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Reviewed by Michael Smith on July 11, 2014

Sources

"1. Dhar, M. Did Mayor Mike Bloomberg Make New Yorkers Healthier? Scientific American. http://www.scientificamerican.com/article.cfm?id=did-mayor-mike-bloomberg. Accessed December 11, 2013.""2. National Salt Reduction Initiative. New York City Department of Health and Mental Hygiene. http://www.nyc.gov/html/doh/html/diseases/salt.shtml. Accessed December 10, 2013. "

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Hello. I'm Dr. Eric Topol, editor in chief of Medscape. Joining me today from Medscape one-on-one is New York City health commissioner, Thomas Farley.

Morning.

Thomas, it's great to have you with us.

It's good to be here.

So, um I wanted to get started with maybe a little bit of background. I know you were raised in New Jersey, is that right?

  Right. 

But you somehow wound up in Tulane in New Orleans. How did that happen?

Yeah, I went to Tulane for medical school and ended up meeting my wife up north, but we got married when we were down there.

She's from south Louisiana, ah and so after we later had some opportunities to live anywhere, she wanted to go back to the area where she was raised.

And so I lived in New Orleans for 24 years and raised my family there. It's a great place to live, but later I had an opportunity to come back up here to New York and um couldn't miss the opportunity.

So you trained in pediatrics and also MPH in community health?

Yeah I have a, I'm trained in pediatrics. Didn't work much as a practicing pediatrician. Went off into public health through the CDC's Epidemic Intelligence Service and later went back and got a Master's in Public Health and Epidemiology.

I've been working in public health pretty much my whole career.

And you spent a year in Haiti, is that right?

Spend a year in Haiti working on a community health project up in the mountains in the rural area. Worked really hard.

I would say it was mostly a failure though, and I learned a little bit about the difficulties of putting in place public health projects the community level in an area where there's difficult politics to be honest.

I know you are really into a health lifestyle, right? I mean you exercise every day?

Ah yeah, I'm an exerciser. I'm a runner. I've been doing that for years.

Did you already have a workout today?

Ah, I did, yeah.

You did? What was your workout?

Ah, today I went to the gym, worked on the treadmill a little bit, and lifted a little weights. I'm hoping to run the New York City marathon coming up soon, and so today was kind of a light day for me in my taper phase.

So um, that's a daily routine? You don't miss a day?

Yeah, seven days a week. I don't feel right if I don't get some form of exercise. I'm kind of addicted to it at this point.

Wow, ok now when you came on in was it 2009 to be the commissioner here in New York City?

Right, before then from 2007 to 2008 I came up here and worked as an advisor to Tom Frieden the then commissioner for the Health Department. I did that as a year leave of absence from my position as a professor of community health at Tulane.

I went back to Tulane and thought that was over with, but then Dr. Frieden got tapped to be the director of CDC. Then I had an opportunity to interview with Mayor Bloomberg to replace him. So I came up in 2009.

So now you've been working closely with Mayor Bloomberg for these four years or so, is that right?

Ah, right it's been almost four and a half years with the person that I call the world's first public health mayor. It's been an incredible opportunity leading what I consider to be the best public health agency in the country.

And it's got a big budget, a couple billion dollars or something like that?

$1.6 billion, 6,000 employees, we do everything from providing healthcare in the City's jail systems to putting in nurses in schools, in the 1,200 public schools in the City to dealing with smoking and air quality.

You name it. We have a very broad portfolio.

Before you even took on that position, you had a book, I think it was in 2005, "Prescription for a Healthy Nation," so was this like a warm up for this role?

Well, it wasn't planned that way, but when I was a professor, I started thinking about the fact that much of our health education efforts weren't working and that much of what drives health these days is behaviors.

And so I had a chance to think about what really does determine behavior or what opportunities do we have to influence that.

And I realized that environmental change is the way that influence behavior, but if we can make healthy choices easier, that is the simplest and most cost-effective way to promote health, and so those are not new ideas.

Those ideas were out there in public health, but I put them altogether in a book that I designed to be for general readers, not for specialists called, "A Prescription for a Healthy Nation." It hasn't gotten an awful lot of buyers.

It's not exactly flying off the shelves, but it was a nice opportunity to put my ideas together and try to get, I hoped, the general public to understand public health approaches and their value.

We want to get into some of these. Obviously there has been a lot of controversy about soft drinks, sugary drinks and all that. Can you tell me what that flap has been about and what has happened with that?

First, the biggest health problem right now after smoking is obesity and its twin epidemic of diabetes. The smoking rates are going down; obesity rates are going up.

This is something I have been focusing on for a long time, and it's a complicated problem. The solutions are not going to be simple, but sugary drinks are probably the largest single contributor to that problem.

So we focused a lot on sugary drinks in the last few years with the Health Department, and we also know that portion sizes of sugary drinks have a big influence on what people consume.

There are good studies that are actually pretty disconcerting that show if you give people larger or smaller portion sizes they will consumer pretty much whatever you give them and don't have any sense of having consumed more or less.

And so the fact that when I was a kid, we used to drink Coke in bottles of 6.5 ounces and now you can go into a fast food restaurant and get a 64-ounce cup, a ten-fold increase.

Sixty-four?

Sixty-four, and that's 800 calories. That's a half a gallon by the way. That probably has something to do with how much more soda we are drinking, and that probably has something to do with the growth of the obesity epidemic, so we simply said,

you know, if people were served soda in cups that were smaller, like 16 ounces, people could still consume as much as they want because they could buy more than one, but it might give them a cue that it is a more appropriate size than 64 ounces.

So ah,that rule was presented to the Board of Health. The Board of Health approved it.

The Board of Health regulates restaurants in New York City so it would apply to all the restaurants that they regulate, so we felt and still feel that the Board of Health has the authority to do that. But the soda companies hated it.

They sued us. We lost in Court. We appealed. We lost the next round, but we still had one more round to go and our lawyers still feel we have the authority to do this. When I say "we" I mean the Board of Health.

The Board of Health has done many other things to protect the health of New Yorkers over the years that have been ground breaking and incredibly valuable, such as prohibiting lead in paint back well before the federal government did it.

So, we think this is in keeping with their authority, and we are still optimistic that we are going to ultimately win in Court on it.

But, this is about regulating things, the government. Is that the best way to--this kind of mandate or really setting what the boundaries are to control, to modulate behavior?

Yea, where government public health has its greatest value is when we protect people from environmental risks, such as reduce the levels of air pollution, which we just did in New York City and showed that we are saving 800 lives a year

and also create an environment where healthy choices are easier. Now, if you create an environment where healthy choices are easier, people can still behave in an unhealthy way if they choose to, but we make it so that the

default choices are more likely to be healthy. We don't think this is a regulation of behavior at all. If people want to drink 32 ounces of soda, if people want to buy 32 ounces of soda, there is nothing in this rule that prevents that, but what it

is a regulation of how companies can market their products. They're marketing their products in ways that are distinctly unhealthy, we think it is an appropriate role for the government to set some rules there for the sake of public health.

Now is the opposition has been well beyond just the soft drink companies, right? There were a lot of people that said I don't want to have this regulated. I want to do what I want.

There have been several polls on this, and the polls are about 50%. So it's about half and half. I don't think people who are against it feel strongly against it although of course you see some on television.

The real opposition really comes from the industry. It is either the soda industry or the restaurant industry because this is the way that they market things, this is the way that they sell money, and there is a lot of profit in sugary drinks.

Now you also mentioned I think that you think this is at the core of the obesity epidemic, this issue.

Absolutely, right.

Is that clear though? There are a lot of other moving parts in this story I guess.

Yeah, we certainly don't think sugary drinks are the entire obesity epidemic, but if you look at what food products have contributed to the greatest increase in calories during the time that we have had an increase in the total calorie consumption

in the United States over the last 30 years, that product is sugary drinks. Then there are an increasing number of studies that are linking sugary drinks with obesity in a cross-sectional way but with weight gain in a prospective way including

randomized, controlled trials, so there is no question that there is something about dumping in this heavy load of sugar in liquid form which increases people's weight over time.

You also get the whole insulin surge and all sorts of secondary effects of eating more too.

There are two theories as to why. One of them is the insulin surge, and the affect that has on storage and the affect it might have on appetite down the line.

The other is if you consume something in liquid form it doesn't have the same satiety effect of consuming that in solid form. That has been--there are studies that support that as well. So maybe it is a combination.

That's not entirely clear why, but it is entirely clear that the empiric data shows a strong relationship between sugary drink consumption and weight gain.

Again, that's not the entire epidemic, but if we can isolate one thing that clearly is contributing to this, which doesn't need to be there, that's it.

There was a randomized study that I wanted to ask you about where they basically paid people to lose weight, like $500. You probably saw it published in JAMA a few years back, and it was pretty effective.

And actually during the course of getting paid to lose weight, people did it. Is that a reasonable thing to consider in the future kind of like the clunkers, car clunkers that we pay and pay people to lose weight that would actually be beyond sugary drinks?

Right. Well, now about two-thirds of Americans are obese or overweight.

Right.

Do you think that we can afford to pay two-thirds of this entire nation's population to lose weight and not just for a few months but over their entire lifetime?

I don't think so. I don't think that is a cost-effective way of dealing with this problem.

Do you think that would work if funds weren't a limiting factor? Is that an effective way to modulate behavior?

Well I question whether it would work over the long-term. I don't know, and the studies haven't been done over the long-term.

One thing we know about diets is that people put on a diet generally lose weight for about six months and then they bounce back and within a year later they are more or less where they were to start with.

To me there is no question that the obesity problem is an environmental problem. Nobody wants to be overweight. Lots of people, most people, in this world are gaining weight despite the fact that they are trying very hard to avoid it.

So there is something about our environment that is beyond our control that is making us gain too much weight, and to me it is the way that food is marketed to us.

So you can ask people individually to fight those environmental forces. And some people can do it over the short-term. Some people can do it over the long-term, but most people can't do it over the long-term.

Now I wanted to switch to another area like this in some ways, salt. There's a raging controversy, should there be a particular level, what that level should be of sodium intake. What are your thoughts about that?

Actually, there is no controversy that we are consuming way too much sodium. People consume about 3,400 milligrams per day, and the question is should we be consuming 2,300 or 1,500.

So both of those are a whole lot less than what we are consuming now, and we also don't consume enough potassium.

That combination of too much sodium and low potassium gives us hypertension rates where close to two-thirds of people by the time they hit their 60s have hypertension. That is not natural. It isn't necessary.

Isn't it too simplistic? Some people are remarkably salt sensitive, and they will have hypertension. And others are just as remarkably salt resistant.

They can have unlimited salt, and it will never affect their blood pressure. Why do we have this kind of population medicine approach or mentality?

There are some people that try to put people in categories like that, you are either salt-sensitive or you are not.

Yeah.

I'm sure that there is a distribution of this that is continuous. Some people are going to be more salt sensitive than others.

But you look across the entire population, if everybody is consuming too much salt that entire distribution of blood pressure is going to be far higher.

In populations that consume much less salt, the entire population distribution is much less, and some of these isolated primitive tribes their blood pressures are under 100 systolic.

And they don't rise with time, and so it's not a given that hypertension is part of the aging process.

You could say that we are all suffering from a certain level chronic sodium intoxication, and so if we all consumed 30% less, we would probably all be far healthier.

But I don't know about that. I mean my sense is that we don't do enough on the individual level, and if we assume like that we are basically not exactly accounting for this marked heterogeneity in people. But that's okay.

But the relationship between blood pressure and heart disease mortality or mortality is continuous. We don't have evidence of blood pressure being too low.

We do have evidence that the average blood pressure in Americans is too high for their health, and so the idea that reducing sodium for the entire food supply is a good thing for the population to me follows from that.

Now, overall so these policies of whether it's the sugary drinks or these various things, how did you coordinate this with the mayor?

Did you say I think we should do this, and he said it sounds like a good idea, Tom? How did you go about this stuff?

The mayor is extremely smart. He understands the concepts of public health, and he understands data, so any big idea I take to him and I lay it out to him the same way I would to you, a physician, or another specialist. I show him the graphs.

I show him the biologic evidence, and I'll argue how many lives we think we can save from this. I'll talk about what other expert bodies say on this issue, and he will pick apart all of those and make a very intelligent, reasoned decision.

Ah so it's rare if ever that a person like me has an opportunity to answer to an elected official with that kind of intellectual power and interest in the subject. It's great.

Did he ever say to you, you know, "Tom, we're embroiled in this whole mess with this legal issues with the sugary drinks. Why did you do this to me?" Did he every say, "Why did you get me into this thing?"

The mayor is an executive, and he thinks about things when he makes a decision. He doesn't look back. This is the decision I made, and now we are just going to go forward. I think that is the right thing to do.

Yeah wow, so I guess he is moving on after these three terms.

He is, but you are going to continue to hear a lot from Mike Bloomberg in the future. There is no question about it.

I'm sure of that.

He is passionate about public health. He is working at the global level, so his career is far from over.

And how about you? Will you be staying on in your position, or does that change with the change of mayor?

Typically, when a mayor changes he brings in his own commissioner, and so I don't know. I'll certainly continue to work in public health, take a little bit of a breather after this because this is a pretty intense job.

But I hope to continue to be involved in the national conversation around what I consider to be opportunities in public health that we can take right now to prolong life and reduce morbidity.

Well, it seems like a lot of our top people in public health have come from this position, whether it's Tom Frieden at CDC or Peg Hamburg or others, so it seems like New York City is a precursor to having an impact at a national level.

The agency is really unique because it's big, as we mentioned, but it's local at the same time. We can see health problems, put in place interventions and evaluate their impact in a short period of time.

We also have regulatory authority, which the CDC doesn't have, so we can do things that no one else can do. We often do them, and then people around the rest of the country look at that and see whether they want to copy us.

The last thing I want to get into more is probably the most challenging of all, changing people's behavior. I know you've studied that a lot and thought a lot about it.

We touched on it already during the discussion, but obviously we need to do that because we have this epidemic of unhealthy lifestyle.

One way is of course regulating it, but are there things that we are missing today that we could do better to get people, are there some--is it gamification, or incentives, for example, employers in employee health systems that try to do?

What can be done to improve this whole kind of behavioral science and get lifestyles on track?

There's always been a lot of focus on how do you deal with an individual person to try to help him change his behavior within a given environment.

But at the population level, there is certainly--it's difficult to do that, and it's certainly not cost-effective to do that.

The way that we change the behavior of entire populations, which is the way that I think we improve the health of entire populations is to make healthy choices easier and sometimes to make unhealthy choices a little more difficult.

So smoking, for example, we made it a little bit more difficult to smoke by saying you can't smoke indoors, we raised the price of cigarettes.

You used some pretty strong images too to help convey that.

Right, we had an impact on the media environment. So people tended to have a very positive image of smoking, as something that was sexy because actors do it on the screen. We associated a negative image with that.

That actually, it makes you get sick, and it can be kind of disgusting to think of what your lungs look like. But it is that environmental change where you can change the behavior of populations the easiest.

So right now we are in an environment where it is actually difficult for most people to expend energy because they have to drive to where they are going to go and there aren't other opportunities to exercise where they are.

And it's too easy to consume too many calories. Everywhere we go there's food within arm's length, and we are biologically programmed to want to pack away those calories for the next famine if we have that food so that if we can change

our food environment, if we can change our built environment so that the calorie balance is naturally a little bit in the opposite direction, then we can reverse the obesity epidemic.

And that's environmental approaches are where I think we have the greatest benefit, and the opportunities that we can still take.

Yeah, well this has been fascinating. It is great to get your insights, and I give you a lot of credit for the aggressive stance that you have taken here in New York City since you came on as commissioner and these four and a half years.

We have learned a lot. The whole world has been watching New York City, and I know so much of it was the efforts that you have done to try to improve public health, this model, this phenomenal model. Thank you so much for joining us, Tom.

Okay.

And thanks to all of you for joining MedScape one-on-one. We look forward to further interviews with some really interesting people like Dr. Farley.

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