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Why eating isn't like smoking

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I forgot to link to my latest Food policy column, but it centers around a farmer's market stroll with OMB health-care policy adviser Ezekiel Emanuel. The government is fairly sure-footed when it comes to health-care policy. But what about when it comes to health?

The government really doesn't know what its role should be when it comes to how Americans eat. It knows that it can't afford Medicare and Medicaid if the rise in such diet-related conditions as diabetes, heart disease and cancer doesn't level off. But what does that imply? Should Peter Orszag publish a cookbook? Should Emanuel have a cooking show? Should fruits and vegetables be heavily subsidized? Soda taxed? The head of Hardee's executed?

Our political system is a lot more comfortable talking about health care than about health. We'll pay enormous amounts of money to treat diabetics, but we don't do much to change people's diets to prevent diabetes. That's a strange use of resources: Focusing on health-care coverage without doing more to address the factors, such as diet, that determine our health is a bit like buying fire insurance while ignoring the fact that you have a gas stove and a large fireplace in a wood cabin. A dry wood cabin.

It's better to prevent fires than rely on fire insurance, as homeowners know. But preventing fires, it turns out, is really hard. "My own view," says Emanuel, "is we know there are large parts of health that are primarily best approached as a public-health issue and not as a doctor-patient issue. Nutrition, wellness, exercise and smoking, for instance. But lifestyle change is hard to accomplish. What smoking showed is it's not a single thing. It changed from being socially acceptable and doctors would recommend it in the '50s to being scorned and barred indoors."

The smoking case is an interesting one. Emanuel brings it up repeatedly as one of the few examples where public-health advocates managed to change the culture around a previously unexamined act, which is exactly what they're going to have to do with diet. "On smoking, there are a combination of things that had to happen," he says. "We had to make smoking socially unacceptable. We took it outside the building. We raised taxes on it. It became linked to cancer." But as he admits, "you can't take eating outside the building." Nor can you demonize it entirely. Certain products can be attacked, but in a world of organic Oreos and Splenda with added fiber, it won't just be an uphill climb. It'll be a climb with constantly changing footholds.

Talking to folks who worry about food policy is a profoundly depressing experience. Even the optimists -- and Emanuel probably counts as one -- are looking back at an example that seems, in retrospect, immeasurably easier.

After all, the big insight with cigarettes was that they were physiologically addictive in ways that led directly to excess (it took more nicotine to satisfy the craving) and so we had to keep people from ever starting to smoke. Food is also addictive, and people have trouble with moderation, but the answer can't be that people don't eat. They have to eat. Every day. The problem is that once people start to eat, they find it hard to stop, an observation that's now been buttressed by plenty of experimental data. Imagine, however, how hard it would be to keep people from smoking very much if everyone needed five cigarettes a day.

Or take the dangers of secondhand smoke, which provided the crucial evidence of external harm that led to states banning indoor smoking. You're not going to get that with food. Or take the banning of cigarettes for people under 18 years old. Who wants to be the first to limit Wonder Bread to adults?

Which is all to say that the single workable playbook is almost entirely useless here. But in the absence of some genuine breakthrough, we're going to be a pretty sick society. And with Medicaid and Medicare threatening to bankrupt the country, and private insurance costs chewing through our wages and sitting heavily atop our employers, that's going to be a serious problem.

Photo credit: By Wilfredo Lee

By Ezra Klein  |  November 5, 2009; 5:32 PM ET
Categories:  Food  
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Comments

Ezra,
I was just thinking about the cigarette metaphor with regard to climate change when I opened up this article.

I think you raise some interesting points but I object to your characterization of the Administration's handling of healthcare reform as "sure-footed". I sometimes think when you insert these little pats on the back to the Administration or other Washington elites that you don't even reflect back on your own writings on this matter. The Administration and Congress have looked damn awkward in dealing with healthcare reform and have, in my estimation, missed the mark in terms of framing the debate and arriving at an workable outcome.

Yes, "health" and prevention have not been discussed but, believe me, Americans are a lot better at moralizing about individual behavior than designing a workable publicly managed or regulated health finance system. I think you will see that it is going to be far easier for politicians to encourage Americans to "take responsibility for their health" than confront the large companies and interest groups that control the healthcare delivery system.

Posted by: michaelterra | November 5, 2009 5:45 PM | Report abuse

There are many more moving parts with eating as opposed to smoking. And food is symptomatic of deeper societal problems than tobacco was. But one thing both issues have in common is that very large industries and corporations, as well as suppliers, make a great deal of money from food and have vested interests in the problems they have contributed to. And of course with food there are many, many more corn, wheat and soybean farmers than tobacco farmers and they are spread out over a wider area, so subsidies and farm and export policies are more complicated.

I think there are multiple problems here. Nutrition is a subset of a cluster of problems for poor people. What they need is not just nurtirion advice and readily available fresh fruits, vegetables and protein, but easier, less stressful lives where they feel a greater sense of control. Everyone could benefit from more cohesive family life, with food as a cohesive force like the sit-down dinners of my childhood where people talked to each other. Our society seems to me to be profoundly unnourishing as compared to most European societies. It is also hypercompetitive and harsh. Even within ethnic and regional subcultures, a culture, of which cooking would be a part, is no longer being passed down.

We are very attracted to the glitz and glamour generated by advertising and many people have become centered on shopping and consumption. We fix o9n surfaces, not substance. I used to have a quote on my refrigerator from a longer piece, something to the effect that it isn't that some coffees aren't measurably better than others, but that being absorbed in finding the best consumer goods makes one a pretty shallow person.

In short, trying to improve our nutrition is like trying to improve education or politics or any number of things that are the produicts of a materialistic, overly competitive society that measures everyone and everything by money but concentrates wealth in a very few.

Posted by: Mimikatz | November 5, 2009 5:55 PM | Report abuse

There was a great post on the Freakonomics blog a while back about how people who used chopsticks and smaller plates tended to eat less than with a fork and larger plates.

I think this issue is one for behavioral economics, and can't be tackled with traditional policy.

Posted by: donhalljobs | November 5, 2009 5:58 PM | Report abuse

" The problem is that once people start to eat, they find it hard to stop..."

That's only true for almost everyone if they eat high-carbohydrate junk food, as that study demonstrates. Time after time it's been shown that if people eat a more "paleo" or Atkins type of diet--low-carbohydrate, moderate proteins and healthy fats--the body's natural appetite mechanisms work just fine, and calorie intake matches needs.

All calories are not the same, because they elicit different hormonal responses. And it's the hormonal responses that determine if you're going to keep eating, or if the calories are going to be stored or circulated as fat, etc..


Posted by: sbguy | November 5, 2009 6:04 PM | Report abuse

And reading that study, what they called a "high fat" diet consisted of " Ho Hos, sausage, pound cake, bacon and cheesecake." That sounds like a high-sugar diet to me. Describing it simply as "high-fat" is just kind of ridiculous. High-fat diets, in the absence of sugars don't have this effect.

Try eating a stick of butter, or bacon that hasn't been sugar-cured and see how much that causes you to overeat.

By including the high-sugared foods in the diet, they totally confounded the results. Which may have been the point, of course.

Posted by: sbguy | November 5, 2009 6:10 PM | Report abuse

--"The head of Hardee's executed?"--

Some of Klein's readers probably think that's a joke, but it's the logical conclusion of the argument that begins when one invites government participation in any area. The only tool governments have is force, and the only debate that can take place with government is about how much force it is going to bring to bear in its endeavors.

Oh, but that could never happen in America. Certainly not in Klein's happy go lucky airhead America where government is friendly but stern, and it's all for your own good, so shut up and eat your gruel America.

But, say that Congress outlawed Hardees' six dollar burger (which is very tasty, I must say) and the management of Hardees refused to comply with the government directive. Who can guess how it would end, were said management to remain stalwart in their resolve to live as free men in a free land? Anyone? Klein?

Posted by: msoja | November 5, 2009 7:17 PM | Report abuse

I think there's a more basic difference here. Smoking annoys the hell out of other people in the vicinity. Eating just about anything doesn't.

Posted by: sacman701 | November 5, 2009 7:27 PM | Report abuse

Maybe we could just, I don't know, stay the hell out of people's personal lives, don't subsidize any foods, and let people decide for themselves what they'd like to eat.

Posted by: ab13 | November 5, 2009 8:03 PM | Report abuse

--"Maybe we could just, I don't know, stay the hell out of people's personal lives, don't subsidize any foods, and let people decide for themselves what they'd like to eat."--

But Klein has shown that people are too stupid to buy TVs! And health insurance! How can they possibly be allowed the responsibility of providing themselves a balanced diet?

At the very least it will take a UCLA grad to direct all our nutritional needs. Pregnant women and children first, as long as the food lasts.

Posted by: msoja | November 5, 2009 11:07 PM | Report abuse

In France restaurants are closed from 2 to 7pm and snacking is frowned on. There are classes on gastronomy in public school from kindergarten on, etc.

Not only that but French eating habits (including the not snacking part) were formed by government policy in the 1920s or 30s -- at least that's what I read somewhere.

The French have a saying about hunger -- "bonne maladie" it's a good ailment, if you are hungry. Wait until dinner.

I'm not suggesting we slavishly copy France, but there are things one can do. And France is also just as endangered from cultural erosion of its dietary habits as we are.

Posted by: harold3 | November 6, 2009 1:01 AM | Report abuse

With cigarettes, government and the medical community provided sound and simple advice: "stop smoking." People listened and smoking declined. With eating, the advice from government and the medical community was to eat a low-fat, high carbohydrate diet. People appear to have listened to that as well, but it may have been bad advice. As a commenter above noted, there are biological reasons why such a diet could make the obesity problem worse. See, for example, Gary Taube's NY Times Magazine article on the topic from July 2002. The contrast between trends in smoking and obesity seems like more evidence for Taubes' argument.

Posted by: jbakija | November 6, 2009 6:36 AM | Report abuse

Smoking was made socially unacceptable.

Today, there is an effort to make extreme obesity socially acceptable.

It is no longer politically correct to make fun of fatty.

Place ever more stringent stigma/taboo over overweight people and see the pounds drop off.

Posted by: MyrtleParker | November 6, 2009 8:44 AM | Report abuse

Maybe it isn't clear what the government can do to get people to eat healthier food, but if we ever get to single-payer health insurance, at least the *incentives* will line up.

As jbakija notes, "With eating, the advice from government and the medical community was to eat a low-fat, high carbohydrate diet. People appear to have listened to that as well, but it may have been bad advice."

Best advice I ever had, healthwise, was "eat more plants," which was the theme of a video clip Ezra linked to from his blog at The American Prospect a couple of years back. (Ezra, if you read this, link to it again sometime, OK?)

In general, the closer a food is to its original natural state, the better it's likely to be for you. And the more processed and refined and whatnot it is, the worse it's likely to be for you. There are exceptions to this, I'm sure, but the logic of a tax on processed foods seems pretty strong to me.

I also like the idea (which I believe Ezra has advocated) of requiring restaurants (chain restaurants, at a minimum) to post the caloric content of their menu items on their menus.

A lot of people eat a lot of meals out, and we know the stuff we're eating is bad - but we have no idea HOW bad it is. Is that fast-food burger 400 calories, or 1000 calories? Hell if I know, and I'm trying to pay attention. Information can change individual behavior, which in turn can change the restaurants' offerings: until now, there's been effectively no price to the restaurant of adding as much sugar and fat as is needed to an entree or appetizer to maximize the pleasurable feelings one gets from eating it. Having the calorie numbers right there would impose a cost of sorts, and that would change the equation.

Posted by: rt42 | November 6, 2009 8:51 AM | Report abuse

We could make people pay for their choices. They do pay...they pay with their own misery but with our money. Here's where my libertarian streak shows through - if people paid more of a financial price for their choices they might make different choices.

Ezra you have written a little about the problem with equating health care reform with health insurance reform. We are reforming health insurance. We are not reforming health care. If we were truly revolutionizing health care we might be able to impact some of the choices people make every day.

That said, I have quit smoking many times (currently not smoking fwiw). It's hard. I also need to lose 20 lbs. That's hard, too.

I worked in an Eastern city for a couple months a couple years back. I walked everywhere - didn't have a car. Everything I carried home had to fit in two bags. I did not buy cases of Coke, giant boxes of Cap'n Crunch, frozen pizzas, etc etc. I never even thought about weight, calorie intake, burning calories on the stair climber, etc. It just was not an issue.

Posted by: luko | November 6, 2009 10:25 AM | Report abuse

I think social pressure does work. Following up on the comments about France. Although France is starting to have childhood obesity problems, most French people in the cities are thin and don't snack and don't eat second helpings because that is frowned on. They eat dessert but they often don't finish it I watch French families at the table. Meals are prolonged, not rushed. People talk. They take 3 times as long to eat as the typical American, talking a lot in between bites.

Kids are taught to eat slowly, to eat in small quantities... from childhood. It is social pressure and it does seem to work.

Posted by: robinshuster | November 6, 2009 11:38 AM | Report abuse

There are a number of levers that public policy can use to promote healthier food and lifestyle. Stop subsidizing HFCS. Promote healthy food in schools, where governments are directly in control.

The most important lever, however, and the one that nobody thinks of, is the control of the cost of energy. The American junk food and obesity problem can mostly be traced to cheap oil, extreme automobile dependency, and subsidized sprawl. *This is where government policy has the most consequential impact an food habits.* The problem, of course, is that criticizing America's car diet is even more taboo than criticizing its junk food diet. But, forget about smaller plates: this is what really matters.

Posted by: carbonneutral | November 6, 2009 12:03 PM | Report abuse

This reminds me of an Yglesias post on education. He said you could fix a lot of the problem by reducing child poverty.

I think we could solve a lot of the health problems by reducing poverty. Furthermore, if our policies were more like those of Nordic countries, we would have more time to reflect and learn, exercise and cook. Additionally, we would have less stress.

Posted by: bcbulger | November 6, 2009 12:35 PM | Report abuse

--"There are a number of levers that public policy can use to promote healthier food and lifestyle."--

How about the government stop using tax dollars to pay for people's bad choices?

Too simple for you?

Posted by: msoja | November 6, 2009 1:46 PM | Report abuse

"Maybe we could just, I don't know, stay the hell out of people's personal lives, don't subsidize any foods, and let people decide for themselves what they'd like to eat."

Maybe, but let's start with ending corn subsidies, which are the reason that high fructose corn syrup is in just about everything.

Posted by: Janine1 | November 6, 2009 2:53 PM | Report abuse

"How about the government stop using tax dollars to pay for people's bad choices?

Too simple for you?"

I have been specific about ending corn subsidies, fossil fuel subsidies, and other ways of subsidizing sprawl. What are your specific suggestions? What is your point, anyway?

"People's bad choices" are not made in a vacuum. They are shaped in many ways by public policy, often unintentionally. People's food choices are shaped to a surprising degree by transportation policy, and in turn reinforce those policies. Eric Schlosser's "Fast Food Nation" made that point impressively. The problem is that these connections keep being ignored. Reality is too complex for pundits and politicians. Ezra Klein is just a case in point.

Posted by: carbonneutral | November 6, 2009 3:20 PM | Report abuse

--"[L]et's start with ending corn subsidies"--

Excellent. And don't forget to abolish the sugar import quotas.

Posted by: msoja | November 6, 2009 3:53 PM | Report abuse

"And don't forget to abolish the sugar import quotas."

Wow. We actually found something we agree on.

Posted by: Janine1 | November 6, 2009 4:24 PM | Report abuse

The evidence against smoking was unambiguous. Diet is much more complex and much less clear.

At least with smoking we had ends, so we could focus on means.

Posted by: zosima | November 6, 2009 6:34 PM | Report abuse

Everyone agrees that changing dietary patterns is exceedingly difficult. While we incrementally attempt to do so, there is a short term very low cost highly effective easily implementable measure that can dramatically improve the health of most Americans. And that is to simply ensure that Vitamin D levels are optimal. An abundance of research in the past 5-10 years documents that Vitamin D levels to be suboptimal, often dramatically in the vast majority of the American public, and particularly among African Americans. Spending $15 a YEAR per person can provide supplements to bring levels back up.

Doing so is likely to reduce cancer incidence by 50% or more, reduce heart disease and stroke, diabetes and obesity, swine and seasonal flu, osteoporosis and most likely autism and at least a dozen other significant medical conditions. Let's demand that something that will improve people's health in a matter of months be made a national priority.

PLEASE! Millions are suffering and dying unnecessarily when we have a promising cheap, non toxic essentially magic bullet that government and organized medicine willfully ignore.

No surprise there. Pharma profits would be wiped out in many cases and the billions in govt research funding for esoteric treatments would be shown to be unnecessary in many cases, so it's no surprise that the Vitamin D evidence is being ignored.

If you are skeptical of what I say read www.vitamindcouncil.org carefully. It's all documented there.

Posted by: oderb | November 6, 2009 9:49 PM | Report abuse

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