Public Health and the Peril of the Poles

Comments in response to my most recent post -- and all of my posts, for that matter (and perhaps everyone else's) -- predictably cluster at the poles. The more conservative among us object from my right, the more liberal from my left. What tends to be overlooked in the process is not only the potential promise of a middle path but the slippery slope toward quagmire in either direction.

With that in mind, along with the adage "one man's meat is another man's poison," let's revisit the use of SNAP funds.

We could say: It's not their money, so of course food choices can/should be regulated. Leaving aside the contradiction in a government that is too big by offering food assistance in the first place, but too small by not regulating how it's used -- let's consider the implications. What is out of bounds?

Is a breakfast cereal with a first ingredient of sugar (candy by another name) but fortified with 11 essential vitamins and minerals and "part of a complete breakfast!" within bounds, or out of bounds? I personally consider such products the lousy part of a complete breakfast, and no one in my house eats them. If you want to pour milk over a multivitamin, you might as well leave out the jelly beans.

What about salad dressing or pasta sauce with more added sugar than ice cream topping? Oh yes, those products are out there -- on every supermarket shelf in the country. Are food stamps good for them, or not?

What about a bacon cheeseburger well-slathered with ketchup and served on a white bun? Talk about one man's meat! Most Americans would view this as the perfect meal, I suppose. But nutritionally, it is in fact a delivery vehicle for almost every excess that plagues the typical American diet: saturated fat, trans fat, starch, sodium, sugar and calories. Are food stamps good for that?

So the argument for regulation succumbs quickly to the devilry in the details. Can you just imagine the committees, hours and tax dollars required to address systematically where to draw all the lines that distinguish in bounds from out of bounds? We will probably need a whole new government agency.

But look in the other direction: no regulation at all. Then, money from the common pool specifically intended as a safeguard against true hunger could be used for candy and soda. Since poor dietary choices, adding up to poor diet, constitute one of the -- if not the -- single greatest sources of chronic disease and premature death, allowing food assistance to go in that direction clearly threatens to turn "live and let live" into "live and let die." We find ourselves very close to the no-strings-attached line, where public assistance is simply a blank check. It might as well be used for alcohol or tobacco.

As many noted in response to my prior blog, it's not "their" money -- it's "our" money. But that, too, is a slippery slope. Medicare is paid for with "our" money. If older people on Medicare didn't eat so badly, they would have less chronic disease -- and thus would burn through less of "our" money caring for pathology that need not have arisen. So should the food choices of everyone on Medicare be regulated, too? How about everyone on Social Security? Are those who contend we have too much government in play already by offering such assistance in the first place really suggesting we need a whole new government bureaucracy to regulate how it's spent?

The position I was advocating -- using an objective measure of nutritional quality to apply a system of financial incentives -- was not about ideology, despite all of the ideological opposition it engendered. It was about epidemiology. My view always is epidemiology over ideology. Let's do what actually works. If we don't know what works, let's test the things that might and find out.

Food assistance dollars are already regulated to some degree -- they cannot be used to purchase tobacco. So this is not "no strings attached" money. Once there are strings, we are invited to think collectively about how best to tie up loose ends.

Advocating for regulation is easy -- but for it to be done in a manner that is not haphazard and arbitrary, the nutritional quality of tens of thousands of foods has to be judged, reasonably and objectively. That's a lot of work. I know, because we've done it.

Much dialogue about public health policy and practice takes place at the poles. And there is peril for us all in that. Because at the poles we cannot hear one another. At the poles, we listen only to ourselves. At the poles, we are too far apart to ever get together. And so, in fact, there is no dialogue -- there is just competing monologue. And nothing gets done.

At times, our inalienable convictions will place us at a pole. So be it. But surely, this needn't happen all the time.

There is no real difference between a system of financial incentives and one of disincentives, except that one feels better than the other. Either way, you win doing one thing and lose doing another. A carrot withheld is a bit like a stick.

But they do feel different, and the incentive approach honors the autonomy of the individual, even while providing a nudge in the right direction.

Linking a system of financial incentives to a system of objective nutrition quality scores allows for the fact that one man's meat may be another man's poison, while addressing a status quo that is poisonous to all concerned.

-fin

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

 

Follow David Katz, M.D. on Twitter: www.twitter.com/DrDavidKatz

Comments

[dpgaff]

01:10 AM on 10/09/2011

If we took all the foods out of the supermarket that are dietary sugar, there wouldn't be very much left at the market. All carbs and starches are dietary sugar. Most fruits and some vegetables are dietary sugar. What if people buy tea, lemons and OMG sugar? Would that be disallowed under snap?
The thing is most disease is caused by germs. It is those things called pathogens making us sick and anyone can catch a germ.

[detailz1]

12:48 AM on 10/06/2011

Who is going to regulate the regulators?

[Sinestro Jones]

06:39 PM on 10/05/2011

This is not worth the headache. How can one's food choices be policed? Who will do the policing? Just stop. We have people who need food stamps to survive..provide advice on healthier food options and leave the rest alone.

[hugatree]

03:11 PM on 10/05/2011

I am a senior citizen who receives Food Stamps. What irritates me is that I can buy soda, candy, salty snacks with my Food Stamps (I don't, but it's permitted), but I cannot buy salad from a salad bar or a healthy soup from Whole Foods. I live alone and do not eat enough salad to buy all the ingredients individually or even the packaged greens without them spoiling. If I could make a salad from the bar, I can choose enough for two to three days at a time and not waste food. The cooked soups at Whole Foods are much healthier than soup in a can which is filled with sodium and preservatives. What's great this year in California is that I can use my Food Stamps dollars at the local Farmers' Market. All I would like is for the food choices allowed to make nutritional and food-saving sense.

[steve12]

10:39 AM on 10/05/2011

I would ban candy, soda, processed food and high calorie snack products. I would require nutrition classes be taken by all recipients and offer optional cooking classes.

I would start it as a pilot project in a single state before implementing anything nationwide.

[dpgaff]

01:13 AM on 10/09/2011

Sounds expensive. Who pays for that? It would only be the same things that we hear on TV all day.

[steve12]

05:08 AM on 10/09/2011

Obesity costs the U.S. $147 billion per year. This does not even include the lost productivity of that results from that healthcare nor the family loss of loved ones.

Over two-thirds of our people are overweight or obese now. Based on current trends, in just four years, that will increase to three-forths with over 41% obese.

We can choose to do nothing and let current trends continue and allow our people to get fatter, and fatter and fatter or we can do something about it. We did not eliminate smoking, but we reduced it by half since we started making significant public health decisions to curtail it.

It is also a national security risk. Our teens graduating high school are too fat to join the military. Obesity robs our people of their health, years of life and their productivity.

I can assure that the cost of some cooking and nutritional classes will be far less than allowing current trends to continue. Also, I would add a "fat" tax, as Denmark has done, on known culprits to help fund such efforts.

The most expensive thing that we could possibly do is nothing.

[Eric Mann]

10:48 AM on 10/09/2011

Expensive at the outset, in the long run, it saves us money.

[steve12]

09:40 AM on 10/05/2011

I would ban candy, chips, soda and processed food from the food stamps program. I would then require all recipients to take a class on nutrition and how to stretch their food dollars within 6-12 months after being on Food Stamps. I would then offer optional cooking classes.

I realize that this would be a restriction n

[jandos]

06:22 PM on 10/04/2011

I am not familiar with how much assistance food stamps provides. Is it safe to assume it only supplements a family's grocery bill or is it supposed to provide for all of it? Why not only allow ONLY bread, produce, meat and dairy and their canned or frozen equivalents? Wouldn't that eliminate the issue of having to deem each and every other product acceptable or not? If food stamps only supplement the grocery bill, shoppers could be expected to pay for any other items with their own funds, that way we're not arguing about sugar content, etc. They can make that decision for themselves while assistance provides for the healthy basics.

[hugatree]

03:19 PM on 10/05/2011

Food Stamps are supplemental to a monthly grocery bill. That being said, many people are forced to live entirely on the SNAP supplement due to financial issues. I am a senior citizen. I receive $133 a month in food stamps. I can make it pretty well if I buy very little meat and use a lot of rice and beans to stretch things to make it through the month. Many people my age live on Social Security alone (often because we were forced at some point to withdraw pension funds and use up savings on health costs). My senior apartment's rent (taxes subsidized by the government to allow reduced housing costs) is approximately 85% of my income. Add utilities, a basic phone for emergencies, and there is very little left for personal care products, laundry soap, bus fare, etc. I wish Food Stamps covered good, healthy food AND let us buy some laundry soap and a few personals like toothpaste and deodorant. Those costs really add up.

[lezahgg]

02:45 PM on 10/11/2011

There are people/family who sell their stamps at 50 cents/dollar, usually towards the end of the month. Some do it specifically because they need money for toothpaste, soap, etc. Some do it to buy cigarettes and liquor or just part of some kind of a scam. People buy these cards not only because they pay 50 cents on the dollar but I think there are some sort of tax benefits. Having been lucky enough not to have been in the position of needing stamps and always having enough to buy food, I was very critical about some people asking on Facebook if anyone knew anyone who wanted to sell some. There are people I work with who are very upfront about going to the markets at the end of the month to try to buy some from people standing outside selling. Some justify this by saying that they have big families and have not much more disposable income to spend on food than families receiving stamps so why shouldn't they buy them. It feels wrong to me but is it?

[khymarra]

02:47 PM on 10/04/2011

Regulating foods to a degree is understandable. However, when one considered the preventative drugging of our food supply prior to its processing, is there truly anything that can be deemed "healthy" that is not raised or grown in your own back yard.

Animals meant for the table are regularly dosed with antibiotics to prevent the possibility of illness; then agri-corps throw in an extra boost of hormones to make sure that they can harvest the maximum amount of meat from the animal. Edible plants are dosed with heavy chemical insecticides and their own hormone cocktail to insure maximum crop yields that are grown from genetically engineered seed.

As a nation we a facing elevated medical issues, obesity, and a failure of formerly successfully drugs along with a shortage of said drugs because of the alteration and so-called enhancements of our food supply. Regulating what can and cannot be purchased with food stamp benefits will not solve the problem of unhealthy purchasing. Before guidelines can be placed on buying there needs to be a reformation of food at the source.

Unhealthy eating comes from more than just bad or lazy habits, a lack of knowledge, or a lack of place of purchase. Unhealthy eating stems from the practices used to affect food at its origin.

[sunnybunny]

02:24 PM on 10/04/2011

It wouldn't be a huge stretch to limit eligible foods by type and amount like WIC does. People still have choices. They just have strict guidelines.

http://www.fns.usda.gov/wic/benefitsandservices/foodpkgregs.HTM

I think they should just expand this customized nutrition program to include everyone needing nutritional assistance (not just women infants and children) Giving everyone nutritious food in the right amounts would be less expensive for the government in the long run and nobody actually goes without. There may also be the added benefit of the incentive if people want those things that are not provided.

[Swegin]

12:29 PM on 10/04/2011

Its really quite simple if food suppliers want their food eligible to be bought with SNAP cards, then they have to meet some nutritional guidelines. Then the UPC code for that product is entered into a data base that all Grocery stores need to interface with their computerized cash register and inventory system they already have. It would cost hardly anything to implement, and would push the Government towards being the advocate for healthy food that they should have been doing all along. Next if Medicare recipients what a lower deductible they will voluntarily allow their food purchases to be monitored and if they are eating right, going to a gym for some modest exercise, their premiums and deductibles get lowered. That's not "big brother" thats the Government being good stewards of the taxes it collects, along with motivating people to live healthier lives. In 10 yrs we would save billions of dollars in health care costs, and people would be much happier and in less pain and destress

[hugatree]

03:27 PM on 10/05/2011

You have some great ideas, but I would point out to you that for myself and for the other 299 seniors who live in my low-income senior complex, "going to the gym" is a dream long past. We could no more afford the gym than we could a luxury car (or ANY car, for that matter). If the government is being a good steward for people who need help, it would provide some health programs that include exercise to keep Miedicare recipients healthy. Even the community-sponsored gym and pool in our town charges $5 per visit. I simply do not have enough discretionary funds at the end of the month to afford a gym. I walk when the weather is good. I do some basics at home, but my teeny apartment barely allows me to turn around let alone exercise. I don't need candy, chips, and soda apid for by the government; I need the exercise most people take for granted.

[Swegin]

06:15 PM on 10/06/2011

I understand Hugatree, and agree, that there should be arragements made for those on low fixed income such as your self. In the meantime though Tai Chi and Chi Gong are excellent small space exercises that would help. I will bet you couild get a teacher of either one to volunteer some time to teach if you looked around and asked.... just a suggestion that may help in some small way.

[evie]

10:53 AM on 10/04/2011

Why should gas stations, dollar stores, drug stores, etc., be authorized to accept food stamps? Shouldn't food stamps be used at food stores, commonly referred to as grocery stores, where a shopper has a wide and complete selection of fresh, whole foods, canned foods, milks, cheeses, breads, available to them? Why not have the food stamps pay for basic foods, eggs, bacon, grits, pasta, on and on and on, and the consumer pay for the extras they may wish to purchase? How did this get so out of hand? I do not have any problems with the government helping its citizens through a rough patch, but the abuse to this system is incredible. In my county in Florida I have come to realize that one child may be claimed for elegibility by more than one parent~ if the parents/cutodian of the child have separate residences, each residence claims that child, along with any others ~ so someone is gaming the system, and it is not the child. I don't know what the answers are, I wish I did.

[Kocho123]

01:26 PM on 10/09/2011

For one thing, I think that often in places where a large portion of the community uses food stamps, there are not many grocery stores, fresh produce, and healthy foods. If there are, these items are actually quite expensive. For many people, it is simply easier to get the maximum amount of calories for the smallest book by buying foods that are cheap and unhealthy (candy, chips etc). I also read that nutrition classes are suggested. It is doubtful that poor people or seniors on government assistance will have the time to leave their jobs or take time off to attend classes. Or have a means to get there. The concept of a food desert is unfortunately a stark reality for many people. Check it out.

http://www.marketmakeovers.org/node/147

[Jon Burr]

10:44 AM on 10/04/2011

The Netherlands is instituting a "fat tax," to global outcry from the "live and let live" gang - yet, here, from the "front left," I'd weigh in that they have the wrong target. Saturated fats raise resting metabolism, mood, satiety, and promote brain health. The problem with the burger is the bun, with its HFCS and HVO (hydrogenated vegetable oils)... but this is my opinion and belief, based on everything I've read... so, here's an example of the problem we face. Policy decisions are likely to be made on accepted (but outdated and incorrect) dogma. True, Nutrition is not "settled science" - it's a dynamic and fast-moving field. Public policy is slow, and usually unjust.

[TheCycad]

10:57 AM on 10/04/2011

there should be a fat tax. obesity is one of the most dangerous and expensive health problems we face in this country.

[Jon Burr]

11:30 AM on 10/04/2011

The point I'm making is that there is debate as to which components of diet are the most causative of obesity. Sugar, flour, HFCS and HVO are the main culprits. There are populations (the Inuit, and those in the southwest of France) with saturated fat consisting of +90% of dietary calories but with low rates of heart diesease and obesity. The blanket indictment of saturated fats is just wrong. See here: http://www.health-report.co.uk/saturated_fats_health_benefits.htm

[Pleroma]

11:26 AM on 10/04/2011

Great comment, but I think it is Denmark which is instituting a fat tax.
I totally agree with your comments about saturated fats, which have been a target of the food processing industry in the USA, which of course substituted hydrogenated factory fats for butter, palm oil, coconut oil and other fats the food processors don't make money on. Rather like the medical profession, Dr Katz emphatically included, which sells the public toxic pain meds, toxic anti-inflammatories, toxic psychiatric drugs, and fights to prevent the use of cannabis, which is cheap, effective, and safe.

[Jon Burr]

12:44 PM on 10/04/2011

Although I agree with much of what you're saying, your characterization of Dr Katz couldn't be further from the truth. He's the director of the Institute for Preventive Medicine at Yale, and comes from an honest, passionate perspective as an advocate for public health, and is a prolific researcher who has made major contributions in the field of nutrition and public health. He's not the garden-variety medical drug pusher with minimal nutritional education, as you accuse.

[TheCoyote20]

09:54 AM on 10/04/2011

The problem with "objective" health standards is that no one has any idea what these standards are. You can certainly claim to, but as you say, one mans meat is another mans poison. Health is individual. Some thrive on a low-carb, high fat diet, seeing no I'll effects from saturated fat (cited here as an objective bad). Some can thrive on a raw vegan diet of almost pure sugar from fruit. Regardless of who's money it is, if you say that saturated fat is a no-no, you allow me to say sugar is a no-no, or that wheat is bird food not meant for human consumption. Nutrition is far from settled science, and usually operates individually depending on genetics and family history. Until you can give me the absolute blueprint to human health, for every individual in all circumstances, trying to legislate food choice, even if that food is a "gift", is not doable. Even prohibiting truly objectively unhealthy foods like candy (zero nutritional value) opens the door to questionable foods like wheat and saturated fat that, depending on the source, are totally healthy. You are the whim of who controls the beuracracy.

[SteveC 1979]

10:42 AM on 10/04/2011

Good points. I wonder if it would be possible to determine a list (albeit short, maybe) of items that everyone considers are unhealthy and should not be "buyable" with food stamps. I am thinking soda, candy, and fast food would be on that list. The devil is in the details on this issue...but I absolutely think this is something that should be looked into given our country's average health profile.

[Pleroma]

11:33 AM on 10/04/2011

Hot, ready to eat food is already not allowed. The government in this case, as always, is responding to lobbyists.

[Meggleface]

11:58 AM on 10/04/2011

I have solved the writer's problem. Where he thinks there needs to be an entirely new government bureaucracy (like MORE government will help) I say, let the card be redeemable for only the essencials such as meat, vegetables, fruit, dairy and bread. That should cover it. No matter who you are or what you eat, you can make it from my list. The rest is luxery. If I can't afford to buy dorritos and chocolate icecream, neither should someone who receives food stamps. Let me say that again for good measure. If I can't afford to buy dorritos and chocolate icecream, neither should someone who receives food stamps.

[David Katz, M.D.]

07:05 PM on 10/04/2011

This space is far less controversial than all that. The consensus that more fruits, vegetables, beans, lentils, and whole grains have the potential to promote health is robust, widespread, and stable for decades. Nuts and seeds are now clearly on that list as well- as are fish. The ideal place in the diet for dairy and meat is subject to some legitimate controversy.

These issues can, and should be data-driven; not diatribe driven. We have both intervention studies and large cohort studies establishing what dietary patterns- and foods- promote health, and what patterns can threaten it. Regarding the nutrition metric I suggest using, it has been shown to correlate with health outcomes, including all-cause mortality (http://www.ncbi.nlm.nih.gov/pubmed/21496749). I agree we should be judicious, but that includes acknowledging what we DO know- and affirming that we are not entirely clueless about the basic care and feeding of Homo sapiens.