A Big Fat Crisis (20 page)

Although calorie-labeling on menus was intended to help people
make better choices in the same way a speedometer helps people estimate and control their driving speed, it hasn’t been very successful.
¹
Without a speedometer, people cannot precisely estimate how fast they are traveling. Their only clue might be based upon how quickly the scenery flies by. Drivers are trained to regularly check the speedometer. Road signs let them know when they can drive at which speeds and when they need to stop. But there are no signposts that define the optimal calories to choose or stop signs that indicate when we have consumed enough. It isn’t patently clear to many people how to respond to the calorie counts on menus.

Every restaurant serves different portion sizes: some are large, some giant, and others gargantuan. This leaves many of us confused and prone to eating far too much. How much easier would it be to control our intake if we knew that a cheeseburger had 400 calories whether we purchased it at McDonald’s, Burger King, or Denny’s? Or that lunch was going to contain just 640 calories, regardless of what we ordered?

Why can’t restaurants be held responsible for designing and serving meals that contain what we need? If people eat too much at one meal, they usually don’t eat less at the next to compensate. Similarly, if we don’t get enough of something at one meal, like fruits and vegetables, we don’t usually make it up by eating more of those foods later. This means that when restaurants serve us too much food with too many calories and too few essential nutrients, they put us at risk for chronic diseases.

Right now, as a society we accept this risk, and we don’t expect restaurants to be responsible for taking care of us. However, this is something we need to seriously reconsider, because it is too difficult for most people to figure out how to compensate for meals with too many calories and too few nutrients that protect us from disease.

Just as policies like standardized serving sizes evolved to support the moderate consumption of alcohol, we need commonsense regulations that will moderate our consumption of food. Alcohol regulation provides an excellent model for food because of the inherent similarities: consuming too much alcohol—just like consuming too much food—leads to chronic disease. In the case of alcohol, it’s cirrhosis of the liver, hypertension, and a variety of cancers. In the case of eating
too much of the wrong kinds of food, it’s diabetes, hypertension, heart disease, stroke, and a variety of cancers. (Binge drinking also leads to injury and aggression, but there is no parallel to food in that regard.)

Alcohol control policies have a proven track record of keeping the public safe—or at least safer—from harm. Although they have not eliminated alcohol-related problems or alcoholism, such policies have been highly effective in controlling alcohol’s harms. Over the past three decades, deaths from alcohol-related traffic crashes have declined by 60 percent. Alcoholic liver cirrhosis declined by 48.3 percent between 1970 and 2005.
²
Compare this to the incidence of obesity and diet-related chronic diseases, which have been skyrocketing.

We are beginning to recognize that people are limited in their ability to control how much they eat. We have already recognized that many people have limitations when it comes to behaviors like smoking, drinking, and substance use. Although eating food is not the same as drinking alcohol or taking illegal drugs, the evolution of our understanding of people’s ability to control how much they consume of these substances is quite instructive. It is only because we changed our view of alcohol that our society developed public health responses that have reduced alcohol-related illnesses and deaths.

The Transition to Alcohol Control

Two hundred years ago, excessive alcohol use was a substantially bigger problem than it is today. William Rorabaugh, author of
The Alcoholic Republic
, wrote that in its earliest beginnings, America was known as a nation of drunkards.
³
Historian Harry Levine, who has written extensively about the changing view of alcohol, notes that for most of the seventeenth and eighteenth centuries, the prevailing belief was that people drank because they wanted to and could stop at any time.
⁴
The concept of addiction was not part of the common vocabulary. Alcohol was not considered addictive, and habitual drunkenness was not thought to constitute a disease. Alcohol was the beverage of choice in the Colonial period in part because people didn’t have access to potable water or couldn’t trust the local water supply.

During the Colonial period, most families brewed their own alcohol
and produced their own wine because it was too expensive to import. Fermented apple juice, or applejack, was a staple, with an ethanol content similar to that of beer. Alcohol was served to all, even to children.

Spirits became commonly available in America before the Revolutionary War. Slave labor on Caribbean sugarcane plantations made it possible to cheaply produce and sell molasses, the key ingredient of rum. Almost every town had its own distillery to meet increasing demand, and the tavern was the primary social institution. Employers gave workers allotments of rum in lieu of wages. Every man, woman, and child was estimated to have consumed more than 3.5 gallons of hard liquor each year. Alcohol consumption appeared to peak in 1830 at roughly triple the consumption today.
⁵
Even though lots of people were tipsy all the time, drunkenness was not considered a significant problem, and drinking was a natural, normal choice made for pleasure. Social control was maintained by community relationships.

After the Revolutionary War ended, British traders reduced imports of rum and molasses to America because of higher import taxes. By the early 1800s, the slack had been easily taken up with the expansion of new distilling technology: the perpetual still, which increased the yield of distillation.
⁶
Corn crops were difficult to ship, so settlers transformed them into abundant supplies of whiskey. Drinking continued to be highly prevalent throughout the American continent.

The general attitude was that drinking alcoholic beverages was healthful, while water was fit only for livestock. Strong drink was frequently prescribed by physicians, even for babies with colic, and was believed to cure colds, fevers, headaches, depression, and snakebites.
⁷
Spirits were part of the democratic process, and candidates usually courted voters with free drinks.

At some point around the turn of the nineteenth century, people’s views toward alcohol changed dramatically. Why this happened is still a matter of speculation—perhaps the growing urbanization led people to have more frequent and unpleasant confrontations with drunks. Perhaps the change was inspired by the religious concerns that drinking constituted sin and gluttony. Or the advance of medical science and identification of cirrhosis may have spurred it. The growing practice of autopsy documented a clear link among excessive alcohol consumption, organ damage, and death.

Dr. Benjamin Rush, a renowned physician of the late eighteenth and early nineteenth centuries, is believed to be the person who developed the idea of addiction. He characterized frequent bouts of drunkenness as a “disease of the will.” Compulsive drinking became recognized as commonplace, the cause of ruined health and early death. People who consistently drank too much were unable to earn a living or provide for their families.

The concept of drunkards being physically and mentally unable to refrain from drink became increasingly accepted. However, the source of the addiction was initially considered to be alcohol itself rather than a defect in the person. People were largely sympathetic to drunkards, who were viewed as victims. “Demon rum” was named the perpetrator. Efforts to protect these victims and their families focused on restricting the sale of alcohol; for example, no sales on Sundays, no sales from unlicensed vendors, and no sales to children.
⁸
In 1849, Wisconsin passed a statute that required tavern owners to post a bond supporting those who became widows and orphans because of a patron’s drinking.
⁹

Yet the biggest reduction in alcohol consumption occurred between 1830 and 1840, when several things happened along with restrictions on the sale of alcohol: the rapid growth of steamboat transportation in the early 1800s made it possible to ship corn long distances cheaply, so farmers were less motivated to distill it into whiskey; incentives to limit drinking on the job, like reductions in insurance rates, became available; and groups of businessmen agreed to subsidize alcohol-free taverns, so people could socialize without being pressured to drink.

It was only in the late nineteenth and early twentieth centuries, after a myriad of new regulations limited the sale of alcohol and prompted a substantial decline in drinking, that activists began to focus on what are now known as the “externalities” of alcohol use—how inebriated drinkers hurt others, not just themselves and their families. With advancing technology—the building of the railroads, the invention of cars, and the mechanization of factories—liquor became associated with train crashes and industrial accidents that injured innocent bystanders. Drunkards were no longer viewed sympathetically; they were considered social menaces. Inner discipline and individual responsibility began to be considered as a fundamental requirement for societal well-being.

After 1840 the basic regulations that limited the sale of alcohol to particular places and people, and at specific times, along with the evolving norms that reduced drinking in the workplace, kept overall consumption at a low level. Nevertheless, the Temperance Movement kept expanding and was able to get the majority of US states to prohibit the sale of alcohol within their borders. By 1920, when the Volstead Act prohibited alcohol sales nationwide, thirty states were already dry.

The American experience with Prohibition was a clear demonstration of how regulations can go too far. The total ban on alcohol led to black markets, corruption, and gang warfare, which is very similar to what we are experiencing today with regard to illegal drugs. Prohibition ended in 1933, but a substantial portfolio of regulations remained, including “partial” prohibition, which made it illegal for anyone under age eighteen to purchase alcohol. By 1986, every state had expanded “partial” prohibition to those under twenty-one, and as a consequence the deaths of thousands of young adults and teens by alcohol-related car crashes were averted.
¹⁰

Campaigns against excess alcohol use continue in the United States, and multiple organizations are dedicated to alcohol control. It is because we are vigilant that the amount of alcohol consumption has remained substantially lower in the United States than it was in 1820. When regulations are relaxed, as they were in the 1970s, alcohol use rises (see
Figure 5
).

Alcohol Control as a Model for Obesity Control

Eating too much food leads to being overweight and obese, but this is generally regarded as something every individual has the capacity to control. Yet we no longer think this is the case for a subgroup of people who drink too much alcohol, namely alcoholics. We consider the source of alcohol addiction to be located in the person, not in the product, as was thought in the nineteenth century. Today, we view addiction to alcohol as a disease that is largely genetic and not necessarily the consequence of character flaws. We understand that many individuals are highly vulnerable to alcohol, and that for them staying sober is an eternal struggle that requires unending support.

Although we believe that only a small percentage of individuals are vulnerable to alcohol addiction, we do recognize that alcohol can cause harm and destroy self-control among people who are not otherwise alcoholics. Everyone is susceptible to becoming drunk if they imbibe too much. Indeed, the majority of alcohol-related injuries and other problems occur among people who are not alcoholics. For example, two out of three people arrested each year for driving while intoxicated are first-time offenders.
¹¹
For this reason, our society has retained broad measures that restrict the sale and consumption of alcohol for everyone, not just the most vulnerable.

Annual per Capita Alcohol Consumption
^1-3

Gallons of ethanol

1
. Hall W. What are the policy lessons of National Alcohol Prohibition in the United States, 1920–1933?
Addiction
. Jul 2010;105(7):1164–1173.

2
. Levine HG, Reinarman C. From prohibition to regulation: lessons from alcohol policy for drug policy.
Milbank Q
. 1991;69(3):461–494.