PUBLIC HEALTH
June 27, 2012

A Tempest in a 16-Ounce Cup

Is the move to restrict serving sizes of soda in NYC a bad idea or a bold way to begin tackling obesity?

Recently New York City Mayor Michael Bloomberg proposed an amendment to the city’s health code that would prohibit the sale of sugary soft drinks in containers larger than 16 oz. in New York restaurants, movie houses, sports stadiums and other public facilities.

Under the proposed change, if you need to drink more than 16 oz. of soda, you’ll simply have to deal with the inconvenience of getting up and buying another bottle. It is hoped that this extra effort might slow overconsumption of these empty, non-nutritional liquid calories.

Among major nations, current data from the World Health Organization ranks the U.S. first in the percentage of adults who are obese (33.9%).

The Mayor’s initiative follows an earlier, and unsuccessful, attempt to place a special tax on sugary soft drinks, as a way to make New Yorkers more mindful of the adverse health consequences (e.g., obesity and diabetes) of drinking too many sugary beverages. That effort was blocked in New York and other states by intense lobbying by trade groups such as the American Beverage Association.

Bloomberg’s new health code proposal cleverly avoids the need to propose and pass a new tax. With U.S. rates for type 2 diabetes and obesity rising to epidemic levels, the mayor’s action, from a public health perspective, makes sense. But will the mayor be able to overcome the expected and predictable blowback from the beverage makers and other large food companies who will undoubtedly claim that their brands and their inherent right to maximize profits with large portions and containers are being unconstitutionally threatened?

The fact is we have been here before. Alcohol and cigarettes are, like sugary beverages, health-threatening substances that have as many fans as detractors and powerful business interests with deep pockets and political muscle.

America, The Land of the Big, The Home of the Obese

The problem is Americans have always loved big. We’ve created giant industrial enterprises that made chemicals, steel, refined oil, built transcontinental railroads and highways, mass-produced automobiles and airplanes that carried people to far way lands. We were known and admired for our big cars and big universities and big ideas. From Super Bowls to Big Macs, to 64-oz containers and Grand Mocha Lattes, Coca Cola, PepsiCo, Dunkin’ Donuts, Starbucks and other food companies have each capitalized on the “big” fixation encoded in the American DNA.

The downside of American devotion to “big” is that we eat too much and drink too many calorie-loaded beverages, often because the servings are larger than they need to be to satisfy hunger or thirst. As a consequence, many Americans are Obese, and many suffer from type 2 diabetes.

Large multinational food and beverage companies, many of them U.S.-based, despite their prominent and deliberately well-publicized support for the public health through various forums, alliances and foundations, make and sell products that are not especially healthy.

Among major nations, current data from the World Health Organization ranks the U.S. first in the percentage of adults who are obese (33.9%). By comparison, the obesity rate for adult Mexicans is 23.6% and for Canadians 22.9%, almost one-third less than the rate for their North American neighbor.

In 2010, 12.3% of Americans between the ages of 20 and 79 had type 2 diabetes. Though China and India have the highest number of citizens with type 2 diabetes, the U.S. with a much smaller population is in third place. The rate is expected to surge to 14.0% by 2030. Because China and India have substantially lower adult obesity rates, 2.4% and 1.3% respectively, the U.S. can expect to hold onto its dubious obesity first place ranking for the foreseeable future unless we change our nutritional habits.

Can Public Health Officials Protect Us From Big Gulps?

The basic conflict American public health officials face is that large multinational food and beverage companies, many of them U.S.-based, despite their prominent and deliberately well-publicized support for the public health through various forums, alliances and foundations, make and sell products that are not especially healthy.

The top ten beverage companies, for example, captured “52.3% of sales worldwide; Coca-Cola and PepsiCo lead with 25.9% and 11.5% of sales, respectively.” Though Coca-Cola owns Minute Maid orange juice and PepsiCo’s brands include Tropicana orange juice and Quaker Oats cereals, their primary products (Coke and Pepsi) are the drivers of corporate profit and the leading examples of sugary beverages with empty, non-nutritional calories.

These companies are expert marketers and promoters, with armies of lawyers and public relations consultants. They have the clear ability, and goal, as a matter of corporate survival, to stifle all meaningful efforts to restrain and restrict their brands. The practical challenge, then, for governmental health professionals is to find a path that protects the public and doesn’t unduly interfere with corporate strategies and profits. What, then, can be done to address this challenge?

Can We Find a Model in Alcohol and Cigarette Regulation?

The historical evolution of two consumer products may provide the perspective for both manufacturers and health officials. The first product, cigarettes, was, like sugary beverages, successfully promoted by well-established companies who were, and still are, prominent in the marketplace.

When lung cancer victims were able to prove in court that the tobacco companies had knowingly continued to sell products they knew to be unhealthy, their days of opposition were numbered.

For years tobacco companies with powerful allies in the media and political worlds fought, at great cost, against a warning notice on cigarette packages, against bans on TV advertising, against prohibiting smoking in airplanes, restaurants and public places, against targeted higher taxes, against informal social changes such as non-smoking in Hollywood movies and TV shows, only to lose every fight.

Eventually, in the face of accumulating and finally overwhelming evidence of the link between cigarette smoking and lung cancer, the cost of maintaining their opposition became higher and higher. When lung cancer victims were able to prove in court that the tobacco companies had knowingly continued to sell products they knew to be unhealthy, their days of opposition were numbered.

Yet, after all these public health efforts, some people still smoke cigarettes. That, of course, is their choice. For today’s profitable cigarette manufacturer, all this change has had one benefit – no longer can plaintiffs easily assert that they were unaware of the dangers of cigarette smoking and were deceived by manufacturers.

The second risk-benefit consumer product is America’s other favorite beverage, alcohol. Once even banned by a constitutional amendment, alcohol survived Prohibition and continues to be popular and profitable.

Unlike sugary soft drinks it is taxed heavily; it is controlled by state and local laws; and its consumption is further restricted by age as well as where and when it can be sold. Yet, beer, wine and hard liquor companies remain extremely profitable, advertise and market freely, and have largely escaped the legal, social and political nightmares that overwhelmed the cigarette industry.

These companies are expert marketers and promoters, with armies of lawyers and public relations consultants. They have the clear ability, and goal, as a matter of corporate survival, to stifle all meaningful efforts to restrain and restrict their brands.

Because public health-beverage company alliances and joint efforts to improve nutrition are essentially at odds, some kind of official regulation of sugary soft drinks will be needed to protect the public health. After all, some may assert that the secret formulas of Coke and Pepsi may be as deliberately addicting as the nicotine in cigarettes.

Beverage companies will then have a choice. Like the cigarette manufacturers, they can resist endlessly every attempt to address the public health concerns and spend their corporate lives in court and elsewhere fighting lawsuits from consumers claiming their diabetes and heart disease were made worse by their addictive products and marketing.

Or, they can choose to help guide the regulatory process, like the alcohol industry did, and agree to commonsense positions. In this regard, Mayor Bloomberg’s initiative seems to be a modest first step that should be welcomed by industry leaders anxious to avoid the fate of cigarette manufacturers.

If they choose to resist even these tiny efforts, the likely result will one day be some kind of use tax because studies show that a tax would not only save lives but produce real savings in medical costs. Y. Claire Wang from Columbia’s Mailman School of Public Health estimates that a nationwide penny-per-ounce tax on sugary beverages would decrease consumption by 15%, generate $13 billion in tax revenues and reduce medical costs by $17 billion over the next decade.

Surely at this moment in American society, where affordable health care is on everyone’s mind, a use tax might be politically do-able. And if cigarettes and alcohol are any indicators, it's likely that we are just witnessing the first game in a long match between Big Food and good health.

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