From the 2013 Joan H. Tisch Public Health Forum, held at Roosevelt House, January 29, 2013, as reported by Laura Holbrook.

Click here for video from the forum.

The fourth annual Joan H. Tisch Public Health Forum: Can City Food Policies Reduce Disparities? Lessons from New York and London presented an informative panel discussion to explore what cities can and should do to make a difference to health inequities through food-related policies.  Both the US and the UK are currently experiencing obesity epidemics. The health consequences of food-related illnesses including diabetes, heart disease and cancer are well documented, as are health disparities among different populations related to these diseases. This program examined the benefits and challenges of addressing disparities through food policies and the role of municipal governments in tackling this issue.

Highlights of the forum included a discussion of the regulation limiting soda proportion size in New York City (NYC), broader efforts made to date by corporations in response to pressure from the public health sector, future public health targets to help stem, and perhaps reverse the rise in obesity and how seemingly small changes can drive larger public health benefits.

From the onset of the discussion, the panel agreed that oversized portion sizes and calorie dense foods were the drivers of obesity.  To the amusement of the crowd, Sue Atkinson noted the large American portion sizes saying, “I haven’t finished a meal since I’ve gotten here.”  Thomas Farley somewhat ruefully noted that when it came to public health efforts to stem obesity, it seemed many people had only heard of the soda portion cap.  He explained that the administration’s focus on sugary drinks was supported by data that increasingly supports the view that soda consumption is a major contributor to the obesity epidemic. In response, the portion cap regulation was developed to decrease the default size of soda to a less caloric and therefore healthier size.

Opposition to the soda portion cap and other proposed regulations to reduce soda consumption was put in perspective by Marion Nestle who pointed out that the rationale for these regulations were driven by a utilitarian view of how government should respond to public health.  However, Nestle suggested a different ethical view drives the opposition. That view frames regulations as a reduction of choice and therefore a freedom issue.  The same difference in view divided the anti-obesity and anti-hunger communities when NYC proposed a pilot program that would ban soda purchase with food stamps even though there are already restrictions on what products can be purchased with food stamps (including prepared foods, chewing gum, alcohol).

Farley expressed some frustration at opposition to the regulation since obesity and the chronic diseases it engenders, affects double the percentage of African American and Hispanic communities. Nestle suggested that corporations who stand to lose business are happy to exploit these differences. In the case of the food stamp pilot program, the USDA declined approval of the pilot program. Recently soda companies have filed suit in an attempt to overturn NYC’s soda portion cap and have been joined in their suit by the NAACP and Hispanic organizations.

After discussing some voluntary actions taken by corporations in response to pressure from the public health community, Yach suggested that although marketing by corporations may lead to a higher caloric intake, we should also look at what drives behaviors in different social groups.  Citing the difference in smoking rates between societal groups in the UK, he pointed out that the entire population was subject to the same taxes and restrictions on marketing and public smoking but rates of smoking were more than twice as high among lower income groups. The same inequities are prevalent in the U.S. as observed earlier by Farley. Yach went on to assert that to encourage a change in the types of food purchased, it would be necessary to shift the perception of value from the quantity to the quality of food purchases.

Yach also discussed new approaches pioneered by corporations in partnership with health insurance companies and sometimes government organizations, to improve health outcomes. An example was a program discounting healthy food called Discovery South Africa.  This program had shown increases in purchases of health food although a corresponding reduction in body mass index (BMI) or obesity had not yet been documented.  A trial of the same program will be undertaken in the U.S.

The establishment of free school breakfast in both New York and London was cited as an example of a “small change” that had a health multiplier effect. Atkinson reported that free school breakfasts, which had initially been greeted with skepticism by educators, had won converts in the UK as teachers noted improved behaviors and readiness of students.  The same results were seen when New York City’s schools began serving free breakfasts.

Asked to suggest government action to improve public health the participants cited using the soda size cap to promote a broader discussion of portion sizes and their role in obesity; changing food labeling to better reflect nutritional content; stopping calorie dense food marketing to children; changing the farm subsidy structure to support growing fruits and vegetables; and restoring funding to the CDC for preventative programs. After pointing out that the change in attitude towards tobacco came after doctors themselves started to quiet smoking, Yach suggested pressuring doctors to do a better job counseling their patients on healthy eating and the dangers of obesity.  Unlike the legacy of governmental social responsibility that exists in the UK, in the US participants felt a grassroots level push to reduce is needed to pressure government to make policy changes.