Regulating Sugar: It’s All About the Nudge

UCSF health policy Professor Laura Schmidt has plenty to say when it comes to the availability of sugar in the American diet. She agrees with the assement made by her UCSF colleagues in “The Skinny on Obesity: Drugs, Cigarettes, Alcohol..and Sugar?” that there is a definitive public health demand for regulation of the food industry in response to the obesity epidemic. Her research focuses on what works and what doesn’t when it comes to regulations and she made her case in  U.S. News & World Report editorial published on March 30, 2012. What follows is the unedited version:

“Regulating Sugar: It’s All About the Nudge,” by Laura A. Schmidt, PhD
Professor, UCSF School of Medicine

The overabundance of sugar in the American diet isn’t just making us fat.  It’s hurting our health.  We were all raised to think of sugar as benign “empty calories.”  But science shows that too much sugar—i.e., the amount consumed by the average American—leads to high blood pressure, dyslipidemia, fatty liver, insulin resistance and pancreatitis.  Excessive sugar consumption leads to metabolic disease, which leads to the main chronic illnesses that will eventually kill most of us: heart disease, stroke, cancer, as well as diabetes.  Sugar overload also creates a cascade of chemical changes in the body, turning off the hormones that tell us when we’ve eaten enough, and affecting brain neurotransmitters that leave us craving more sugar.   

The point is that too much sugar has all of these harmful effects on health in addition to its role in America’s obesity epidemic.   This growing awareness has led to a trenchant public debate about whether it isn’t time to regulate sugar.

The debate about regulating sugar is, however, based on a false assumption: If we regulate the stuff, we will wind up with government bureaucrats telling us what we can and can’t eat.  Fortunately, there are alternatives that lie somewhere between political extremes — in gentle, market-based alterations that improve health while actually increasing choice.

For decades, America’s main strategy to prevent obesity and metabolic disease has been education: nutrition labels, public service announcements, and mainly, school-based health education.  There is now solid evidence that health education doesn’t work to change behavior, especially for substances with abuse potential.  It can change attitudes and knowledge, but it doesn’t have lasting effects on what people actually do.

Most of us intuitively understand why health education doesn’t work. We may try for a while to eat healthy by limiting added sugar.  But we quickly find that it actually takes a lot of planning, money, and effort to not eat sugar, and that many of us crave the stuff due to effects on the brain’s “reward center.”

The fundamental problem is that we live in what addiction researchers call a saturated environment.  You know you live in a sugar-saturated environment when you have to go out of your way to find a drinking fountain or a fresh apple.  But junk food counters and vending machines line the walls of workplaces, airports, shopping centers and even schools.  Our saturated environment doesn’t just make sugar-laden products easy to get.  It makes them hard to avoid.

In their New York Times bestseller, Nudge, two professors from the University of Chicago School of Economics (a bastion of conservative politics) point out what public health researchers have known for years:  Most of the time, most of us tend to eat and drink what’s in front of us.  The best way to promote healthy weight and metabolism is to make the healthy stuff cheaper and easier to get than the unhealthy stuff.  These authors describe a simple experiment that vividly illustrates the point. A school cafeteria lady put the low-fat milk on the front shelf while the sugary drinks went up high and in back.  Guess what?  The lunch lady increased milk consumption while helping kids get off the sweet stuff throughout the school.

Effective public health regulation is all about the nudge.  It’s about making healthier options easier and cheaper to get, and asking people to reach a little farther for products harmful to health.  More importantly, it’s about nudging producers and distributors to increase the availability of healthier alternatives through market incentives: by ending subsidies and pro-rating taxes based on how much sugar has been added to the product.  There is now a vast body of international research showing that such simple strategies are easy to implement and tangibly affect population health.

But one question remains: How is it possible that regulating sugar will actually increase personal choice?  Well, we all know that junk food companies have massive marketing departments working 24/7 to figure out ways to nudge us towards their products.  That’s why candy in the supermarket checkout aisle is at eye level for a child, and why the milk is at the back end of the store.  That’s why 80% of the foods in America are laced with added sugar—to make us want to buy these more and more of these products. What we need is a nudge back.  At a minimum, there should be a level playing field for consumers to choose.

There is one assumption that lies at the heart of these new public health regulatory solutions — that, at the end of the day, most Americans want to live long, healthy lives and would prefer a smorgasbord of options for what they choose to drink and eat.  We don’t want anybody—government or corporations—telling us we can or can’t have a soda.  But we do want choosing health to be an easy option, if not the default.  This assumption, unlike others framing the current sugar debate, seems like a reasonable one to make.

Of course nobody wants a government bureaucrat telling us what we can eat and drink.  But neither should we want to live in an environment where powerful corporations tell us what to eat and drink, by continuously nudging us toward products that undermine our chances for a long, healthy life.

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