Why is there a Chick-fil-A in the Texas Medical Center? Sara Bleich, Harvard T.H. Chan Professor of Public Health Policy, shows a photo of the restaurant within the largest medical complex in the world.
“If you take a step back and think about the roughly 5,500 hospitals around the entire country, the vast majority of them do not have fast food restaurants in them, but the vast majority of them do serve unhealthy food,” she says. “If you take a step even further back and consider the broader food environment, there are more than 600,000 restaurants in the U.S., and we care about that because on a typical day a third of adults and a third of kids are eating in these fast food restaurants.” And, of course, we tend to eat more calories, often bad ones, at these restaurants.
Hospital environments have changed over time — not long ago, it was fine for patients to smoke in their rooms, or for doctors to smoke in their lounges. But social norms around smoking in hospitals and other public places have shifted. “Why can’t social norms about what sorts of foods are healthy and what sorts of foods should be available to us, why can’t those norms shift, too?” Bleich asks.
She points to One West Café in the University of Pennsylvania medical complex as an example of a healthy health system cafeteria. Why can’t health care environments look more like that? “Imagine if your patients ate here instead,” says Bleich. “Imagine if you ate here instead, and everywhere you went in different hospitals this is what the cafeterias look like.”
Some might say to get rid of all the fast food restaurants or all the unhealthy food, but that’s not a realistic approach. “What is realistic is thinking about, how do you actually make environments healthier, how do you push people toward healthier directions when it comes to making choices about food?” says Bleich. And this is only one of many approaches to solving the obesity epidemic. “It’s going to take a harmony of issues happening at the same time to actually move the needle” on sustainable behavior change. Bleich focuses on policy levers that we can push at both local and federal levels.
Beverage taxes are one promising example at the local level, ranging from 1 to 2 cents per ounce. The first sugary beverage tax in the U.S. was passed in 2014 in Berkeley, California, on both sugar-sweetened (e.g., Coke) and artificially sweetened (e.g., Diet Coke) beverages. Philadelphia’s beverage tax is 1.5 cents per ounce. Without the tax, a 2-liter bottle of soda is inexpensive. But adding 1.5 cents per ounce, the price increases by $1, which doubles the price of the bottle or increases it by 50%, depending on its base price.
And it can work. “We know from a long history of research that prices matter. People are extremely sensitive to prices. We’ve seen this in tobacco; we’ve seen this in lots of other areas,” explains Bleich. “The expectation with these beverage taxes, which are really starting to proliferate around the country, is that people are purchasing fewer sugary beverages, people are consuming fewer sugary beverages, and as a result obesity risk potentially is starting to go down.”
Importantly, this type of policy could have a disproportionally positive impact on more vulnerable, low-income minority populations that tend to have high rates of sugary beverage consumption and obesity.
Menu labeling has potential on the federal side. As part of the 2010 Affordable Care Act, and with a compliance deadline of May 2018, menus at large chain restaurants and entertainment venues must post calories alongside price.
“The question is, does this matter? If you see these calories posted alongside price, will that have a difference to consumers at the point of purchase?” asks Bleich. Many localities around the U.S. have had menu labeling rules, and a body of about 50 studies overwhelming say it’s had little meaningful effect or the effect is unclear — maybe stronger in cafés and coffee shops than elsewhere.
What about restaurants? Could restaurants change their behavior in ways that might promote the public’s health? Bleich’s team has studied calories in food at the largest-revenue generating restaurants in the U.S. and found that newly introduced items are dropping by about 56 calories, or 12%.
“That sounds small, but on a given day it doesn’t take a lot of extra daily calories to drive the obesity epidemic,” says Bleich. Some restaurants have also pulled their highest-calorie items off the menu in anticipation of the menu labeling law. “If you could imagine people going into restaurants and you’re pulling out some of those calories and not relying on individual behavior, that can actually have quite a big impact at the population level.”
What can health systems do to meaningfully help patients? Partnerships between health systems and community organizations that deal with social determinants of health, Bleich says — “the causes of the causes,” like hunger and poverty, that often underlie diabetes, hypertension, and obesity.
Innovations in this area are happening across the U.S., such as a MassHealth ACO social determinants screening program where patients who need services are triaged into different groups that can help. “That task is being taken out of the job of physicians and health professionals and put into the hands of people that can help patients meaningfully navigate that process,” says Bleich. “There’s so much about a patient’s environment which, if known, can help physicians provide much more meaningful advice.”
Bleich reiterates that we don’t have to pick one approach over another to create healthier environments. Rather, at the population level, implementing a variety of approaches to help people achieve a healthy weight could prove effective.
When targeting different populations, how do we harmonize those efforts to maximize impact? By working across a variety of settings and levels — taking the same intervention and applying it to child care, hospitals, and schools, for example, or focusing on individuals, families, and then broader communities. And by getting the right stakeholders, such as lawmakers and health professionals, at the table.
“If we are successful and we have more environments that look like One West Café and fewer environments that look like fast food, and we completely get rid of the problem of having physical access to healthy food, and we solve the problem of financial access so healthy food is affordable and very convenient — even if we do all of that, we will have not fully solved the problem of obesity,” Bleich says. “But it will be a really important step in the right direction.”
From the NEJM Catalyst event Patient Behavior Change: Building Blocks for Success, held at Duke University, April 4, 2018.