Monthly Archives: January 2018

Salutogenesis, Self-determination, and Soda Taxes: What can Positive Health Teach us About Nutrition Policy?

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Calls for taxes on sugar-sweetened beverages (SSB) by health professionals and advocates continue to occupy news headlines. Seattle recently joined the growing list of U.S. cities that are experimenting with a tax on SSBs, while Cook County (Chicago) repealed a similar policy after only two months. Advocates of the tax point to studies using economic modelling, which paint rosy pictures of increased tax revenues, decreased SSB consumption and significant health impacts, to argue for the value of this strategy. Although much more empirical research is needed to determine long-term effects of taxing sugar-sweetened beverages, the existing empirical evidence suggests little effect on SSB consumption or health. This is not surprising given that people can purchase SSB from neighboring municipalities, order them from online retailers, substitute from newly taxed beverages to other unhealthy beverages, or switch to a generic brand of soda. Wellness, which draws heavily from self-determination and salutogenesis theories, provides insight into how professionals might think more constructively about nutrition policy.

The Rational vs. The Evidence 

Taxes on sugar sweetened beverages are not new and have been implemented in many areas in many different ways. Thirty-four states currently have a sales tax imposed on soda sold in grocery stores, and 39 states tax vending machine sales. The most prevalent argument in support of levying a sugar-sweetened beverage excise tax (on top of any existing sales taxes) is the potential impact on public health. The CDC suggests that 49% of American adults drink SSB on a daily basis, with the average consumption of 149 calories. Soda and sugar-sweetened beverages have been implicated as a major source of excess calories and sugar, leading to weight gain, diabetes, and dental caries. Advocates argue that an excise tax on SSB will encourage people to decrease their SSB consumption, leading to significant improvements in weight and subsequently health.

But at what cost? Are the actual changes in consumption or health outcomes substantial enough to be considered worthwhile? How sustainable or long-lasting are these changes in consumption? And are there other programs or policies that would lead to more significant health outcomes and have a societal or individual cost that is equivalent to or lower than a SSB tax?

There is little evidence to support the claim that SSB taxes have significant influence on consumption. Although SSB tax supporters cite several studies that estimate 7.9%-21% decreases in SSB consumption, with the greatest impact occurring among low-income individuals, resulting in an estimated 30 fewer ounces purchased each week per household. However, most of these studies have significant limitations that constrain their ability to make substantive conclusions about SSB consumption impacts.

The first important limitation is that even if consumers decrease their consumption of SSB, the studies do not account for the substitution effects that a randomized field experiment shows increases the consumption of water, milk (flavored and unflavored), juice, generic brands, beer, and milkshakes or yogurt smoothies. Consumers may also choose to cut costs in other parts of their household budget to cover the increased cost of SSB or shift their purchases to stores in neighboring areas or online retailers. Most studies do not account for any of these substitution effects.

The second major flaw with studies on SSB taxes is that most do not control for the considerable overall downward societal trend in soda consumption over the past two decades or the effects of tax campaigns on social norming. This is critical since SSB consumption has been decreasing at a rate of nearly 1% a year since 1998 as people recognize the adverse health effects of consuming large amounts of added sugar.

Lastly, the sampling and analytical methods in some studies have been criticized for inflated demand elasticity estimates or weak sampling strategies. Therefore, it is not surprising that evidence based on self-reported soda consumption and household budget surveys suggests that a SSB tax did not significantly change in the case of Berkeley, CA, and that SSB taxes are predicted to decrease body weight by less than one pound in Mexico. So, if SSB taxes show lackluster impacts in practice, how can wellness professionals start to think differently about their policy advocacy?

Self-determination theory

Self-determination (SDT) is a theory of human motivation that begins with the assumption that people evolved to be “inherently active, intrinsically motivated, and oriented toward developing naturally through integrative processes.” Essential to the process of becoming aware of, and internalizing behaviors that move one closer to achieving their full health potential is fulfillment of an individual’s psychological need for competence, relatedness, and autonomy. In the context of food and nutrition, competence refers to developing individual and community capacity to identify, source, and prepare affordable, culturally-appropriate, healthy foods. Relatedness is about providing people with spaces and opportunities that create a sense of personal connection with others who value the health-promoting behavior. Lastly, autonomy means that people must recognize the value of a behavior for themselves and feel that doing this behavior is their own personal choice, free from the external coercion of incentives or penalties.

Taxes on sugar-sweetened beverages as a public health strategy violate the psychological need for autonomy. It is no wonder that many people perceive this tax as intrusive and react negatively toward the idea of health professionals and politicians coercing them to make particular decisions about what they eat and drink. Furthermore, these policies do not support cultivation of competence or relatedness. In this way, SSB taxes undermine self-determination. Public health education campaigns have contributed to a greater societal awareness of SSB adverse health impacts and, like the case of tobacco, contributed to individuals making autonomous choices to decrease their SSB consumption, without the excise tax.

Salutogenesis and Positive Health

Avoiding a bad behavior does not necessarily lead to the existence of good behavior. This subtle aspect of human behavior is the key to framing health strategies that enable people to learn how to live fully if we really mean it when we say “health is more than just preventing disease”. Salutogenesis refers to proactively generating full health potential. The key concept here is “potential”. Health approaches based on salutgenesis study the origins or causes of health. This is conceptually different that the traditional pathogenesis approach which seeks to understand the origins or causes of disease and design interventions that aim to reduce risk and avoid problems.

Reducing disease risk is important, but it is not the same as cultivating health potential. Sugar-sweetened beverage taxes respond to a situation that threatens to cause disease. However, decreased SSB consumption does not inherently lead to healthier eating patterns that include more fruits, vegetables, legumes and whole grains (causes of health). Without policies that enable the conditions for people to cultivate healthy diet patterns (e.g., living wages, shorter work weeks, access to quality fresh produce, cooking skills, affordable healthcare), SSB taxes are not likely to produce better eating habits.

Is there an appropriate use of SSB taxes?

Food policy initiatives warrant special attention because of their ability to cause great benefit or great harm to society. In some cases, regulations that restrict individual choices are necessary to support public health. Although SSB taxes may only have a trivial influence on consumption habits, they may have other important goals, such as providing subsidies for fresh produce or nutrition education, which may be justifiable to promote wellbeing by bring people together, build competence, and support autonomy in nutrition decision-making. Some SSB tax policy initiatives propose using revenue to fund nutrition education and fresh produce subsidies.

This strategy is not without challenges of its own since the revenue typically goes to the city’s general fund for use on whatever programs the city council ultimately decides to fund. In practice, ear-marking tax revenue for specific purposes is politically challenging. However, if the goal is for consumption of SSB to decrease, that also means revenue will decrease. In fact, many cities that implemented an SSB excise tax are reporting lower than projected revenues. For SSB taxes to generate sufficient revenue to fund public health programs, SSB consumption must remain stable or new sources of revenue must be found. A Catch-22. Finally, it is important to consider whether or not the same ends could be financed through a progressive tax that is less burdensome to low-income populations.

Drawing on the works of Antonovsky, referenced by Becker, Glasscoff, and Felts, we can adapt guidelines for developing strategies that advance health can help nutrition and public health professional advocate for salutogenetic public policies:  (1) look at the public health data differently: instead of looking at populations who have succumbed to a problem like diabetes to find out what they are doing wrong, look at those who are succeeding and try to find out why they are doing well (what policies facilitate these behaviors?); (2) persuade policy-makers to consider outcomes related to success (e.g., greater consumption of fruits and vegetables), not just outcomes related to problem reduction (e.g., decreased soda consumption); and finally (3) stimulate the development of innovative policies that cultivate the conditions for these desired outcomes to occur. If SSB taxes are conceived as public health-promoting strategies in themselves, they have an obligation to be evaluated on the extent to which they will support self-determination and salutogenesis and be mindful about the place of health policies in relation to other aspects of well-being.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Establishing Ethical Boundaries: Experience of an Emerging Evaluator

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Shortly after starting my first semester as a PhD student, I came across an opportunity to get involved in a community food system research project as a data collector. It was a collaboration between a local food coalition, nutrition scholars, and city officials. This was just the type of experience and connections I felt I needed to begin establishing myself as a researcher within a new community and among faculty in my field. Instead, it ended up being a lesson on establishing my ethical boundaries as an emerging researcher and evaluator.

The Situation

The lead researcher on the project was an assistant professor from a large university in the South. In this post, I will refer to her as Dr. Susan. I had little background on the project, so I asked Dr. Susan about the research questions guiding the data collection. She stated that she was working with the primary stakeholders and that they just wanted to do an “assessment”. I pressed for a more precise answer, but it seemed that she either didn’t know the purpose of the study or that the stakeholder group really didn’t have a clear purpose in mind. This was just the start of my discomfort.

We moved on to discussing the data collection instruments. As we read through the survey items together, there were several that required explanation because of ambiguous wording, so I pressed for clarification. By the third or fourth unclear item, Dr. Susan appeared to be impatient. She instructed me to let the respondent decide what the item means to them, or to have them “think about it hypothetically” if it did not pertain to their life experience. I was frustrated. If I had trouble interpreting the items as a PhD student with a nutrition background, what did that mean for the reliability of our data among a less-educated population?

Finally, we came to the demographic items on the survey. With the exception of the income questions, none of the demographic items included a response choice of “prefer not to answer.” I asked Dr. Susan if she wanted to make them consistent by adding a “prefer not to answer” response option to the other items. She declined. I followed up and asked if we could include an introduction to the survey where we could inform respondents of their right to decline to answer any questions, without risk of losing their monetary incentive. Dr. Susan explained that if we let them know they have the option to skip questions, then they might choose to not answer some of the items and we would have missing data. I could feel my muscles tightening and a feeling of panic.

I left the meeting anxious and unsure about continuing with the data collection. On the one hand, I really wanted to build a relationship with the food and nutrition community in this city and worried that backing out of the data collection would make me appear difficult or arrogant. But, the ethical gnawing in my gut was keeping me up at night. Fortunately, my professors had introduced several tools during my nascent PhD career that helped me navigate the situation and make a decision that put my mind at ease.

Researcher Journal

Reflexivity is a critical evaluator competency. In the qualitative methodology class I took during this first semester, we were required to start a journal to explore our growth as researchers. In one exercise at the beginning of the semester, we were asked to write down things that were ethically important to us in conducting research. There was a moment of clarity when I referred back to key words from this statement while reflecting on my options: self-determination, transparency, and autonomy. I also described how it was important to me that individuals providing their data were respected and that I felt the particular methodological choice did not provide voice to the community members. I wrote that it “reinforced a power structure of researchers and government officials deciding on an intervention based on (flawed) data they collect through an instrument that they designed in isolation.” Two themes emerged from my journal entries over those few days: concerns about data integrity and social justice.

American Evaluation Association Guiding Principles

The concerns I saw emerging in my journal are addressed explicitly in the Guiding Principles of the American Evaluation Association. We were asked to reflect on these principles early on in the semester. Two areas in particular provided the direction I needed to make a decision about moving forward with the data collection.

Integrity/honesty: If evaluators determine that certain procedures or activities are likely to produce misleading evaluative information or conclusions, they have the responsibility to communicate their concerns and the reasons for them. If discussions with the client do not resolve these concerns, the evaluator should decline to conduct the evaluation.

Respect for people: Evaluators should abide by current professional ethics, standards, and regulations regarding risks, harms, and burdens that might befall those participating in the evaluation; regarding informed consent for participation in evaluation; and regarding informing participants and clients about the scope and limits of confidentiality.

One of my concerns was that the poorly constructed survey items would provide misleading information about the population. This could potentially lead to an ineffective and wasteful intervention in this community. Furthermore, without a clear understanding of the purpose of the data collection or provision of informed consent to respondents, I could not confidently conclude that my work would maximize benefit and reduce unnecessary harm. Since Dr. Susan was not receptive to modifying the survey items or establishing informed consent, I felt the right decision was to decline the opportunity to participate in the data collection.

Trusted Mentor

Although I felt fairly confident that I needed to let go of this opportunity and focus on research and evaluation work that aligned with my ethical boundaries, there was a lingering feeling of self-doubt. I was a first-year PhD student with little experience. Who the hell was I to question the protocol of a more experienced assistant professor? What did I know about conducting field research anyway? The AEA Guiding Principles provided direction, but was that how evaluation really worked in practice?

I turned to a faculty member in my department for advice. I knew this person had made similar ethical choices as an emerging researcher because she had talked about her experience in class. As I shared my experience with her, I felt sensations of vulnerability. My face was trembling like I wanted to cry. She reassured me that this protocol was not business as usual in field research and that even though this project was not subject to IRB review, it should still adhere to the ethical treatment of research subjects. She described three courses of action I could consider: 1) walk away from the project with no explanation, 2) walk away from the project and give an exit interview with the researcher to let her know my reason for leaving the team, or 3) move forward with the data collection and use it as a learning experience of what not to do.

My Ethical Boundaries

Later that evening, I went home and wrote an email to the researcher. I explained that I was unable to continue with the project and communicated my concerns about informed consent, coercion and respect for research participants. As a learning experience, this situation highlighted the importance of actively articulating ethical boundaries as part of one’s research philosophy early on in the graduate career. I was fortunate that the faculty in my program provided the tools and mentorship for navigating these situations on several occasions early in my first semester.