What is a Balanced Diet For a Type 2 Diabetic?

This question came up on one of the forums I am on recently. There were many conflicting responses, often including discussion about various macronutrients (fat, protein, carbohydrates) and micronutrients (minerals, vitamins etc), the evils of sugar, cholesterol and saturated fats, the need for lots of fruit or grains etc etc. A lot of people also went into great detail about maximum and minimum percentages for fats, carbs and protein.

I believe in KISS, so I try to keep it simple with easy to follow rules for my way of eating. As I have to eat this way for the rest of my life I do not want an excessively complicated food selection system.

My definition of a balanced diet for a type 2 diabetic (me) is pretty basic and not in terms of percentages of anything. The basic description is simple, although the personal investigation creating the way of eating I follow today was fairly complex. The links at the foot of this post describe the journey to this point.

The simple version:

• I let my meter show me my carbohydrate limits for the time of day and the meal.
• I let common sense and satiety limit my protein and fat portions.
• I include a reasonably wide variety of vegetables in my menu, favouring fresh and seasonal vegetables where possible.
• I also include fruits but those are limited to minimise blood glucose spikes.

In applying those basic rules for myself I also take these factors into account:

• Variety in choices of meats, fish, seafood, dairy, vegetables and fruits makes the menu interesting and also improves the chances of getting all needed vitamins and micronutrients.
• Excess of any macronutrient is not wise.
• Excessive restriction of any macronutrient is just as unwise.

 These links to past posts expand on those points and others: 

• Food, Farmers and Factories
• Test, Review, Adjust
• Are Carbs Really Necessary?
• Vegetables
• Grazing
• Red, Red Wine
• Yoghurt
• Eggs, Carbs and Cholesterol
• Cinnamon, Spices, Herbs and Similar
• Food and Recipes

Cheers, Alan, T2, Australia.

Everything in Moderation - Except Laughter 
There Is Nothing I Could Eat I like More Than my Eyes

Fat: The New Health Paradigm

I have just read the opening summary of a startling document published by the Credit Suisse Research Institute.

Fat: The New Health Paradigm

I predict that this publication is going to become one of the most hotly debated documents in the fat vs carbs diet wars this year. The conclusions the authors arrive at are summarised very succinctly on the opening pages.

Their conclusions will not surprise many in the on-line diabetes community as most of us have been saying this for years (for example Eggs, Carbs and Cholesterol, Cholesterol, Fats, Carbs, Statins and Exercise) but they will cause consternation in many of the world's respected dietetic and diabetes authorities. This is not a journalist's article or a book by an organisation with an agenda or a diet to sell; it is a very well researched and supported scientific paper.

Below are abbreviated selections from the summary; these statements are well supported in the body of the document which I am still in the process of studying. I decided to post early to alert readers to the document and allow others to read it in full.

••
Triangulating several topics such as anthropology, breast feeding, evolution of primates, height trends in the human population, or energy needs of our various vital organs, we have concluded that natural fat consumption is lower than “ideal” and if anything could increase safely well beyond current levels.
••
Saturated fat has not been a driver of obesity: fat does not make you fat. At current levels of consumption the most likely culprit behind growing obesity level of the world population is carbohydrates.

••
A proper review of the so called “fat paradoxes” (France, Israel and Japan) suggests that saturated fats are actually healthy and omega-6 fats, at current levels of consumption in the developed world, are not necessarily so.
••
The big concern regarding eating cholesterol-rich foods (e.g. eggs) is completely without foundation. There is basically no link between the cholesterol we eat and the level of cholesterol in our blood.

••
Doctors and patients’ focus on “bad” and “good” cholesterol is superficial at best and most likely misleading. The most mentioned factors that doctors use to assess the risk of CVDs—total blood cholesterol (TC) and LDL cholesterol (the “bad” cholesterol)—are poor indicators of CVD risk. In women in particular, TC has zero predictive value if we look at all causes of death. Low blood cholesterol in men could be as bad as very high cholesterol. The best indicators are the size of LDL particles (pattern A or B) and the ratio of TG (triglycerides) to HDL (the “good” cholesterol).

••
Based on medical and our own research we can conclude that the intake of saturated fat (butter, palm and coconut oil and lard) poses no risk to our health and particularly to the heart. 

••
The main factor behind a high level of saturated fats in our blood is actually carbohydrates, not the amount of saturated fat we eat. Clinical trials show that a low carbohydrate diet is much more effective in lowering the level of saturated fat in our blood than a low-fat diet.

Cheers, Alan, T2, Australia.

Everything in Moderation - Except Laughter

Blood Glucose Targets 2015

Several years ago I investigated the different targets suggested by three major respected US diabetes authorities. As a result I wrote this: Blood Glucose Targets. My 2006 summary included this comparison table:

Over the years those have changed very little. The 2015 comparison noting significant changes in bold is:

Sources: ADA, Joslin (up-dated 2018), AACE. 

The ADA and Joslin now agree on the looser 2hr post-prandial target of 180(10) and both have also lowered the threshold for fasting. The AACE guidelines are unchanged. If you read the details on the linked pages all add caveats concerning relaxation of targets in case of other medical conditions, age etc.

Thirteen years after diagnosis, thankfully still free of complications, I see no reason to significantly change my closing remarks originally written nearly ten years ago.

The AACE advise much tighter post-prandial targets. I doubt that anyone would consider the American Association of Clinical Endocrinologists, a professional community of several thousand physicians specializing in endocrinology, diabetes, and metabolism as a bunch of fanatical radicals. Nor would they be promulgating guidelines impossible to be attained by the majority.

Unfortunately, nobody but pro-active type 2 diabetics talks much about 1hr PP targets. My personal logic is that I treat their 2hr as my recommended max peak for any post-prandial, as I discussed in When To Test? Those AACE guidelines then agree very closely with Jennifer's Test, Test, Test advice. Make your own judgment on which of those guidelines you think will lead to fewer complications.

Sadly, it appears that only 1/3 of senior diabetics are achieving even the loose ADA targets, but that is a discussion for another topic.

Cheers, Alan, T2, Australia.
Everything in Moderation - Except Laughter

Comments Allowed

I was a little disappointed to notice the lack of comments over the past year or so.

Recently a friend informed me she tried to comment and was blocked.

I had not checked my blog settings for years, as I didn't see a need to change them. I was surprised to find Google had changed my settings without my knowledge and comments were now restricted.

I have changed them back. I welcome comments from anyone, anonymous or named. My only restriction is to moderate them before publishing.

Cheers, Alan, T2, Australia.
Everything in Moderation - Except Laughter

Are Diabetes Complications Inevitable? Not necessarily...

This is a very personal post, reporting on my own recent reports on three aspects of my health: my eyes, my heart and my other affliction, leukaemia.

I am writing this partly to celebrate but also to motivate any newly diagnosed type 2 diabetics, shocked and scared, who have been warned by their doctors of the inevitability of their diabetes progressing to complications. I suppose some doctors feel they need to do that to scare new people into making lifestyle changes, but too often I find dire predictions of long term complications or heart attacks lead to loss of hope. That can lead to a 'why bother' mentality. 

Please, do not give up. I know managing type 2 diabetes can be bloody inconvenient. You will have to make some annoying changes to your life such as pricking holes in yourself, adding some activity to your day, forever watching what you eat and drink and possibly taking meds and insulin. 

Let me assure you: taking control of your blood glucose levels is worth the trouble. I am just one example of many I read on the better diabetes forums where pro-active type 2s are learning how to take control.

Possibly my continuing story will give you hope.

I was first diagnosed with leukaemia and type 2 diabetes in 2002 at the age of 55. I discovered early I could do nothing at all about the leukaemia; for that reason I concentrated on beating the diabetes. I was thirsty for knowledge. For the first couple of years I spent a lot of time learning from many wise people, mostly on usenet. Some were medical professionals but most were experienced diabetics. I learned something from all of them, even if the main thing I learned was how to tell good advice from bad because, unfortunately, a lot of it was bad. I still believe the best advice was Jennifer’s Test, Test, Test: “Use your body as a science experiment.” 

I tested and experimented to find what worked for me. On usenet over the next couple of years I gradually changed from reader and student to lay advisor, passing on information based on my experience. In 2004 I joined some online forums. In 2006 I started this blog. 

Eventually I wrote a book based on my experience to help any newly diagnosed people who might not be computer-savvy. Of course, as my suggestions for good type 2 management differ significantly from the mainstream there will always be critics. In part this is a response to the critics, describing the results of practising what I preached for the past decade.

Motivation

We each must find our own motivation for maintaining the discipline. For me, it is my sight. Since the day I first learned about the possible complications of diabetes my over-riding motivation has been my vision. I came to accept the possibility of death and I certainly don't want to lose limbs from neuropathy or kidneys from nephropathy, but the thought of living in darkness scared me silly. I have tremendous respect and admiration for vision-impaired people who successfully live with that daily. But I do not want to join them. I am a reader of books, an appreciator of beauty, a user of computers and above all I want to see my grand-daughter’s joy as she grows and learns.

The tests used by doctors to monitor our diabetes such as HbA1c, fasting blood glucose and post-prandial blood glucose are all important but they are really only surface indicators. I use those indicators to set my goals, but they don't directly alert me to dying nerves or optic cells. The acid test is whether complications eventually appear as the years pass. 

Limbs and Kidneys

So far neither blood tests nor physical symptoms, including filament tests by my podiatrist, have indicated any signs of neuropathy or nephropathy. I am hopeful that will continue.

Eyes

I had some good news last month. It is over thirteen years since diagnosis and I had not seen the ophthalmologist since 2010. I had a good report then after a scare in 2006 when he discovered minor scars from healed retinopathy. The scars had disappeared by then. This recent visit was almost identical to that 2010 consultation.

The waiting room was packed. After various eyesight checks on new strange machines by the assistant, then the anaesthetic drops, followed by the dilation drops, then another wait, then more tests on machines, I eventually saw the ophthalmologist. He did a very thorough inspection. He warned me that as I age (I am now 68) I may start developing cataracts but at this stage I had no problems apart from inevitably getting older. I wanted reassurance so I asked specifically about retinopathy, macular degeneration and glaucoma as there is some family history of the latter. He re-inspected carefully. He expressed no concern and no evidence of past damage. Then he complimented me on my "superb diabetes control with respect to eye health". I cannot express in the written word how happy that made me feel. Is there a cloud ten above cloud nine? At his request we then spent a few minutes of his valuable time discussing the Test, Review, Adjust technique.

OK, that covers the ‘opathies. None at all. But there is another lurking danger for diabetics: the heart. 

Heart.

I dropped Lipitor ten years ago; the more I read about statins the less I am convinced of my need for one. My doctor has been polite and patient with me when I have consistently refused a statin for the past nine years despite high cholesterol by official standards. My HDL and triglycerides are fine but my LDL is very high. He suggests that may be because of my low-blood-glucose-spike (which many interpret as low-carb) way of eating. He strongly recommended I have a stress echocardiography accompanied by ultrasound of my heart, mainly to reassure him I am not going to keel over tomorrow. I had those tests last September. First, the gooey preparation and the ultrasound, twisting to awkward positions. Uncomfortable but not painful. Then walking faster and faster on the treadmill, with wires hanging off me, having problems reaching the heart rate he wanted. Eventually we got there. As I cooled down it was fascinating seeing the movies of my own heart pumping away on the playback screen of the ultrasound. 

The cardiologist was very thorough and pleased with the results. It seems my heart and vascular system are in fine shape. No problems at all. I will continue to refuse the statin and eat low-carb, moderate fat, for good blood glucose levels. I no longer care at all what my LDL is.

Leukaemia

 

Finally, although I would like to, I cannot forget my Chronic Lymphocytic Leukaemia sitting in the background like the Sword of Damocles. I make no claims about my diet or lifestyle for that. I’m just lucky I suppose. All of my indicators have improved over the years until almost all are in normal range. I still have hypogammaglobulinemia associated with the CLL but one of the indicators for that, IgM, has crept back into normal range. The IgG and IgA are still low, but oddly I don’t seem to be catching anything despite wandering the far corners of the world since diagnosis. I saw the haematologist quarterly at first, then every four months, then every six, now I waste his time annually.

The haematologist, ophthalmologist, podiatrist (who displays my book at reception and has sold several copies) and my General Practitioner tell me to keep doing what I’m doing. 

That sounds like good advice to me. I will heed it.

Cheers, Alan
Everything in Moderation - Except Laughter

Do Doctors Matter?

I feel this is a very important point needing emphasis for the many type 2 diabetics I know participating in diabetes web forums, social media groups and similar online support groups.

I have seen this question posed too often lately:

"Do doctors matter other than for renewing prescriptions?"

The questioner usually complains about poor support (in their eyes) from their medical advisors and praises the help and support they have received from other diabetics on the web.

I understand where they are coming from. I have seen some abysmal diagnostic, testing and dietary advice by medical professionals reported on many forums by newly diagnosed people. I have seen those same people turn their lives around using suggestions from experienced people on those forums. 

I still unequivocally believe our doctors matter and must always be our primary source of medical information. 

I have learned a great deal about type 2 diabetes over the past decade but I do not pretend to have medical qualifications even though in some specific areas, such as testing or diet for type 2, I may believe I know more than some doctors.

I know my own limitations. If and when the time comes for more medication or insulin the doctor will be the first person I consult. After I consult him I may use the web or ask questions on forums to research the meds he prescribes to decide whether or not I will choose to follow his advice. But I will always see him first. 

If your own doctor does not meet your needs it is time to find another better doctor, not to simply ignore your doctor's advice.

On the rare occasions I decide not to follow prescribed advice after doing my own research I will also let him know and discuss it further with him before acting; as I have for the statins my doctor prescribes but I choose not to take. 

The final decision deciding the action to take is mine but I would be a fool to weigh anonymous advice on the web higher than the qualified advice of my doctor without a lot of thought and discussion with him.

The web is an incredible, wonderful and very useful information source but it is not always easy to sift the wheat from the chaff nor do we always have the training or experience to do that sifting wisely. The web will never replace the ability of a good doctor to interact with and personally treat a patient.

Cheers, Alan, T2, Australia.
Everything in Moderation - Except Laughter 

Type 2 Diabetes and the Shame Game

Some time ago I repeated on this blog three guest posts originally published on dLife:

• The Diabetes Diet Wars
• Miracles and Wonders
• Turning Points

I re-posted them here to ensure that they did not disappear if the dLife editors chose not to archive them. Since then I have written a couple of guest posts for DiabetesMine and CarbSmart. For similar reasons I will post them here occasionally to ensure they do not disappear. 

This was published on DiabetesMine in 2011. It is a topic which rears its ugly head a little too often. 

Type 2 Diabetes and the Shame Game (edit Oct 2018. Healthline took over Diabetes Mine and the direct link has gone. The link now goes to the Wayback Machine archive) 

Ignorance may not be bliss after all, and there are occasions where it can be downright dangerous to a type 2 diabetic. But there are some times in life when it can be useful. For me, one of those occasions was April 2002 when my doctor advised me of my diagnosis with type 2 diabetes. 

At that time I was blissfully ignorant of diabetes in all its forms. So I never suffered diagnosis guilt. Sure, I was overweight, but in my country at that time we weren’t bombarded with commercials earnestly and incorrectly telling us “for our own good” that diabetes is caused by obesity. Just as importantly, the lack of that media barrage meant none of my relatives or friends or any of the type 1s I met at my local support group sneered at me for causing my own condition. I never wasted any time or effort on guilt or recriminations.

I didn’t realize it at the time, but I had a major advantage over my American friends, whom I met later on diabetes forums. Far too often over the past eight years I have encountered misery and depression as a consequence of the “blame game” in newly diagnosed type 2s; conditions which often interfered severely with their diabetes management. I reckon that is a direct result of media campaigns, often well-intentioned, which make it abundantly clear that new type 2 diabetics are just as guilty of a self-inflicted wound as the soldier who shoots himself in the foot to avoid a battle. And just as shameful, placing an enormous load on the nation’s healthcare system.

It is also becoming a divisive wedge between type 1 and type 2 diabetics on forums and in the media. We should be working with a common purpose where our needs intersect — not fighting each other. We are increasingly seeing complaints from type 1s who should know better but who get upset at being “lumped together in the public mind” with those fat, old, lazy slobs like me: the type 2s.

From my reading, it is becoming increasingly clear to me that the genetic tendency to diabetes is related to the genetic tendency to obesity, and which comes first is becoming a chicken-and-egg argument. There is a correlation between obesity and diabetes, correct. But correlation is not causation. And that is irrelevant here anyway. What really matters is that all those idiotic commercials promoting weight loss to prevent diabetes are a counter-productive waste of money; they do not lead to weight loss, they only reinforce the blame game. Worse, they often lead the viewer to sites promoting “low fats and lots of whole grains” diets. It’s hard to imagine a more rapid path to the unwanted goal. They’re essentially recommending a high-carb diet for people with diabetes or a strong tendency towards developing it.

To the type 2s reading this: drop the guilt. Whatever the reason for your condition, there isn’t a darn thing you can do to change the past. What matters is what you will do today to improve your future.

To the type 1s reading this: stop the blame game. Join with the type 2s in your community; in unity you can strive for better research and support for all types. Division in the tough world of medical research funding is never fruitful.

And to the people who put those stupid ads on our television screens: you should be ashamed of yourselves. Spend that money investigating the true causes and better treatments for the two separate afflictions of obesity and diabetes in the Western world. You could start by looking at the drastic changes in carb:fat:protein ratios in our menus since WWII. But that’s a subject for another day.

What's In a Name? Am I a Diabetic or A Person With Diabetes?

A very brief post today about a regularly recurring question. Lately I have seen several posts on different forums from people getting upset about being referred to as a diabetic.

The bard put it, as usual, so well:

What's in a name? that which we call a rose
By any other name would smell as sweet;
So Romeo would, were he not Romeo call'd,
Retain that dear perfection which he owes

   Romeo and Juliet, Act II, Scene II, by William Shakespeare.

I don't get precious about labels. Many will disagree with me, but I also tend to be a bit old-fashioned about many of the politically correct terms that have entered our language since I went to school.

Context matters. I rarely care about the word that is used to refer to me if the context is appropriate and the speaker or writer's intentions are good. For example, I am:

• a father
• a son
• a brother
• a husband
• an engineer
• ex-RAAF
• retired
• ex-military officer
• a pensioner
• aged 66 
• an oldie
• a senior 
• an ancient 
• a child (to my mother) 
  
• a traveller 
• a seeker after wisdom 
• an omnivore 
• a curmudgeon (at times ) 
• a man 
• a baldy 
• a six-footer 
• a diabetic
• a leukaemiac 
• a hypogammaglobulinemic
• and many other things

All of them are descriptively accurate, none define me. I object to none of those words in the proper context. To me the intent in context of the writer or speaker is far more important than any of the specific words. I cringe sometimes when I see the unwieldy "person with diabetes" or even "person with type 2 diabetes" when diabetic or "type 2" may be simpler, more succinct and probably more apt, especially when used by a medical professional, another diabetic or some-one who cares for the diabetic. There are times when the longer description may be more appropriate, but not many in my opinion.

Stop worrying so much about words. If a word offends you, look deeper than the word to discover the cause before reacting. Be more concerned about correcting ignorance than the words used to display it. For years I used my own version of Hanlon's Razor before I found others had discovered it before me:

• Never assume malice when stupidity will suffice.
• Never assume stupidity when ignorance will suffice.
• Never assume ignorance when forgivable error will suffice

There are more important things in life and diabetes.

Cheers, Alan, T2, Australia.
Everything in Moderation - Except Laughter  

I'm a New Type 2. Do I Really Have to Test so Much?

I see that question a lot. 

The answer is no, nobody has to.   

But I believe it is wise to. Your meter, properly used, is the bright beacon that will light your way through the dark and confusing maze of food advice that bombards type 2 diabetics. You will get advice from every side. If you have not encountered the Food Police yet, you will. Expect to be told that you should change your diet in all or any of the following ways: low fat; low carb; lots of wholegrains; lots of fruit; vegetarian; vegan; raw; no red meats; avoid sweeteners; sugar-free; no dairy; add expensive herbs and supplements; the list goes on and on. What is right and wrong for you? Is no food safe?

Let your meter guide you to the answer. 

There is no doubt that the Test, Test, Test method is a lot of testing at first when compared with the minimal testing prescribed for type 2s by most doctors. But I believe it is well worth it. The investment of time and test strips in a concentrated effort in the short term has tremendous long term benefits that will last you the for the rest of your hopefully longer, healthier life. And, fairly swiftly, the need to test so much is reduced. The initial period is the heaviest testing load because at that stage you have a blank slate. As you fill in the blanks the load swiftly decreases.

I recommend the following intensive testing routine for people newly diagnosed with type 2 diabetes. It can also be very useful for those who have been diagnosed for a while but who feel they have "hit the wall" in their progress towards good control. 

For the first couple of days test fasting blood glucose (on waking, before breakfast) and also at one and two hours after absolutely everything you eat, unless you eat again before the second test. That includes breakfast, lunch, dinner and all snacks. This may help if you are not used to testing so much: Painless Pricks

Log everything on the menu including drinks, sides and portion sizes. Every evening spend a few minutes reviewing that log and use it to plan the following day's menu with a view to achieving better results. 

Some people are adamant that you must also test before meals. I agree that it may help to know the starting point when assessing a rise, but I do not think it is necessary to add an extra half a dozen tests every day to an already heavy initial load when the other tests will still achieve your goal. 

On the evening of the second day take some time to review all the results. Some of them will seem crazy, but you should see some patterns emerge. The first thing to look for is the timing of your most consistent peaks. That may be a little different for breakfast, lunch and dinner. Is it closer to one hour or two? If you can pick the most consistent peak time then replace the one and two hour tests with just one test at the peak time after each meal. If the peak time is unclear then continue to test at one and two hours and re-assess each evening until it is clear. If necessary add tests at 30 or 90 minutes to be sure; you won't need to do those for long.

Use of the peak post-meal time reduces your test load to fasting and peak time after every meal and snack. My own peak time is about one hour after my last bite, but yours may be different. Over the next few days, using this Test, Review, Adjust technique you should be able to discover several "safe" menus for various meals. You will also find that some meals are OK for the morning but not for the evening or vice-versa. Treat breakfast, lunch and dinner as quite separate results. 

When deciding your goals I suggest you start with the targets suggested in Test, Test, Test:

Fasting............................Under 110
One hour after meals.......under 140
Two hours after meals.....under 120

or for those in the mmol parts of the world:

Fasting............................Under 6
One hour after meals......Under 8
Two hours after meals....Under 6.5

Do not be distressed if your starting numbers are much higher. It took you a long time to develop your diabetes; you should not expect to correct those numbers overnight. 

Give yourself some time. It may take a few weeks, or even a few months, but the investment in strips and testing you make now will pay you dividends for years or decades. Eventually, when you find you can easily hit those targets consider revising them as I did. See my present targets at the foot of Test, Test, Test. 

Proceed cautiously if you use insulin or one of the insulin-stimulating medications. You do not want to go from hyperglycemia to hypoglycemia. Make modest adjustments to your carbohydrate intake, test the results and continue modest changes every meal until you achieve your goals. Eventually you may need to discuss reduction of your insulin or medications with your doctor as the numbers improve.

During the second week repeat some of those safe meals. Before your post-meal test try to guess what the result will be. If you can usually predict good results note that menu for future use; you will only need to test after that meal occasionally in future for reassurance. That removes another test from your day.

Gradually, over successive weeks, your knowledge of safe meals and food portions will grow and your need to re-test them will reduce. Fairly swiftly you should be able to plan menus that you know in advance will not cause blood glucose spikes; as a consequence your need to test so often will drop quite dramatically within a few weeks. Also, as my fasting blood glucose became fairly predictable I reduced that to just a couple of times weekly. 

You are building a database that is unique to you. I know it seems like a lot of effort at first, but believe me it will be worth it. 

These days I sometimes don't test for several days unless I am trying a new menu item or a new restaurant. If you have insufficient strips, time, or motivation to do it that intensively, that is OK. This will work too, but it will take a lot longer: Testing on a Budget

Cheers, Alan

Everything in Moderation - Except Laughter. 

Taxes For Our Own Good

Recently there have been disquieting moves by social engineers in several countries proposing use of taxes to force the public to eat healthier. Examples are: Denmark introduces food fat tax and from the UK: Fat tax' on unhealthy food must raise prices by 20% to have effect, says study.   

I didn't worry much about it when those proposals were in far-off places; I was confident that Aussies were much too sensible to let that happen here. But now our media are starting to join the push: Chew the fat on a sugar tax to trim waistlines.

I should have seen it coming when the “Traffic Lights” concept was first proposed: The WA Health Traffic Light System and Green Light, Eat Right. 

It appears that those who wish to save us from ourselves - and from overloading the public health system - are resolved to make us eat healthier whether we like it or not.

There are a lot of things I dislike about that concept, not the least being the idea that the government or its agencies has any right to direct me on a matter as basic as the food I choose to put in my mouth, apart from ensuring that it is not actually poisonous and is safely and humanely produced. I'll leave that philosophical side of the discussion for now and concentrate on the practical aspects.

There are two separate parts to the question:

1. Does prohibitively taxing items based on their impact on health have a significant effect on public use of those items?
2. If taxes or public education programmes are used with the intention of improving public health are the right food groups being taxed, promoted or discouraged? 

Do Taxes Work To Change Bad Habits?

There are two clear examples in this country. In Australia the Federal government has been steadily increasing taxes and excise on tobacco and alcohol over the past century. Our taxes are quite heavy on those items when compared to many other countries. For example, a packet of 20 Marlboro is over $16 and a 700ml (24oz US) bottle of cheap whisky starts at $28. Our dollar and the US dollar are close to parity at the moment.

Historically each time taxes or excise were increased on either commodity there were short-term reductions in use, but time shows those were just temporary blips. Changes in alcohol taxes sometimes led to changes in preferences from beer to spirits or wine or vice versa, but had little effect on overall consumption or consequent health problems such as youth drunkenness or adult alcoholism.

We had a recent specific example with the alcopops tax. The government was concerned with drinking problems in teenagers. They decided that the root cause was alcopops, a form of popular alcoholic soft drinks. They decided that drastically increasing the taxes on those was the way to fix the problem.

Effect of the increase in “alcopops” tax on alcohol-relatedharms in young people: a controlled interrupted time series

Med J Aust 2011; 195 (11): 690-693. doi:10.5694/mja10.10865

Objective: To measure alcohol-related harms to the health of young people presenting to emergency departments (EDs) of Gold Coast public hospitals before and after the increase in the federal government “alcopops” tax in 2008.

Design, setting and participants: Interrupted time series analysis over 5 years (28 April 2005 to 27 April 2010) of 15–29-year-olds presenting to EDs with alcohol-related harms compared with presentations of selected control groups.

Main outcome measures: Proportion of 15–29-year-olds presenting to EDs with alcohol-related harms compared with (i) 30–49-year-olds with alcohol-related harms, (ii)15–29-year-olds with asthma or appendicitis, and (iii) 15–29-year-olds with any non-alcohol and non-injury related ED presentation.

Results: Over a third of 15–29-year-olds presented to ED with alcohol-related conditions, as opposed to around a quarter for all other age groups. There was no significant decrease in alcohol-related ED presentations of 15–29-year-olds compared with any of the control groups after the increase in the tax. We found similar results for males and females, narrow and broad definitions of alcohol-related harms, under-19s, and visitors to and residents of the Gold Coast.

Conclusions: The increase in the tax on alcopops was not associated with any reduction in alcohol-related harms in this population in a unique tourist and holiday region. A more comprehensive approach to reducing alcohol harms in young people is needed.

Similarly, taxes on cigarettes have had only a marginal effect.

Smoking prevalence and tobacco excise revenue

1991-92 to 2007-08 (2007-08 dollars)

Note that smoking was relatively unchanged when taxes were increased in the early '90s but dropped significantly later despite steady taxes from the mid-90s on. The significant reductions in cigarette smoking in this country came from better public education and various new State laws such as restriction of advertising, labelling changes, restricting sales to minors and drastically reducing the public places where people could legally smoke; allied to a paradigm shift in public acceptance of smoking in social situations. For example: 

Tobacco Control in New South Wales

5 CONCLUSION

The current focus of the anti-tobacco lobby on the rights and health of non-smokers has led to a proliferation of smoking bans in enclosed public places. The NSW Parliament only recently passed the Smoking Environment Amendment Act 2004 which will gradually phase-in an extension of smoking bans to include licensed premises in NSW. The support for such smoking bans has been growing and the implementation of similar restrictions in Ireland and New York appears to have been successful.

Smoking bans are only one method of tobacco control. The use of tobacco is also controlled through restrictions on the way it is packaged and advertised. Particular strategies are applied to minors such as prohibiting the manufacture and sale of toys and confectionery that resemble tobacco or the act of smoking, as well as prohibiting the sale of tobacco to persons under the age of 18. Health warnings have been included on tobacco packages for thirty years but have continued to adapt to contemporary requirements with graphic warnings the most recent development. The price of tobacco may be influenced by taxation policies and smoking cessation can be encouraged through media campaigns, and the availability of nicotine replacement therapy and telephone counselling. Litigation may also affect the activities of tobacco companies.

Tobacco continues to be the cause of much death and disease not only in Australia but also worldwide. The damage attributed to tobacco has been recognised by the World Health Organization and by the numerous countries to have signed and/or ratified the Framework Convention on Tobacco Control. Accordingly, governments continue to seek strategies that will encourage the minimisation, prevention and cessation of tobacco use.

I write as a long-term heavy smoker, who became increasingly annoyed as those changes occurred over the past few decades but eventually gave up in 2001. Now I look back and wonder why I took so long to wake up to the harm it was doing to me.

Will They Tax The Right Foods?

In my opinion this question is actually more important. If we accept the dubious hypothesis that taxes will work to solve the problem, to have any chance of success those taxes should target the right foods. Similarly any public education initiatives should be providing valid and useful information.

Based on the present proposals the foods to be targeted are fats, sugar and salts. The West Australian "Traffic Light" system clearly indicates what we could expect:

Green Foods and Drinks

Foods and drinks classified as Green are the healthiest choices. They are excellent sources of important nutrients needed for health and wellbeing, and low in saturated fat, added sugar and salt, and are lower in energy density.

Can be eaten every day or at every meal.

Examples include: Plain or whole grain breads and cereals, vegetables and salads, fruit, low fat milks and dairy products, lean meats, fish and poultry, eggs, and nuts and legumes.

Amber Foods and Drinks

Foods and drinks classified as Amber are mainly processed foods. They have some nutritional value but contain moderate levels of saturated fat, added sugar and/or salt and can, in large serve sizes, contribute to excess energy intake.

Should be carefully selected and eaten in moderation.

Examples include: Full fat milk and dairy products, some breakfast and cereal bars, some un-iced, plain, lower fat cakes and muffins, some processed meats (e.g. ham, pastrami), poly- or mono-unsaturated spreads, breakfast cereals with no added sugar or fat.

Red Foods and Drinks

Foods and drinks classified as Red are energy dense and nutrient poor foods and drinks that are high in saturated fat, sugar and/or salt. They can contribute to excess energy intake if consumed in large amounts or on a frequent basis.

Red foods also include deep fried foods, confectionary and chocolate (energy size limit), crisps, corn chips and similar salty snacks (energy size limit), sugar sweetened soft drinks, energy and sports drinks (energy size limit).

Should only be eaten occasionally.

Examples include: Fried foods, savoury commercial products such as pies and sausage rolls, snack bars, sweet biscuits, cakes and sweet pastries, small size confectionary and packets of crisps, some sweetened drinks and processed meats such as salamis.

Logically, taxes would be highest on the "Red Foods" and education would be focused on promoting the "Green Foods". In other words, we would be taxed and educated to eat in a way that is extreme low-fat and high-carbohydrate.

I can't imagine many programmes likely to lead to worse results. That would entrench the terrible low-fat high-whole-grains doctrine of the 20th century that I am becoming convinced is a significant factor in the so-called obesity epidemic occurring in the 21st.

Fat consumption in moderation is a trivial part of the problem and sugar is only part of the problem. My definition of moderation in that context is very different to the dieticians who advise governments; it is more like my Grandma, who wasted very little of the sheep when Grandfather killed it. She lived to 102.

The real problem is excessive carbohydrate consumption; sugar is only part of the carb load. A tax on sugar, even if it worked to cut sugar consumption, would have only a minimal effect as the nation continued to start its day with a wonderful 'healthy' bowl of highly processed cereal, drenched in milk, accompanied by some low-sugar spread on multigrain toast and margarine, washed down with a glass of 'healthy' fruit juice. Then, after a 'healthy' breakfast the day continues with an overload of 'healthy' multigrain breads and loads of fruit, spuds, corn, rice and pasta. All, of course, fat-free and low-sugar; so wonderfully healthy. Yeah, right.

Taubes puts it together better than I can; I agreed with him long before I had heard of him: Why We Get Fat and Good Calories, Bad Calories.

I believe that the suggestions to tax foods for public health reasons are misguided at best and may be counter-productive at worst.

Cheers, Alan, T2, Australia

Everything in Moderation - Except Laughter

PS See also this follow-up post: The Fat Tax: Dare I say I Told Them So?