by Tom Farley
In 2002 reporter Gary Taubes stoked a national fad for low-carb diets with an article in The New York Times Magazine called “What If It’s All Been a Big Fat Lie?” He quoted some scientists who argued that eating carbs floods the bloodstream with sugar, which triggers a sharp release in the hormone insulin. Insulin brings blood sugar down and also tells the body’s cells to store fat rather than burning it. After a carb-led surge in blood sugar, the scientists argued, the outpouring of insulin is so great that within about two hours the blood sugar crashes down to below normal levels. That low blood sugar makes people feel hungry, prompting them to eat more. By this line of thinking, a calorie wasn’t just a calorie. Maybe it was the starchy potatoes in French fries that made you fat, not the grease they were cooked in.
The argument that the blood sugar surge and crash was to blame for obesity wasn’t mainstream thinking, but it had some intriguing studies behind it. In one study, when researchers gave a dozen overweight teenagers a carbohydrate lunch that caused a blood sugar surge, later in the afternoon the teens got much hungrier and, compared to a typical day, ate an astonishing 600 more calories.
At around the same time, Dr. Robert Lustig was arguing that sugar is not just another carbohydrate but is uniquely bad—he called it toxic—because it interferes with metabolism in the liver. Cane sugar has two pieces, glucose and fructose. Fructose, Lustig believed, is as damaging to the liver as alcohol. When it hits liver cells, he argued, it sets off a hormonal chain reaction causing chronically high insulin levels that, over years, lead to obesity and diabetes.
Yet another group of researchers were showing that calories in beverages are not nearly as filling as calories in food. A startling example was their study involving jelly beans. The researchers gave fifteen young adults over four-week periods 450 calories of sugar a day in the form of either soda or jelly beans. When the young adults ate the jelly beans, they compensated by eating less of other foods, cutting down their calorie intake by even more than the 450 calories in the jelly beans. But when the people drank the soda, they didn’t just fail to compensate—they actually increased the calories they ate from food. Studies outside of food labs also started to point a finger of blame at sugar in liquid form. In several studies, including one that tracked more than 50,000 nurses for eight years, people who drank more soda gained more weight.
In the end, it didn’t matter much to the health department whether soda leads to weight gain because it delivers unnecessary calories, or because those calories come from carbohydrates, or because those carbohydrates are sugar, or because the sugar is in liquid form. Sugary drinks make people fat.
And that mattered very much, because Americans were guzzling sugary drinks. Over the previous quarter century, per capita sugary drink consumption in the United States had more than doubled, in parallel with the rise in obesity. The average teenager in 2000 drank 300 calories (24 ounces) of sugary drinks a day. Many teens drank twice that. Sugary drinks accounted for 40 percent of the sugar that people ate and between a third and a half of the total increase in calories in Americans’ diets over thirty years. Sugary drinks had not caused the entire obesity epidemic, but they looked to be responsible for a big chunk of it.
Lynn Silver had included a soda tax in the long list of ideas in her initial plan for chronic diseases, and within a few months of starting her job in 2004, she further developed the idea in a memo for Frieden. Economists’ studies suggested that a 10 percent increase in price should cause a nearly 10 percent fall in soda sales. She proposed two options. The tax could be 2 cents per 12-ounce can, which would only raise money to run an obesity prevention program. Or it could be 2 to 3 cents per ounce, which would roughly double the price of a 2-liter bottle and increase the price of a 20-ounce bottle from $1.25 to $1.65 or $1.85, cutting into sales. At the time, Frieden wasn’t ready to fight for a tax, but Silver kept the idea percolating.
In 2006 Silver tried to talk to soda companies, just as she had tried to talk to McDonald’s the year before. She called PepsiCo headquarters in nearby Purchase, New York, and was able to get a meeting with the North American president. At the meeting, she and Frieden asked what PepsiCo could do in New York City to accelerate the shift from drinks loaded with sugar to those without it. The two suggested a few marketing ideas for no-calorie drinks, like lower prices, better store placement, and redirecting advertising dollars toward them.
At the time, Pepsi CEO Indra Nooyi was trying to give Pepsi an image as the healthier company. At the meeting, the Pepsi executives talked about their “healthier product” portfolio and agreed to try a pilot program in New York to promote healthier drinks. But they didn’t pick up on any of Silver’s ideas. “It basically fizzled,” Silver recalled later. “We never felt like they were really willing to steer the ship in a different direction.” The soda money-making engine clearly had the company trapped. Later, Nooyi had to backtrack from her healthier image to mollify Wall Street investors, who thought that by straying from the core brands of high-calorie soda and chips, she was hurting profits.
In 2007 Mary Bassett invited me to join a group she hoped would come up with ideas for reducing New Yorkers’ consumption of sugary drinks and other junk foods. The smoking program inspired three ideas. The cigarette tax had worked, so we revived Silver’s soda tax idea, and we also thought about taxes on junk food. TV ads were a success, so we decided to try counter-advertising against soda or junk food. Smoke-free workplaces were winning, but what was the parallel for food? People revolted at the idea of “food-free workplaces,” but the group pursued the idea of making workplaces junk-food-free.
One idea didn’t get very far, at least not then. Lynn Silver turned to Tom Merrill at the first meeting and asked whether the city could pass a law banning soda bottles bigger than 6 or 8 ounces. For a few seconds, Merrill looked as if he had been hit over the head by a brick. The idea of prohibiting 2-liter bottles, 20-ounce bottles, or even 12-ounce cans of soda throughout the city just felt outrageous. After recovering Merrill asked, “Do you mean legally or politically?” He looked into it anyway and came back with a no.
In the spring of 2008, two things made Frieden think seriously about a soda tax. First, the housing market crash of 2007–8 had crippled Wall Street, the state’s main financial engine, slashing tax revenue. Like the cigarette tax, a soda tax would need approval by the state legislature, and the legislature would now be desperate for money. And second, the mayor was nearing the end of his second term, so this looked like the last chance to push big public health ideas. Frieden asked me to estimate what a soda tax would do. I created a model that suggested that a tax of 1 cent per ounce would raise $1.2 billion, cut calorie intake from sugary beverages by 10 percent, and over one year might reduce the number of obese people statewide by 75,000 and prevent 10,000 people from developing diabetes.
In June 2008 Frieden pitched the soda tax to Mayor Bloomberg. First he put up a slide showing the state’s projected $8 billion budget gap. “New York State is broke,” he said. “This is a good thing for us.” Much of that deficit came from soaring Medicaid costs, especially for illnesses related to obesity. Aside from the human suffering that obesity caused—700,000 New Yorkers with diabetes, 2,900 of whom needed amputations and 1,700 of whom died from the condition annually—the epidemic, Frieden explained, was costing city residents more than $4.5 billion a year in medical care. A tax on soda would encourage people to drink less and contribute to reversing the obesity epidemic; it was a tax that no one would be forced to pay because everyone could buy unsweetened beverages or drink water for free. The businessman in Bloomberg understood economics and was proud that his cigarette tax was cutting smoking rates. Getting a soda tax through the state legislature would be very tough, but he was willing to try.
• • •
In the summer of 2008, calorie counts bloomed on menu boards across New York City. Many New Yorkers were stunned. A smallish slice of lemon loaf at Starbucks was listed at 440 calories—nearly one-quarter of a ty
pical woman’s daily calorie budget. A Big Mac combination meal—one that wasn’t supersized—rang up 1,130 calories. A Times reporter caught up with a marketing specialist who learned that his Whopper combination meal contained 1,720 calories. The foods offered at sit-down restaurants were even worse: Pizzeria Uno’s Individual Chicago Classic pizza was 2,310 calories. One columnist wrote that the new menu boards were like “a poster about herpes at an orgy.”
But no one knew how many New Yorkers would actually use those calorie counts or how. In the early days, Kelly Christ, one of Frieden’s assistants, wasn’t encouraged when she heard a woman waiting in line at Starbucks say with a sweet Southern accent, “Look, y’all. The doughnuts are only four hundred calories. I might could get two.” With experiences like that, the health department in 2008 ran ads in subways to ground people. “2000 calories a day is all most adults should eat,” the posters read. “Read ’em before you eat ’em.”
Rather than depending on customers alone, the health department team was hoping that embarrassed chains might discontinue their 1,500-calorie sandwiches or shrink their 800-calorie snacks. By late summer, Dunkin’ Donuts had announced that it would add two egg-white sandwiches below 300 calories. I read in blogs that Starbucks customers had picked clean the lower-calorie pastries by the end of the day, while the high-calorie pastries were still stacked up. Soon Lynn Silver noticed that “mini-scones and teeny chocolate chip cookies” appeared in the Starbucks display cases.
But that was just Starbucks. A few months later I stopped in at a Dunkin’ Donuts shop in lower Manhattan and asked the man working the counter whether customers noted the calorie counts. “All the time,” he said with a Spanish accent, “every day.”
“What do they say about them?” I asked.
“They say, ‘Why do they have to have that there?’” He shrugged. “I say it’s not up to me, we have to do it. I just work here.”
“Do they switch to doughnuts with lower calories?” I asked.
“I don’t know about that. . . . But maybe it’s a good thing for some of the women.”
“Do they leave after seeing how many calories all these doughnuts have?”
“No. They like their doughnuts.”
• • •
The idea of creating “junk-food-free workplaces” wasn’t entirely new. Mary Bassett and Lynn Silver didn’t use that phrase, but the health department had actually been working on them for years. The key step was to write standards that distinguished healthy food from junk.
In 2003 the New York City public school system made its cafeteria food healthier by switching to low-fat milk. Soon afterward it limited sodium and cholesterol and added fruits and vegetables. Then one day Silver spotted a report showing that one in three children in Head Start preschool programs were already overweight. “I thought, ‘Wow! This is early!’ Waiting until school is too late.” New York City’s health code already had regulations for child care centers, written during a burst of interest in day care in the 1950s. Silver decided to add rules to help prevent obesity. Her rules banned sugary drinks and limited juice, required low-fat milk, made drinking water readily available, and limited television time. Compared to the fights over trans fats and calorie labeling, enacting the day care standards proved surprisingly easy. Frieden liked the idea, and so did the Board of Health. Very few people complained about the new rules during the public comment period, and the board passed them.
That opened another idea. New York City likes government. Its huge network of agencies provide some 260 million meals and snacks a year through more than 3,000 sites: not just schools but also jails, senior centers, homeless shelters, public hospitals, day care centers, after-school programs, and programs for people with mental illness. When Linda Gibbs’s food policy coordinator arrived, he realized that the entire city government could set a healthy example. The coordinator brought together the twelve city agencies that gave out the most food, and over a year and a half of meetings, the health department wrote food standards that were more detailed and extensive than could be found anywhere else.
The agencies disagreed, and it wasn’t easy to settle the arguments. The public hospitals had their own nutritionists and resisted citywide rules. (Their doctors liked to write orders for cranberry juice, which has more sugar than Coca-Cola.) The jail system fed more than ten thousand prisoners, who scrutinized their trays. “This is about more than just food,” Silver remembers the jail staff saying. “We have to be careful that we don’t create a riot. These guys will be really upset if they get one less slice of bread or can’t get their Coke.” But ultimately the agencies agreed to one set of rules. There were standards for foods that the agencies purchased that banned sugary drinks, and standards for meals served that required two servings of fruits or vegetables at lunch and dinner. The city’s contracting agency then wrote the standards into contracts with the nonprofit organizations that ran programs funded by the city. Even group homes for people with mental illness—who tend to die young of diabetes and heart disease—would now serve meals with fruits, vegetables, and whole wheat bread and without soda.
Then Mary Bassett’s junk food group, and later the food policy coordinator, trained their sights on vending machines. In the early 2000s health advocates across the country began agitating to banish vending machines from schools. State legislators introduced bills, which the soda companies mostly beat back. In 2006 Bill Clinton—who had never before dabbled in nutrition—swooped in to announce an agreement with the soda industry. The soda companies said they were eliminating full-calorie soda from school vending machines, but the rules left some important loopholes, like allowing high schools to sell so-called sports drinks, and delaying the implementation until 2009.
The New York City health department wanted to go further and ban all sugary drinks from school vending machines. Like schools across the country, New York’s were making money from soda vending machines—about $6 million a year citywide—much of which paid for athletics in middle schools. The soda sales were not so big that by themselves they contributed much to obesity, but they amounted to an endorsement that encouraged children to drink sugary drinks everywhere else, too. After plenty of back-and-forth between agencies, during which Lynn Silver “felt like I was the person who was being a stubborn pain in the butt,” the schools adopted stricter standards. In schools and other places regularly used by children, vending machines could sell only water, unsweetened low-fat milk, and drinks with fewer than 25 calories per 8 ounces. All bottles had to be labeled with calorie counts, artificial sweeteners were prohibited, and the vending machines themselves couldn’t advertise sugary drinks.
If sugary drinks were bad enough to merit their own tax, the health team felt that they didn’t belong in other government buildings either. Unlike other cities, New York went on to write vending machine standards for the other government agencies. It proved much harder to take soda out of adult spaces than schools or day care centers. The best the food policy coordinator could manage was to limit sugary drinks in vending machines to two slots and to balance that with more slots of bottled water. But at least the city government now had anti-junk-food rules—rules that the health department could shop around to other organizations.
• • •
By the end of 2008, New York State’s plunging tax revenues had ballooned the projected deficit to $15.4 billion, creating the largest budget crisis in the state’s history. On December 17 Governor David Paterson, who had succeeded Eliot Spitzer after Spitzer was caught in a prostitution scandal, presented his plan to manage the crisis. “We’re going to take some extreme measures,” Paterson told the state legislators. He proposed $9 billion in spending cuts, including big whacks in education and a $1 billion cut in payments to hospitals, nursing homes and other medical providers. He also proposed 137 new taxes and fees, one of which he called an “obesity tax”—an 18 percent sales tax on sugary drinks.
Paterson’s “obesity tax” was Tom Frieden’s soda tax, only mang
led by the state’s Office of Management and Budget. Frieden had proposed an excise tax, paid by distributors based on the ounces of sugary drinks they shipped to retailers. The state agency had converted it into a special sales tax paid by retailers, who already paid the state’s regular sales tax.
The state’s version would help with the state’s budget crisis, but it nearly ruined the potential health benefits. First, unlike an excise tax, the sales tax would not appear in the price on the bottle or on the grocery shelf but instead would be added at the cash register. Most shoppers buying a basket of groceries would not see how much extra the soda cost them. Second, the cost of soda on a per-ounce basis varied dramatically with the size of the bottle. A 20-ounce bottle of Coke in a vending machine often sold for $1.25—the price of a 2-liter bottle in a grocery store. The per-ounce excise tax proposed by Frieden would have added 20 cents to the 20-ounce bottle but 68 cents to the 2-liter bottle, encouraging people to switch to the smaller sizes. On the other hand, an 18 percent sales tax would add the same 23 cents for the two sizes, which might even inspire consumers to choose larger bottles to get the better “deal.”
Nonetheless, for the first time ever, a governor had proposed a tax on sugary drinks to combat obesity. It was a new idea—after calorie labeling, the first serious public policy proposal to respond to the epidemic. And the mayor of the nation’s largest city—the man who was becoming recognized as the nation’s loudest public health advocate—was cheering him on. At Paterson’s state of the state address in early 2009, Bloomberg said that “the governor is 100 percent correct . . . obesity is the single largest public health issue in this country that is growing. We have to do something about it.” He would work with the legislature on the final shape of a soda tax, “but to sit back and let our kids get themselves into a health situation where they’re going to get diabetes and die is not something we can do.”
