You can get garden variety health advice from the daily newspaper, the "health" section of most book stores, and of course thousands of web sites. I'm hoping to present thought provoking and maybe change provoking thoughts about individual and community health. This blog is not just what to do about health, but how to think about it. I'm looking forward to an exchange of ideas with readers. July, 2010


Thursday, September 13, 2012

Life by a Thousand Cuts

There is historical evidence that in ancient Chinese culture, continuing up to as late as 1905, a method of execution was used called "death by a thousand cuts."  In this blog I want to celebrate life and health, not death, and so choose not to elaborate on a method of capital punishment.  It is enough to say that the method relied on the cumulative effect of very small injuries, none of which was life threatening, but the process would build until the cumulative effect of a "thousand" small wounds ended with someone's death by hemorrhage and shock.  I'm using this as an analogy for health policy and health promotion.

According to news reports, this week the New York City Board of Health is prepared to enact a limit on the sale of sugared soft drinks, with a cap of 16 ounce serving sizes.  If the proposal is approved, fast food workers will only be able to say "Can I moderate-size that for you?"  Not exactly a zippy sales line. The local health code rule change was first announced in May of this year, and has been debated vigorously since.

One of the arguments against limiting serving size is that it won't matter, that people will get too many calories in many other ways, and in fact, they can just buy 2, 12 or 16 ounce beverages, effectively doing an end run around the rule.  It is not hard to find oppositional arguments that have face validity, and in fact, the sugared-beverage restriction cannot be called an "evidence-based" strategy.  Here is what is known: 1) Obesity is increasing dramatically, and the consequences for morbidity and economic impacts will be great; 2) sugared beverages are a huge contributor to excess calories in people's diets; 3) when people are given larger portion sizes, they eat and drink more; 4) if there were no other changes in diets, people drinking a few less ounces of sugared beverages would lead to substantial weight loss in the population.  All of these are persuasive points, but don't unequivocally resolve the debate.

From a health promotion perspective, it is worth trying all kinds of strategies for big public health problems.  Here is a chart that portrays many of the interventions used to limit tobacco use in society.

Many, perhaps most of the items in the chart have only a marginal impact by themselves, but taken together, the impact is to create a social environment in which non-smoking lifestyles are reinforced and encouraged at every turn.  That is where we are trying to take society with respect to obesity.  Sugared beverage restrictions in isolation may have limited effect on calorie consumption, but in combination with "thousands" (well maybe dozens) of other strategies, both policy and persuasive, we can create community contexts where healthy food and beverage choices are the norm.

This will take time, but only long-term change will be sustainable.

No comments: