Obesity and Public Policy

By Mike Koetting August 8, 2021

I think it is obvious that one of the duties of a nation is to protect its citizens. But to what extent should this go? And when does it become overreach—either philosophically or practically?

I have been thinking a lot about these issues in recent weeks because I have been thinking about obesity in America. Simply looking at people on the streets suggests that, despite decades of official concern, American obesity continues to rise. The data bear this out. Research published in the New England Journal of Medicine predicts no state will have an obesity prevalence rate below 35% by 2030. In 2000, no state had an obesity rate above 35%.

The increase in obesity related mortality and morbidity is cutting into the gains made from decreased smoking. A recent study estimates the medical costs of obesity and related dietary issues at $600 billion annually, Moreover, while there is significant obesity in all sectors of our society, it is increasingly a class issue—with lower income, lower education and non-white status all correlated with greater obesity.

We tend to think of obesity as a private problem—individuals eating too much, eating the wrong foods or not exercising enough. No doubt, those are factors, although there is much we don’t know about how exactly those factors interact and what are the social determinants that influence those choices. That said, there are significant structural issues at work, which means that there are potential public policy responses.

The problem is that responses that would make a difference seem to cut to the heart of how and where government should interfere in people’s lives. Although, perhaps, the operant question is how and where should government interfere in the operation of corporations, which we euphemistically refer to as “the market”.

Which is an instructive place to start. Economists are wont to pretend “the market” is like a farmers market. If more people want tomatoes, the price of tomatoes goes up, and farmers start producing more tomatoes. But the connection between this idealized version and reality is slim.

In the real world, there are a huge number of intermediating factors creating a context in which food is subject to myriad forces about which the consumer is, at best, dimly aware.

Consider the world of food recommendations. It is well-known that food producers intervene in government processes to protect their interests. Coca Cola, for instance, has run a consistent campaign to deflect governmental attention on the role of sugar in the current obesity trends. They, and many other producers, convinced the last administration to overrule the advice from the scientific panel on food guidelines to lower recommended level of sugar.

I suspect, however, these overt actions are much less important than the food industry’s overall business approach—which is to figure out what people want and give them more of it. A lot more of it. Average calorie intake has increased by about 25% over the previous 40 years.

It is hardly surprising that the food industry has encouraged this. These are corporate interests. More sales are good for profits. The food industry uses very specific, sophisticated efforts to create demand for the foods they sell. This includes marketing and advertising, but also engineering the food not for nutritional values but for tastes that make consumers eat more, and, at the same time, ingredients that enhance shelf-life, make shipping easier, and whatever else improves their bottom line.

It is no accident that the rate of obesity skyrockets wherever Western, highly processed products take over.

But what do we do about this? Does protecting a nation’s citizens extend to protecting from themselves? And how do those lines get drawn?

One the one hand, it is good to be cautious about government “protecting people from themselves.” All kinds of silliness—think Prohibition and the war against marijuana—has been created with that justification.

On the other hand, if we continue down the current path of simply exhorting people to do better, I can’t see it having any more effect than it has since David Satcher declared obesity a “national epidemic”—20 years ago. If it is cheaper and easier to eat food that otherwise appeals to you, why are people going to change course?

As a society, we have to decide if we are willing to let obesity rates continue to increase or are we going to undertake action that will make a difference.

Frankly, I am pretty pessimistic that the country is likely to take anything like the appropriate steps. If something as blindly obvious as Covid vaccine mandates are beyond the reach of our dysfunctional society, how will anything as complicated and fraught as obesity policy get off the dime? I don’t know if there is at any point at which the society will say “enough” and be willing to take this issue seriously.

But while we are waiting for society to get serious about regulating the food supply chain, there are some policy steps that could be taken that will not shake the foundations of the democracy.

Continue to sound the alarm. Government needs to persist in calling attention to this problem. It also needs to promote research that sheds light on both the structural contributors to the increasing rate of obesity, including better understanding of differential impacts in different portion of the populations; and on the mechanisms that would promote control of obesity but can be practically implemented. In many cases this will involve better understanding how to motivate people to undertake the efforts needed to avoid obesity. It is optimistic, but not quite crazy, to believe at some point the message will start to cohere into a willingness to take further action.

Engage health professionals. I think there are few physicians who are not aware of the issue and, I suspect, most are reasonably conscientious about telling their patients. But more may be needed. We need to keep encouraging them and, hopefully, providing them with ideas and tools that help them deliver the message more effectively.

Use leverage of Medicaid. More than one-third of American children are covered by Medicaid and virtually all of these in managed care programs. About one fifth of those are obese, rising to 25% of among Hispanic and Black populations. State Medicaid agencies should work with their managed care programs to lower those numbers. This will be tough because continuity is key to changing life styles and children cycle in and out of Medicaid. It might make sense to use Medicaid funds to support public health entities to carry out these types of programs so they could maintain continuity and focus on longer term outcomes. States could push managed care organizations to cooperate with these public health efforts.

Review role of SNAP. More than a quarter of all children are covered by SNAP (Supplemental Nutrition Assistance Program, the modern name for Food Stamps), virtually all of whom are also included in Medicaid. There have been some attempts to create incentives for healthy-eating and there are unending attempts to make SNAP more punitive. These have not helped much. To make any difference in this regard, it will be necessary to rethink how SNAP interacts with the food supply chain and make serious interventions. Pumping more money into the existing SNAP is not likely to have much effect on obesity, although it may be desirable for other reasons.

Diversify health professionals. This is an issue that goes well beyond obesity but will be particularly important as the obesity rates among minorities grow faster than other parts of the population. It is difficult to persuade people to change their life styles. Having messengers that patients believe understand their lives will help.

Tax sugary beverages. These are not a trivial source of sugar—accounting for an average of 7% of all calories consumed. It seems that teen consumption of soft drinks has declined somewhat in the last 15 years, but this may move it further. The first places to enact such policies will be bitterly contested as “nany-statism,” as it was in Cook County when opponents used this rallying cry to repeal such a tax. But once the precedent is set, this will get easier.

These are small steps. If the society were more interested in really changing the arc of weight, there are many other steps that could be taken. But they are beyond the reach of our broken society. The coalition of big corporations whose profits are at stake, and voters who care about nothing more than not having elites tell them what to do are likely to leave us spectators to even further weight gains.

I believe this constitutes a failure to protect our citizens that could be accomplished without inappropriately limiting people’s rights. But it will not be accomplished because the issue of how rights are best expressed in the complex society that we have created has become so muddled we are bringing our democracy to a standstill.

Author: mkbhhw

Mike Koetting’s career has been in health care policy and administration. But it has always been on the fringes of politics. His first job out of graduate school was conducting an evaluation of the Illinois Medicaid program for the Illinois Legislative Budget Office. In the following 40 years, he has been a health care provider, a researcher, a teacher, a regulator, a consultant and a payor. The biggest part of his career was 24 years as Vice President of Planning for the University of Chicago Medical Center. He retired from there in 2008, but in 2010 was asked to implement the ACA Medicaid expansion in Illinois, which kept him busy for another 5 years.

One thought on “Obesity and Public Policy”

  1. I couldn’t agree more and have seen it for years in the various communities my hospitals have served. What is most disturbing is that in high SES communities, over eating and eating the wrong foods remains a constant. Go to a buffet and you’ll see what I mean.
    It is easy to pinpoint those without resources as the source of the problem but when those with resources are obese as well and one has to look at what is really going on.
    For the poor communities, the prevalence of obesity and the lack of adequate, non-fast food food sources go hand-in-hand. To address obesity in these communities, one has to look at the social determinants of health as well.
    Finally I agree with your Covid comment. When something is that obvious and 40% of the population choose not to participate, what is the country going to do when faced with the attractions of sugar and fried food.
    Incentives? Role Models? Dis-incentives? There is no obvious answer which will produce the results we need.
    Now, let’s move on to climate issues and what we are not doing to curtail our demise.


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