American Journal of Medicine, internal medicine, medicine, health, healthy lifestyles, cancer, heart disease, drugs

The Limited Public Health Impact of ‘Lifestyle’ Change


heart hovering over fast food

Two main factors are responsible for premature disease and mortality. One is smoking, often referred to as a “lifestyle choice,” but better described as a “habit.” The other is poor nutrition resulting largely from the sugar, alcohol, salt, and saturated fat content (SASS components) of ready-to-consume food and drink, much of which is manufactured on an industrial scale. Collectively, these dietary components are the main drivers of the global epidemic of stroke, heart attack, obesity, and type 2 diabetes. Apart from drinking too much alcohol, personal choice and “lifestyle” change have a limited effect on their consumption in the general population. There is little lifestyle choice in avoiding such a nutritional assault unless one is knowledgeable and wealthy enough to buy the right unprocessed foods and organize one’s own cooking. It is not surprising that although life expectancy at the age of 40 years among the wealthy in the United States has increased by approximately 2.5 years between 2001 and 2014, it has scarcely changed among the poor—a difference that was not explained by access to medical care.1

The problem is systemic in that processed foods rich in added sugar, salt, and saturated fat are convenient, cheap, heavily advertised, and ubiquitous. A hamburger and fries and a nondiet canned drink can, at a modest cost, provide more than half a person’s daily calorific requirement. It has easily become the necessary economic “choice” for people on low incomes. A solution is to create a financial incentive that encourages food retailers and manufacturers to reformulate their products with less of the 4 “culprit” dietary components—a SASS excise tax. The tax would be calculated on the basis of the amount of each of the components in the food or drink, not as a percentage of the final price (ie, not a value added tax or a sales tax), which would diminish the incentive to reformulate. This fiscal approach would preserve consumer choice, but tilts that choice in the direction of encouraging a healthier food supply and perhaps even portion size. The case for a SASS tax was published by the Royal Society of Medicine as the Jephcott lecture, delivered in 2011.2 At that time, such a tax was regarded as politically unacceptable. Public health policy relied on consumer choice and voluntary agreements with industry. Now, some 5 years later, several countries have accepted a sugar tax.3 A per gram excise tax on the 4 specified components introduced explicitly as a public health measure and monitored each year in relation to its effect on consumption of the 4 components would focus intervention on the source of the epidemic. This is likely to be more effective than relying on personal choice in a context where choice is limited, the food and drinks industry is understandably concerned with protecting their market, and voluntary targets have only a modest effect.4 A SASS excise tax is fair to different food manufacturers and does not focus on one food component, so it is also fair to different sectors of the food industry.

A SASS tax, supported by an intelligent public education program, would help align the public health interest with the food industry’s financial interest to its shareholders. It would also help dispel the myth that unhealthy personal behavior was the root cause of the epidemic arising from poor nutrition. Therefore, the priority is for governments to take responsibility for nutritional public health and take action that will improve the overall quality of the diet at a societal level, not to abrogate their responsibility by relying on personal lifestyle changes that are, in the field of nutrition, unrealistic, unlikely to be effective, and largely impractical among the less well off.


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-Nicholas J. Wald, DSc (Med), FRS

This article originally appeared in the December 2016 issue of The American Journal of Medicine.

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