Health Affairs

Editor’s Note: This is the second installment of a two-part post by Amitai Etzioni examining the nation’s anti-obesity policies through the lens of a responsive communitarian philosophy. Yesterday, Etzioni laid out a responsive communitarian framework and used it to diagnose the problems with our current methods of fighting obesity. Today, Etzioni describes how these current policies should be refocused. Julia Milton contributed research assistance to this post.

For more on obesity, see the March issue of Health Affairs, a thematic volume on child obesity.

How can obesity reduction policies be refocused to better enhance the social good and reduce their intrusions on personal autonomy, as well as their secondary costs?

Promote exercise more than dieting. Exercise should be promoted more than dieting, rather than the opposite. Michelle Obama’s 2010 obesity reduction campaign emphasizes both healthy eating habits and exercise and even drew its name of the drive from exercising: “Let’s Move.”  Still, many of the media reports focused on efforts to reduce caloric intake.  One New York Times headline read: “A Federal Effort To Push Junk Food Out of Schools.”

The most popular weight loss books are diet books such as Dr. Atkins’ New Diet Revolution, The South Beach Diet, The Zone Diet, and The Flat Belly Diet. The most popular weight loss programs such as Jenny Craig, NutriSystem, and Weight Watchers also focus primarily on dieting. (As in many other industries, the programs that generate the largest profits tend to be most vigorously promoted by private sector lobbyists in the halls of government. Dieting is a cash cow compared to exercise because its “products” are consumed daily, while there are only so many sneakers, spandex pants, and such one can sell to those who exercise.)

There are strong reasons to suggest that exercise should be given prominence and dieting should become a secondary consideration, at best. First of all, exercising is more effective at reducing BMI. Moreover, while dieting has few, if any, benefits if no reduction in BMI is gained and maintained, exercise has many benefits beyond BMI reduction. Many of these are well known. Exercise improves heart function and decreases the risk of heart disease, lowers blood pressure, regulates insulin sensitivity, helps to prevent and alleviate osteoporosis, improves metabolism, increases endurance and joint health, improves psychological and cognitive functioning, and generally lowers morbidity and mortality, via mechanisms beyond lowering body mass.

One may well respond that people should both exercise and diet. However, given that many do neither or little of each, the choice of which element to promote more is important. It should be exercise.

Focus on children (and parents), not adults. Data suggest that set weight ranges—the level of body mass into which most adults seem to be locked—are set early in life (aside from whatever effect genetic predispositions set). According to one source, obesity in infants is only a 20 percent predictor of obesity in adulthood; by the time they are 6, it is 50 percent, and by the time they are adolescents, it is 90 percent. Other data, though some  less dire, point in the same direction. It seems that once pathways are set they become very difficult to modify.

Assuming that additional evidence would reinforce these findings, they strongly suggest that obesity reduction policies and campaigns should focus on early childhood; on educating parents; on meals in child-care centers, pre-school programs, and primary schools; and on pediatricians. (It should be noted in passing that these findings can explain the fact that while the BMI of succeeding age cohorts is rising, that of adults changes little.)

Focus on societal factors. not just lifestyle changes. The campaigns to reduce obesity largely focus on changing lifestyles. The clear implication is that it is up to the obese people to lead a healthier life. They are exhorted to take the stairs instead of elevators, to walk and bike instead of “running around in their cars,” and so on. “People are told they only have themselves to blame if they are fat,” writes Gina Kolata.

This approach draws on and feeds into the precept that people have personal responsibility for the etiology of their illnesses and thus for their health. It is based on a strong American cultural precept that we each have free will and are autonomous individuals, in control of our lives. Failures are due to us, not “The System.”

Actually, as far as obesity is concerned, unlike some other behaviors—say, drinking and driving—individuals’ degree of freedom is relatively limited. Reference was already made to pathways set in infancy by one’s parents, over which the individual has no control.  Even a libertarian may acknowledge that we cannot choose our parents. The same is true for genetic predispositions. Also, obesity is promoted by societal factors. A sound public policy would focus on modifying these factors rather than focusing largely on personal efforts. The argument is not that people have no responsibility in this matter, but that societal factors are relatively important in this particular area.

To illustrate the kind of societal factors involved, a few examples follow. The American economy is pressuring people to work longer and harder and often forcing two members of each household to become breadwinners. (In 2000, 1.7 earners were needed to get the same income households earned in 1970 from one person.) As a result, a growing number of people resort to fast food chains or purchase ready-made processed food, which is high in calories and fat.

Another example of societal factors is the role played by farm lobbies, the Department of Agriculture, and Congress in determining the composition of food served by the National School Lunch Program to millions of low-income children. The composition reflects the kinds of foods agribusiness is keen to unload, and those that reduce the costs of the meals, rather than that which is best for the children’s health. The former FDA Commissioner David Kessler details in his book The End of Overeating the ways food scientists working for major corporations engineer foods that motivate us to eat more and purchase more.

The role of societal factors is evidenced in the role played by cereal advertising aimed at children. In 2008 alone, four major cereal companies (General Mills, Kellogg, Post, and Quaker) spent more than $156 million combined on marketing to children. The average preschooler sees 642 cereal ads per year on television. Children’s cereals have 85 percent more sugar and 65 percent less fiber than cereal marketed to adults, and eight of the top ten least healthy cereals are in the top ten of those most frequently marketed to children.

Until recently, soft drink lobbies successfully prevented schools from banning the sale of sodas and blocked drives to remove vending machines from schools, even paying schools to keep the vending machines. Recently, many school districts responded to tight budgets by eliminating physical education requirements. Thus children, including those of the age at which the best long-term results can be achieved, are given an unhealthy diet and removed from the most promising treatment: exercise.

True, in recent years, there has been some improvement in the role played by societal factors from the viewpoint of curbing obesity. A fair number of schools now provide healthier food, some have removed the vending machines, and cereal companies have scaled back some of their advertising. And there has been some movement toward “taxing fat rather than fat people,” an approach also referred to as “sin taxes.” In 2008, Maine imposed a $0.42/gallon tax on bottled soda. In 2008, New York Governor David Paterson proposed an 18 percent tax on non-diet soda.  Although his proposal did not make it into the final budget, it brought attention to the issue and was endorsed by The New York Times. In October 2009, an article in the New England Journal of Medicine called for a penny-per-ounce tax on all sugar-sweetened beverages, which would include sodas, some fruit juices, energy drinks, etc.

The Morality Of Scarcity

In contrast to a widely held position that we as a community (whether local or national) can successfully engage in campaigns that cure much of what ails us, the baseline of the analysis advanced here is that such changes are very difficult to advance. So far, obesity reduction policies have been examined largely in isolation. However, societies at any one point in time face numerous challenges and opportunities. The resources available to deal with these changes and exploit these opportunities are always in much shorter supply than those needed (including not just economic assets but also political capital, administrative capacities, public support, and psychological attention).

Moreover, change is very difficult to achieve. Progress tends to be slow and halting and exacts much higher economic and social costs than first assumed. Thus, decades after a “war” against cancer has been launched, despite progress on several fronts, many types of cancer remain incurable. The long-running war against illegal use of controlled substances is far from won. Numerous drives to reduce inequality have had only limited results. The difficulties the US faced for decades in reforming health insurance, and the great difficulties it has in formulating a policy to deal with climate change, are further illustrations of the difficulties involved in developing new public policy. Hence, adding one more campaign to the public agenda should never be taken lightly.

Thus, the question of to which policy should resources be dedicated acquires a normative dimension.  There are numerous public policies that would seem to have better profiles than the high visibility and significance accorded to obesity reduction drives, including gun control, stopping reimbursement for medical procedures that are not proven effective and safe, testing the numerous chemicals used by manufacturers for unhealthy effects, and increasing the taxes on alcohol, to give but a few examples. All of these may face greater political difficulties than calling on people to diet, but this empirical observation does not attest to their normative standing.

Conclusion

Obesity is a serious health problem, but a rather intractable one. It requires costly interventions that will generate little gain as long as the focus is on reducing caloric intake through encouraging individuals to change their eating habits. Much more focus should be given to (a) caloric expenditure (exercise); (b) on parenting and children, as opposed to adult lifestyle changes; and (c) on societal rather than on personal factors. In addition, much more attention should be paid to the adverse side effects of dieting. Finally, the merit of making obesity reduction a high-ranking public health drive should be weighed against the value of other campaigns.

This entry was posted on Friday, July 2nd, 2010 at 10:57 am and is filed under All Categories, Employer-Sponsored Insurance, Insurance, Obesity. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.