Public Health Strategies Part 4C: Bans

Public Health Strategies Part 4C: Bans, Steven Hamley

Bans on Unhealthy Foods

In earlier blog posts I discussed taxes and subsidies as public health strategies, mainly related to the current more popular calls to tax sugar sweetened beverages (SSBs) and subsidise fruit and vegetables.  In researching those posts I came to the conclusion that both strategies have some potential to influence consumer choices and therefore population health when implemented broadly (e.g. tax ‘extra’ foods instead of just SSBs) and strongly (e.g. 50-100% tax rather than 10-20% tax).  However, the narrow range of targets combined with the weak tax/subsidy is unlikely to substantially improve population health.  In addition, assuming consumption wouldn’t be affected, a 100% tax on SSBs would only increase the average household budget of low income earners by 1% [1], which is something that even most low income earners in an affluent country like Australia could shrug off (not to mention those on higher incomes).  This raises the question of whether more aggressive market controls such as bans on the marketing, sales and/or possession (the latter has actually been proposed [2]) of foods like SSBs are required to truly reduce the prevalence of obesity and metabolic disease

Bans can apply to the ability of producers to market a product or sell a product and the ability of consumers to possess a product.  Bans are not necessarily universal, it may only apply to certain times (such as advertising on TV when children are most likely to be watching and bands on selling alcohol after a certain hour of the night), places (such as bans on selling SSBs in schools) and very specific products (such as the proposed New York City ban on big gulps).  Non-universal bans on selling products are intended to lower consumption by reducing convenience, while universal bans on selling products or being in possession of them (such as illicit drugs) are intended to eliminate consumption

Like any other policy, putting a ban on unhealthy foods is likely to have unintended consequences and these will depend on what kind of ban is implemented.  A universal ban on unhealthy foods with little to no redeeming qualities like SSBs is unlikely to happen, and it could result in unintended consequences similar to the war on drugs and the American prohibition on alcohol, in addition to losing an opportunity for tax revenue.  Alternatively, a non-universal ban that reduces convenience can be easily circumvented by a determined consumer who can plan in advance to take extra drinks with them to consume late at night, to take SSBs with them to a school/university campus and to simply order to small size drinks instead of the big gulp.  Of course, not everyone will be the determined consumer and the point is that small changes in convenience can have large impacts in behaviour.

The rationale of banning something like SSBs (as opposed to TFA, asbestos, etc) is to save people from themselves, but is it the government’s job to do this?  Some people would object to the nanny-statism and demand the freedom to eat/drink what they choose, although if you’re asking the government to pay for your healthcare one could argue that you are implicitly trading some liberty for security.

Bans to reduce the consumption of unhealthy foods by children are another story.  Unlike adults, we do not hold children completely legally responsible for their actions (which scales with age of course), and so there is an argument to be made to protect children from themselves, or from their parents*.  With health issues like obesity and tooth decay being an issue among some young children, perhaps banning the sale of SSBs for children or to children (SSBs would be an 18+ substance like cigarettes and alcohol) would be help to reduce these issues.  Unfortunately, my look at the research at the moment suggests that just banning sodas at high schools results in an increased consumption of other SSBs [3], while banning the sale of all SSBs at middle schools only seems to reduce consumption at school and doesn’t appear to reduce overall consumption [4].  Perhaps there would be more success at primary schools, but also it seems people will get their sugar fix no matter what, and so the narrower the ban, the less likely it is to be effective at all

* Bit of a rant: sorry Guardian author, if a 2 year old needs 20 teeth removed due to tooth decay, that’s not an issue with oral health prevention [5], that’s child abuse from parents who don’t sufficiently care.  This is similar to issue that sometimes comes up where children fed a vegan diet are malnourished, leading to an Italian proposal to jail parents feeding young children a vegan diet [6].  I don’t want to necessarily jail vegan parents or vilify parents who give their children SSBs, just when there is evidence of harm, because it’s about the outcome (in the absence of losing the genetic lottery), not the methods to get there.  Vilifying ‘wrong’ methods regardless of any feedback from outcomes could lead to a hideously broad application of that Italian proposal (‘oh, you’re feeding your child a low carb diet?  That’s against the dietary guidelines.  It doesn’t matter that there’s nothing wrong with your child, you’re going to jail’) and leads to dogmatically sticking with the ‘right’ method, such as the dietary guidelines, rather than updating your methods based on the feedback from outcomes in research and clinical practice (outcome based medicine > evidence based medicine).  If you think I’m being harsh, consider how you would feel if you had your teeth removed, got type 2 diabetes or suffered developmental issues before you had the chance to make your own choices or because your mother smoked and drank heavily while pregnant with you.  The right as a parent to bring your child up their own way should not trump their responsibilities to bring them up well.

** The Torba province of Vanuatu is aiming to impose strong restrictions on junk food while promoting locally grown, organic food [7].  It will be interesting to see how that goes.  They have a fairly special advantage from being isolated and a small community which might lead to it working out very well (but good luck trying to implement the same in Australia, etc)

*** Alternatively if you see obesity and lifestyle diseases as an product of market failure, you could just ban capitalism and adopt socialism or communism, which is proving to be a really effective policy at reducing obesity in Venezuela at the moment :p

Ban on Trans Fats

This leads me to the FDA ban on partially hydrogenated oils (PHOs).  In the US, the FDA has ruled that PHOs are not generally recognised as safe for use in human food.  The response to this seems to generally be positive, with a small number of doubts and concerns coming from some libertarians.  I agree that banning PHOs won’t have much effect as consumption of PHOs is quite low and they aren’t actually that bad.  In Australia in 2009, the average intake of TFA is 0.5% of total energy intake, with 60-75% coming from animal foods, so only 0.125-0.2% from PHOs, though intakes in the US seem to be quite a bit higher [8].  A recent study using the Nurses’ Health Study and the Health Professionals Follow-up Study found that each 1% increment of total energy intake from TFA was associated with just a 10% increase in total mortality (the effect would be diluted as TFAs from animal foods are pretty neutral, but still) [9]

Even though at current intakes, PHOs aren’t that bad, they are still a great example of something that should be banned.  (1) PHOs are really only convenient for the food industry and consumers don’t seek them out (copha is disgusting) (no black market).  (2) They will likely just be replaced with SFA rich fats/oils (no negative unintended consequence for consumers, just a drop in sanity from the Heart Foundation).  (3) It’s unlikely that this will translate to regulation on ‘unhealthy’ foods like red meat because PHOs don’t have any nutritionally redeeming qualities, whereas red meat certainly does (particularly when most people could use more protein, iron and zinc, etc) (so the libertarian concern of increasing government regulation is unlikely)

Some objections to a ban on PHOs is the false dichotomy that SFA is a larger issue [10], concerns that the PHOs would be replaced with SFA rich fats/oils, and concerns that that enforcing a ban would be too hard [11].  The ban would be hard to enforce 100%, but would be just as hard to enforce accurate labelling [12] which seems to be the Australian Heart Foundation’s preferred method, at least initially.  Mandatory labelling hasn’t been implemented because TFA intake in Australia is less than the WHO target of 1% [13], but I still think consumers should still have a right to know

Down the Conspiracy Theory Rabbit Hole

Given that the FDA is banning PHOs due to their adverse health effects and having no redeeming qualities, why aren’t cigarettes also going to be banned?  Cigarette smoking is associated with far worse health outcomes than PHOs and also results in second-hand smoke and more litter.  About 15% of Australians still smoke despite decades of health messaging stating the adverse effects of smoking, cigarettes been heavily taxed, advertisements for cigarettes been banned, plain packaging laws, and graphic imagery depicting some potential consequences of smoking.  Surely banning the sale and possession of cigarettes entirely would be one of the most productive policies for public health (and even poverty), and potentially a popular policy for the vast majority who don’t smoke (cleaner air and environment) and especially for ex-smokers.  One could speculate that the reason why governments haven’t banned the sale and possession of cigarettes is that the tax revenue they get from them exceeds the healthcare costs from smoking.  When looking at the costs of smoking, you see stats along the line of ‘smoking costs $X’, but these stats are probably irrelevant if not compared with the costs of not smoking.  I came across a study from the Netherlands (so could be different elsewhere) that predicted that the healthcare costs of smokers and of people with obesity are actually lower per person because they live shorter lives [14], and haven’t yet seen another study with a similar type of analysis.  Another consequence of smokers and people with obesity or diet and lifestyle diseases tending to die younger is that on average you would expect them to cost the government less money on pensions.  I wonder if these reason are a factor why many governments aren’t aggressively addressing diet and lifestyle diseases.  After all, even if the average life expectancy suddenly increased by 10 years because the government implemented rigourous public health policies, people will still want their pension at 65 and moving the pension age up to 75 might be more politically unpalatable than getting people to stop having pizza and coke for dinner.  (That might be a bit of a stretch, but I think you could make a reasonable case for pensions being a factor (alongside more major ones like debt) behind the constant drive for economic and therefore population growth and for the migrant crisis in Europe, but that’s getting quite off topic).  But this is hardly a flawless conspiracy theory given that government had a major role in the reduction in smoking, the investment governments make in medical research, and the demographics that receive most of the healthcare expenditure (i.e. not working).

Public Health Strategies Part 4B: Subsidies

Public Health Strategies Part 4B: Subsidies, Steven Hamley

In an earlier blog post I discussed taxation as a public health strategy, particularly related to the proposed tax on sugar sweetened beverages (SSBs) in Australia.  In this post I’m going to look at the opposite of taxation: subsidies.

Putting a tax on unhealthy foods would generate extra tax revenue and so the question becomes whether the government should reduce taxes in other areas (or use it to help pay off national debt) or put that extra revenue into something, and if so, what?  Generally I have seen calls to tax unhealthy foods being coupled to calls to subsidise health foods, like fruit and vegetables (F&V).  There are a few rationales for subsidising healthy foods like fruit and vegetables:

  • Reducing the cost of fruit and vegetables would increase the consumption of them and displace unhealthy foods, which will ultimately improve population health and reduce healthcare costs
  • Coupling a fruit and vegetable subsidy to a tax on unhealthy foods (like sugar sweetened beverages) is also a means to reduce the increase to cost of living as a result of the tax, provided people purchase fruit and vegetables

However, there may be a few problems if a health food subsidy was put in practice

  • A recently published Australian modelling study estimated that a F&V subsidy ($0.14 per 100g of fresh and preserved F&V*) would increase F&V consumption by 42g (a serving of fruit and vegetables is considered 150g and 75g respectively).  However, it was estimated that the subsidy would also increase sodium consumption by 48mg and energy consumption by 236kJ (56.6 calories), because “however, using price subsidies or discounts as an incentive to purchase more fruits and vegetables may have the effect of increasing real income available to buy food, including unhealthy products, and could therefore lead to an overall increase in dietary measures such as saturated fat, sodium, or total energy intake”**.  As a result, their model predicted that a F&V subsidy would actually have adverse health outcomes [1].  The major benefit of food taxes is that they generate revenue [2].  This revenue should go towards initiatives that are at least cost effective, but with a F&V subsidy there’s this study says there’s a 89% chance that it wouldn’t be.  Not a great policy
  • A subsidy on F&V isn’t likely to offset the increase in cost of living from a tax on unhealthy foods such as SSBs.  The estimates show that there isn’t going to be much change in behaviour.  So the people who are already low SSB consumers and high F&V consumers are the ones who will benefit.  This got me thinking if the promotion of taxes + subsidies in some people (not all) is at least partly driven by financial self-interest, but you can defend this motivation in countries with socialised healthcare.  (By the way, my diet is very rich in F&V, with no SSBs and low added sugar, so I would benefit a lot from such policies)

In my opinion as a stingy student currently on an unflattering income, many F&V are already very cheap as there’s a lot you purchase for < $4-5 per kg or even less.  I think the reason why so many people don’t consume the recommended intake of F&V [3] is because other foods simply taste better, the structure of their habitual meals is not conducive to eating many F&V (cereal for breakfast, sandwiches for lunch, etc), and they don’t value/are empowered about their health enough to change.  When people say cost is important, they are comparing apples with apples, and not apples with muffins.  The apple wins easily on cost, but the café bought muffin wins on palatability and reward, and because most Australians have that money to spend, that’s what most people choose

A tax on unhealthy foods should be coupled with a subsidy or health initiative that is actually cost effective in itself.  An idea circulating around AHSNZ is that a tax on SSBs could be coupled to subsidy on dental health or free dental for children.  This would disproportionately benefit lower income families who are less likely to have private health insurance, see the dentist less often and more likely to have worse diets.  It is also likely to be more cost effective as healthcare spent in younger people has a greater return on investment, and dental health is one of the major health issues for children, and one (rampant tooth decay) that is potentially not reversible unlike obesity and type 2 diabetes.  Some people may be against the government using taxes and subsidies to save people from themselves, but may concede that something should be done as tooth decay is so common in children [4].  I would still like to see an estimate of the cost effectiveness of any policy, as good intentions do not necessarily create good policies

* For example, if a fruit or vegetable was priced at $4 per kg, this subsidy would cover 35% of the costs.  This method of subsidising has a greater effect on cheaper F&Vs such that it wouldn’t be practical as very cheap F&Vs like carrots would be almost free.  In fact, at the time of writing this Coles has a special on carrots at $1.20 per kg, so they would be paying the customer to purchase them, pretty crazy! (but don’t forget that F&V are expensive and cost of healthy foods is a limiting factor in population health…)

** I think this point is debatable.  Paying less for F&V would result in consuming more F&V and this may have the opposite effect on calorie intake as F&V are more satiating than most foods per calorie.  In addition, the sodium > blood pressure data they used was based on a large effect from observational studies [5] rather than the small effect in RCTs [6], although sodium could be a surrogate marker for highly processed foods and such foods are unhealthy for other reasons besides sodium.  That being said, if the estimates on calorie and sodium intake were ignored, increasing F&V intake by 42g alone isn’t going to have that impact on population health

*** The study also modelled the effect of taxes on SSBs, sugar, saturated fat and sodium.  The study estimated that all these taxes combined, plus the F&V subsidy, would reduce 470,000 disability adjusted life years (DALYs, or years with chronic disease) and would reduce health healthcare expenditure by $3.4 billion.  These figures seem impressive, but need to be put in context.  The study used a population of 22 million, so this works out to average reduction of 0.0214 DALYs per person (7.8 days) and average reduction in healthcare costs of $155.55 per person across their lifetime (or a few dollars per year, depending on how long you think the average person will live for (e.g. 40 years = $3.86 per person per year)).  This magnitude of response is consistent with another Australian study I discussed previously.  Modest taxes on unhealthy foods are somewhat useful at generating revenue for the diseases they increase the risk of, and will very marginally improve population health, but they won’t come close to solving the obesity/chronic disease epidemic.

Public Health Strategies Part 4A: Taxes

Public Health Strategies Part 4A: Taxes, Steven Hamley

In an earlier post I mentioned a few different commonly proposed public health strategies, and how most of them fit quite nicely into a political spectrum characterised by an authoritarian-libertarian axis and a left-right axis.   In this post I’ll discuss the strategy of taxation/subsidies, which I thought fits nicely into the authoritarian left quadrant.  This is because this strategy holds the food environment primarily responsible for people not adopting healthy lifestyle behaviours rather than personal responsibility, and then uses government controls to manipulate the free market.

Rationale

There are a few targets people have suggested to tax or subsidise.  There was the failed Danish tax on saturated fat, and sometimes there are suggestions that fruit + vegetables and even gym memberships (because you couldn’t possibly exercise without one) should be subsidised, but this isn’t very common.  At the moment, a tax on sugar sweetened beverages (SSBs) is far more commonly proposed and is actually being implemented in a few areas, so I’ll focus on that

There are two main rationales to support a tax on SSBs.  The first is that a tax on SSBs will increase their price and this would reduce the consumption of them, particularly in people on lower incomes, who consume more SSBs on average, as they are more sensitive to changes in price.  This is textbook supply and demand, as price goes up demand decreases.  In this respect, a tax on unhealthy food or a subsidy on healthy food could be seen as a form of nanny statism.  Generally, implicit in the support for a tax on SSBs is the belief that education programs haven’t or will not work on some people (the laggards).  This usually isn’t mentioned when a tax on SSBs is proposed (probably out of political correctness and not risking alienating others), but it is an important premise to justify taxes/subsidies, because otherwise why not use education instead?  And so a tax on SSBs appears necessary to reduce SSB consumption and therefore improve health, or, to save some people from themselves.  Or perhaps more importantly, to save the overweight/obese children with a mouthful of tooth decay from negligent parents.  But people who are against many forms of nanny statism argue that what right does the government have to control/influence individual choices that don’t adversely affect others?*  In addition, cigarettes are heavily taxed but plenty of people still smoke, and as David Gillespie points out, there is already a tax in Australia on many processed foods including SSBs in the form of the GST [1]

This leads into the second rationale for taxing SSBs which counters the previous argument.  In countries with a socialised healthcare system the consumption of SSBs creates a negative externality.  When people purchase SSBs they are paying the costs for the product but are mostly or totally externalising the increase in healthcare costs from SSB consumption increasing the risk of several chronic diseases.  As a result, it could be said that they are not paying the ‘true costs’ of a SSB.  Let’s say 1 litre of SSBs costs the consumer $1.50 but each litre of SSBs is associated with an increase in healthcare costs at about $0.30.  Therefore, in this scenario a 20% tax on SSBs is necessary to internalise the healthcare costs.  With this rationale of internalising externalities, a tax on SSBs could be considered a successful policy even if no one changes their behaviour as a result of the tax, and also doesn’t make it about nanny statism or a moral judgement (a ‘sin tax’)

Of course, the government (and health associations [2]) also has a motivation to tax things that are politically acceptable as a form of cash grab, particularly if they’re the kind of government that likes to spend money, which seems to be the main motivation for the Danish tax on saturated fat [3].  “A lesson learnt from this chain of events is that if a tax on fat is to survive it needs more than merely to be passed. It probably needs to be politically supported for health rather than fiscal reasons and to be supported or at least accepted by prominent actors in the food arena including researchers.” [3]

* This can also apply to laws against recreational drug use (that doesn’t expose people to second hand smoke for example), ‘unsafe’ playgrounds and bike helmet and seatbelt laws

Efficacy

Danish tax on saturated fat: some people in public health have praised the Danish fat tax because it reduced the intake of saturated fat [3].  However, simply implementing a well-intentioned policy doesn’t mean it’s necessarily going to have good outcomes.  The most important outcome of such policies should be related to health rather than consumption, and in this respect even diet-heart diehards should judge it to be a failure.  Based on ecological data, the Danish tax on saturated fat appears to have reduced SFA, MUFA and PUFA by 0.3%, 0.2% and 0.1% of total calories respectively (this is because foods high in SFA are often high in MUFA and PUFA on a grams per weight basis).  As a result, LDL-C would be expected to decrease by 0.008 mmol/l and HDL-C would be expected to decrease by 0.005 mmol/l, and this would be expected to increase the risk of CHD by 0.2% (-0.3% for LDL-C +0.5% for HDL-C) [4].  While it’s ideal to be able to judge the efficacy of the tax based on actual changes in population health rather than modelling, the estimated effect size here is probably too small to notice and would likely be drowned out by noise.  The Danish fat tax also had the issue where consumers could avoid the tax by purchasing heavily taxed foods in neighbouring countries without such a tax

SSB tax in Australia: a tax on SSBs hasn’t been implemented in Australia but one study in particular has estimated effect of a 20% tax on SSBs in Australia, and found the following [5]:

Males Females
Consumption 141g/d to 124g/d 76g/d to 67g/d
Total energy intake -16 kJ/d -9 kJ/d
Change in BMI -0.10 -0.06
Weight loss 0.32 kg 0.06 kg
Obesity prevalence 2.7% (0.7 percentage points) 1.2% (0.3 percentage points)
Health-adjusted life years 112,000 (4.54 d/per capita) 56,000 (2.27 d/per capita)

The estimated change in BMI as result of the tax is similar in magnitude to other studies in the US [6].  The tax is expected to cost 27.6 million AUD upfront, but generate 400 million each year and reduce healthcare costs by up to 29 million per year (savings are expected to increase over time and plateau at 29 million) [5].  This is a decrease of just ~0.024% in total healthcare expenditure (29 million/121.4 billion [7]) and is why it’s important to put those kinds of figures in context

Given that the revenue generated equates to about 0.329% of total healthcare expenditure, and that SSB consumption is likely responsible for at least a 1% of total healthcare expenditure (not aware of an estimation for this, but 1% seems like a reasonably conservative estimate), if the rationale for taxing SSBs is to internalise externalities then the tax would need to be substantially higher.  This is also true if the goal is to meaningfully improve population health

One of the problems with this model is that the health outcomes are based on BMI, which in turn are based on the very small estimated reduction in calorie intake, and doesn’t look at any effects of SSB intake independent of calorie intake and BMI.  And of course it looks at adults, whereas if it also included children the estimated effects would be greater because the analysis would include more people and because the expected health benefits are larger for younger people.  That being said, a modest (~20%) tax on SSBs in an affluent country like Australia (where the economic effect can be largely ignored by almost everyone) is certainly not going to be a silver bullet.  The food industry has a point when they say that SSBs only contribute about 3% on average to total energy intake.  ‘Extra’ foods contribute about 36% on average to total energy intake in Australia [8], so there’s a lot wrong with the average Australian diet.  Therefore, one could argue a lot of potential targets to tax, but also that there’s a lot more that needs to be changed by even a 10% reduction (~3 percentage points) in ‘extra’ foods as a result of a broad taxation policy

Other Objections

Some people argue that a tax on SSBs is a tax on the poor, as poorer people on average consume more SSB and are more motivated by changes in price, but there are a few issues with this objection.  (1) They are confusing intent with outcome.  This is a mistake many people make related to other issues where there is a race/sex/etc disparity.  The tax is not discriminatory (except against SSBs) as it’s not intended to disproportionately tax poorer people, but it’s simply that the people who consume more SSBs happen to be poorer.  It’s not like this is a tax on renting or living in apartments, which actually has more of a causal relationship with being poorer (2) People are free to purchase SSB or not.  There’s nothing forcing poorer people to consume more SSBs on average.  If they don’t want to pay the tax they can choose not to purchase them, after all SSBs are very discretionary food items.  (3) While the tax is estimated to cause large relative differences in total household expenditure (consumption multiplied by income differences), the actual increase in expenditure for low income earners is very modest (~0.2% household income, ~1% of food budget) [9] (4) A tax on SSBs is likely to disproportionately benefit the health of poorer people.  People in public health usually try to engage and improve the health of low SES people disproportionately.  After all, no one in public health is really advocating for a subsidy on salmon, avocado, blueberries and quinoa.  (5) Who do you suppose the tax revenue is likely to disproportionately benefit, almost regardless of what it’s used for?

Another objection is that a tax on SSBs will reduce sales and as a consequence some employees will have to be laid off (if the food industry objects to the tax for this reason, then you know they think it will work to some extent).  The goal isn’t (and shouldn’t be) to punish the food industry as they are reacting to consumer demand for the most part (but they should be punished when they distort science, and there are numerous examples of this).  But the food industry and their employees shouldn’t get upset that in countries with socialised healthcare, the government at some point may tax unhealthy food to improve health and/or internalise externalities, after all there is a rationale and incentive for it to do so.  While it’s unfortunate that a very small number of people may lose their jobs, it’s important to recognise that there are other jobs out there, and that changes in the world will always create winners and losers (the internet is a great example), and part of life is setting yourself up to manage such likely changes well

While I thought taxes/subsidies and bans fit nicely into the authoritarian left quadrant, a modest (~10-20%) tax on SSBs isn’t really that authoritarian.  However, a major concern, particularly from libertarians, is that a tax on SSBs sets up a precedent for governments to tax other things, where these other things may be quite inappropriate targets for improving population health, while also leading to a progressive loss in individual freedom.  This should also be of concern to people in ancestral health, low carbers and other, regardless of political opinion, as by adopting such dietary practices we acknowledge that the government and mainstream isn’t always right.  A good example of an inappropriate target is the Danish tax on saturated fat, as saturated fat is not associated with coronary heart disease in meta-analyses of observational studies [10], replacing saturated fat with polyunsaturated fat does not reduce coronary heart disease in adequately controlled randomised controlled trials [11], and reducing fat intake is hardly the best strategy for weight loss [12].  Similarly, total fat is a potential target, but increasingly less likely.  (Red) meat is another potential target for taxation for health or environmental reasons, despite evidence to the contrary [13] [14] [15].  Salt is another potential target because people in public health seem to have an almost pathological hatred of salt, despite the relationship between salt intake and mortality being on a U-shaped curve [16] and that reducing salt intake doesn’t affect blood pressure much but does have some undesirable side-effects [17].  Being in academia and around nutrition students hasn’t alleviated these concerns, it has strengthened them

This post is already quite long so I’ll simply list a few more papers if you’re interested:

  • Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study [18]
  • Impact of the Berkeley Excise Tax on Sugar-Sweetened Beverage Consumption [19]
  • Using price policies to promote healthier diets [20]
  • Modelling the potential impact of a sugar-sweetened beverage tax on stroke mortality, costs and health-adjusted life years in South Africa [21]

Public Health Strategies Part 3: Education

By Steven Hamley

In an earlier post I mentioned a few different commonly proposed public health strategies, and how most of them fit quite nicely into the political spectrum characterised by an authoritarian-libertarian axis and a left-right axis.   In this post I’ll discuss the strategy of education, which I thought fits nicely into the libertarian left quadrant.  This is because this strategy holds a lack of education and empowerment primarily responsible for people not adopting healthy lifestyle behaviours rather than character defects, and then ultimately leaves the adoption of healthy lifestyle behaviours up to individuals once these educational needs are met

 

Role of Education

In earlier blog posts I discussed how one of the weaknesses of relying on individual personal responsibility is that that strategy depends on individuals having reasonably easy access to reliable information that when implemented would improve their health, substantially reduce their risk of chronic diseases (which I consider as >80-90%), and better treat or even reverse the chronic diseases they currently have

The whole point of improving health is a (reasonable) belief that poor health and chronic disease substantially impairs quality of life, whereas the sacrifices to quality of life in adopting healthy lifestyle behaviours is/should be very small or improves quality of life as early as the day you make them or the following day.  Otherwise, if the costs of adopting healthy lifestyle behaviours exceed the benefits of good health and reducing the risk of chronic disease, then education as a public health strategy is simply one big con

If we assume for the moment that humans are rational creatures, we would therefore make decisions based on objective cost-benefit analyses, and so this shift in favour of healthy lifestyle behaviours in theory should be quite automatic and shouldn’t be too difficult.  However, these analyses depend on our perception on the costs and benefits of various behaviours and our perception is based on our knowledge of the world (perceived cost-benefit).  Therefore, the rationale of education is that providing information regarding the efficacy and implementation of healthy lifestyle behaviours, and the consequences of good health and chronic disease, would shift peoples’ perceived cost benefit analyses in favour of adopting behaviours that improve their health and reduce their risk of chronic disease

You could break down this information to along simple-complex lines and along theoretical-practical lines.  The dietary guidelines are actually a fairly good example of this as they include both a complex 100s of pages long report, and a summary report including how to implement these guidelines.  I’ve included another example of what I’m thinking of below, using the scenario of vitamin K2 for osteoporosis:

Simple Complex
 

Theoretical/justification

 

Stating that vitamin K2 helps put calcium in bones

 

RCT evidence with effect sizes, mechanisms

Practical/implementation  

What foods are rich in K2?

Eat X serves of Y

 

Supplementation, blood tests to measure vitamin K2 status

Health Associations

Here’s the problem, Osteoporosis Australia doesn’t have content on vitamin K2 alongside their content for calcium and vitamin D, and the information they do have only satisfactory checks the simple-theoretical box.  They don’t provide RCT evidence from the vitamin K2 supplementation trials, they say what foods are rich in vitamin K2 but don’t give an indication on how much you should aim for with prevention and treatment (like what they did with calcium and vitamin D), and they don’t inform people on possible blood tests to check for vitamin K2 status.  Osteoporosis Australia also doesn’t have a section for protein (alongside their sections on calcium and vitamin D) which I would think is important considering the popularity of the debunked hypothesis that high protein intake contributes to osteoporosis due to the acid load of protein, despite higher protein intakes actually improving bone mineral density

I’m not targeting Osteoporosis Australia specifically as you could level similar criticisms against just about every other health association.  Many of these health associations provide the earthshattering information that their disease is caused by genes and environment, spread information that is outdated or based solely on observational studies, feature a disproportionate number of recipes for deserts if they have a recipe section, don’t discuss any science beyond the most basic, don’t mention that their disease was historically near absent and near absent in various populations prior to adopting a western diet and lifestyle.  For example, on the Diabetes Australia website you will be told that type 2 diabetes is a progressive disease and see a disproportionate number of recipes for desserts, but won’t be told about superior strategies to manage type 2 diabetes such as a low carbohydrate diet or strategies that have a good chance at reversing type 2 diabetes such as the very low calorie Newcastle diet.  On the Heart Foundation website you will be told that salt is a meaningful factor in the development of hypertension and that saturated fat increases your risk of heart disease, and once again you will see a disproportionate number of recipes for desserts, but you won’t see much on the Mediterranean diet, the PREDIMED Study or the Lyon Diet Heart Study.  On the cancer council Australia website you will be advised to eat a low-fat diet and that red meat increases the risk of colorectal cancer.  You will read about the evils of sun exposure, but won’t be told that vitamin D reduces the risk of other cancers or the possibility of a ketogenic diet potentially improving cancer prognosis.  (I wouldn’t include dietetic associations on this list, as it is clear that their primary goal is to benefit dieticians as a group rather than the health of the general public (they function much like a trade union in this respect))

Suffice to say, I think information regarding health and disease can be substantially improved, and this is a reason why I’ve gone down this path.  I think health associations should:

  • Remove things that aren’t correct
  • Provide information that allows people to increase the number of methods by which they can improve their health and reduce the risk of chronic disease
  • Justify these approaches with evidence, particularly from RCTs
  • Add some clinical information in case that their doctor doesn’t know about the latest research, because otherwise this will be limited to online forums
  • Provide more information regarding the probable causes of disease.  We may not know everything, but we certainly know more than the obvious genes + environment

Education is not Always Sufficient

That being said, we don’t live in an ideal world where education/knowledge is sufficient to cause behaviour change.  I’m sure each of us could identify at least one area of our lives where this is the case.  But most importantly, it’s clear the education has worked in a sense that people know the basics of a healthy lifestyle (fruit and vegetables are healthy and that soft drink and desserts are not, walk regularly and do some moderate to vigourous physical activity each week, and get enough sleep) and have some understanding of their importance (one could hardly go through life and not be exposed to health information via school and the media at least).  However, that so many people are failing at the basics suggests that simply restating the basics won’t achieve much (the anointed strategy of ‘if it fails, just do the same, but bigger’) and also that education is not always sufficient to change behaviour

Some of the reason for this is that we are wired to be more like instant gratification monkeys rather than deeply logical and rational robots.  In fact this acknowledgement of our own irrationality and impulsivity is something I think that’s missing from health education and education in general*.  Many healthy lifestyle choices require a sacrifice of instant gratification now for a larger payoff in the future.  The way that that health information is presented doesn’t help this as the benefits of a healthy lifestyle is discussed in terms of risk while rarely providing information regarding the magnitude of risk reduction.  Our environment doesn’t help either, as maintaining good health and a healthy weight requires consistently making more effortful and less hedonistic choices such as the purchase of blander and less well marketed foods rather than hyper palatable, high reward and well marketed foods, as well as doing some exercise, meditation or going to sleep when something on the computer or TV is more engaging, etc**

* Something else I think that’s missing from health education is dispelling people’s beliefs that they are healthy when they’re not, although I appreciate that telling people that they’re fat, sick, instant gratification monkeys is a hard sell, but it’s probably necessary.  A recent report found that about 50% of Australians heave a chronic disease and 63% are overweight or obese, but 85% said they were in good or excellent health [1]

** I consider the environment to be the most important factor regarding health.  Remember, I don’t believe in free will, and consider everything to be a consequence of genes + environment, and our genetics haven’t significantly changed in the last few decades.  But I don’t think that a substantial change in the environment (like a regression back to the 1950’s or earlier) is a feasible public health strategy because we want cheap delicious food, labour saving devices and entertainment.  We can make some changes to incentivise healthy lifestyle behaviours (such as a user pays healthcare system and taxes/subsidies) and ban the worst offenders that no one really wants (industrial trans fats).  Beyond that, it’s really up to education and having people create their own micro-environment that promotes health

Targeting the Early Majority

In addition, while it’s probably politically incorrect to say so, some people just don’t care about health, and all the health education in the world isn’t going to change that.  Smoking has had many strategies used against it (education, taxation, bans, stigma, graphic images to invoke disgust, nicotine patches, support for quitting, etc) but people still smoke anyway, much like how people know various crimes are wrong but still commit crime anyway

The following graph is the prevalence of number of healthy behaviours in the US (not smoking, ≥7 hours of sleep, moderate or no alcohol, met physical activity recommendations, normal BMI) [2].  It may not seem too bad, but diet isn’t included, and “76% did not meet fruit intake recommendations, and 87% did not meet vegetable intake recommendations” [3] (similar to “…95 per cent of Australians did not eat the recommended servings of fruit and vegetables” [1]).  There is an explanation for everything, in this case, our high incidence of overweight/obesity and chronic disease.  We are only as good as our weakest link so unless you won the genetic lottery, you will need to do them all

I think you could draw a parallel between the theory of diffusion of innovations, the prevalence healthy lifestyle behaviours, and health consciousness and consequently the receptivity to health education/information

Innovators + early adopters = highly motivated by health (4/5 – 5/5).  These people will seek out health information beyond what is provided by health associations.  Public health doesn’t need to target these people, but providing more complex information will make their research more convenient

Early majority = fairly motivated by health (3/5 – 4/5).  These people are fairly receptive to health information but health education may need to be improved to sufficiently inform, motivate and empower them (such as changes suggested here, plus others I haven’t thought of).  Since the theory of diffusion of innovations suggests targeting the early majority and this group is fairly receptive to health information, I don’t think health associations/etc should be too concerned with providing more detail, depth and complexity than the bare minimum

Late majority: not very motivated by health, but not a disaster either (2/5 – 3/5).  Once the early majority has adopted more healthy behaviours and become healthier, and such things have become normalised, the late majority will see that such behaviour change is both feasible and a net benefit to their life.  We might then see a social contagious model of health rather than one of obesity [4]

Laggards = doesn’t really care about health (0/5 – 2/5).  This group can get some rare and awful health scares, but these health scares rarely change behaviour.  Other strategies are probably more productive if you want to improve the health of these people (see next post)

You can read more on Steven’s work HERE

Public Health Strategies Part 2: Personal Responsibility

By Steven Hamley

If you find one of the ideas in these posts on public health strategies objectionable consider waiting before jumping to conclusions because I may address your concerns in a later post

In an earlier post I mentioned a few different commonly proposed public health strategies, and how most of them fit quite nicely into the political spectrum characterised by an authoritarian-libertarian axis and a left-right axis.  In this post I’ll discuss the strategy of personal responsibility, which I thought fits nicely into the libertarian right quadrant.  This is because personal responsibility is a key value of the political right, and because personal responsibility is a strategy that maximises individual freedom and ultimately limits the influence of government and others

It’s tempting to blame what’s called the obesogenic environment (which is a decent point I’ll discuss later) and ‘evil corporations’ for the rise in obesity and other chronic diseases across the globe.  Similarly, because free will cannot exist, one could justify playing the victim, that they are not personally responsible for the bad things that happen in their life including their poor health behaviours and health status, that they are a victim of being born to the wrong parents and living in an obesogenic environment.

As discussed in the previous post, even though free will does not exist there is value to society and us as individuals to emphasise a belief in personal responsibility.  We have plenty of options to make healthy or unhealthy lifestyle choices; we all know the basics of what to do to improve our health (that whole foods are on average healthier than highly processed foods and that getting enough exercise and sleep are important); and no one has a gun to our heads forcing us to make the wrong choices.  The blaming of business is not really appropriate (except when they distort science and engage doctors/dieticians for hire) as businesses cannot force us to purchase their products (unlike government), but instead they are reacting to what consumers want when they decide to open more stores and make more products (supply and demand).  In addition, there should come a time when people realise that although playing the victim may give you an excuse and sympathy in the short-term, but in the long term others will become desensitised to the strategy such that it no longer has the same effect, and is ultimately unproductive as your problem will remain until you take active steps to fix it.  In this respect, holding yourself and others personally responsible is more empowering than wallowing in self-pity

The efficacy of personal responsibility as a public health strategy is difficult to assess.  Some people may argue that it’s the status quo and so is failing as a public health strategy.  However, I don’t think this is completely true

1) Taking personal responsibility for your health isn’t as incentivised as it could be.  Most Western countries have some degree of universal healthcare, health insurance, subsidised pharmaceutical drugs, and government funding into the basic sciences that can lead to drug development.  These policies and institutions mean that individuals and not completely financially responsible for the costs of poor health resulting from poor lifestyle choices, and the financial costs are instead shouldered by others to varying degrees in the form of more taxes, or from funding being taken away from other public services.  Under such conditions it would be expected that individuals would be less motivated to prevent and treat diet and lifestyle diseases themselves by improving their diet and lifestyle

2) Our society’s narrative on ageing and chronic disease is one that emphasises an inevitability of chronic disease and the role of bad luck, rather than personal responsibility.  I think some of this narrative is to protect against blaming and shaming when people are at their most vulnerable, but it has the unintended consequence of fostering a belief that humans are broken and creating a sense of hopelessness

So the potential of personal responsibility as a public health strategy is not likely to be realised in a society that has universal healthcare, social norms against personal responsibility and a pessimistic attitude towards ageing and chronic disease.  So the strategy of personal responsibility should be coupled with:

(1) a major change in universal healthcare, or at least the addition of a mechanism that incentivises people not getting lifestyle diseases/adopting good health choices (focus of the next post I have planned); and

(2) a change in society’s narrative of chronic disease to one that empowers people

The second point illustrates a weakness with personal responsibility as a public health strategy.  Which is that it requires that people either know or have readily available access to the knowledge that will allow them to make the healthy lifestyle choices that will dramatically reduce their risk of chronic disease or in other cases treat or reverse existing diseases.  Some of this knowledge is already widely known, but most people don’t know about even well supported interventions (such as very low calorie diets for type 2 diabetes, vitamin K2 for osteoporosis, and higher protein diets for fat loss and sarcopenia) and there will almost certainly be more options available that no one knows yet until more research is done.

Part 3 of this Public Health Strategies series coming soon.

Steven Hamley is a PhD candidate at Deakin University in Melbourne. His research project is on the prevalence of pre-diabetes and insulin resistance in healthy young adults and the relationship these have with body composition, diet, metabolites, and alterations in insulin signalling.

Steven will be speaking at the upcoming AHSNZ Symposium 20-22 October 2017. His presentation is titled Insulin Resistance: the Elephant in the Room of Chronic Disease.

Part 2: Addressing 21st Century Excesses and Deficiencies

This post follows on from Part 1 – On 21st Century Excesses & Deficiencies.

Dr Karen Faisandier gives her thoughts on how to restore yourself to your most optimal level of wellbeing after physical and mental health difficulties, using a range of nutritional and lifestyle interventions. 

Symptoms of physical and mental health difficulties often co-occur via the gut-brain-axis (because your body is not separate from your mind), and therefore integrative solutions are often required (Greenblatt & Brogan, 2015). So when the gut-brain-axis has been compromised (read Part 1 all about this if you haven’t first), and is causing ill health, it often requires a considered effort to return to a state of wellness. At the end of my talk, an audience member aptly asked me the question, “But how do I actually do this?” This question stayed with me for weeks afterwards with thoughts about how hard it can be to recover your wellness when you’re physically and mentally symptomatic, especially when you don’t have energy, don’t have sufficient time or resources, and have an absence of support. So the following is my considered response to this compelling question.

An Intricate Jigsaw Puzzle

When you encounter chronic physical or psychological difficulties, there are many multifaceted pieces to find on the road back to wellness – much like a jigsaw puzzle. Sometimes you’ll find the right pieces yourself, sometimes you’ll need a hand, and sometimes pieces don’t fit. Sometimes you may want to give up – it seems too hard or you’re too unwell. Sometimes a piece may go missing, or you need a break from looking, or bits you’ve started have to be re-done. Along the way you may feel frustrated, impatient, elated, renewed, empowered, or like you’’ll never get there. Your world view can be forever changed by the experience and new values and boundaries may develop around your health and wellness.

 

 

Anyone who has any experience with doing a jigsaw puzzle will know that in order to get anywhere (and not become extremely frustrated and give up) you need to have the picture on the box to guide your process – this is a reference point. In healthcare, this picture is analogous to an evidence base, which also requires a strong therapeutic alliance with the practitioner you work with (e.g, the degree of trust, compassion, and credibility they bring to their work). Everyday in my job, I sit with people who are working out the pieces of their own puzzle, and I am tasked with providing them a robust picture on a box and compassionate guidance. In recent years, more and more of the pieces of the picture I provide have revolved around nutrition, gut health (gut-brain-axis), and lifestyle design, alongside traditional psychological and therapeutic models.

If you have had to work out your own puzzle (or are still working on it) because of chronic illness, this process usually involves a philosophical shift and a journey – it took you time to arrive at this point and it will also take time to learn and apply what’s needed for your recovery. This journey is yours alone and won’t look exactly the same as anyone else’s. Hence, my key points in maintaining or resuming an individuals gut-brain-axis health involve a broad and individually tailored approach. This applies whether you simply want to learn how to stay well or whether you have experienced a health crisis that has required you to sit up and pay attention to your body. If this is you, and you notice a sense of overwhelm or resistance to what this journey might involve, just choose where you want to start and do what you can. It is the journey itself that matters and this requires both knowledge about, “What it takes” and an understanding of, “How to do it”.

 

“The known is finite, the unknown infinite.”

                                                           ~ Thomas Huxley

What it Takes

Having attempted to boil everything down simply (I am a minimalist at heart), I fitted onto one slide all the vital components of maintaining or returning to a well functioning gut-brain-axis.  In an even further reduced form, my core message is this: Find ways to dampen the stress of modern living on your body and mind, in whatever form these stressors take for you. Of course, having identified these is the easier bit – the devil is in the details.

Seven Thoughts on “How to do it”

1) Some things are in your control

The choices you make (nutrition and lifestyle) have a significant effect on the route your path will take when it comes to your physical and mental health.  In this model, you can avoid, treat or lessen symptoms through addressing the excesses and deficiencies you are bombarded with daily, to support your gut-brain-axis. And even more importantly then simply reducing symptoms; you can function optimally, as you were designed to.

2) Find your people

Find your people – a journey can be less arduous and lonely if you have other people for the ride. We need others – good attachments are so powerful that they are found in studies to offset our stress response, reduce the experience of pain, and promote wound healing (Cassidy & Shaver, 1999). There are now many local groups interested in community and wellness – the AHSNZ is one such group who provide social media connection and local events (not to mention an awesome international Symposium coming up later this year). Work with health practitioners that you feel heard by, can trust, and who have a sound philosophy and evidence base that informs their practice (Note: sound evidence is more than randomised control trials alone). Notice who uplifts you in your family and peer group and find those who are likeminded and supportive of your intentions. If you don’t have this important component, connect online and find a suitable tribe that way.

3) Just take one step

Remind yourself that you can only do what you can do – especially when you are unwell. Start small and take one step, whether that step may be deciding to work with a health professional, informing yourself by listening to an educational evidence-based podcast like Revolution Health Radio (Chris Kresser) or ancestrally oriented health podcasts such as The Primal Shift orHarder to Kill Radio. Or read some guiding “how to do it” books like The Ultramind Solution (Hyman, 2008) or A Mind of Your Own (Brogan & Loberg, 2016).

4) Address excesses

Build on each small step with one more – the benefits will accumulate. For the excesses you face, which perpetuate a stress response, it may be cutting down and stopping coffee for a month to observe positive changes to your anxiety, stress, energy and sleep. It could involve committing to a break from alcohol and noticing the effects on your physical and mental health (especially sleep and mood quality). It could be getting a relaxing, pleasurable, and screen-free evening routine to optimise your sleep (e.g., using a website blocking App like this to externally control use of social media). In my house, I often do technology-free Sunday’s. Every time, after the first couple of hours of device-checking withdrawal, I feel fundamentally changed from a state of busy ape-brain to feeling content and more present.

5) Address deficiencies

To deal with the deficiencies that we all face to some extent, start with adding in as much nourishing food and good hydration as possible. Optimal nutrition involves an individually tailored approach as everyone is different, but as a general rule, focus this around food that was recently alive (i.e., not in a packet), seasonal fruits and vegetables (organic where possible), nuts and seeds, and well treated animal products. The macronutrient balance you eat matters to your wellbeing – so having sufficient protein, good quality fats (e.g, olive oil, avocado, coconut oil, animal fats), and complex carbohydrates for you is important to maintain a stable blood sugar, make hormones and neurotransmitters, and support adequate energy production. Research evaluating nutritional interventions as a clinical psychology treatment for psychological difficulties is being produced through the Food & Mood Centre in Australia, led by Dr Felice Jacka.  This research is in its infancy; however we know enough to advise that nutritional interventions like that outlined above are low risk, accessible, affordable interventions people can investigate, and that an improved diet is associated with lowered rates of anxiety and depression, and improved brain functioning.

If you have more complex gut health issues to contend with then you will likely require working with a health practitioner (my clients often work with my naturopathic colleague alongside me – the very lovely and skilled Felicity Leahy), and having some tests to rule out commonly overlooked deficiencies like B12, Folate, Iron, and Zinc. You might consider appropriate supplementation to boost any nutrient deficiencies up to optimal levels (e.g., this is particularly the case in adrenal and other hormone dysregulation, gut health issues where absorption is impaired, or if vegan or vegetarian). Nutriceuticals (vitamins and minerals) can be important in mental health treatment, and research supports the specific application of these for different types of psychological concerns like ADHD, stress/anxiety/mood after trauma, and insomnia (check out this trailblazing research via the Mental Health and Nutrition Research Group).

Another deficiency I see regularly in our current time, where we are caught up in the constant treadmill of society, is of people not being present in their own lives. Our minds take us into our past and ahead into the future, so much so that we often struggle to sit in the experience we have now. Thus, it can be revolutionary to discover and practice your own brand of mindfulness. Note that the definition of mindfulness that I subscribe to is not about reaching a zen state, but about being able to be compassionately present with your experience, and to do what it takes in that moment to head towards what is important to you.This can involve focusing on your breathing (which itself can shift you from the stress response into the relaxation response), ‘unhooking’ from thoughts, allowing difficult emotional or physical experiences to come and go, or a formal practice that could involve physical components (e.g., kundalini or yin yoga or mindful time in nature).

6) Shape a new lifestyle philosophy

Chronic physical or mental health problems often require that certain difficult questions be confronted, and these are questions that come up all the time in my practice as people attempt to make sense of their situation and find their way to wellness. Have you ever asked yourself these questions?

  • How did I get to be unwell?
  • How do I want my relatively short time here to be spent? (e.g., Stats report we spend an average of 50 minutes face-booking per day – that’s a lot of time lost into the mindless abyss: What else could you do with that time?).
  • How do I want to treat my body and mind?
  • What health behaviours do I want my children to learn from me?
  • What really matters to me – what’s the point of all this?
  • If I did change my health behaviour – what would motivate that change – e.g., children, finances, relationship, sustainability/ethical values, confronting death or disability? Use these values to leverage your motivation.

7) Avoid perfectionism in the quest for health

Importantly, be aware that your expectations, personality traits, and the drive towards perfectionism in health may also maintain a state of unwellness. Orthorexia Nervosa is not an official diagnosis but has recently been used to describe the experience where someone has fixated on rigid eating and lifestyle rules. This is different to choosing to follow a specific food protocol for a health condition (e.g., gluten-free for coeliac disease) or having a passion for a consistent healthful routine. In the quest for optimal functioning after a period of chronic ill health, while you can continue to strive towards recovery, the mantra of “good enough” may be more health-inducing then aiming for “perfect.” “Perfect” is often obsession or anxiety driven and can perpetuate a stress response in its own right.

Thanks to all the attendees who came out in the wake of the November earthquake to gather with us and converse on all things women’s wellness.  Getting to partake in this event with my co-presenters was a huge honour and I look forward to speaking at further events with the team at the AHSNZ – especially the 2017 Symposium in Queenstown October 20-22nd.  The topic I am speaking on will be released very soon and involves a focus that I’m very excited about pulling together between now and October

Brogan, K., & Loberg, K. (2016). A Mind of Your Own: The Truth About Depression and How Women Can Heal Their Bodies to Reclaim Their Lives. New York: HarperCollins.

Cassidy, J., & Shaver, P. R. (Eds.). (2016). Handbook of attachment. Theory, research, and clinical applications (3rd Ed.). London: The Guilford Press.

Greenblatt, J. M., & Brogan, K. (Eds.). (2015). Integrative Therapies for Depression: Redefining Models for Assessment, Treatment and Prevention. CRC Press.

Hyman, M. (2008). The ultra mind solution. Fix your broken brain by healing your body first. Simon & Schuster.

Part 1: On 21st Century Excesses and Deficiencies

Dr. Karen Faisandier provides an overview of her talk in late 2016, under the auspices of AHSNZ. This talk was part of a women’s wellness event with Dr Lara Briden and Dr Anastasia Boulais. Karen discussed the psychological expression of physical excesses and deficiencies.

Here is part one of her summary of the talk, including an important question raised by a member of the audience.

The speakers and attendees of the AHSNZ Women’s Wellness talk held in Wellington, 2016

Karen will be a speaker at the AHSNZ Symposium, 20-22 October in Queenstown. You can read more about Karen’s work HERE.

While our basic human physiology is largely unchanged, never in history have we collectively contended with as many unremitting and insidious insults to our wellbeing and vibrancy as we do today.

First, check out this quote I like, from the book Psychological Masquerade:

“Psychological symptoms are not always best explained psychologically.”               Robert Taylor

It’s true. They also may not always be best explained by other reasons that are accepted by the masses at the time. For example, when you look at some of the proposed causal understandings of female physical/psychological suffering over time, they include sexual and reproductive organ issues (and lack of sex/orgasms), possession and black magic (with exorcism and execution), and penis envy (thanks Freud). ‘Hysteria’ was the first known descriptor of what are now termed “psychosomatic” disorders, and was originally applied to women and defined as “the conversion of psychological stress into physical symptoms”.

Things progressed post-world wars however, after men returned home with the physical and psychological effects of prolonged or acute stress and trauma. There was a shift to obtaining a greater scientific understanding of such experiences, as well as effective treatments for the debilitating effects (Van der Kolk, 2014). This eventually led into well-known biological models that have been generally accepted until recently, including catecholamine dysfunction as the explanation for depressive and anxiety disorders (e.g., low serotonin, dopamine, GABA), with psychiatric medications widely used as treatments (e.g., selective-serotonin re-uptake inhibitors – SSRI’s). Under a medical model, binary or dualistic concepts of mind and body relationships became the focus within clinical practice rather than integrative, as per NZ based mind-body expert Dr Brian Broom (Broom, Booth, & Schubert, 2012). More recently though, there has been discussion on the limitations of both dualistic and catecholamine models, as we’ve seen an emergence in research on the gut-brain axis (see below). Concerns have also been raised around rising rates of mental disorder despite the commonality of psychiatric medication use (e.g., as per 2015 NZ Pharmac data 1/6 women used an SSRI).

The gut-brain axis involves the complex interaction of our gut microbiome (the array of microorganisms in our gut which require balance), the hypothalamic-pituitary-adrenal axis (the cortisol and adrenaline producing stress response), the vagus nerve (gut-brain/two-way communication line), and the immune and neuroendocrine systems, among other things. How our modern diet and lifestyle jeopardise the harmony of the gut-brain axis, and how to repair this harmony, is a promising area of research within many fields, including mental health. Problems within the gut-brain axis explain overlapping physiologic and mental symptoms such as those seen in ‘psychosomatic’ disorders (Greenblatt & Brogan, 2015). For example, anxiety, panic attacks, emotional lability or flatness, cognitive changes, and insomnia can arise with physical food allergies/intolerances, nutrient depletion, insidious hormonal problems including thyroid, sex hormone, or adrenal dysregulation, and autoimmunity. This brings us around to how modern excesses and deficiencies affect the gut-brain axis and contribute to these phenomena.

Excesses & Deficiencies

When I talk about 21st century excesses I include this non-exhaustive list of modern factors that were absent or minimal at earlier times in history:

  • processed food and food intolerances/sensitivities
  • device notifications and screen time (especially in the evening)
  • sugar
  • caffeine
  • medication
  • alcohol
  • mindlessness (chronic “automatic pilot”)
  • perceived stress, rushing, and being “busy”
  • toxicant exposure (pesticides etc.)
  • social media/self-focus and the ‘imaginary audience
  • intrusive sensationalist media of many forms

Then there are the deficiencies of things that our ancestors likely had more ready exposure to:

  • adequate nutrients (e.g., vitamins, minerals, macronutrients)
  • true relaxation
  • sunlight
  • movement/physical strength
  • time in nature
  • deep quality sleep
  • meaningful connection and community
  • hands-on childrearing support
  • environmental intuition (respecting the wisdom and rhythm of nature)

In just one example of the physical/psychological overlap, the slide below contrasts various symptoms of suboptimal nutritional intake (arising from a combination of the excesses and deficiencies listed above) with the common symptoms of a depressive episode (Note: a diagnosis of depression also requires other factors like ruling out other explanations, symptom duration, and degree of impairment to functioning).

That is a large overlap, right? Yet broad nutrient insufficiency is often not delved into and worked with, and so people are frequently not aware of how much their diet and lifestyle may be impacting psychologically. To have the nutritional foundation for mental and emotional wellbeing, the brain requires individually sufficient macronutrients (healthful fat, protein, and complex carbs) and all the various micronutrients that are abundant in food as designed by nature (e.g., optimal B vitamins, Iron, Folate, zinc, Magnesium, Vitamin D etc.). Our heavily processed and highly carbohydrate based modern diet does not provide these adequately, plus, when there are additional insults from the lists above (and let’s face it, we all have some), they use up extra nutrients, make absorption difficult, and place strain on the gut-brain axis.

Here are what I consider to be other common key deficiencies from a psychological perspective:

  • secure attachment
  • compassion (for self/others/world)
  • aligning our behaviour with our values
  • a sense of meaning and purpose
  • and allowing difficult emotional experiences

Stay tuned for Part 2!

There is Nothing Inevitable or Natural About Chronic Disease

This article is republished, under Creative Commons permission, from Aeon.

Clayton Dalton is a medical resident at the Massachusetts General Hospital in Boston. He attended medical school at Columbia University. 

In the 1830s, British settlers in New Zealand imported European rabbits for food and sport. With no native predators, the rabbits soon took over. Accounts from the period describe thousands of hectares run through with burrows, and huge tracts of arable land destroyed by overgrazing.

In a desperate bid to stem the scourge, the New Zealanders brought in a natural predator of the rabbit – ferrets. Without native predators to pick them off, the new imports did well. But they also played a prominent role in the decline of several endangered bird species, including the kiwi, the weka, and the kakapo. It’s a familiar parable (Mark Twain even riffed on it) about unintended consequences, and the danger of applying reductionist logic to a world that is characterised by extraordinary interdependence and complexity.

As a physician, I can’t help but be reminded of ferrets in New Zealand as I write prescriptions for the drugs we use to manage chronic disease. Hydrochlorothiazide for high blood pressure. Sulfonylureas, a class of medication used to treat Type 2 diabetes. Statins for heart disease.

Don’t get me wrong, these drugs work. They absolutely save lives. But the human body is a precisely interdependent system, and these drugs are like sledgehammers. The ferrets did kill rabbits, but they were such an indelicate intervention that they wrought their own special havoc on the native ecosystem. The kakapo might never again be seen on the New Zealand mainland. How much collateral damage are we inflicting on the human ecosystem with our powerful medicines?

Perhaps more than we think. Hydrochlorothiazide, a widespread treatment for high blood pressure, increases haemoglobin A1C and impairs glucose tolerance. These are indices of insulin resistance, which is associated with diabetes, obesity, cardiovascular disease and dementia. Hydrochlorothiazide raises LDL cholesterol and triglycerides, and lowers HDL cholesterol – a pattern known to confer increased risk of cardiovascular disease.

Sulfonylureas have been shown to increase the risk of cardiovascular disease as well.

And statins, some of the most widely prescribed drugs in the United States, have been found to impair glucose tolerance and increase the risk of diabetes.

While there is no doubt that the collective benefit of these medications currently outweighs their adverse effects, it’s remarkable that many of the drugs we give to treat chronic disease can actually increase the risk of those selfsame diseases. It speaks to the intricacy of human biology, and to the crudity of even our most advanced pharmaceuticals. Twain would have loved the irony.

The hope of academic medicine is that research ­– especially in molecular biology and pharmaceuticals – will save us. As we zero in on the elusive, primordial mechanisms of disease, we can design ever more precise pharmaceuticals, or even cures.

But rather than producing any outright cures for chronic disease, decades of basic science research seem to have yielded a different kind of truth – that the human body is an incredibly, devilishly complex system. The deeper we dig, the more convoluted becomes the pathophysiology of chronic disease. What has become clear is that these chronic diseases – high blood pressure, diabetes, cardiovascular disease – are manifestations of aberrant metabolisms, rather than a lone faulty switch buried somewhere within our cells.

There seem to be no silver bullets. Causation at the molecular level, deep inside the body, appears to be beyond our current reach. But what about pushing against the ultimate cause – not within us, but in the outside world? Are we fated to follow the New Zealanders’ folly, causing damage with every effort to treat? Or, can we learn what external forces have made us so chronically ill, and push back there?

Perhaps we can. It turns out that traditional cultures across the globe, from hunter-gatherers to pastoralists to horticulturists, have shown little evidence of chronic disease. It’s not because they don’t live long enough – recent analysis has found a common lifespan of up to 78 years among hunter-gatherers, once the bottlenecks of high mortality in infancy and young adulthood are bypassed. We can’t blame genes, since many of these groups appear to be more genetically susceptible to chronic disease than those of European descent.

Evidence suggests it is how they live. Though traditional cultures span an immensely diverse gamut of lifestyles, they share a common denominator defined by the absence of modern banes: absence of processed foodstuffs, absence of sedentary lifestyle, and likely absence of chronic stressors.

Indeed, evidence suggests that lack of chronic disease in these groups flows from how they live, how they move, how they eat. Diet looks to be an especially powerful driver – adoption of a Western diet, rich in processed foods, has mirrored the development of chronic disease worldwide, and prospective studies with healthy and diabetic subjects have documented the powerful influence of food on health. Physical exercise, long touted as merely a means to calorie disposal, turns out to have complex endocrine and metabolic effects on insulin signalling, stress response, sleep, mental health, and even neuronal function in the brain. What the science seems to say is that an ancestral way of life aligns the machinery of our metabolisms toward good health.

Thus it appears that our bodies aren’t, after all, destined for chronic disease as they age – rather, it is the environment we’ve put them in that should bear the blame.

But isn’t this obvious? Yes, physicians and public health researchers have long acknowledged the influence of environmental elements on health, but we remain beholden to a paradigm that places first priority on mastery of molecular mechanisms. The sophistication of our sciences is a triumph, and technological progress must no doubt continue. But we know enough about the environmental determinants of health to act, even if we don’t fully understand the mechanisms.

Our ship is sinking, and the current approach is akin to bailing with a thimble. If we are to stem the rising tide of chronic disease, we must alter the elements of our environment that promote chronic disease. With the global price tag of chronic disease projected to rise to $30 trillion by 2030, we simply can’t afford not to.

Weight Loss: Pot of gold at the end of a rainbow?

DR ANASTASIA BOULAIS

MBBS (University of Sydney), BMEDSC

Any discussion about health and well-being, whether at your doctor’s office, office tearoom or over a coffee with friends, inevitably focuses on weight loss. As a society, we are preoccupied with our relationship with gravity and we often judge our health, social success and overall happiness against that marker. The recent rebirth of the ancestral health movement is no exception, with many people attempting to apply evolutionary biology principles for the sole purpose of getting thinner. However, as we will hear, weight loss is a foreign concept in most ancestral cultures and modern indigenous populations. Concentrating our individual and public health efforts on pursuing this red herring makes us lose focus on the truly vital markers of well-being.

 

 

Modernity’s Fadism

DR ANDREW DICKSON

PHD Sociology (Massey University)

Nutritionists, dietitians and others in this industry are living in tense times. Practitioners who aspire to follow an ancestral health philosophy are no exception. Tensions abound in many facets of their work, such as those that exist between contradictory bodies of knowledge within the general field of nutritional science. In this presentation, Massey University’s Dr Andrew Dickson argues that ‘fadism’ is the most significant current issue threatening the ancestral health movement. By tracing the ethics of fadism and comparing to the existing ethics of nutritionism via philosophical thought, Dr Dickson concludes by presenting an alternative ethical strategy for practitioners of ancestral health, one that moves away from fascism within fadism toward a respect for the subject.