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Public Health and the Illusion of Your Autonomy: Kill the Umpire?

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I watched this year's Sugar Bowl with particular interest, given my daughter's graduation from the University of Michigan last year. So, I was happy with the outcome. Regarding the wild and wooly play, I can say only: Thank goodness there were referees! And that is the real point of this tale.

You may be one of those stopping by here because you tend to agree with me, or at least find what I have to say interesting. If so, thank you. I like being liked as much as the next guy!

But, I fully appreciate that you may just as well be one of those stopping by here because you almost never agree with me, and are looking for the next opportunity to put me back in my place or pick a fight. If so, I'm game. This one's (mostly) for you.

What you probably like least about me and my left-leaning inclinations is my penchant for so-called nannyisms (a conclusion I derive from innumerable less-than-complimentary comments in response to my columns). I realize I am by no means the quintessential nanny -- you probably like many of my friends and colleagues -- Mike Jacobson, Marion Nestle, Kelly Brownell, Michael Pollan -- even less. But let's talk about me.

Yes, I think food marketing to children should be regulated; I don't think a Madison Avenue marketing executive vs. the average 6-year-old is a fair matchup. I think nutrition guidance systems should be devised independently of the companies selling the food, should convey overall nutritional quality, and should correspond to health effects. I think a soda tax is perfectly reasonable, although I favor a nutrition-based system of financial incentives. I think tobacco should be banned. And what the hell, let's really go for it: I believe in gun control. Nannyisms, all.

But not so fast. Let's look at this from a different quarter altogether -- such as the fourth quarter of the Sugar Bowl.

For that matter, pick a sport, any sport -- preferably one you like to watch and/or play. With very rare exception (bowling comes to mind), that sport -- up to its highest levels -- is supervised by some kind of... well... nannies.

Baseball has umpires. Football, basketball, soccer and hockey have referees. So does boxing. Tennis and the Olympics have judges.

Should we kill the umpire, and all the rest?

That inclination does take over when the calls go against our guys. But chances are, we don't really mean it.

We don't mean it, because in the absence of an umpire or referee, any game becomes a no-holds-barred affair.

Of course, it might all run sweetly in accord with the honor system. But if you believe that, it's time to talk about my moonlighting as a bridge salesman. I've got a doozy for you...

No, what tends to happen in the real world when we've killed off all the umpires and referees is that the less scrupulous team prevails. Cheaters prosper in a world of no accountability.

What's that you say? You can look after yourself? You are, after all, a fully autonomous adult?

Well, alrighty then -- you and your team can indeed fight fire with fire. The other guys throw low blows, or lob pitches at the batters' heads, and your team can do the same. But that rapidly evolves into an arms race, and devolves into a debacle. Such a contest ends either when someone wins, or when a whole lot of people get very seriously hurt -- and everyone loses.

Viewed through an uncompromising "We're all adults who can look out for ourselves" lens, umpires and referees are unneeded, unwelcome nannies who wantonly trample the autonomy of the players.

But viewed through a lens I suspect most of us might be more inclined to use, they simply make sure the rules of engagement are reasonable, equitable and enforced. They prevent cheaters from prospering. They prevent an arms race. They prevent the outcome where whoever actually plays by the rules gets clobbered.

I won't speak for my friends and colleagues in public health, although I suspect they feel the same; I'll just speak for myself. I am nobody's nanny. But as you play with the military-industrial establishment with your health on the line, I don't mind being a referee.

You may feel you don't need one. But just like the basketball player who believes he doesn't need no stinkin' refs just before taking an elbow in the kidney... You are wrong. With all due respect, and meaning no offense -- you are dead wrong.

I find that often my job in public health is not about telling people things they never knew -- it's about telling them things they never knew they never knew. Nutritious food does NOT need to cost more. "Organic" and "natural" do not reliably mean organic and natural -- let alone better for you. "Zero grams trans fat" doesn't really mean zero.

If you have diabetes and are advised to control your sugar intake, beware pasta sauce -- which at times contains more added sugar than ice cream topping. If you have hypertension and are advised to watch your sodium intake, beware breakfast cereals -- which are, as a matter of routine, more concentrated sources of added salt than potato chips.

"Multigrain" doesn't mean whole grain. "Fat-reduced" does not mean more nutritious. Sugar may appear divided up into ten different aliases in an ingredient list so it doesn't have to be listed as the first ingredient. Physical activity during the school day does not interfere with academics, but often tends to enhance them. A slice of pizza is NOT a vegetable. And so on.

You may think you are defending your autonomy by opposing a ban on toys in Happy Meals. But while you are resisting the tyranny of public health, you are playing right into the hands of a large and rich corporation that is far more concerned with its profits than the health of your child. Did they consult you about putting the toy in -- or did they hold a closed-door session where highly-paid marketing executives told them how to manipulate you by manipulating your children?

You may not need your hand held in the supermarket, because you can make sense out of things all on your own. But which is better for you -- the unfortified breakfast cereal made from whole grain, or the highly fortified cereal made from stripped down grains with added fiber? Which is better for you, the whole grain bread which may or may not contain partially hydrogenated oil, or the bread made with less whole grain and canola oil? Do vitamins and minerals truly "enhance" water?

If you think you know the answers, I think you're wrong. I've devoted 20 years of my career and nine years of post-graduate education to these issues, and I find them challenging. I've written two editions of a textbook on nutrition, and still think this stuff is hard to sort out. What isn't hard to sort out is how the front-of-pack messaging is designed to take advantage of your confusion, and influence what you buy.

That you can even attempt to make informed decisions about nutrition (even if often failing in the attempt) is because products carry a nutrition facts panel and ingredient list -- mandated by that pack of nannies in the federal government. Absent that nannyism, none of us would have a clue what's in our food. I think we can, and should, do a whole lot better than a long list of factoids the average shopper and most experts can't readily assemble into a summative measure of overall nutritional quality -- but that's a discussion for another day.

Perhaps you have such faith in your autonomy that you believe you can outwit Ph.D.s in marketing paid large sums to outwit you. Perhaps your autonomy is the equal to the collaboration of food scientists, nutritional biochemists, and neuro-physiologists who have used functional MRI scans to determine what combinations of flavors and ingredients make it a virtual certainty that you can't eat just one!

If so, you probably don't want rules for airline safety checks either. No matter what the financial pressures, we can surely just count on the airline industry to avoid any corner-cutting, can't we? Airplane safety inspections and maintenance are endeavors overseen by aviation nannies.

Or maybe they are just referees. Objective third parties with a priority other than which team wins. Umpires who are committed to making sure the game is fair.

I don't think we're surrendering our autonomy by acknowledging a role for referees. In their absence, the team with more resources and fewer scruples will, indeed, win.

We needn't wade into the weeds about scruples, but let's acknowledge the resource inequity in public health. The companies and industries my fellow referees and I work to constrain have hundreds of millions of dollars to spend; you don't. They have access to every doctoral-level expert money can buy; you don't. They have proprietary data about the details of what makes customers like you tick. They've got the ear of Congress. All you've got is caveat emptor. You're going down!

Which is where I come in. Not as a nanny, but as a referee.

I realize I may still make calls you don't like. There may be times you want to kill the umpire. But perhaps we can agree that unlike a nanny, an umpire is not here to curtail anyone's autonomy. The job is to do the best one can to make sure the contest is fair.

After that, it's up to you. Play ball!

-fin

For more by David Katz, M.D., click here.

For more on personal health, click here.

Dr. David L. Katz; www.davidkatzmd.com
www.turnthetidefoundation.org

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