Rationing drink size to help rationalize our sugar intake

Canadians seeking successful, progressive public health action on nutrition should look south. The New York City Board of Health has unanimously approved, effective March 2013, a limit of 16 ounces on the maximum size of sugar-sweetened beverages that can be sold at restaurants and concessions in the city.1 This is the most recent in a series of innovative public health measures pioneered by the city under Mayor Michael Bloomberg. Previous successes have included drastic restrictions on trans fats in restaurant meals, requirements for chain restaurants to display calorie information, the launch of a national collaboration to reduce sodium in foods and a recent initiative to remove a disincentive to breastfeeding by restricting the distribution of infant formula in hospitals.

Because sugary drinks are the leading source of dietary calories in North America,2 New York City’s latest measure is a rational strategy to combat obesity on a population level. The scientific case for reducing sugar consumption is stronger than ever. Recent evidence has established that the amount of sugar-sweetened beverages consumed substantially increases a person’s genetic risk for obesity.3 This association persisted even after adjusting for overall calorie consumption, suggesting that sugary drinks make a specific and disproportionate contribution to obesity risk relative to other dietary components. Moreover, recent randomized trials have found that substituting sugar-free drinks for sugar-sweetened ones reduces weight gain in children and adolescents,4^,5 suggesting that a focus on reducing the consumption of sugary drinks can be effective.

Public health interventions to regulate health-related lifestyle factors typically meet with controversy and debate. These debates are often fueled by industry and are effective in influencing public opinion: following a particularly aggressive and well-financed industry campaign, most New Yorkers currently oppose the new limit on beverage size.1 The primary arguments against such measures are that they are overreaching, paternalistic and infringe on personal freedoms.

These arguments discount the proper and necessary role of government in protecting the public. Public health departments regularly take far more intrusive actions to combat communicable diseases; actions that are widely accepted as reasonable infringements on individual liberty when weighed against the threat posed to the population. Obesity and other diet-related diseases represent population health burdens of a similar scale to those of epidemic infections, but their lesser acuity might make this less obvious.

Such arguments also depend upon false assumptions that people currently make entirely free and informed choices about what they eat and that government regulations would infringe upon this freedom. The content, availability, quantity and affordability of the foods available at restaurants and grocery stores is often determined for us, usually without our explicit consent or awareness of how unhealthy these foods may be, by the restaurant, food and beverage industries who often prioritize profits over health concerns. Only governments have enough influence to balance this relationship.

New York City’s new regulation on sugary drinks exemplifies how governments can intervene: not by limiting personal freedoms, but rather by normalizing the definition of what a serving is supposed to be. It is neither normal nor a recipe for long-term health to consume, in a single sitting, the 25 teaspoons of sugar contained in a quart of soda, the smallest drink size one can currently purchase at some establishments. Indeed, serving such excessive portions to consumers already conditioned from childhood to finish what they’ve been served represents a far greater limit to freedom of choice than regulations that limit portion size. New Yorkers will remain free to buy more than one 16-ounce soda at once if they wish, but because they will no longer be induced by default to do so, many will realize that one is enough. Making people aware of dietary norms while arming them with explicit information about the food they are served can help them make healthier choices and become less obese.

New York City’s leadership on public health nutrition puts Canada’s inaction to shame. Our federal government has time and again refused to enact regulations on many of the issues New York is already addressing, disbanding expert panels and ignoring scientific advice.6 Faced with a paucity of federal support, the Canadian public must look to lower levels of government for action. We should all be inspired by New York’s lead, showing us that this can be done successfully.