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Editorial |
Department of Preventive Medicine and Biometrics
University of Colorado School of Medicine
Denver, Colorado
Tim.Byers{at}uchsc.edu
In their commentary in this issue Temple and Balay-Karperien state that, because we are losing the war on cancer, we need to now bring out the heavier guns of nutritional policy [1]. Although I do not agree with their assessment of our progress in the war and I do not agree with many of their specific suggested policies, I do agree with the need for a rational consideration of policies to support healthy choices in food and physical activity. I will discuss the progress in cancer control in the U.S. and reflect on the balance of risk and benefit in the deployment of new cancer control policies.
First, it is important to correct the record on progress in the war on cancer. The reference cited by Temple and Balay-Karperien to document our lack of progress was published in 1991 [2]. U.S. cancer rates peaked in that year, though, and in the years thereafter cancer mortality has continuously declined [3]. The rate of decline has been substantial for cancer sites amenable to prevention and screening, such as a 2.4% decline each year for lung cancer deaths in men (1992–1998), a 3.4% decline each year for breast cancer deaths (1995–1998), and a 4.5% decline each year for prostate cancer deaths (1994–1998). These historic downward trends in cancer mortality have been the result of many favorable trends, especially in tobacco control and cancer screening. Cancer mortality will continue to decline in the coming decade due to the continued effects of these ongoing trends, as well as to real advances in cancer treatment [4]. Clearly, though, much more can be done. Recent unfavorable tends in physical activity and obesity in the U.S. will dampen future declines in breast and colorectal cancer, for instance, but just which new nutrition policies we should therefore adopt is not at all clear.
The urgency of war gives rise to many broad-sweeping policies. We in the US and elsewhere are quite willing to make policy changes in the current war on terrorism, for example, but at the same time we need to consider carefully the potential collateral damage to our societies from going too far with those changes. To win the war on cancer, policy changes may well be helpful to better enable and support individual behavioral choices. However, the precise policies that will be most fair and most effective to that end without creating collateral damage to public health efforts need to be measured carefully. Although I like the general idea of progressive social policy, I dislike many of the specific policy examples set forth by Temple and Balay-Karperien, who cite an intentionally absurd metaphor for the difficulty in affecting behavior change: "You can lead a horse to water, but you can’t make it wear a swimsuit." The application of this metaphor to policy, of course, is that we could, in fact, cause horses to wear swimsuits with a strictly enforced equine swimsuit law. Just as it is possible that this could happen, it is also certain that it should not.
The devil of policy is in the details. Could we tax bad foods to fund the subsidies for good foods or the work of nutrition educators? Yes, we could, but are food price manipulations and the funding of basic public health functions with arbitrary taxes what we should choose as a society? I would say no. If we are to make food policy decisions on the basis of cancer risk, such as the taxation of bad foods to subsidize good foods, then the scientific basis for the naming of "good" and "bad" needs to be very compelling. I agree that fruits and vegetables could be considered "good" and might sell better with a subsidy, but which foods would then be named "bad" to be taxed? Nestle and Jacobsen suggest soft drinks [5]. Others suggest snack foods or high fat foods [6]. I am not sure what would be just or practical. I see no other specific foods that are well enough linked to increased cancer risk to support their taxation for the purpose of cancer risk reduction. Neither red meats nor fats nor sugar would meet my standard of sufficient certainty. Excessive calories might, because obesity is an unequivocal risk factor for some cancers, but just how one could fairly tax calories is not clear to me. Would it be fair, for instance, to tax foods produced or served in excess of specific caloric levels? If so, would the tax on super-sized items be fair to those who share meals? Would the tax on a cake depend on the number invited to the party? On what basis would a tax on soft drinks be fair without a tax on sugar? How about the 10% fruit juice drinks sweetened with the same fructose used in soft drinks? Would diet drinks be exempt from a soft drink tax, and would products made with Olestra be exempt from a fat tax? If we were to tax automobiles as being agents contributing to reduced physical activity, then why not also tax televisions, computer games and escalators? Should we tax slippers to subsidize dancing shoes? In taxation and food pricing policies the devil is, indeed, in the details.
In his remarkable book, The Nazi War on Cancer, Robert Proctor documents the lost history of the anti-cancer crusades in Germany in the 1930’s [7]. This is a fascinating look into a set of what by today’s standards I would regard as a progressive public health campaign mounted by Adolph Hitler to reduce cancer risk in Germany. Fueled by his cancer phobia and a vegetarian conviction, Hitler instituted many stiff anti-cancer policies, including an extensive anti-tobacco campaign and nutritional policies to promote healthy foods, including a law requiring all bakeries in Germany to use whole grains. Just because these policies were promoted by Hitler does not make them bad ideas, of course, but the authoritarianism of that system should give us pause.
What general principles can we apply to policies to support individual choices for healthy foods and physical activity? My opinion is that it is important not to elevate the manipulation of food prices as the principal strategy to affect healthy choices. It is not surprising to learn that lowering the cost of healthy foods by a subsidy will increase their consumption from a vending machine [8]. However, is food price manipulation the policy we wish to initiate to affect behavior change? I do not think so. A more sustainable guiding principle would be the support of free choice for healthy foods and physical activity. Policies that assure access to healthy food choices in places such as schools, worksites and communities of poverty, and policies that afford safe environments and support for physical activity would seem to me to be more feasible, effective and sustainable. The differences between nutrition policies and tobacco control policies are many, as the demons in nutrition are less clear than those in the tobacco industry. It is unlikely, in my view, that we will succeed in demonizing the food manufacturers as we have the tobacco companies. However, there are also important similarities with tobacco. The most important principle behind our policies against tobacco can also be used to support progress in nutrition and physical activity—the right of free choice. Because free choice is lost when a teenager becomes addicted to tobacco or when one inhales second-hand smoke, youth tobacco laws and clean indoor air laws have enjoyed widespread support. Likewise, policies to assure the availability of healthy foods in schools, worksites and inner cities, and policies to encourage safe choices for physical activity in recreation and transportation could also be framed as policies to enable free choice. Such an approach to policy could be feasible, effective and sustainable. In contrast, I suspect that policies dependent on the manipulation of food prices to affect behaviors would likely fail in the long term and/or do substantial collateral damage as they would eventually be regarded as heavy-handed policies designed to impede free choice.
The fortunate circumstance for those of us interested in cancer risk reduction through better nutrition and physical activity is that the very same behavioral choices that reduce cancer risk also reduce the risk of heart disease and diabetes. Recommendations for cancer risk reduction are virtually identical to guidelines to reduce CVD risk [9,10], and it is now clear that those same diet and physical activity recommendations are also effective in preventing diabetes [11]. This convergence of evidence for the prevention of these three major chronic diseases is important in the formation of policy. An open discussion of reasoned policy approaches to support healthy choices in nutrition is long overdue. I would prefer policies intended to enable free choice of healthy behaviors, rather than those designed to limit free choice of behaviors we label as unhealthy. In the final analysis, though, it will not be so important which policies are supported by Temple and Balay-Karperien or which by Byers, but it will be critical to arrive at a consensus about which ones can be supported by a broad enough constituency of the American public to make them both effective and sustainable.
References
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