Obesity is now increasingly recognised as the “natural” consequence of societal changes that have occurred over the past decades to foster an increasingly obesogenic environment.

Yet, rather than focus on the root causes of these societal drivers of obesity, governments apparently prefer to make obesity prevention a personal matter, with a strong emphasis on trying to get individuals to change their lifestyles.

It is clearly far easier to simply tell people to eat more fruits and vegetables and to walk 10,000 steps than it is to provide them with the means or the environment that would actually allow them to do so.

A paper by Celeste Alvaro and colleagues from Dalhousie University, Halifax, Nova Scotia, Canada, published in the latest issue of Health Promotion International, explores why Canadian government policies, particularly those related to obesity, appear to be ‘stuck’ at promoting individual lifestyle change.

The paper uses key concepts within complexity and critical theories as a basis for trying to understand the continued emphasis on attempting to change individual lifestyle factors despite strong evidence showing that a change in the environment and conditions of poverty is truly what is needed to tackle obesity at the population level.

As the authors note, not just in Canada have health promotion programmes and policies had a ‘lopsided’ emphasis on individual lifestyles, with limited attention given to addressing the broader social, economic and political factors that create and produce obesogenic environments in the first place.

As the authors point out, “Individuals are continuously blamed for unsuccessful modifications to their lifestyle, even though living in an obesogenic environment makes achieving a healthy lifestyle close to impossible.”

Despite some attempts to change ‘environments’ (such as schools and workplaces), as recently undertaken in programs such as ActNow BC, they often fail to comprehensively address key economic issues underlying obesity, but rather focus on encouraging individual behavioural change.

The paper calls on both complexity theory to conceptualize governments as ‘systems’ with a history that shapes their current decisions and actions as well as critical theory to draw attention to power struggles within the policy implementation process, and to the role of dominant interests and ideologies in maintaining particular policies.

The authors provide several illustrative policy examples that highlight key concepts explaining why governments prefer to perpetuate and appear to be ‘locked’ into a focus on these largely ineffective lifestyle policies.

Although the paper may help better understand why governments are so reluctant to address the true underlying drivers of obesity, the authors admit that the path to actually and substantially moving government policies in the direction of fundamentally altering the obesogenic environment is far from clear.

Whether or not their suggestion that health promoters and others inside and outside the health field must develop collective action to catalyse the required changes across government and political sectors, will in the end move government in the right direction remains to be seen and may well prove overly optimistic.

Given that many ministries have a say in the drivers of the obesogenic environment but have left it largely to the seemingly powerless Ministries of Health to deal with the issue of obesity, the authors suggest that it may be time for a critical debate about how to promote the active, sustained and collective involvement of multiple sectors and groups to address obesity.

Clearly, as long a governments continue ignoring the real factors at play in the obesity epidemic, and remain focused on ‘reactive’ solutions that target individuals rather than society as a whole, prevention efforts are unlikely to translate into a meaningful decrease in the incidence and prevalence of obesity anytime soon.

AMS
Lincolnshire, IL

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Alvaro C, Jackson LA, Kirk S, McHugh TL, Hughes J, Chircop A, & Lyons RF (2010). Moving governmental policies beyond a focus on individual lifestyle: some insights from complexity and critical theories. Health promotion international PMID: 20709791

Yesterday, University of Alberta’s John Spence (on faculty of the annual Canadian Obesity Network’s Student Boot Camp) together with Valerie Carson (former Bootcamper) and coworkers, published a most interesting article in BMC Public Health.

The paper looks at the uptake and effectiveness of the Children’s Fitness Tax Credit (CFTC) on Canadians. This tax credit was introduced by the Government of Canada in 2007 and allows a non-refundable tax credit of up to $500 to register a child in an eligible physical activity program.

A basic assumption of such tax rebates is of course, that they will help alleviate economic barriers that inhibit participation in physical activity.

Based on a 2009 survey of a representative sample of 2135 Canadians, around 55% of parents with children aged 2 to 18 years of age (n = 1004) stated their child was in organized PA and 55% were aware of the CFTC.

However, parents in the lowest income quartile were significantly less aware and less likely to claim the CFTC than other income groups. Thus, while only 28% of parents in the lowest income quartile had claimed the CFTC for the 2007 tax year, the tax credit was claimed by 55% of parents in the highest income quartile.

Parents in the highest income quartile were 2.5 times more likely than parents in lower income households to report their child being involved in organized physical activity, 4.1 times more likely to be aware of the CFTC, and around 3 times more likely to have claimed it for 2007 or were planning to claim it for 2008.

Among parents who had claimed the CFTC, only 16% believed it had actually increased their child’s participation in physical activity programs.

As Spence and colleagues discuss:

“It appears a tax credit such as the CFTC will only benefit those people who can afford to pay the costs of registration for a PA program and carry that burden through to the end of the tax year.”

These findings are in contrast to the Government of Canada’s objective that parents from “different circumstances” have equitable opportunity to benefit from the CFTC.

Basically, families at the lower end of the income continuum cannot afford the costs associated with organized PA and are less likely to be able to take advantage of a tax credit.

Therefore, if a tax credit is to be effective for all children, alternative solutions need to be sought for dealing with issues of inequity.”

Irrespective of what such a tax credit to increase physical activity will actually do for the obesity epidemic (the evidence is certainly not clear on this), this paper nicely illustrates how well-meant policies may often not have the intended effects for the population that needs it most.

AMS
Duchesnay, Quebec

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Spence JC, Holt NL, Dutove JK, & Carson V (2010). Uptake and effectiveness of the Children’s Fitness Tax Credit in Canada: the rich get richer. BMC public health, 10 PMID: 20565963

One commonly heard propositions to combat the obesity epidemic is to tax soft drinks. No doubt, sugary soft drinks are a common and important source of “empty” calories, but will taxing soft drinks really reduce obesity rates?

This assumption was now examined by Yale University’s Jason Fletcher and colleagues, in a paper just published in Contemporary Economic Policy.

The researchers collected information on taxation of soft drinks with respect to specific excise taxes on soft drinks and other snack taxes, general state sales taxes, and special soft drink exceptions to food exemptions from sales taxes in several US States between 1990 to 2006. Height and weight data was used from the representative NHANES III data set.

Using complicated models accounting for a variety of potential confounders, the authors confirmed that state soft drink taxes have a statistically significant impact on behavior and weight; however, the magnitude of the effect is surprisingly small.

Thus, a 1% increase in the state soft drink tax rate leads to a decrease in BMI of 0.003 points and a decrease in obesity and overweight of 0.01 and 0.02 %, respectively.

There were also significant differences on how soft drink taxes affect different demographic groups. For e.g. a 1% increase in the soft drink tax rate decreases BMI by over 0.01 points for the lowest three categories (income below $20,000) and nearly 0.01 points for the highest category (income above $50,000).

In addition, The impact of state soft drink taxes is larger for females, middle-aged and older individuals, individuals with greater education, and varies according to race and ethnic categories.

The authors point out that soft drink consumption represents only 7% of the total energy intake and one should therefore expect only modest changes in population weight through soft drink consumption responses to small tax increases.

In fact, they estimate that even a 20% increase in soft-drink taxes would only lead to a mean BMI change of 0.06 points, although the impact may be somewhat larger for some demographic groups.

Indeed, even if soft drinks were to be taxed at around 58%, the current average taxation rate for cigarettes,
the researchers estimate that mean BMI in the United States would likely only decrease by 0.16 points and reduce the proportion of overweight or obesity in the population by 0.7%.

In comparison, the between 1990 and 2006, the average increase in population BMI in the US was around 2.3 points.

While the authors conclude that although the effect of increased taxation of soft drink may do little for obesity, they point out that there may be other health benefits, including improvement in dental health.

Additionally, an increase in the soft drink tax of this size would raise considerable revenue for the federal and state governments that could perhaps be used to implement other measure to address the obesity epidemic.

While the authors by no means wish to condone the increased consumption of soft drinks, their analysis clearly suggests that any hope that simply slapping a tax onto soft drinks will somehow reduce obesity rates appears unfounded.

AMS
Edmonton, Alberta

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Fletcher JM, Frisvold D, & Tefft N (2010). Can Soft Drink Taxes Reduce Population Weight? Contemporary economic policy, 28 (1), 23-35 PMID: 20657817

Readers, who recently followed my postings from the XI International Congress on Obesity in Stockholm Stockholm last week on FaceBook, will perhaps recall a brief note on a talk by Garry Egger, Australia, raising the question whether we may have stayed too long at the “sweet spot” of economic growth resulting in both the obesity epidemic and climate change?

Together with his Australian colleague Boyd Swinburn, Egger has written a short book called, Planet Obesity, in which the two authors further elaborate on this notion.

The basic tenet of the very readable short treatise is simply put the following: obesity and climate change are both the seemingly inevitable consequences of economic growth that focusses solely on maximising (rather than optimising) consumption.

In every example cited in the book, economic development is inadvertently accompanied by an increase in body weight (first in the rich, then in the poor), till in highly economically “developed” societies obesity assumes epidemic proportions.

Readers of these pages certainly do not need to be reminded of the pandemic nature of obesity now affecting rapidly developing countries like China and India.

To state the converse, the authors present those rare examples of (involuntary) modern-era economic downturns (as in Cuba after departure of the Soviets or Nauro after the depletion of their natural super-phosphate bonanza), which were accompanied by a marked decrease in overweight and obesity associated with reduced incidence of complications like diabetes and heart disease.

While the authors fall just short of suggesting that all governments should now pursue the utopian goal of economic sustainability rather than growth, they do point to a few programs that may nudge things in a more positive direction.

Whether countries are quite ready to embrace instruments like personal carbon trading (PCT) or whether majorities can be found to support the creation of more equitable societies remains doubtful. But I certainly do support their views on the promotion of public transportation and restrictions on advertising to children.

Although I do not seriously expect anyone (especially no governments I know of) to pay the least attention to Egger’s and Swinburn’s message, I do very much recommend the read for a concise, well-rounded, and mind-opening discussion of the causes behind the causes behind the causes of the obesity epidemic.

AMS
Summerland, BC

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A single mom juggling two jobs and four kids may be right in thinking her life is complicated - but it is certainly not complex - at least not in the scientific sense of the word.

In medicine we also differentiate between procedures that are complicated (difficult, requiring skill) and complex (no clear solutions, unknown and incalculable risks, unpredictable outcome).

The best description of complexity was the “simplified” one I found in a book called Black Swans by Nassim Taleb:

“A complex domain is characterized by the following: there is a great degree of interdependence between its elements, both temporal (a variable depends on its past changes), horizontal (variables depend on one another), and diagonal (variable A depends on the past history of variable B). As a result of this interdependence, mechanisms are subjected to positive, reinforcing feedback loops, which cause “fat tails”…In lay terms, moves are exacerbated over time instead of being dampened by counterbalancing forces. Finally, we have nonlinearities that accentuate fat tails.”

As some readers may know, the term “fat tails” refers to an unexpectedly thick end or “tail” toward the edges of a distribution curve, indicating an irregularly high likelihood of extreme or catastrophic events.

How is this discussion of complexity relevant to obesity?

When we speak of obesity as a complex problem (and not simply a matter of calories in and calories out), we allude to the complex interactions of a multitude of societal, psychological, and physiological variables that do not allow a ready dissection as to cause and effect (are large portion sizes leading to obesity or do obese people drive the demand for larger portions?).

Perhaps more importantly, complex systems are difficult to model - tweaking the system at one end (e.g. banning pop machines from schools) may lead to unintended consequences elsewhere in the system (e.g. schools have less money to invest in sporting activities).

This means that coming up with system-wide interventions (or rather predicting their effect) with regard to reversing the obesity epidemic will prove challenging. Well-meaning legislators may suddenly find themselves in a game of “whack-a-mole” as the system responds in unpredictable and erratic ways. (Politicians may still choose to pass populistic laws to demonstrate that they are not unresponsive - but no results are guaranteed).

Because of the temporal dissociation that may well occur in complex system, even when solutions look like they seem to be working, only time will tell, as unintended consequences may take years (or generations?) to manifest themselves.

This should not be an excuse to throw up our hands in despair and do nothing. It should, however, be a warning to anyone, who believes to have the “simple” solution to the obesity problem, to tread cautiously and to always expect the unexpected.

AMS
Whistler, BC