist does not typically help in avoiding them. Relying only on cognitive control and on willpower often yields disappointing results. Furthermore, consistently reminding individuals to vigilantly monitor their actions around food is not realistic.[2]



The science on how sugary drinks themselves impact obesity as an endpoint is not quite as clear cut.  The argument goes that sugary drinks provide not only provide empty calories, but somehow bypass the mechanisms we have for self regulating consumption.  Where we might eat a smaller dinner after a big lunch, these drinks do not seem to cause that compensation.  That seems to make them a fair target for regulation rather than the barrage of other foods that critics have sardonically suggested come next (a ticket violation for a bagel with full-fat cream cheese perhaps?).  However the data for the connection between sodas and obesity is a contentious topic that has resulted in a meta-meta analysis and a lot of questions about researcher ties to industry. A meta analysis in 2006 out of the Harvard School of Public Health looking at 30 different studies concluded that the weight of epidemiological and experimental evidence supports the connection between sugary drinks and obesity.  A reexamination of the same data set by Richard Mattes and David Allison found the results inconclusive however.  A number of competing results from these and other meta-analyses led to a meta- meta-analyses by Douglas Weed who found the data so sloppy to be inconclusive and perhaps obscuring the truly important factors affecting obesity.  The send-up:  Weed was employed by the Coca-Cola Company as a private research advisor, and several other researchers playing a part in the debate likewise have ties to industry.


So where does this messy, but all too representative, history of the science leave me?  The weight of the science probably does content a link between high amounts of sugary drink consumption and obesity- but doesn’t answer for me whether this is one of the most vital factors to address, or just the most expedient.  It also doesn’t guarantee that banning large sizes from particular establishments will affect consumption patterns, or make enough of a difference to reach the level of influencing the health of a city.  And even if it can’t, is setting this precedent of a seemingly small change enough to begin laying the groundwork for larger changes in the future?


But these are not the questions I am hearing debated by the local media, the national politicians and pundits.  The first cry of outrage, based on the frequently cited fear of regressive taxes and regulations, is epitomized by a blog entry over at The Economist (titled “Civilizing Thirst”-just to let you know what you’re in for):


At any rate, we yuppie pinot-drinkers know how to look after ourselves. In contrast, the wretched classless hordes, many of them being of dubious heritage, lack the refinement of taste necessary to make autonomy unobjectionable. Those who abuse their liberty, filling the sidewalks of our great cities with repulsive shuffling blimps, can't expect to keep it, can they?”[3] 


This fear and antipathy towards elitism is a recurring theme in our cultural wars, as is the second and more vocal contingent who want the government to “Keep Their Hands of My (insert issue of the day here)”.  There has always been a healthy debate in this country as to what the legitimate role of the state is, and under what circumstances it can be effective in improving the health and wealth of our nation.  But more and more, the answer has been, “Nothing.” A ban on a large size soda is not an inconvenience or an annoyance, but a violation of a fundamental freedom.  But I think a large question looms- a freedom from or to what end?  


Developmental economist Esther Duflo has a strong answer to some of these larger inquiries.  While her work focuses mainly on low- and middle-income countries, it can be highly resonant in our own.  In our discourse, paternalism always seems to run counter to freedom.  But freedom and choice always come embedded in a cultural matrix of norms and institutions- no one starts from a completely abstract places in making decisions about how best to live their life.  It is also constrained by our own cognitive biases and conflicts.  Few are the people who have never battled with the desire for immediate satisfaction over future gain. And when you exist outside the rarefied world of the top income brackets, your daily choices may be constrained by dilemmas about money, about health care, about figuring out how to take care of your family, about what you will eat that night.  New evidence in psychology elucidates how willpower and mental energy to make those decisions-the “right” decisions- are an exhaustible resource.  When you have to worry about whether your children are put at risk because your water isn’t fluoridated or you couldn’t afford a vaccine, the paternalism inflicted on most of society regulating that drinking water is safe and public environments healthy, seems like quite a luxury.  We live in a country where it is a privilege for some to be able to question the validity of vaccines, to drink bottled water- things that great swaths of this country and world would love to be able to take for granted.  


Duflo puts it like this: “the rich people live under a much more paternalistic set of circumstances than the poor.”[4]  Having basic decisions already accounted for provides the freedom to expend our time, mental effort, and passion on things we care more about.  On things that are more important.  That can provide added value to both ourselves and our society.  I have never had a patient say, “I would like the freedom of choice to make my life harder.”  It’s always “If it were just a little easier...”  Public health measures like banning a large drink size- however small, however questionable their impact might be- may actually be serving to give people the freedom to focus about things that matter more.  




[1] Bad Popcorn in Big Buckets: Portion Size Can Influence Intake as Much as Taste

Journal of Nutrition Education and Behavior, Volume 37, Issue 5, Pages 242-245

Brian Wansink, Junyong Kim

[2] doi: 10.1146/annurev.nutr.24.012003.132140



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