The Health of Nations

If all of us were simply to make better use of our feet, our forks, and our fingers — if we were to be physically active every day, eat a nearly optimal diet, and avoid tobacco — fully 80 percent of the chronic disease burden that plagues modern society could be eliminated. Really.

Better use of feet, forks, and fingers — and just that — could reduce our personal lifetime risk for heart disease, cancer, stroke, serious respiratory disease, or diabetes by roughly 80 percent. The same behaviors could slash both the human and financial costs of chronic disease, which are putting our children’s futures and the fate of our nation in jeopardy. Feet, forks, and fingers don’t just represent behaviors we have the means to control; they represent control we have the means to exert over the behavior of our genes themselves.

Feet, forks, and fingers could reshape our personal medical destinies, and modern public health, dramatically, for the better. We have known this for decades. So why doesn’t it happen?

Because a lot stands in the way. For starters, there’s 6 million years of evolutionary biology. Throughout all of human history and before, calories were relatively scarce and hard to get, and physical activity — in the form of survival — was unavoidable. Only in the modern era have we devised a world in which physical activity is scarce and hard to get and calories are unavoidable. We are adapted to the former, and have no native defenses against the latter.

Then, there’s roughly 12,000 years of human civilization. Since the dawn of agriculture, we have been applying our large Homo sapien brains and ingenuity to the challenges of making our food supply ever more bountiful, stable, and palatable; and the demands on our muscles ever less. With the advent of modern agricultural methods and labor-saving technologies of every conception, we have succeeded beyond our wildest imaginings.

So now, we are victims of our own success. Obesity and related chronic diseases might well be called “SExS” — the “syndrome of excessive successes.”

The problem with this beyond its obvious consequences is its profound cultural inertia. Having worked for 12,000 years to reduce physical exertion and increase available calories, it’s rather a challenge to suddenly reduce available calories and increase exertion. Everything in modern society is inclined the other way.

And, of course, the so-called “military industrial establishment” stands in the way as well. Many of our modern institutions, from big food, to big pharma, profit from the obesogenic status quo. Although, of note, the military per se certainly does not — quite the contrary. Ever more concern is being expressed about the potential for rampant obesity to interfere with our military preparedness. So it’s just the “industrial establishment” in this case.

But those institutions that do profit have deep pockets, and use them to oppose sudden change. Over time, food companies can reformulate and sell better products that preserve profit margins, but they are not inclined just to sell less of what they make right away. Over time, drug companies can become health promotion specialists; but they are not going to sit back and watch their stock values plummet.

What all this means, quite simply, is that progress toward the public health prizes that beckon will tend to be incremental, at times slow, and almost never perfect. Perfect tends to be the enemy of good in the real world.

That point was apparently lost on a certain David Lazarus, who wrote an opinion piece in the Los Angeles Times that was highly critical of Anthem Blue Cross for operating a program that provides clients with discount coupons for better, but often quite imperfect, foods.

The program is provided by a company called LinkWell, which links food companies to insurance companies in just this way. The insurance companies provide access to their clients, and the food companies pay to discount their better-for-you offerings. The idea is that people can be “nudged” this way toward better choices; the food companies can sell their products; and the insurance companies can potentially reduce their costs. In principle, everyone can win.

I find that principle quite sound, and for that very reason, and the fact that I have long been an avowed public health pragmatist, I serve on Linkwell Health’s Board of Advisors.

Mr. Lazarus ridiculed the fact that Anthem provided coupons for deodorant. This, of course, has nothing to do with health — but everything to do with building bridges. By sending out coupons for some products unrelated to health, Linkwell, Anthem, and the other insurance companies using the program gain traction to address the choices that do influence health.

Mr. Lazarus also beat up on those, noting that better-for-you ice cream is still ice cream. He suggested that the coupons be limited to vegetables and fruits, or maybe meats and fish.

Leaving aside an apparent willingness to attribute the same health effects to meats and vegetables, Mr. Lazarus’ suggestion has intrinsic merit. The best foods generally do come direct from nature, and switching from one ice cream to another may not do much for health, personal or public.

But there is one important problem with Mr. Lazarus’ suggestion. It doesn’t work.

We have been encouraging Americans to eat more fruits and vegetables for literal decades, and yet only 1.5 percent of us (yes, 1.5 percent!) get the recommended daily intake of both. We have goaded and harangued, given produce out for free, and financially incentivized it. These things do make a difference — but a very small difference. That is in part because there are important barriers to more produce intake other than price, and in part because people are simply accustomed to choosing many foods that come in bags, boxes, bottles, jars, and cans.

This is not likely to change overnight, and arguments to the contrary make perfect the enemy of good.

I have been subject to such arguments myself. I led the development of a nutritional guidance system intended to guide people to more nutritious choices within any given food category. Yes, in fact, if you are inclined to eat ice cream, there truly are more and less nutritious choices. Yes, if you are inclined to eat chips, there are better chips. And frankly, it just isn’t relevant, when you are inclined to eat chips, that broccoli is better for you.

The purists among my colleagues criticize such guidance because it does not advocate for consumption of pure foods only — although those, of course, do score highest of all. But I am not aware of any scientific evidence that encouraging people to eat pure foods, mostly plants has ever changed health outcomes — because such advice only reaches people already inclined to live that way. Such advice is routinely cheered by those who embrace it already. Such guidance makes no difference at all to the people who most need some help.

In contrast, I am aware of real-world evidence that guidance for trading up every food choice to a slightly better one can make an enormous difference. And that it actually has done so, repeatedly. And that simply by making slightly better choices often, the net nutritional benefit can add up tolower rates of both chronic disease and premature death.

If only perfect would do, then calorie counts, nutrition fact panels, and ingredient lists would be moot. We could simply tell everyone to eat more spinach, and leave it at that. If only perfect would do, then modest doses of daily physical activity would be pointless. Either make the Olympic Team, or enjoy your couch.

But just last week came evidence that a mere 20 minutes of daily physical activity can be the difference between a child succumbing to Type 2 diabetes — or not. That matters. As do the actualchoices made among foods in packages. So the public health can, in fact, be advanced with programming to empower modest amounts of daily physical activity in adults and children alike, and by programming in schoolssupermarkets, or that is sent in the mail to help people trade up their food choices.

I quite agree that Linkwell’s program is not perfect, and I am confident the company executives would say the same. No doubt Anthem would agree as well. But the reason the program isn’t perfect is, quite simply, because those involved in it are committed to doing some good in the real world, where perfect tends not to be a viable option.

In the real world, often the best you can do is insert the thin edge of the wedge — and then keep pushing. You can be candid about ideals and objectives, but often must be compromising about opportunities so something gets done while waiting on the world to change.

For better health, people really should eat more wholesome foods direct from nature, mostly plants. But between here and there, choosing better cereals, breads, chips, crackers, sauces, spreads, dressings, and, yes — even ice cream — can add up to dramatic improvements in overall diet quality. And that, in turn, could result in meaningful improvements in health. And it’s actually feasible.

That’s what Anthem, and Linkwell, are working on: progress, imperfect though it may be. In my view, that’s good.

David Katz, MD, MPH, FACPM, FACP, is the founding (1998) director of Yale University’s Prevention Research Center. This piece first appeared at The Huffington Post.

2 replies »

  1. “If all of us were simply to make better use of our feet, our forks, and our fingers” – nicely put

    you can add “and our iphones and internet connections” to your list, and I think you’ve come up with a pretty good philosophy of life at the beginning of the 21st century!