January 14, 2011

This government makes me look fat

By Erin Anderssen

Policy-makers have tried humiliation, disgust, fining and cajoling, but obesity
rates keep going up. Now, Erin Anderssen reports, experts have a fresh idea:
Nudge people into weight loss with incentives

If you tuned in to afternoon soaps on CBC in the late 1980s or early 1990s, you still may be
able to hum the corny theme song for Body Break, with sprightly hosts Hal Johnson and
Joanne McLeod. One 90-second spot from 1992, still found on YouTube, demonstrated leg
lifts on airplane flights (three to five sets, we're told, to relieve stress) and urged travellers to
find hotels with gyms.

Sponsored by Ottawa's ParticipACTION program, the pair, who to this day sell Body Break
products online, made more than 250 of these public-service segments. "Until next time," Hal
always signed off, "keep fit and have fun."

But such earnest, government-sponsored exhortations failed miserably. Instead, we packed

on pounds and slurped back junk until, according to Statistics Canada, today half of the
adults in this country are either overweight or obese, and our kids aren't far behind. The best
Canadians can boast is that we're not as fat as our Krispy Kreme-loving neighbours to the
south.

As waistlines expand, policy approaches in the world's better-off countries become more
desperate - even downright nasty. Instead of nudging us into weight loss with incentives, as
research suggests, they shove their citizens toward being skinny.

In the U.S., schools in Arkansas have starting weighing students and sending the results
home on report cards, and West Virginia has tried to tie Medicaid coverage to lifestyle habits.
Three Mississippi legislators introduced a bill that would ban restaurants from serving obese
people (its authors later claimed it was only an awareness-raising stunt). And first lady
Michelle Obama called obesity a "national-security threat" because it reduces the pool of
potential military recruits.

In 2008, Japan introduced a law requiring employers to measure the waistlines of middle-
aged workers - exceeding a certain limit leads to mandatory dieting and company fines.

Southwest Airlines, which requires heavy passengers to buy a second seat, feuded last year
with moviemaker Kevin Smith last year over whether he was "too fat to fly." Air France,
meanwhile, "encourages" a second-seat purchase but maintains that it wouldn't kick anyone
off.

And Australian doctors have proposed "disgusting" people into dropping pounds with an ad
campaign that depicts a man drinking congealed fat.

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The shame game is a losing proposition

The message is clear: You are lazy, a glutton and a burden to society. Feel the shame, and
slim down. If that worked, of course, there would be no obesity epidemic to combat.
Politicians, as our current shape would attest, can't embarrass or nag us thin.

"Shame and blame - these are really quite a disturbing waste of taxpayers dollars, and
they're really just politically expedient, just to show the government is doing something," says
Neil Seeman, director of the Health Strategy Innovation Cell at the University of Toronto and
co-author of the upcoming XXL: Obesity and the Limits of Shame.

Obesity, he points out, is not like smoking or drunk driving, which turned out to have
relatively simple public-policy solutions once the consequences became clear: tax, ban and
jail.

"No one has to smoke," write Mr. Seeman and his co-author, Patrick Luciani, an expert on
urban affairs and a senior resident at the University of Toronto's Massey College. "But we all
have to eat."

So what can Ottawa do? Make good food cheap and bad food expensive, economists say.
Change the environment, urban planners propose. And Mr. Seeman and Mr. Luciani's book
makes perhaps the boldest suggestion yet: Stop spending money on public-service
announcements that everybody is ignoring anyway, and give Canadians themselves the
cash to develop their own weight-loss plans.

Supersize or shrink our pocketbooks, these theories say, and we'll act. After all, what makes
people salivate almost as much as food? Money.

Canada's weight gain is expensive, and Mr. Seeman argues that it is due to surpass even
smoking as a health burden. Cigarettes kill you; obesity may do the same eventually, but first
it makes you sick, possibly for a long time. Rates of hypertension, joint pain, asthma and
diabetes are rising rapidly; obesity lengthens hospital stays and spikes the risk of certain
cancers.

This week, a new study put the price tag for Canada at $30-billion a year and climbing.

But how do governments formulate policy for a problem that science hasn't figured out how
to solve?

Giving motivational science a workout

To lose weight, it has long been assumed, you simply burn more calories than you eat.

But researchers now know that genes can predispose even the most active to weight gain,
that mental-health issues such as depression make a difference and that the environment
may trump willpower - a complexity consistently absent from public messaging.

Consider how urban sprawl confines people to cars and long work hours keep them behind a
desk. Time-pressed families are more likely to eat packaged food and oversized restaurant
meals. Poor Canadians tend to be heavier than their wealthier neighbours, but poverty is

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only one factor in a big pot. (Indeed, the only people not getting fatter, Mr. Seeman reports,
are the super-rich.)

What's more, obesity appears to spread like a virus, in what researchers call the social-
multiplier effect: People put on more weight when their family and friends are also heavy.

Still, even experts can't agree on what works, so governments have relied on blunt
instruments such as shock-value billboards or promoting nutrition and fitness guidelines.

A different philosophy comes from the field of behavioural economics, which suggests that
people can be "nudged" into better choices with incentives and disincentives, environmental
design, peer pressure or even simply posing the right question at the right time - for instance,
asking people to be organ donors when they renew their driver's licences.

The idea, also described as "choice architecture," was popularized in the influential 2008
book Nudge by economist Richard H. Thaler and legal scholar Cass R. Sunstein. One of its
biggest fans is British Prime Minister David Cameron, who commissioned a small group of
civil servants and academics as a Behavioural Insights Team to advise his cabinet.

Its report in December suggested, among other initiatives, installing swipe machines that
would allow students to collect movie tickets for walking to school, and rebranding fruits and
vegetables as "sports candy."

Crunch the numbers: What works?

Still, it's not clear that just building sidewalks will lead to weight loss, Cornell University
economist John Cawley points out. Hiding the junk food and showcasing the baby carrots in
school cafeterias is good practice, but will that stop the kids from dashing across the street to
McDonald's?

"This is a complex world we live in now," says Tim Lang, a professor of food policy at City
University London. "We've got to do a massive attempt to change how people eat and what
they eat. This is long-term stuff."

Last fall, the Organization for Economic Co-operation and Development released a 270-page
report that priced out current policy approaches against results. While not dismissing the
usefulness of public-education campaigns - by far the most common approach in the
countries studied - it found that overall those costs outweighed their benefits.

In most cases, mass-media campaigns, much like warning labels on cigarette boxes, drive
home a message most consumers already know (while potentially, as Mr. Seeman points
out, fostering a stigma a that prevents people from seeking help).

Food labelling, a cost borne primarily by private industry, also showed only marginal
behavioural changes - though Prof. Cawley says it's cheap enough to be worthwhile even to
influence just a small segment of the population.

School-based interventions were harder to cost out, since the benefits are long-term. But the
report's authors did find it made sense to educate a captive audience, young enough to still
be setting lifestyle patterns.

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Restricting food ads during children's programming, as Quebec has done for decades, leads
to children seeing about 40 per cent fewer ads for fat, salt and sugar-rich foods. A good idea
in principle, the report said, but Quebec's child-obesity rates have continued to rise with the
rest of the country's.

The 'ka-ching!' route to a healthier population

But by far the most cost-effective measures, according to the report, were taxes and
subsidies - while politically tricky, these approaches pay for themselves in reducing health
costs.

A recurring debate, in many countries including Canada, centre on whether to apply a form
of sin tax to soft drinks, for instance, making empty-calorie sweetened beverages more
expensive, while bringing down the rising cost of fruits and vegetables - perhaps in the form
of vouchers for low-income families.

In Britain, where the government has vowed to stop badgering people into weight loss,
consumers may now receive coupons for healthy food, such as yogurt, as part of a $390-
million (U.S.), industry-financed plan to promote health eating. Prof. Lang harshly criticizes
the program as a "nanny state" approach that sidesteps the culpability of industry in stocking
kitchens with cheap, high-fat food.

Taking a more sweeping strategy, Denmark is rolling out a "fat tax" on everything from
chocolate bars to soda pop, fatty meat and whipped cream.

A Canadian study commissioned by the Heart and Stroke Foundation last fall proposed a 20-
per-cent tax on sweetened "caloric" drinks. (The tax on cigarettes is about 70 per cent.) It
argued that, unlike fast food, the drinks have no nutritional value. Therefore, it wouldn't
unfairly penalize poorer families, who would have other choices.

Canadians might not see it on their scales in the morning, but one can of pop less per week
per person could make "a significant population level change," says Guy Faulkner, a health-
psychology professor at the University of Toronto who led the panel behind the report. (The
OECD report estimates that a 10-per-cent price change typically produces a 2-per-cent shift
in consumption in the opposite direction.)

You do have to wonder where it stops, though. "Apple juice can have just as many calories
per ounce [as pop]," Prof. Cawley says. "Why aren't you taxing the Xbox for making video
games, or HBO for making television more interesting?"

A corny example might be a guide

Still some economists and obesity researchers argue that taxing sugar-rich foods is a small
step toward correcting an imbalance already created by agricultural subsidies, particularly for
corn grown by U.S. farmers.

That subsidy led to overproduction, Prof. Cawley says, so producers made corn-fructose,
one of the cheapest and most health-harming forms of sugar, the stuff that sweetens soda
pop.

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In Canada, where subsidies play a much smaller role, research and development have
focused on producing and delivering food cheaply, without much consideration of the health
impacts. "The problem is that the least high-quality, the most calorie-dense foods are also
the cheapest," says Diane Finegood, who studies obesity at Simon Fraser University.

But if agricultural subsidies and taxes have changed how we eat, why can't a similar
approach be used to make us eat better?

"If these incentives were used in a more sensible way, with health objectives in mind, they
could achieve a lot," says Franco Sassi, a leading economist on the OECD report.

A revamped food policy might consider how to create incentives for farmers to grow local
fruits and vegetables, Prof. Faulkner adds, with revenue insurance to help protect them from
transportation delays on produce with a shorter shelf life.

Tax incentives, in general, are an underused method of fighting obesity, Dr. Sassi says. But
it's not as simple as handing out cash to parents who send their kids to hockey, as the
Harper government is doing - one study showed the majority of families benefiting from the
tax break would have been headed to the rink anyway.

Get families to vouch for their own health

Giving money directly to Canadians to get healthy is what Mr. Seeman and Mr. Luciani
promote. Their book makes the case for a healthy-living voucher, similar to an education
voucher in the U.S. - a $5,000 payment to each Canadian over 16 to design an individual
health plan, following guidelines and in consultation with their doctor, who could bill the
province extra for the service.

Such a program, Mr. Seeman suggests, would allow for individual solutions to the various
reasons people gain weight. Some might use the money for personal trainers or nutritional
consultants; others might receive mental-health counselling. If all went well, gyms and
grocery stores would spring up in low-income areas, as residents pool funds and offer new
markets for neighbourhood facilities.

Of course, the program is complicated: How do you prevent people from taking the money
and doing nothing? How do you enlist the support of an already overworked medical
community? And how do you fund it? The book estimates it would cost up to 4 per cent of
provincial budgets. (For starters, Mr. Seeman proposes spending less money educating the
public on what they already know. The payoff comes later, with a healthier population.)

But as the OECD report agrees, the advantages are also clear: It allows for individual
autonomy and recognizes the complexity of obesity.

However, most experts suggest the best programs will tackle the problem from different
angles. Prof. Faulkner finds the voucher concept promising, but also points out that to reduce
smoking, "we threw everything at the problem. We tax cigarettes, but I can still call a helpline
to get personal help to quit smoking. That's what we need to do with obesity."

All these measures take time to produce results - requiring patience, a quality typically
lacking in governments, especially minority ones. One good place to start would be to

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require, as Britain has, that every provincial and federal public policy be considered for its
impact on health.

To fight obesity takes more sweeping changes than TV commercials and healthy cafeteria
food. And certainly, Mr. Seeman says, the image of a man drinking fat is the last thing that
will make us thin.

He's speaking from experience: He recalls, after a difficult struggle with his own weight,
standing in a New York subway aghast at a poster of fat glugging into a glass, sponsored by
the city's department of health and mental hygiene.

"That ad jarred me," he says, but it certainly would not have helped the depression that had
complicated his health, for which he'd sought counselling.

In the end, as his book advocates, he found his own way: He took up boxing.

Erin Anderssen is an Ottawa-based feature writer for The Globe and Mail.