Public Policies to Address Obesity: Pediatric Obesity 2017

Welcome back to uh latest evidence and trends in pediatric obesity, and we're gonna switch, go over to our co-host, our virtual co-host, Chris Bowling. Thanks, Mark. Uh, greetings from across the state of Ohio here. So I'm down in Southwestern Ohio and I get the great honor to um introduce, um, someone who I really consider to be sort of a hero of mine. Uh, Doctor Kelly Brownell. Doctor Brownell, um, is the dean of the Stanford School of Public Policy at Duke University. And I will guarantee that he will turn your mind around a little bit on the topic of how public policy affects obesity in the United States. Um, Doctor Brownell, um, uh, you may have seen him in The Weight of the Nation, you may have seen. in a lot of other uh media appearances. He's really a thought leader. He's, um, used to be at the Rudd Center in Connecticut, which was at Yale and is now at UConn, um, really leading the way, um, on topics like, um, weight bias, um, public policy around, um, uh, sweet drinks, um, and built environment. So, with no further ado, I'd like to introduce Doctor Kelly Brownell. Uh chris, thank you for that really very warm introduction. I'm grateful for it and I look forward to meeting you in person someday. Um, so I'd like to talk about public policies to address obesity, uh, child. In particular, um, the public policy picture on this is really incredibly important, as I think most people recognize because The ability to affect millions of people at the same time or to address environmental issues that are driving obesity in the first place rests mainly with public policy changes that might be made. So, for example, school nutrition, uh, public policies that affect the nation's school nutrition standards would be an example of that. So it's really important that we get it right. Um, I'm also really pleased to say that the first frontier on which public policies Uh, to address obesity occurred have been around children and their diets. So schools really were the first frontier of this as school nutrition policies changed. So there's a lot to be proud about, a lot of changes occurred, um, and let's see where it all goes and how we might think about this. So I'd like to begin with a conceptual scheme and talk about how we might go about thinking about addressing the obesity problem. So let's see, here we go. Um, we're going too fast here. Let me go back. OK, so the technology is going a little too fast. OK, so as we think about making changes in behavior that affects individuals, so their diet, their smoking, their drinking, whatever it is, we generally as a nation first focus on the individual and try to apply things to the individual in hopes that they change. So, we may, for example, try to give them knowledge or skills. We might try to motivate them in order to create change. And so, this really boils down to educating and imploring people. In the case of obesity, we can medicate and operate as well, but we hope at the end of the day, That we have less of the obesity problem. Now, the, there, you can get partway down the road by doing these sort of things, but we've been doing a lot of these things over the years with individuals, giving them knowledge about diet and trying to implore them to be thin, and a lot of social pressure to do that. But we've just had rising rates of obesity, so this alone doesn't seem to be getting the job done. Uh, when we ask ourselves, can information alone really motivate change, we can look at data on other behaviors, in this case, physical activity. So here's the percentage of people in the population getting the recommended physical activity amounts every day, uh, plotted from 1986 to 2000, and the numbers subsequently look pretty similar. And during that time, a lot of work occurred, um, that encouraged people to be physically active. Uh, lots of infomercials, advertisements, gyms opening, surgeon General's reports, lots of science and the like. But let's see whether the rates of physical activity increased during that time. Well, the numbers look like this. You know, it's not a very resounding um Uh, mark for increasing physical activity by information alone. Well, we could look at diets, so percentage of adults getting the recommended fruit and vegetable servings, and we see similar trends where the numbers are really low and discouragingly stable. Uh, maybe we're doing better with our children, so here are the number of percentage of children getting recommended fruit and vegetable servings, and, and we see this a similar sort of thing. So in order to provoke change, more has to happen than just giving information or to individuals and imploring them to change. So if we think about what we're doing now, we're essentially focusing on these things, but the question is, could we come up with a different view of the world and uh look at things a little bit differently in ways that might help. So otherwise. We wipe the slate clean and instead of um or in addition to focusing on the individual, focus on things that occur before the individual gets involved in the decision making process in hopes that the behaviors improve because the environmental drivers of the behaviors are changing. So from a policy point of view, you'd want to ask, how can you change the environment that's addressed, that's driving obesity, how can you use things like economic change, how can you use legislation, public policy change, the regulatory authority of government, in order to change what economists call, and I'm borrowing this term from them, optimal defaults. So there are default conditions that affect us all. Um, so for example, we're all in, in a space where we expect the air to be breathed, that we're breathing not to be unhealthy, and if we go down the hall or go into our kitchen to get a glass of water, we expect the water not to make us sick. So we have ceded to government authority to make conditions safer, so that our default air and water conditions are healthy. Um, and there are lots of other examples, automobile safety standards and the like that create a healthy set of defaults. Now we could say the government doesn't belong in this space, and that it would be up to us to remediate the safety of our water. Our water would cost less because we wouldn't have to process it, but we'd have to put pills in it or boil it or do something to make it safe, but we don't want to do that, so we allow government to take action on our behalf to create a better set of. Faults and we have reasonable air and water defaults as a consequence. So the question is, does the food environment, physical activity environment fall into the same sort of conceptual scheme, and can we do things to create better defaults that then in turn create less obesity? So I'll give you an example of how two non-obesity related examples of how powerful defaults can be. Uh, this study was one done by economists, and there have been lots of others like this, and you've probably heard about this in the context of nudges, uh, and, and other language like this that, that people have used in the popular language. But with pension plans, uh, people enrolling in pension plans. when they get a job. There are two fundamental ways people can do this. One is you're, you're not enrolled in the pension plan by default, but you can opt in of, and the, you're given that choice by your employer. In the other case, it's the reverse. You are enrolled in the pension plan by default, but you're given the option of opting out. So under both sets of circumstances, the employee. Has freedom of choice. They can choose to be in or out, clearly, but whether people join pension plans is determined largely by what the defaults are. So if the employee has to take the active step of enrolling, if the default is not to be in the pension plan, you get about 50% of people. But if the different set of defaults is used, then you're near 100%. So you could try to educate or employ your way from 50 to 100%, but would it take a lot of time and effort and money, and you probably wouldn't even get near to that 100% anyway, or you can just change the default. And here's a health related example, organ donation. This is a very famous study done um in Europe, and it looked at the percentage of people in different countries who agree to be organ donors. That white uh vertical line that you see kind of in the middle. Um, it shows 4 countries to the left, Denmark, Netherlands, UK, and Germany. They use the US model for being an organ donor, where you're, you're not an organ donor by default, but you can opt in when you get your driver's license. And then to the right are countries, as you can imagine, do it the reverse. You are an organ donor by default, but you can opt out. So the countries on the left and the right both have the same set of choices, clear choices. For the individual, but the rates of organ donation are quite different. Using the US model, you get something like this, uh, using the, the reverse set of defaults, here's what you get. And those numbers are breathtaking. Um, it's amazing you can get 99.98% of people to do anything, um, but the fact that you can get those kind of numbers by simply changing the fault is really pretty remarkable, and no amount of money, no amount of effort, no amount of education or employing could take you to those numbers on the right. So, again, thinking about food, are there food and physical activity related defaults that we could help change in our country through public policy in order to create a healthier set of circumstances for people. Uh, if we look at food defaults, we, we all of us know this because of the things that have happened in our lifetime, and even for those of you who have been are younger than I am, you can see really pretty remarkable changes just in, you know, over a person's uh years since they were children. And food norms have really become toxic, so we can think about these things just as we begin. Um, you know, when I was a boy, nobody ever ate in their car, um, and now if you're an automobile maker and the, the cup holders aren't large enough to hold those very large drinks, you will lose market share. Um, people didn't eat, used to eat all day long at different sorts of places, like in their car. Um, the, some of you may have seen the, uh, fast food advertisements for companies encouraging basically people in a kind of young adult demographic to come and eat fast food after midnight. So they're basically recalibrating people to say, not and and Taco Bell has called this the 4th. Meal, so they're very intentional about it. And what they're saying is that not only is it OK to eat between dinner and breakfast, that it's OK to have a meal during that time and that fast food is OK to eat as that meal. So these are profound changes in food norms that have occurred, and there are different reasons for it. Part of it is intentional behavior by the food industry, but part of it are just things that are happening in our culture. Uh, we can think of portion sizes, we can think of pricing incentives for people to buy things like value meals, um, and then, you know, what, what is acceptable to eat has really changed profoundly as well. Um, you know, you get these, these foods that, you know, you get, for example, Pizza Hut started, I don't know if they were the first, but they were one of the companies that started baking cheese into the crust of the pizza, and then they went beyond that and in one version of their pizza, they had a hot dog baked into the crust of the pizza. So it's hard to imagine more salt, fat getting delivered to people and so something like that, but those things have become acceptable in our culture. So if we have toxic food defaults, and then toxic defaults regarding physical activity that make people more sedentary, then it can't be a surprise that we get record levels of obesity, and it can't be a surprise as other countries adopt our, our defaults that they have problems with obesity as well. So changing these defaults can become a really important way of thinking about addressing obesity through public policy, particularly with children. Now, this, this um um runs counter to some arguments people make that obesity is an issue of personal responsibility and in the case of children, it's a problem of parental responsibility. So we took this on in this particular paper uh that we wrote in Health Affairs, and I'd be happy to share this with anybody if you uh just get in contact with me by email. But this was written with a political scientist, several physicians who work on pediatric obesity, uh, and public health, um, the dean of the Yale Law School and several colleagues who were with me at, at, uh, Yale at the Red Center. And basically what we said is that the, the concept of personal Responsibility is completely consistent with this idea of changing environment through defaults, because what it does is it helps people become more responsible. That if you'd like kids to develop a responsible approach to their food, you don't want to surround them in an environment of unhealthy food and then have remarkable amounts of marketing pushing those kinds of foods. So changing the defaults can be lined up with this idea of personal responsibility. Um, if we ask how good are we at creating change, uh, that becomes an interesting topic, especially for people in scientific settings. So, if we think about how much we know about the things we might do in public policy, and then what actually occurs in public policy, there's a real disconnect. So, our hope is that as we do more, we and lots of others do more research on uh public policies that might help prevent obesity or help people who already are overweight, um, how can we create impact from knowledge? And so we hope that we can produce knowledge that will serve society and then society somehow gets served. This is the whole concept behind academic medicine and scholarship in general, but it's a real question mark about whether society actually gets served, that is what whether public policy is, is changing as much as it might given what we know from scholarship. And so a key purpose of the work we do is to help address this issue. And our frustration has been that research tends to reach small audiences, um, that it tends to miss the, the people who are really in a position to do something with public policy because they're not reading academic journals, and that that creates these poor links that become a real problem. And the metaphor we use to describe this is like a relay race where the baton gets dropped. So, in a relay race, you only can qualify to win the race if you successfully pass the baton from one runner to the next. And in a lot of ways, when we're creating research in hopes that policy change will occur, we're running our lap of the race, but then there's nobody to hand the baton to, or nobody is there to successfully take the baton, so it gets dropped, because there's not much of a connection between the people producing the scholarship and the, the actual public policy world. And typically, academics respond in this way. We don't blame it on ourselves, it's not that we're doing the wrong thing. But that the world doesn't care, they don't care about science, they're just too stupid to pay attention. There are a lot of these attributions that I think are quite incorrect, and in fact, if we were talking to these change agents and um we're able to do research that was really relevant in their world, then I think they would pay a lot more attention. So if we think about research affecting the world of public policy, public policy moves very fast. All you have to do is look what's happening in Washington now, and you can see an awful lot of fast movement in some cases. But in, in the case of academics, it tends to move very slow. Um, so we, it moves slow, uh, it's poorly communicated with the outside world, it tends to be unresponsive to these needs of the. Policymakers, it tends not to be strategic. There can be conflicts of interest, and this is a real problem. And of course, academics create this in jargon that's indecipherable to the rest of the world, and that makes it hard to communicate as well. So we really do all these things as researchers, and it's important that we turn this around so the work really matters. And I'll give you some concrete examples of this. So here's how we address this particular problem. Uh, beginning when I was in my position at Yale and now at Duke University, we're working on this. Um, what we, we want is to create a link between research and these things, and we're pretty good at creating links with other scientists, but not very good at creating social and policy change, which obviously is the priority. So we have created this model that we hope will help where we've really started to pay attention to what falls in the middle, what's necessary in order to create this change. And this model that we've developed uh involves something like this, that those middle boxes represent change agents. So if you ask who are the people or institutions who are in a position to do something about whatever problem it is you're addressing. How can you work with them in order to create the social and policy changes? And so a lot of different players could be at work. So if you think about obesity, for example, we automatically think about legislators, but people who are leading regulatory agencies, departments of agriculture, um, the Food and Drug Administration, and the state versions of these agencies can really be very important in this picture. Uh, the courts can be important, um, uh, you can think of lots of examples over the years where public health has been improved because Cases, uh, you can think of the press as being a change agent of the public, uh, you can think of, um, NGOs, uh, local and, and other organizations, and in this case, the food industry, and they're all potentially important. So you might decide, for example, that the best way to get action on a particular issue, uh, is to identify a change agent that might happen to be a state attorney general. They might have some authority over a particular issue, and then they become the person to interact with to help create. The research questions that didn't get translated into policies that can affect a lot of people at the same time. Then once those people are identified, you create this, hopefully, this virtuous cycle that leads to solutions that begins with Identification of these change agents. Excuse me, then. Develop strategic questions that you address through your research. There are not things that the scientists are saying important, but they're, they're gaps in knowledge that you figure out by talking to the change agents. Then the research can be done, and then this communications occurs back to the change agents, and that's what we hope the, the virtuous cycle will be. So, There are some interesting examples of this I'd like to share, but if any of you are interested in this, um, this conceptual model, this particular paper, uh, we published on this issue about strategic science contains that, and again, if anybody would like to um get in contact with me, I'll be happy to send this along. Excuse me. Um, so here's a case study, consumption of sugar-sweetened beverages. Uh, I don't really need probably to convince people listening here that consumption of sugar-sweetened beverages is a problem, but here are some of the reasons, and I'll, I'll focus on one of these in particular, uh, which is bullet point number 3, it's that. That well known, but it's a pretty robust scientific finding that when people are consuming calories in liquid form, they tend not to feel as full, and they tend to overconsume compared to consuming the same number of calories in a solid form. So if people have um overdo it on, let's say, a solid food, it could be pizza or donuts or ice cream for that matter. Versus consuming the same amount of sugar in a beverage, uh, people are more likely to compensate by consuming less later if they're getting the calories in a solid food compared to the beverage, and the fact that Americans have been consuming a higher percentage of calories in in liquid form in beverages than what used to be the case is a concern in this context. So sugar sweetened beverage consumption reduction would be a pretty good public policy ambition. So, one thinks first about the, the metabolic pathways that uh create problems from consumption, heavy consumption of these beverages, and you can see that it was discussed here, um, but I'd like to talk about one particular public policy issue, taxes on sugar-sweetened beverages, and discuss uh some of the strategic uh. On that. So I, I've been working on the issue of surrogacy beverage taxes for decades now, um, but the issue has now become really public policy, which is very nice to see. In 2009, uh, policymakers began talking more about, uh, taxes on sugared beverages, and one of the primary reasons is the American economy was in such tough shape that the policymakers were looking for extra sources of revenue. And what better way to think about generating revenue from an action like a tax on sugar beverages that could in turn reduce healthcare costs, then you would get a double benefit. So, at that time, I wrote this opinion piece in the New England Journal of Medicine with Tom Frieden, who at the time was the commissioner of health in New York City. Uh, and until just the past few days was the head of the Centers for Disease Control. We then followed with a second paper, uh, written by a broader range of experts, including economists, um, making both a public health and an economic case for taxing sugar-sweetened beverages. And the argument from the public health point of view was, was pretty clear, you'd reduce beverage consumption and Um, there would be improvements in health, but the economic argument is very interesting as well, and focuses primarily on the issue of externalities, that is that people who aren't consuming the beverages or aren't, um, uh, selling them are affected by this transaction between buyer and seller. That is, we're all paying through Medicare and Medicaid for the health consequences of obesity. Um, and in the case of children, you can make an especially strong case about externalities. So this provided a conceptual basis for moving ahead on taxes, but it wasn't really strategic scholarship in the sense that it didn't really address the issues that were relevant to policymakers. So what did we do? Well, we set out first. To do work on the elasticity of, of, of beverage consumption with price changes, that is, with a given price change, how much would consumption change? And this is important to know because if you change prices a lot, but consumption doesn't really change, it's not a worthwhile enterprise. Uh, but we worked out those numbers and it looked like there was a considerable elasticity for sugar beverages, that is, with relatively modest changes in prices, you can get pretty big changes in consumption. So that helped, but the um the the legislators who were proposing these taxes weren't really interested so much in the health benefits. They were interested in generating revenue. And so we then created some research that looked at the revenue generating potential of the taxes and uh worked out those numbers as well. And so, the economists working with us, Tanya Andreva did some wonderful work on this, and created an algorithm where you could calculate for any jurisdiction. I mean, most major cities and all states, if you calculate how much revenue would get raised if you put in a tax of a certain amount, and we created an interactive website that still exists today, uh, if you want to look at it, you can put in Rud Center tax calculator. Um, but it, it gives you a web page like this where you can enter a city or a state and a certain amount of tax. The default, um, tax that is being proposed is 1 penny per ounce, that is, uh, in addition a tax of 1 cent per ounce of any beverage with added sugar, and the, the red. The algorithm then generates a chart that looks like this, so just taking California as an example, it produces this whole table of numbers, but the most important is the one at the bottom right, which is the annual revenue, um, avenue, the average revenues that a state or city would raise if it were to introduce a tax of 1 penny per ounce. And in this case, the state of California would generate more than a billion dollars a year. So this is enough to catch the attention of legislators because you can do a lot with this amount of money. And so the taxes now have been passed in a number of places. Um, and, and I'll give you one case study that I think is really interesting. Um, these are three people you may recognize. Um, the top person is Michael Nutter, the previous mayor of Philadelphia. Person on the bottom list is Don Schwartz, who was the health commissioner of Philadelphia, now working with the Robert Wood Johnson Foundation, and on the right is Mayor Kenny, who is the current mayor of Philadelphia. When Mayor Nutter was in office. Um, from what I, what I hear from speaking with a former commissioner Schwartz, is that the two of them were talking about dealing with the obesity problem in Philadelphia. They were especially interested in obesity in children, and, but the mayor also had a budget deficit, so they have to deal with, so they really couldn't think about spending a lot of new money, and so the idea of a soda tax came up in their discussion. And they used the calculator that we had on the website, and they found out what the revenues could be for Philadelphia, and Mayor Nutter then introduced the idea of a tax and came very close to getting what passed in Philadelphia, but did not quite succeed. Then when Mayor Kenny came in office, but his main focus for this by was for the health benefits and the ability to address childhood obesity. When Mayor Kenny came in, he favored the idea of a soda tax as well, but he turned the rationale on its ear. Instead of focusing on the the health benefits, he focused on what could be done with the revenue. And he introduced a tax to fund early childhood education programs and a few other things in the city of Philadelphia, and then he got it passed. So the tax is 1 penny.5 cents per ounce of beverages with added sugar, and there really was a breakthrough when Philadelphia passed this, uh, partly because of the way it was framed. So if you look around the world and in our country, uh, you can see that. There are a number of countries that have sugar sweetened beverage taxes, and the number of cities in the US. In the most recent election, um, the 4 California cities, well, no, actually 3, and then 1 in Colorado, Oakland, San Francisco, Boulder, and Albany, California all passed taxes, and then shortly after that, Chicago Cook County passed a tax. So within the United States, there are different parts of the country, the Midwest with Chicago. And then the, the West Coast and the Colorado examples are there, but these taxes have passed in a number of other places as well, and then, uh, taxes are close to being passed in in other countries outside the US and there are a lot more discussion about things going on in the United States. So to me this is Exciting development because number one, this is a policy that really could help. The tax, a tax of about 1 penny an ounce increases price by about 15%, and it's expected that the tax of that size would reduce consumption of sugar-sweet beverages by about 15%. And the evaluations that have been done so far in in Mexico and in Berkeley suggests that the taxes are being passed along to consumers, that this is affecting behavior in the case of Mexico, there's been an increase in water people are consuming as opposed to the sugar beverages. So this is all very positive, at least in my mind, and It shows not only that these kind of um uh uh taxes can be passed, but uh they can be passed across a variety of geographic areas. Um, we don't know whether this is true yet or not, but it's possible that it will be true that these taxes have an especially powerful effect on youth. Um, tobacco taxes turned out to be that way because youth, uh, tend to have less expendable, uh, resources than adults, and therefore particularly price sensitive, and if that plays out as well, uh, with respect to sugared beverages, that could be very positive in the context of childhood obesity. The other thing that this signals is that Uh, people, uh, in the United States are adopting this idea that government does belong in the space of changing defaults, in this case, a price default, in order to help it. and other maladies related to poor diet, so I see that as very positive, you know, it wasn't very long ago that there was um uh. There was complete disregard for these public policy proposals. When we first introduced the idea of a tax, um, 25 years ago, it, it, it was either ignored or lampooned. Um, and it was considered inconceivable at one point that the food environment might be changed in schools, or the companies might have to change the way they market their foods to children, and all of those things are happening now, so that reflects what I see as a very positive development. So in concert with the clinical improvements that have occurred in addressing obesity, there's some public policy improvements that are quite, uh, quite positive. So there are a number of signs of changing defaults that I find really exciting. So there are information defaults. So, for example, the next time the food label is revised, it's expected to have added sugar put on. This is a big thing. Uh, the nutrition facts panel included trans fats at one point, which put pressure on the companies to get rid of trans fats, and then that later became law. Uh, warning labels on foods are now being provided. Proposed that haven't been enacted yet but are being proposed. So there are information defaults, uh, calorie labeling on restaurant menus is another great example of that. National legislation is expected to kick in soon that will require this of all chain restaurants around the companies. The economic defaults, we talked about one, the soda taxes that would increase the price of an of an uh a food you'd like to see decrease in terms of population consumption. But one could also think about subsidizing the cost of things like fruits and vegetables to change that economic default. And then there's a lot of work on changing excess defaults. Having healthier foods available in schools would be the prime example of that, but addressing the problem of food deserts where people don't have access to healthy foods, uh, changing portion sizes, changing physical activity defaults would be examples of those things. So I see all those as as being very exciting uh changes, and I think representing a wave of what we're likely to see more of in the future. So I'll conclude by saying that uh public policy can be a very powerful tool, not easy to make it happen, but boy you see lots of places around the country where it is, uh, most of the school, uh, the initial school victories about school nutrition. Standards occurred because parents or health professionals in a small community, sometimes larger communities, got involved and really made a difference in, in those environments. And so individuals can really have an impact, uh, individuals can start. Legislators to do soda taxes, but there are a lot of other things as well, um, and these things are very positive, I think, and are, are, it, it's a sign of the changing times. So we're fighting a hard battle, uh, the food industry is very powerful. Uh, Americans are accustomed to eating a lot of unhealthy food, and it's not going to be easy to turn that around. What's being marketed to people is astonishingly, astonishingly unhealthy, so there's a lot to be done, but the fact that we've seen these victories is really exciting. I think as we go forward we're going to see even more of these, and I hope that that. Conceptual scheme of changing default so that people have a healthier set of choices in their environment, uh, is one that will persuade legislators to move ahead on this. So I'll stop there and be happy to answer any questions. A fantastic talk. That was really, uh, really pretty amazing and you threw some pretty remarkable numbers up there. I just, you know, as we polled the audience at the very beginning of your talk and asked who was in favor of a tax, and 27% said no, 73% said yes. So then we said just about 2 minutes ago we put it back up and said, well, now do you think the government should tax sugar and so far it's 100%. I don't know that the other folks just are afraid to respond now. Or if you really persuaded them, but it is quite remarkable. One question I have is, uh, the, when you look at those tax numbers and the revenue, does it take into account the decreased consumption? And is it, I know like in the tobacco, you know, you can, in the tobacco world, you can say that well if a pack of cigarettes costs x amount, you'll decrease consumption by this percentage. Do we know that about sugar? Do we have enough information or data yet? There are, there were estimates by economists suggesting that um with, with a, as I mentioned, a 15% increase in price might reduce consumption by around 15%, but those were just estimates, and you'll have to wait longer in the real world to see how these things play out. The results so far, there have been evaluations in Mexico, preliminary evaluations in Mexico and in Berkeley, and they look positive, but we don't know exactly how much. The consumption will change. Philadelphia will be a really important test, and people are doing research to evaluate the impact on that, but it's too early to know because the tax just went into effect. But that will be interesting because it's a different community that has been studied before, and also the tax is higher than what's been used before. It's 50% higher than the penny per ounce used in, say, Berkeley. Uh, one of the questions, uh, also that was asked, uh, by Doctor Smith, uh, Anthea Smith, uh, can you speak to the food subsidized by the US government and the impact on food consumption, and are there any efforts to change to healthier food subsidies? Good. That, well, I'm happy that question got asked. It's a really important one. Um, the, as you know, subsidies, heavy, heavy duty subsidies went into effect in the Nixon administration to subsidize commodity crops like corn and soybeans. With the price of those declining because of the subsidies, the food industry had this steady stream of very low cost ingredients they could make foods with, and so they began to process them into lots of snack foods and salty things and beverages and the like, uh, and then you could produce high fructose corn syrup, for example, at low cost and sweetened things like beverages. So the, the kind of knee-jerk response here is to say, let's take away the subsidies from those big commodity crops and put them toward things like fruits and vegetables, and it probably makes sense to do that, but the health economists really have to get in and work it out and figure out what prices on what products will be optimal to get the. Maximum population shift in consumption, and people are beginning to do that. Now. The good news is that uh for the for all these subsidies are bound into this massive piece of legislation called the farm bill. Um, the farm bill, uh, nobody ever talked about the impact of, of the farm bill on nutrition. It was all about agriculture and its vitality, but now people are having that discussion. Uh, it's very hard to push around the farm bill because they're very heavy duty agriculture interests lobbying for certain parts of the farm bill, um, but at least the discussion is occurring, and I expect in future iterations of the farm bill, we might find cases where the nutrition priorities of the country are lining up with the agriculture priorities of the country. Yeah, thanks. Yes, so, and so Matt Hammer also on the soup exec team wrote in a question about, um, asking about what type of arguments might best protect school nutrition standard from those who complain of increased costs and food waste as reasons to throw them out. Um, and how does one sway the reasoning of policymakers who seem to govern more by feeling than by logic? Any thoughts? Well, yeah, the, the second one, the feeling and and logic, you know, prevailing over logic, I'm not sure how to address that one, but it's a, it's a huge problem, of course. Um, the, the research on changes in school nutrition standards has been very positive. Uh, you, you, you can find anecdotal cases of kids not liking the healthier foods and throwing it away. That tends to be temporary. And especially with younger kids as they're just developing their eating habits and learning food preferences. If the um if the the the schools can introduce foods in a pleasant way, it can be part of the educational programs of the school, then kids will get used to the better foods and will come to like them, and then just adopt them, and then that's just the way the school environment is in in a given institution. So I think the results on these about whether these actually improved diets in children are very positive, that not only are the kids eating healthier foods in school, but there tends to be this impact back in the home where kids are eating somewhat healthier in those settings as well. So that's why schools are such an important place for this battle to be fought. Tory, do you have any thoughts on that from the 5210 goes to school project? Yeah, so Kelly, that was an incredible, incredible presentation, and here in Maine we're working on a tax on sugar sweetened beverages, so we're very excited about all the work that you've been doing over the years on this, and the Philadelphia story is, is fantastic. So there are a lot of data out there that says there aren't waste in schools. And so I think for folks who think that with the new nutritional standards that kids aren't eating the food, just look at the data. The data are telling us that the kids are eating that. And we know in the 280 schools that we work in in Maine that you put healthy foods in front of kids in a, in a positive way, they'll eat them. The adults have a harder time. The teachers have a harder time, but the kids are eating them. We also, I, I think the important piece for us here in Maine is that it's not just what's happening in schools. We also work with the out of school programs. We work with the sports-based programs. We support the parents in a positive way. So it's that wrap-around effect that I think can really um. Really have the biggest impact. So, uh, Kelly, you're absolutely right. The work that's happening in schools is really exciting. Um, I don't, I have a question for you though. I, I, I've seen some new, uh, literature out and some new review articles about what we should do with our SNAP benefits and should we be restricting, uh, SNAP benefits, um, around sugar sweetened beverages. Do you have any thoughts on that? Um, I do. The, it, it's a very interesting, well, thanks for the example, but, um, about the reports from Maine, it sounds like you're doing fantastic work and a lot of good things are happening, and I really Characterize this as a wrap-around program because you're absolutely right, the more touches that you can have with kids in the educational programs and sports programs, all that kind of thing, it just makes the message even stronger. So congratulations for what you've accomplished. It's very inspiring. Um, the SNAP, uh, program is a highly controversial issue, and, um, what it's done, what it's done. It's pitted the obesity community against the hunger community, and both sides have dug in their heels. And so as a result, there's essentially an impasse. So what happened with this is the obesity public health community says, why in the heck should government be buying $4 billion worth of soda every year and giving it to people through the SNAP program? And then of course everybody having to pay. For the obesity and diabetes later on, uh, the hunger community says, wait a minute, um, there are two problems with this. One is that these food entitlement programs, which have very positive effects, are always under threat by some legislators. And if this starts getting talked about more and more, it'll be an excuse for just cutting the program. So a legislator might say, OK, well, let's take $4 billion out of the program, and that's the last thing you want. So that's a very realistic concern. But another one is that they believe that people who are getting SNAP benefits are already stigmatized because of poverty and other issues they face in their lives, and that doing this would further stigmatize them. So if the communities have been talking when the issue first came up, there might have been. And some studies you could have done to help address these issues, and there might have been political ways to address this that would have been a win-win, but unfortunately, the, the, as I said, the two sides have dug in their heels. The US Department of Agriculture. There's some people there, I think were willing to allow some place in the country uh to do an experiment on this, to do a pilot, to try having some people have an adjusted benefit program where they kept the same benefits, but they just couldn't buy sugar beverages with the benefits to see what impact it had and what people did with their benefits instead, whether they would use their personal money to buy the soda if they couldn't buy it with their benefits and things like that. Um, New York City proposed doing a test, but the USDA declined, saying that New York's too big of a place to do a pilot study. And so the hope is that some other place will propose this to the USDA. The USDA will agree, and then there will be some data, and then you'll know whether it's effective or not, and perhaps that would help bring the parties together so you could create some sensible policy. You know, I'm glad you bring it up. The other point that that we have in Maine. So we've started to really talk to the folks that are working on poverty and hunger in our state, and, and I've come around. I've come to the other side that these folks that are using SNAP benefits do not need more obstacles in their way. We should actually make it difficult for all of us to buy sugar sweetened beverages, not just for folks, the most needy, so. Um, we've gotten very involved with food insecurity issues here in Maine and, and really we talked to the, to the folks in hunger. They're, they become my newest best friends, um, as I'm starting to understand that world. So thank you for bringing that up. Oh, I'm so happy to hear that because those kind of conversations are so important. Mhm. Kelly, I have a quick question for you also. Um, one of the lobbies that you We tend to run up against when we're talking with legislators. So, it's easy to say, OK, you know, the, the big soda manufacturers have deep pockets, then we don't need to worry about their financial vitality all that much. But the lobby that always gets thrown back to us is we can't beat up our small business people, our grocers, our corner store owners. Is there an effective, um, Way to talk about that with, with legislators and city councilmen and aldermen. Yes, well, first data would help, and with the evaluations that are going on now around soda taxes, people will be collecting data on just that issue. So hopefully before long we'll be able to find out what actually happens to these merchants as things like soda taxes get put in place. But two things that kind of a corollary of what you brought up is the complaint that the industry always raises when. They're trying to oppose things like taxes is people will lose jobs. They don't even need to explain how that would work. They just say people will lose jobs. But in fact, some economists in Chicago did some interesting research saying that things like soda taxes would probably lead to a little bit of job improvement rather than job loss because jobs would be created in other sectors as this, as the tax went into effect. Um, and that, but back to the merchants, um, people aren't necessarily going to buy less food. If they stop buying soda with their money, they're likely to buy other beverages or other foods, and so there's really no logical reason to think that these merchants would lose money. Uh, that, that if, if people buy less of their one product now, but then they buy more of something else, then hopefully they would come out the same, uh, and it could even be possible that people would shift consumption to things with a higher profit margin that would help you. So there's, there's really no data to, to support that point of view of the industry, and there's logic that would suggest that they're probably not right. They are very low profit margin things for a small business owner. So yeah, no, that's Kelly, fantastic talk. I know we could probably go on for a while with this discussion. Just before we close out, I do want to let you know that you seem to have changed most of the naysayers' minds. We do have one holdout in the poll. But thank you so much, fantastic discussion. We're going to take about a 45 minute break for lunch. We'll be back at 12:15 when our very own Chris Bowling is going to talk about social determinants of health and obesity. And then we have a couple of new sections coming up later on in the In the global cast, in the obesity global cast, one is a journal club. We're going to talk about some latest and greatest papers. Then we're going to do a little piece on bariatric surgery, and then we're going to have rapid fire. So stay tuned and please come on back at 12:15. We'll see you then. Thank you.