17 September 2013

Boyd Swinburn and Obesity Policy: Mosquitoes Don't Have Lobby Groups

Yesterday's highlight of the International Congress on Nutrition was a presentation by Prof. Boyd Swinburn (Deakin University in Australia)  the role of policy in combatting overweight and obesity in high income countries.

Why a highlight?  Well, first Boyd (who I had not met before) is a terrific presenter--a depth of knowledge, communicated in just enough depth, and all with a fine sense of humour.  It was also a highlight because so many of the issues he raised are issues close to my heart, but which I cover in a undernutrition low income context.

At some times it felt like we had been separated at birth.

Boyd divided the policy space up into big P policy (political commitment) and small p policy (specific rules and regulations).  He also divided things up into direct small p, policy that tells people what they can and cannot do, and indirect small p, policy that incentivises behaviour (e.g. tax).  He noted that the "nanny state" criticism is misplaced because there are very few direct policies directed towards obesity.

The big revelations came when he started telling us that the obesity policy community don't focus enough on what he called the "back of the house" issues such as leadership and governance, capacity and resources, knowledge and evidence, and accountability mechanisms.  This is precisely what Lancet paper 4 (Gillespie and Haddad et. al.) outlines and calls for--but for undernutrition in low income countries.

The other big parallel was with his involvement in the collective effort called INFORMAS to assess the commitment of governments to do something about obesity--assessing policies, programmes and legislation--eerily similar to the HANCI index assessing commitment of governments to reducing hunger and undernutrition.

There were three parts of his presentation that were particularly troubling:

First, a study that tells the tale of two towns in California that tried to tax soda (carbonated sugar drinks).  Their mayors put these propositions to the electorate.  The beverage companies spent $150 per voter to demonise the tax, and it lost by 2/3 to 1/3. 

Second, he told us about a study  by G. Jenkin in Obesity Reviews 2011 12(12) which analysed the fate of public health task forces in Australia as they get converted into policy.  The public health task forces typically make recommendations that are in line with collective responsibility (the other end of the spectrum is individual responsibility as advocated by industry). The government then usually describes and responds in ways that move a little more towards the individual responsibility extreme.  The government solution, when put forward is further towards individual responsibility.  The eventual action, when put into law is pretty much what the industry wants or can live with.  Why is this so different from infectious disease, asks Swinburn?  Simple, mosquitoes don't have lobby groups.

Third, he and his colleagues have modelled the cost effectiveness of different policies for obesity control and reduction.  They concluded that the ones most favoured by the Australian government were the ones that were the least cost effective. (I missed the reference).

Boyd definitely has no problem bracketing Big Tobacco and Big Food.  But while we don't need tobacco, we need food, right?  Well we do not need highly processed refined foods which are high in sugar, salt and fats.  But there are no externalities (external effects on others that are not captured in the market) in Big Food, right?  Well, there may be fewer individual externalities but there are many collective externalities, think of health insurance, health care, lost productivity etc.

I asked him what will be the triggers to a step change in public policy--he thought it would be cities going broke because they could no longer afford the health care costs.  As he said, few governments prioritise health over business.  Perhaps we are approaching the point when health becomes a serious constraint on business.  That would be an interesting question to address whether in under or  overnutrition in low and high income contexts. 

It is time to reunite these relative strangers.

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