Should Governments Concern Themselves With Obesity?

sharma-obesity-policy1Yesterday, I blogged about the right-wing Fraser Institute’s report, which claims that the obesity problem is overstated and that government policies are misguided.

An interesting discussion in the report pertains to the fundamental issue of whether governments should at all concern themselves with obesity (even if the problem were really as big as is generally assumed).

The report looks at this from the perspective of whether or not obesity places an economic burden on society and whether or not it would be in the Government’s interest to intervene with the aim to reduce this burden.

Here is how the report views this:

“What is interesting here—and what is important in public policy terms—is the burden of the costs of obesity. A closer examination of the consequences of excess weight…finds that the majority of the costs of obesity are borne directly by the individual in terms of lower income, reduced employment opportunities, reduced enjoyment of life, greater illness, and a potentially shorter lifespan. The only area where these costs are not borne almost entirely and directly by the individual is the increased burden on Canada’s tax-financed health care system….From an externality perspective then (though this is not the only justification used for government intervention, as we shall discuss in the next section) the only area of the “obesity epidemic” where governments may have a legitimate role to intervene is to resolve the costs imposed by the obese [sic] on all taxpayers through the tax-funded health care system.”

However, as the report goes on to argue, the lifetime health care costs for obese individuals may not be all that much higher – in part, because of a shorter life-span.

Here the report quotes studies showing that,

“…while obese individuals incurred higher health care costs than normal-weight non-smokers during their lifetimes, over an entire lifetime normal-weight non-smokers incurred greater health care costs in total because of differences in life expectancy and the costs of care associated with additional years of life….These findings suggest that obese individuals may in fact not be a net burden to all taxpayers over their entire lifetimes, despite imposing a cost burden while they are alive. That finding is bolstered by considerations of reductions in costs associated with public pensions and other old age income supports .”

Thus, economic arguments that governments need to intervene to reduce the burden of obesity may not hold water – while being obese is sad for the folks affected (and they already pay for it dearly), there may not be all that much incentive for governments to  reduce the burden of obesity with an aim to “protecting” the economic interests of the non-obese majority.

Or, as the report puts it,

“…while there is clearly a health and economic cost associated with a high prevalence of obesity, the problem may be much smaller than many have claimed. Importantly, it may be that the serious health consequences lie at the higher end of the weight spectrum, thus affecting a relatively small proportion of the population. And many of the economic costs associated with obesity are borne privately by the individual and thus may not justify government intervention. That is the framework within which policy options should be proposed, and within which they should be considered.”

Thus, given the rather modest economic burden on tax-payers in general (most of who are not obese), it becomes even more important to look at the economic downsides of the government stepping in to impose policies that (even if effective) may not be worth the considerable impacts on taxpayers, on the economy, and on particular industries.

“Many of these interventions would require increased bureaucracy, for example an agency to determine which foods or beverages qualify for targeting or for particular food categories. Interventions may also create barriers to entry for smaller businesses or artificial constraints on growth, generate higher business costs or increase costs for consumers, increase travel times for consumers, impact business prospects, and potentially lead to job losses. Interventions may also result in a transfer of funds from one group of legal businesses to another simply because one provides a product that is disliked by interventionists.”

But irrespective of which side of the political fence you may sit on, it should be obvious that decisions about government spending have to consider more than just economic benefits.

Thus, even if there was a net cost to spending tax-money on preventing and better treating obesity, would this still not be a worthwhile investment?

Indeed, little (if anything) we do in healthcare saves money – or, as I sometimes point out, the cheapest patient is a dead patient. To me at least, healthcare is never about saving cost – it is about easing pain and suffering. Treating cancer and heart attacks does not save money – yet, they are fully worthwhile expenses.

So for obesity treatments the issue of whether or not government should get involved is rather straightforward. If we accept that obesity (at least in extreme cases) is a disease that causes pain and suffering then it is the job of healthcare systems (and in Canada this job falls to the government) to provide treatments that can ease that pain and suffering – anything else would be discrimination. As long as the treatment benefits the individual and is reasonably cost-effective (as compared to treatments for other conditions) there is no ethical argument to deny that treatment.

When it comes to prevention, the issues are less clear (as discussed in the report). Here the responsibility of governments must balance the needs of all of its citizens by broadening its view of the impact that policies would have on the entire population. Thus, the question is not just what impact certain policies would have on those who have obesity (or are at risk of getting it) but also how such policies would impact the majority of the population that neither has obesity nor is at risk of getting it.

This is where the Fraser Institute report stays true to its ideology in that any policies that limit choice or put boundaries on free enterprise are something that governments should stay out of. Rather, it may be best to leave this to the free market to sort out:

“The private sector might also be a source of solutions to concerns about the prevalence of obesity, and already provides a broad range of options for those who wish to alter their lifestyles and diets in search of a reduction in excess weight. For example, the diet and exercise industries are working to counter the prevalence of excess weight through books, videos, weight loss clinics, gyms, and exercise equipment, among other approaches. Restaurants and food producers are also involved in helping people reduce excess weight by offering lower calorie, lower fat, or other more healthful options. Many businesses also support weight loss through employer funded programs. We may also soon see medicinal solutions for excess weight and weight management.” 

The third section of the report goes on to discuss several proposed public-health policies including taxes, restricting access to certain foods and drinks, calorie and nutrient labelling, graphic health warnings, healthier school meals, advertising restrictions, and zoning  laws.

As may be expected, the report highlights the lack of effectiveness and/or the unintended consequences of these proposed policies. For anyone working in the area of public health and health promotion, these sections will make a challenging and perhaps infuriating read.

But then again, that’s exactly what political debates are about – the clash of ideologies where each side cherry picks whatever “facts” support their position.

At least we now better understand where the right stands on this issue – a first step to begin countering their arguments.

@DrSharma
Edmonton, AB

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The Fraser Institute Obesity Report: Being Right Does Not Make It Wrong

Fraser Institute Obesity in Canada 2014This week, the right-leaning Fraser Institute released a report with the rather provocative title, “Obesity in Canada: Overstated Problems, Misguided Policy Solutions“.

The Fraser Institute makes no secret or apology about its political ideology:

“Our vision is a free and prosperous world where individuals benefit from greater choice, competitive markets, and personal responsibility.”

This ideology alone, could make may of us simply dismiss the report as being tainted (conflict of interest) and one-sided. It is indeed easy to see why many in the obesity “establishment” would feel tempted to discredit the scientific accuracy of the report or even employ ad hominem attacks on the authors themselves.

A much more difficult task would be to fairly consider the arguments and counter with a scientifically sound rebuttal on issues where the report clearly deviates from scientific fact.

This may not be quite as easy as one might hope.

Not that there isn’t much about the tone of the report that could be criticized. The Fraser Institute being all about personal “choice”, it is not surprising that obesity is largely presented as the consequence of the “choices” that people with obesity make. There is ample talk of individual responsibility and of course, the simplistic notion of calories in and calories out (or eating and exercise) prevails throughout the report.

Indeed, I could find only one sentence in the report that suggests that things may be a bit more complex:

“The causes of obesity are multi- factorial, where obesity in each individual case may be influenced by literally dozens of physiological, psychological, and socioeconomic factors. These factors include breast feeding, cultural characteristics, diet, education, entertainment habits, exercise, family life and structure, genetics, income, peer pressure, and sleep patterns. Indeed, differences in genetics may mean that, for similar levels of energy input and physical activity, some groups of individuals may experience more weight gain and higher obesity prevalence than other groups.”

Despite this insight, “choice” and “responsibility” echoes throughout the report largely ignoring the notion of social determinants or the complex physiology of homeostatic and allostatic mechanisms that promote weight gain and ultimately make sustainable weight loss so difficult to achieve.

Thus, the report certainly conforms with most public health views of obesity as mainly a problem of individual volitional behaviours and the notion that anyone can be the master of their weight (if only they chose to do so).

This rather general criticism aside, there are indeed substantial areas of the report that warrant serious consideration.

A key argument as to why the authors think that the obesity problem is overstated relates to the observation of-late, that obesity rates appear to be stabilizing (or even declining) in parts of the population. Thus, the report notes that while obesity rates in men and children appear to be levelling off (or even decreasing), we are seeing a continued increase in obesity rates in women. In fact, the only indisputable trend is a continuing increase in the rates of severe obesity – those, who already have obesity are getting even bigger (a clear reflection of our failure to provide treatments to the people who need them).

While this depiction of the problem is not wrong, what it actually means is a matter of interpretation – depending on whether you belong to the church of “glass half-empty” or “glass half-full”.

Of course the report is right in that “alarmist” predictions that soon Canada will be a country where everyone has obesity and that our kids will not outlive their parents are considerably exaggerated. On the other hand, obesity rates of 20% are not exactly an excuse to sit back and call off the troops. If one in five Canadians was infected by a virus (say West Nile), we’d be setting up clinics at every street corner and pouring billions into better prevention and treatments.

A more controversial argument as to why the obesity issue is overstated relates to whether or not having obesity actually has all that much of an impact on health. As the report points out, recent evidence does indeed suggest that the optimal BMI for the best life expectancy may well be in the BMI 25-35 range. So carrying all those extra pounds may not be quite as bad for our health as we are often led to believe.

In this regard, the report is certainly preaching to the converted. Any regular reader of these pages will recall that I have described BMI as a “Basically Meaningless Integer” and have long promoted the use of the more sophisticated Edmonton Obesity Staging System to characterize obesity related health risks.

So, while the report is correct in that not everyone with a few extra pounds is about to drop dead (or even just suffer from a weight-related health problem), there is no doubt that a higher body weight does quite substantially increase the likelihood of having a health problem. Thus, as our own research shows, the chances of not having any obesity related health problem increases from 1 in 2 at a BMI of 25-30 to less than 1 in 20 at a BMI greater than 40.

This still does not make BMI a reliable measure of health. Fortunately, we have other tests for that.

But while we may quibble about what obesity rates based on BMI levels (self-reported or otherwise) may actually mean, areas of the report that I find far more interesting are those that discuss whether or not government should even be concerned about the obesity problem and whether or not it has any role to play in addressing it.

Given the political leanings of the Fraser Institute you may well predict its answers – but I do find the arguments interesting enough to warrant discussion in my next post.

@DrSharma
Edmonton, AB

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Does Early Onset Obesity Really Increase Cardiometabolic Risk?

obesity-childonscaleA much-quoted tenet (with little data to support it) suggests that, as a consequence of the increase in childhood obesity, this may be the first generation of kids to not outlive their parents.

This rather gloomy statement is countered by those who believe that the health impacts of excess weight in childhood are drastically overstated and a growing body of evidence that appears to suggest that childhood-onset obesity may in fact be paradoxically “protective” against future cardiometabolic risk.

This “counterintuitive” finding prompted Laura Howes and colleagues, in a paper published in BMJ Open to test the hypothesis that childhood-onset obesity may increase the odds of being a “metabolically healthy” obese adult.

Their analysis included 2392 obese men (mean age 42), selected from over 360,000 young men (mean age 20) examined for Danish national service between 1943 and 1977. A random sample of 3600 others were used as controls. For 613 of these men, data on childhood BMI were available allowing the researchers to summarise childhood BMI growth (7–13 years). Early-onset obesity was defined as obesity at examination for national service.

Despite certain methodological limitation to the study, the authors found no support for the notion that “early-onset” obesity or weight trajectories between ages 7-13 increased the likelihood of being a metabolically healthy obese adult.

While some metabolic risk parameters (e.g. higher glucose levels) were positively (albeit modestly) related to early-onset obesity and faster rates of BMI increase in childhood, the opposite was true for cholesterol levels.

Nevertheless, greater BMI at age 7, faster rate of BMI increase between 7 and 13 years and early-onset obesity were all associated with greater SBP, DBP and pulse pressure, greater glucose levels and a higher BMI in mid-life

Reason enough to continue taking childhood obesity seriously and to do the best we can to prevent it.

@DrSharma
Edmonton, AB

ResearchBlogging.orgHowe LD, Zimmermann E, Weiss R, & Sørensen TI (2014). Do rapid BMI growth in childhood and early-onset obesity offer cardiometabolic protection to obese adults in mid-life? Analysis of a longitudinal cohort study of Danish men. BMJ open, 4 (4) PMID: 24736038

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Obesity Weekend Roundup, April 25, 2104

As not everyone may have a chance during the week to read every post, here’s a roundup of last week’s posts:

Have a great Sunday! (or what is left of it)

@DrSharma
Edmonton, AB

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Obesity Left, Right, and Centre

sharma-obesity-right-way-wrong-wayMuch of the obesity debate – its causes and solutions – is heavily tainted by conflicts of interest – the most important one perhaps lurking among those, who put their beliefs and ideologies before scientific fact.

An essay by Kathleen Kendall-Tackett, published in (of all places) Clinical Lactation, nicely summarizes how conventional political ideologies and belief systems colour this discourse.

Apart from commenting on the often “moralistic” nature of the obesity debate (thin = good, fat = bad), Kendall-Tackett also reflects on the racist, gender and class overtones of this discussion.

With regard to political ideologies, she notes that,

“For some on the right, the obesity epidemic merely reinforces their beliefs about the cause of the ever-widening gap between the rich and poor or between whites and minorities. After all if African Americans, Latinos, or the poor are becoming fatter than America’s predominantly white elite, it is only more proof that they lack responsibility to take care of themselves…if middle-class Americans, particularly middle-class children, are getting fat, it surely indicates the frailty of their own class status.”

“And for those on the left, the growth of obesity is further proof that large, multinational corporations are running amok, fattening a hapless public with their billion-dollar advertising campaigns and super-size value meals. The American people, particularly the poor and minorities who have the highest obesity rates, they argue, need to be protected from these corporate behemoths.”

Both positions reek of,

“…paternalistic condescension towards fatness and fat people—not only do people with this view assume that fatness is inherently bad, but they also presuppose that fat people (that is, minorities and the poor) are too ignorant to know that they should be thin.”

Or, in words of Paul Campos,

“And what is it with these skinny uptight Anglos, anyway? Who exactly deputized them to be the fat police at their local fast-food emporium?”

Indeed, it is easy to see these ideologies reflected in the political discourse around obesity.

In  prevention,  policies run the gamut from de-regulation (“consumer choice” and “free market forces”) on the right to “shame, blame, tax and ban” policies on the left.

Never mind that neither one of these approaches is supported by hard evidence – indeed, most of the evidence is so poor that it may as well be ignored when it comes to deciding who is right and who is wrong.

While the anti-sugar witch hunt is nearing its climax (the same folks were shouting for anti-fat bans just a few decades ago), those who ignore the mass of data showing the rather modest (if any) effectiveness of “lifestyle change” as a means to tackle excess body weight, continue to propagate “eat-less-move-more” solutions to this epidemic.

Caught in the centre (with nowhere to go) are those who actually bear the weight of the problem (pun intended).

While those calling for better access to and greater investments into pharmacological and surgical obesity treatments are called out by the left for “medicalizing” the issue, those on the right cry out against “coddling” people living with obesity – after all, they are only getting what they deserve given the “poor choices” they have made (you made your bed – now sleep in it!).

Again, both sides of the argument are heavily influenced by the firm belief that everyone can (and should) be a master of their own weight (after all, its just calories and calories out, right?).

No wonder I am wary of ideologies and beliefs as a source of conflict of interest – particularly as these are seldom declared or disclosed.

@DrSharma,
Edmonton

Hat tip to Noreen Willows for pointing me to this article.

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