Menjar millor per viure més (i millor?)

 Life expectancy can increase by up to 10 years following sustained shifts towards healthier diets in the United Kingdom

El titular d'aquest article de Nature és d'impacte, busca notorietat. Una dieta saludable pot augmentar fins a 10 anys la vida, diuen. Això depèn és clar de molts factors, alguns dels quals s'expliquen amb detall. El més interessant és que ha estat fet amb el UK biobank i una participació de 467.354 persones. Estem per tant davant d'un treball amb una gran mostra. I la conclusió és aquesta:

Our results showed that the longevity-associated dietary pattern had moderate intakes of whole grains, fruit, fish and white meat; a high intake of milk and dairy, vegetables, nuts and legumes; a relatively low intake of eggs, red meat and sugar-sweetened beverages; and a low intake of refined grains and processed meat. Analyses adjusting also for body mass index and energy (Supplementary Information) showed slight reductions in inverse associations with mortality for whole grains, vegetables and fruits, reductions in positive associations with mortality for red meat, and stronger inverse associations for both nuts and white meat. For several of the food groups associated with reduced mortality, the lowest intake quintiles were substantially different from the other quintiles. The unhealthy dietary pattern (that is, the quintile with the highest mortality associations) contained no or limited amounts of whole grains, vegetables, fruits, nuts, legumes, fish, milk and dairy, and white meat and substantial intakes of processed meat, eggs, refined grains and sugar-sweetened beverages. The strongest positive associations with mortality were for sugar-sweetened beverages and processed meat, while the strongest inverse associations with mortality were for whole grains and nuts.

Begudes ensucrades i ultraprocessats mostren reducció de la longevitat, i els fruits secs i cereals integrals l'allarguen, això diuen. Quan ho mires amb detall aleshores cal recordar que correlació no és causalitat, i som on érem. Les recomanacions genèriques poden funcionar més bé o no tant. Ben segur que és una mica més complicat tot això, ja ho vaig explicar fa uns dies al post "nutrició de precisió". En qualsevol cas el missatge és que cal millorar com mengem i què mengem.

What we're up against

Biography of Resistance
The Epic Battle Between People and Pathogens

Great book for nowadays.

Antimicrobial resistance does have a future, one that is going to affect the way we get to live and die. The potential doomsday scenario of tens of millions dead annually is real, but so are the hopeful developments of the last few years. On the technical side, there is promise in vaccines and phage therapies. On the economic front, ideas are being proposed that incentivize pharmaceutical companies to commit themselves to research and development.3 There is a new sense of urgency within the WHO to improve surveillance and empower all countries, rich and poor, large and small. 

 Bacteria will continue to do what they have done since the dawn of life—evolve, adapt, and get ready for the next battle for survival. Our actions are helping them acquire a better arsenal at a faster rate than they probably would have on their own. But despite the challenges and frustrations, in the hundreds of interviews that I conducted for this book, there was a sense of optimism about the future. That optimism stems from a belief in human ingenuity, the vast reserves of natural treasures that are untapped, and the power of coming together. That optimism is also predicated on two things: a commitment to peace, and a desire to care for all people—everywhere.

This is the index:

 Chapter 1: What We’re Up Against
Chapter 2: Fifty Million Dead
Chapter 3: Time and Space
Chapter 4: Friends in Far Places
Chapter 5: Near the Seed Vault
Chapter 6: Keys to Karachi
Chapter 7: War and Peace
Chapter 8: From the Phages of History
Chapter 9: Sulfa and the War
Chapter 10: Mold Juice
Chapter 11: Tablets from Tears
Chapter 12: The New Pandemic
Chapter 13: The Man in the Blue Mustang
Chapter 14: Honeymoon
Chapter 15: Mating Bacteria
Chapter 16: S Is for Soviet
Chapter 17: The Navy Boys
Chapter 18: From Animals to Humans
Chapter 19: The Norwegian Salmon
Chapter 20: Closer to Sydney Than to Perth
Chapter 21: A Classless Problem
Chapter 22: The Stubborn Wounds of War
Chapter 23: Counting the Dead
Chapter 24: Clues in the Sewage
Chapter 25: X Is for Extensive
Chapter 26: Too Much or Too Little?
Chapter 27: Visa Not Required
Chapter 28: The Dry Pipeline
Chapter 29: New Ways to Do Old Business
Chapter 30: A Three-Hundred-Year-Old Idea
Chapter 31: Spoonful of Sugar
Chapter 32: Conflict Inside the Cells
Chapter 33: Security or Service?
Chapter 34: One World, One Health
Chapter 35: Bankers, Doctors, and Diplomats
Epilogue

On sugar and taxes

Should We Tax Sugar-Sweetened Beverages? An Overview of Theory and Evidence

The real question is how to tax the addiction industry. Sugar is only one case. Right now, these are the guiding principles (for sugar):

1. Focus on Counteracting Externalities and Internalities, Not on Minimizing
Sugary Drink Consumption
2. Target Policies to Reduce Consumption among People Generating the Largest
Externalities and Internalities
3. Tax Grams of Sugar, Not Ounces of Liquid
4. Tax Diet Drinks and Fruit Juice If and Only If They Also Cause Uninternalized
Health Harms
5. When Judging Regressivity, Consider Internality Benefits, Not Just Who Pays the
Taxes
6. If Possible, Implement Taxes Statewide
7. The Benefits of Sugar-Sweetened Beverage Taxes Probably Exceed Their Costs

Furthermore, sugar-sweetened beverage taxes are not a panacea—they will not, by themselves, solve the obesity epidemic in America or elsewhere. But sin taxes have proven to be a feasible and effective policy instrument in other domains, and the evidence suggests that the benefits of sugar-sweetened beverage taxes likely exceed the costs

 Robert Frank

Taxing unhealthy foods

The effect of prices on nutrition: Comparing the impact of product-and nutrient-specific taxes

Nowadays, many people is asking about evidence oon the impact of taxes for sugar sweetened beverages. The reason is that in Catalonia from May 1st. a new tax has been implemented.Two tax rates have been set in relation to sugar content: For drinks containing more than 8 grams of sugar per 100 ml: €0.12/litre. For drinks containing between 5 and 8 grams of sugar per 100 ml: €0.08/litre
A new article in the Journal of Health Economics sheds light on the issue:

Our main finding from the tax simulations is that nutrient-specific taxes have much larger effects on nutrition than do product-specific taxes, without causing a larger decline in consumer utility. The intuition for this result is that nutrient-based taxes have a much broader base, so it is more difficult to substitute away from any one good in response to such taxes. For example,a 20% tax on soda decreases total purchased calories by 4.84% and decreases sugar consumption by over 10%. However, a 20% sugar tax decreases total calories by over 18% and sugar by over 16%.The larger effect of a sugar tax on nutrition comes despite the fact that it has the same effect on indirect utility as a soda tax. Dueto their negative income elasticities and the patterns of own- and cross-price elasticities we find, taxes on snacks and packaged mealshave very small effects on nutrition. Fat and salt taxes, on the other hand, have much larger effects, decreasing calories by 19% and 11%, respectively. SSB taxes, which can be thought of as a hybrid price policy that targets a set of products based on their nutritional content, also are quite effective, reducing caloric intake by over 8%. However, these taxes are less-effective and only slightly less-distortive than a broad-based sugar tax.

If this is so, the next steps should be to review the initial impact and explore wether new approaches could be more succesful. Unfortunately the article doesn't explains the details of how to implement their result...

PS. On sugar

Ben l'oncle Soul

On sugar as a toxic substance. How little is still too much?

THE CASE AGAINST SUGAR

Last book by Gary Taubes takes a difficult way, how to demonstrate sugar as a toxic substance for our health. Although he tries to show evidence for his words, he finally concedes the following conclusion:

Ultimately and obviously, the question of how much is too much becomes a personal decision, just as we all decide as adults what level of alcohol, caffeine, or cigarettes we’ll ingest. I’ve argued here that enough evidence exists for us to consider sugar very likely to be a toxic substance, and to make an informed decision about how best to balance the likely risks with the benefits. To know what those benefits are, though, it helps to see how life feels without sugar.

The "very likely" expression is crucial. Unfortunately we don't have a explicit causal explanation of the impact of sugar on metabolic syndrome, for example. I think that epigenetics will provide neew perspectives on the issue, however we will have to wait. Meanwhile reducing exposure is the best advice.

PS. On the sugar sweetened beverage taxes. And in this blog

Behavioral health insurance choice

Behavioral hazard in health insurance
Can Consumers Make Affordable Care Affordable? The Value of Choice Architecture

Behavioral Economics is still a great promise for health economics. Anyway, in health insurance some materials are already available. Today I'll bring two articles on the choice of health insurance policy.
Some insights:

People do not misuse care only because the price is below the social marginal cost: they also misuse it because of behavioral biases—because they make mistakes. We call this kind of misutilization behavioral hazard . Many psychologies contribute to behavioral hazard. People may overweight salient symptoms such as back pain or underweight non-salient ones such as high blood pressure or high blood sugar. They may be present-biased (Newhouse 2006) and overweight the immediate costs of care, such as copays and hassle-costs of setting up appointments or filling prescriptions. They may simply forget to take their medications or refill their prescriptions. Or they may have false beliefs about the efficacy of care (Pauly and Blavin 2008).

The key message from the first article:

Incorporating behavioral hazard alongside moral hazard changes the fundamental tradeoff between insurance and incentives. With only moral hazard, lowering copays increases the insurance value of a plan but reduces its efficiency by generating overuse. With the addition of behavioral hazard, lowering copays may potentially both increase insurance value and increase efficiency by reducing underuse. This means that having an estimate of the demand response is no longer enough to set optimal copays; the health response needs to be considered as well. This provides a theoretical foundation for value-based insurance design, where copays should optimally be lower both when price changes have relatively small effects on demand and when they have relatively large effects on health. We show that ignoring behavioral hazard can lead to welfare estimates that are both wrong in sign and off by an order of magnitude.

"Avoidable copayments" , that's it. And about the second:

We examine how well people make these choices, how well they think they do, and what can be done to improve these choices. We conducted 6 experiments asking people to choose the most cost-effective policy using websites modeled on current exchanges. Our results suggest there is significant room for improvement. Without interventions, respondents perform at near chance levels and show a significant bias, overweighting out-of-pocket expenses and deductibles. Financial incentives do not improve performance, and decision-makers do not realize that they are performing poorly. However, performance can be improved quite markedly by providing calculation aids, and by choosing a ‘‘smart’’ default. Implementing these psychologically based principles could save  purchasers of policies and taxpayers approximately 10 billion dollars every year.

That's a lot. glups!

Regulating sugar sweetened beverages

Searching for Public Health Law’s Sweet Spot: The Regulation of Sugar-Sweetened Beverages

Nowadays, obesity prevention lies at the heart on any public health policy. If sugar sweetened beverages contribute decisively to obesity, then something should be done. What?. A recent PLOS article explains the options:

The main regulatory approaches are taxes, restrictions on the availability of SSBs in schools, restrictions on advertising and marketing, labeling requirements, and government procurement and benefits standards.

On taxes:

Savvy regulatory design has tremendous potential. For example, there is growing evidence that taxes that are more salient to consumers, such as those included in a good’s posted price (rather than being levied at the register), are more likely to influence purchasing behavior

On public procurement, a practical suggestion for immediate application:

Restrictions on which beverages may be purchased using government funds are a less visible form of regulation, but one with potential to change the consumption patterns of large numbers of people. Outside public schools, these standards are most germane in two areas: procurement standards for public institutions (e.g., government agencies, hospitals, and prisons) and restrictions on what recipients of government benefits for the indigent may buy with those funds.
The UK’s Government Buying Standards prohibit central government bodies from  procuring SSBs larger than 330 ml and encourage the wider public sector to follow the guidelines. Massachusetts  and many US counties and cities have adopted nutrition standards for government contracts, but most apply to a limited set of institutions, such as childcare facilities or youth centers.

PS. My former posts on the same topic.
PS. Article: The impact of sugar sweetened beverages on depression risk in adults.
PS. Report: Scenarios of Macro-economic Development for Catalonia on Horizon 2030
PS. Report: FBBVA Essential Public Services.
PS. Report: Chronicle of a premeditated offensive.

Public Health Priorities

Start Well, Live Better: A Manifesto for the Public’s Health. London: UK Faculty of Public Health, 2014

These are the 12 suggested priorities for public health in UK for the next 5 years:

Give every child a good start in life

• Give all babies the best possible start in life by implementing the recommendations of the 1001 Critical Days cross-party report
• Help children and young people develop essential life skills and make Personal, Social, Health and Economic, and Sex and Relationship Education a statutory duty in all schools

• Promote healthy, active lifestyles in children and young people by reinstating at least 2 h per week of physical activity in all schools

Introduce good laws to prevent bad health and save lives

• Protect our children by stopping the marketing of foods high in sugar, salt and fat before the 9 pm watershed on TV, and tighten the regulations for online marketing
• Introduce a 20% duty on sugar-sweetened beverages as an important measure to tackle obesity and dental
• caries—particularly in children
• Tackle alcohol-related harm by introducing a minimum unit price for alcohol of at least 50 p per unit of alcohol sold
• Save lives through the rapid implementation of standardised tobacco packaging
• Set 20 m.p.h. as the maximum speed limit in built-up areas to cut road deaths and injuries, and reduce inequalities

Help people live healthier lives

• Enable people to achieve a good quality of life, health and wellbeing—give everyone in paid employment and training a ‘living wage’
• Reaffirm commitment to universal healthcare system, free at the point of use, funded by general taxation

Take national action to tackle a global problem

• Invest in public transport and active transport to promote good health, and reduce our impact on climate change
• Implement a cross-national approach to meet climate change targets, including a rapid move to 100% renewables and a zero-carbon energy system

As you can see, many similar things with our PINSAP, the Health Policy Consensus and Health Plan. However, after yesterday news the pending issue of our public health is mainly alcohol abuse. We should focus on what works to reduce alcohol and addictive substance abuse. And first of all, we need to understand the foundations and best approaches to the problem. I would suggest you have a look at this book and specially this one:

PS. Binge drinking 'costing UK taxpayers £4.9bn'  Does anybody know how much does it cost here???

PS. In Spain, publicly funded health expenditure reached 64.150 million € in 2012,the amount for financial system bailout was 101.283 million € (p.24). Don't forget it: these are the priorities.

A call for a political prescription to tackle obesity

A political prescription is needed to treat obesity
Why Nudge?

Unless there is harm to others, the government cannot exercise power over people. This is the John Stuart Mill's "Harm principle", sometimes called the Liberty Principle. And governments have taken as given that individuals always take decisions in a rational way, fulfilling their preferences. As Cass Sunstein says in his last book "Why Nudge?", such a principle "raises serious doubts about many laws and regulations. Sometimes power is exercised over people in large part to promote their own good, finally people are note entirely sovereign over their body and minds". He argues in favour of paternalism in certain circumstances. We have already explained such details formerly in this blog.
Today I would like to suggest a reading to you, an excellent editorial in the Canadian Medical Association Journal. It is a call for action on obesity and specifically on food policy and taxation on sugar-sweetened beverages.

Our current approach to obesity relies on the assumption that people have choices, often fail to make the right ones, and should be educated and helped to make better choices. This view is simplistic and clearly absurd, given the continued rise in the prevalence of obesity in countries that have been tackling the problem for decades. Are millions of people really choosing to be overweight?

People are not as free to choose as we would like to believe. Neurobiological desires for sweet and high-fat foods gave humans a survival advantage in a world where food was scarce and every calorie counted. Where food is inexpensive and easily available, biological processes related to eating can mirror addiction and will lead to our destruction. We need to change our approach. We need incentives beyond educational messages. Strategies that include individual interventions,  school-based nutrition and activity interventions, incentives for active commuting and changes to the built environment should continue; however, we also need robust ways to restrict portion sizes and reduce the sale of sugar-sweetened beverages and other high-calorie, nutrient-poor food products. Our government needs to consider taxation as a tool to combat the consumption of these addictive foods and beverages, just as it regulates the sale of alcohol and tobacco products for the purposes of population health.

In USA, Berkeley is the first city that will intoduce the soda-tax after a recent ballot. Berkeley’s Measure D proposed imposing a 1-cent-per-ounce general tax on sugar-sweetened beverages and sweeteners used to flavor drinks. The measure will not dedicate funding to a specific cause and did not require only a majority of the vote.
I still remember how a similar measure was discarded some years ago in our country. The times to reconsider the introduction of a soda tax are coming.

Health impact of sugar-sweetened beverages taxation

Averting Obesity and Type 2 Diabetes in India through Sugar-Sweetened Beverage Taxation: An Economic-Epidemiologic Modeling Study

Clever politicians want to know the potential welfare impact of taxation. I said "clever", though this is not always the case. An example of economic modeling for sugar-sweetened beverages to set up the right level of taxation (in India), appears in PLOS Medicine. The summary:

The researchers used survey data relating SSB consumption to price variations to calculate how changes in the price of SSBs affect the demand for SSBs (own-price elasticity) and for other beverages (cross-price elasticity) in India. They combined these elasticities and data on SSB sales trends, BMIs, and diabetes incidence (the frequency of new diabetes cases) into a mathematical microsimulation model to estimate the effect of a 20% tax on SSBs on caloric (energy) consumption, glycemic load (an estimate of how much a food or drink raises blood sugar levels after consumption; low glycemic load diets lower diabetes risk), the prevalence of overweight/obesity, and the incidence of diabetes among Indian subpopulations. According to the model, if SSB sales continue to increase at the current rate, compared to no tax, a 20% SSB tax would reduce overweight/obesity across India by 3.0% and the incidence of type 2 diabetes by 1.6% over the period 2014–2023. In absolute figures, a 20% SSB tax would avert 11.2 million cases of overweight/obesity and 400,000 cases of type 2 diabetes between 2014 and 2023. Notably, if SSB sales increase more steeply as predicted by drinks industry marketing models, the tax would avert 15.8 million cases of overweight/obesity and 600,000 cases of diabetes. Finally, the model predicted that the largest relative effect of an SSB tax would be among young men in rural areas.

The results confirm previous studies, 20% may be the ceiling for a tax . But what happens to health?. Assumptions on a fall in consumption, are just that, assumptions. And former behaviour is extrapolated into the future. This is what happens to any model, and this is the uncertainty and courage that any politician must hold in taking a difficult decision. Such moment is closer than before. If you are not convinced, I would suggest you have a look at this documentary released last week:



The documentary is about weight control, but places special emphasis on sugar (addiction). Please have a look at the quantity of sugar in a beverage!!! (14 sugar cubes). Incredible.

PS. "Superbe" post by Reinhardt: How the Medical Establishment Got the Treasury’s Keys

Mounting evidence about sugar-obesity link

Sugar: Consumption at a crossroads

Should the government and health officials do more to reduce consumption of sugar, and will they in your opinion? The answer is yes, 90% of the European population consider that governments need to act,  but only 52% believe the governments will do it, according to the Credit Suisse Equity Research Nutrition Survey, 2013. You'll find the details in this report.
Why so many people consider that right now something should be done about sugar intake?. Basically because everybody is increasingly convinced about the relationship between excessive sugar consumption and obesity.
The report is a good guide for all the implications and potential governmental regulation and industry self-regulation.
Definitely, something should be done, asap.

Ensucrats fins al capdamunt

Regulation of Sugar-Sweetened Beverages

Regular o no regular les begudes carbòniques ensucrades, aquesta és la qüestió. Al NEJM contraposen les dues perspectives en dos articles. Ho fan a la secció de decisió clínica, encara que és tracta d'una decisió política. I llegeixes el que diuen i en realitat un vol regular més i l'altre menys, però no són visions contraposades.
M'ha interessat novament allò de l'empenta comportamental (behavioral nudge). Fa molts dies que se'n parla però costa concretar. Un dels autors, Brian Wansink assenyala que publicarà un llibre properament titolat "Slim by design; mindles eating solutions for everyday life". Si el títol permet assolir el que diu ens haurem de treure el barret. Altrament potser només sigui un ham comercial, ja ho veurem.

PS. El passat 1 de juny vaig dir això:  "Per cert no hauria de passar per alt que la nova directora executiva del regulador dels aliments prové precisament d'una de les empreses que més aspartam utilitza als seus productes light. Quina casualitat!. ". Avui afegeixo, prové del fabricant de begudes carbòniques ensucrades. Algú es llegeix les lleis? Algú té interès en complir-les?.

PS. Per comprendre què està succeïnt consulteu WSJ. M'ha interessat la cita a NYT on es mostra amb jurisprudència que la ciutadania europea no desapareix! És un dret individual, i d'això no se'n parla.Cal llegir mitjans forasters per conèixer-ho.

Som el que mengem (o gairebé)

Health, agricultural, and economic eff ects of adoption of
healthy diet recommendations

El Lancet es desperta aquesta setmana amb un model d'equilibri general aplicat (CGE) on estima l'impacte de l'adopció de la dieta recomanada per la WHO al Brasil i a UK.És el segon article d'una sèrie sobre malalties cròniques.
Un paràgraf de resum:

Adoption of healthy diets in high-income countries would have substantial eff ects on patterns of population dietary consumption and health. For example, adherence to WHO dietary recommendations in Organisation for Economic Co-operation and Development (OECD) countries would mean a substantial decrease in the consumption of vegetable oils (by 30%), dairy products (by 28%), animal fats (by 30%), meat (eg, pork by 13·5% or mutton and goat by 14·5%), and sugar (by 24%), and a substantial increase in the consumption of cereals (by 31%), fruits (by 25%), and vegetables (by 21%).15 In the UK, if diets matched nutritional guidelines, 70 000 premature deaths could be prevented each year,16 with a saving to the health service of £20 billion every year.

Si bé els autors mostren les precaucions en els resultats obtinguts, cal dir que aquest és un tema molt rellevant. Ho sabem, i massa sovint mirem cap a l'altra banda. L'article és suggerent perquè barreja la perspectiva salut amb la perspectiva económica (agroalimentària) i estima els impactes. És un article típic per a una revista econòmica de nivell.
Dels resultats britànics destacaria les reduccions necessàries de carn i lactis que són molt accentuades. Ens caldria un model semblant a Catalunya, possiblement no sortiria gaire diferent del britànic. Ara bé els estudis serveixen si després de llegir-los algú els té en compte, altrament restaran al calaix com tants que n'hi ha.