1.25.2021
A PLAN FOR A FEDERAL GOVERNMENT ROLE TO REDUCE OBESITY
Introduction
An important question to pose is: “What rightful and legitimate role does the federal government have to play in helping to reduce and ameliorate the obesity crisis in the United States?” If government does have a legitimate role to play, what makes sense and how big and central a part should it have in trying to reduce the scope and size of the obesity problem?
According to the US Constitution (Article 1, Section 8), one role of the federal government is to “provide for the general welfare of its citizens.” By most accounts this includes the health, safety and well-being of the populace. One virtually indisputable public health issue affecting the welfare of the public is the rise in the rate of obesity over the past sixty years, and the consequent increase in obesity-related physical, emotional and mental issues. This is a very significant problem the country is facing right now.1 This problem is expected to grow and become even more threatening in the future. A study released by the American Obesity Society in January of 2021 is startling. It projects that in just four years (2025), 50% of Americans will be obese and by 2030 that number is expected to increase to a staggering 60%, up from approximately 42% to 43% now.
Further exacerbating the consequences of obesity is that obesity is a very important and impactful co-morbidity factor that significantly increases the negative health consequences of Covid19, and will likely do the same in other potential viral outbreaks in the future. Considering all of this, it is clear that the federal government does have a legitimate role to play in trying to reduce obesity and that the threat to public health and safety is real and increasing and should compel the federal government to act.
To date, the government’s role in trying to mitigate the nation’s obesity-problem has been diminutive. There are several reasons that this is the case. First, the federal government’s efforts related to public safety are greatly focused on deploying time, attention and resources toward national defense, not so much on our public health and safety. Second, it is likely that there is an overarching belief that one’s health is much more a matter of individual responsibility rather than being appropriate for government oversight and intervention. Unstated, but also primary, is the belief that any efforts to combat obesity are likely be intrusive and overstep the bounds of government by encroaching on our individual freedoms and prerogatives.
This is a wrong-headed notion based on a narrow view of what kind of governmental intervention might be possible and useful. There is much the government can do that would not be either coercive or highly intrusive and could be implemented in a manner that would not offend people or make them naturally resistant to the government’s efforts.
The role of the federal government to address the issue of obesity, with a goal of trying to reduce it, has, arguably, been weak and inadequate. It has mostly been confined to PSAs (Public Service Announcements) and other promotions telling us that obesity is not healthy and that those who are overweight or obese are subject to some specific health risks, like heart disease. Or offering the public nutrition advice, as though the mere presence of such information can readily affect the public’s behavior (it does not). As the obesity rate has grown substantially over the past twenty years, and continues to increase, it is evident that these campaigns have not been effective or useful.2 A comprehensive and coordinated plan has been lacking.
There are two primary reasons that explain the lack of effectiveness of previous governmental efforts. First, a major survey by a leading nationally recognized hospital found that nine out of ten (88%) Americans polled already know that there is a connection between weight and being healthy, and, specifically, having a healthy heart.3 Further, three-quarters (74%) say that they have already have some concern about their weight. Yet, well under half (43%) have tried to make any dietary or lifestyle changes to address these concerns and even more pointedly, well over one-third (40%) admit that they are not at all careful about what they eat. So, most people are aware that being overweight, and especially obese, is not good for their health, yet most of them are not motivated to try to change their behavior or at least, do not do so successfully. The question is why?
One primary explanation for this, other than the fact that weight loss is difficult, explains this phenomenon of inaction quite well. Humans are subject to many implicit cognitive biases that distort our thinking in a non-logical manner. One of the most important, and least appreciated, is that humans have a significant bias that severely discounts future events or potentialities, that are remote timewise and uncertain to ever occur, in favor of present circumstances.4 In the early days of Homo sapiens a very short-term perspective was optimal for survival and was the only perspective that truly made sense. This mindset, although no longer useful, still pervades our thinking today. Most of us understand intellectually, that there is a threat related to being overweight, especially if obese, but, if we have no emergent conditions arising from it, our brain does not readily accept and recognize it as a threat that needs or demands our current and immediate attention. This bias is instrumental in dissuading more people from addressing the weight concerns that they may have. Any plan to motivate people to adopt a more healthful diet and lifestyle must recognize and deal with this inherent bias. The proposed plan does this.
Bottom-line, more public health campaigns that only repeat and reinforce what many already believe, but, do not view as an immediate threat, will not be effective in changing the behaviors needed to reduce obesity in this country. Logic and rational appeals are not enough, a new approach is needed, one that recognizes these truths. This paper describes a new approach that does exactly that.
Parameters of the Obesity Problem
Let’s put some perspective around the scope of our obesity-related problems. From a cost point of view, experts estimate that all obesity-related expenditures amount to over 200 billion dollars per year in strictly monetary terms.5 This definition, of course, ignores and excludes all of the psychological and emotional costs and distress experienced by many, or at least some, highly overweight people. Further, these calculations do not include any costs from losses in business productivity due to weight repercussions. Additionally, and critically, obesity takes a stiff toll on human life by increasing the number of premature deaths experienced in this country.
In the history of our nation, from 1775 to 2020, US wartime deaths have totaled about 1.3 million causalities.6 In 2019 alone, total US deaths equaled 2.8 million and of these 18% to 20% are related to all causes associated with being overweight or obese.7 That totals about 541,000 deaths. So, in just three-years, deaths due to being overweight or obese (totaling about 1.6 million) is equal to more deaths than the US has experienced from all wars over the almost 250-year history of our country. Clearly, the issue of obesity is highly important and thereby quite worthy of more government attention. It is time for this to change.
The government has an important and legitimate role to play to help counter and reduce obesity in this country in order to promote the public’s welfare, well-being and even enhance our ability to survive. This article articulates one multifaceted plan that has merit, is viable for the federal government to plan, coordinate and implement and is also likely to be cost effective.
The Ground Rules
The proposed plan is grounded on a few basic and important premises. They are that the plan must:
- be affordable and cost effective.
- be firmly grounded in science and psychological principles, beyond mere supposition and speculation.
- be intuitively appealing and understandable (to make it more attractive to Congress and thereby facilitate its being funded.)
Principles of the Plan
First, the plan must be affordable and cost effective. Every year the government budgets about 720 billion dollars dedicated exclusively to national defense.8 We are not here going to debate the wisdom of this budget, suffice it to say, that reducing this budget by one quarter of one percent, or some 1.8 billion dollars should not be an inordinately difficult task to accomplish. That kind of money could finance a very robust experiment to reduce obesity. Further, if annual obesity-related expenditures total about 200 billion dollars, then reducing the US obesity level by just five percent (from about 43% now, down to 40%), would directly save the country annually at least one billion dollars in healthcare costs and potentially billions more in worker productivity gains.9 These are savings and productivity gains which would represent a recurring benefit every year. An even more significant reduction in the level of obesity would, of course, save even more. The predicate, of course, is that the plan will work to help reduce obesity. But, if it was not believed that the plan would reduce obesity, it would not be proposed, approved and funded.
Second the plan must rely on non-coercive and non-intrusive elements in its execution. The reason for this is a least two-fold. First, it helps make the plan much more palatable both to the Executive Branch agency which proposes it, to the Congress that funds it and to the American people who need to accept and follow it. Even more critical perhaps, is that such a plan will be more effective and more likely to make its obesity-reducing goal achievable. Psychological principles tell us that a plan that is not foisted upon people by an external authority (e.g., the government), but, rather one people decide to adopt on their own, albeit with encouragement, is much more likely to be deemed acceptable and worthy of pursuing. Not only is such a plan more acceptable, but, if it is felt that the decision to modify one’s behavior flows from one’s own intention, then the level of personal engagement and ”buy-in”, psychologists’ tell us, is much greater. Persuasive efforts are almost always more effective with a carrot, rather than a stick, even if the carrot is largely invisible to the naked eye (e.g., if the proposed plan is based more on changing people’s environment, rather than offering people direct and specific incentives to modify their behavior, or sanctions that would be applied to those who did not choose to change).
Third, it was stipulated that the plan must be firmly grounded in science and psychological principles, beyond mere supposition and speculation. The science of motivating and inducing behavioral change in one’s diet content and diet lifestyle, is well established to be substantially influenced by one’s external environment. Psychologists and behavioralists know that if environmental conditions change, people are quite likely to adapt their behavior to account for those changes.10 For example, if the price, the availability, the salience and the accessibility of food products change, we will alter our behavior in a way that attempts to counter these changes or takes advantage of them in a manner consistent with our goals. In the proposed plan, the price of fresh produce and other whole, unprocessed foods, relative to that of ultra-processed foods (so called “junk foods”), declines, while the availability and access to more healthful foods increases. Economic and psychological theory tells us that these conditions lead people, naturally and non-coercively, to adapt to these changes by increasing their purchase and consumption of the more healthful foods. This proposition is at the heart of the proposed plan from a supply-based perspective. This plan’s features are non-coercive and non-intrusive, and promote change by changing the food environment that people experience in grocery stores and in their homes, not by dictating how people must change.
The fourth stipulation was that the plan should be intuitively appealing and understandable. By its nature, this plan relies on the subtle encouragement of changing environmental stimuli, cues and triggers to motivate behavioral changes, making it is more appealing than one which relies on mandates, coercion and penalties. Additionally, the proposed plan, at its core, is based on the simple economic principles of supply and demand, ideas well known to many, that most people already understand and accept as valid.
Finally, the plan must be testable in a small-scale experimental manner to assess its workability and its effectiveness, prior to being judged ready for a national rollout. The proposed plan can be readily tested, like a commercial product, in a “test market” experiment, before incurring the expense and difficulty of a national roll out to the entire country. Further, this test can employ quantifiable objectives, e.g., the obesity rate, in addition to more qualitative goals that are associated with mental and emotional well-being. These pre-specified objectives will allow for a reliable and valid determination of how effective and successful the plan is in meeting its goals, before a decision is made on whether or not to implement the plan nationally, while simultaneously providing a strong indication of how cost effective the plan would be.
The proposed plan is concordant with the psychological theory of motivation developed by two Rochester University professors in the 1980’s and increasingly viewed as offering a valid and highly accurate description of what drives many of our choices and our behaviors. These ideas are bundled under the heading of the “Self-Determination Theory.” This theory postulates that there are three universal psychological needs that all people are subject to that drive our behavior as we seek to satisfy them.11 These are the needs for: Autonomy, Mastery and Connectedness. The proposed plan taps in to all three of these psychological needs in a manner that non-coercively motivates people to adopt a more desirable and more healthful diet and diet lifestyle, a circumstance which can help people to lose weight and ultimately lower the rate of obesity.
The proposed plan gives people a free, non-mandated choice to choose to alter their behavior or not, allowing them to maintain control over their lives and their behavioral choices. Engaging in these behaviors, that people know are healthy for the body and mind, and that most know are the right and logical thing to do, makes us feel good. These positive feelings, in and of themselves, are quite motivating. Further, it promotes a sense of mastery by allowing us to practice a lifestyle that increases one’s feelings of being in control and being efficacious. Additionally, it’s a lifestyle with no final endpoint, one that people can always continue to work on, improve and get better and better at following.
Finally, the plan can be encapsulated in a spirt of changing people’s behavior and their diet lifestyle, not just for themselves, but also to serve the interests of society as a whole, i.e., something that also benefits the public good. This works to increase our feelings of connectedness to all of our fellow countrymen in pursuit of a goal larger than ourselves, a condition that naturally increases our motivation to change. So, in every way the plan is consistent with the Self-Determination Theory and will act to optimally motivate people to change their diet and their diet lifestyle.
To summarize, implementing the plan results in altering the food environment in a manner that appeals to, and is consistent with our psychological needs. This makes it much more likely to be effective in driving behavioral change, while avoiding generating resistance that is often associated with plans that dictate what must be done, a resistance that can thwart a plan from being successful.
THE PLAN
The proposed plan uses targeted tax policy to promote expanding the production of ultra-healthy foods, that is, foods like fruits, vegetables, legumes and whole grain products, while simultaneously incentivizing supermarkets to step-up their promotion of these items in-store. These acts work to expand the supply of these types of food products and bring down the ultimate cost to the consumer. Food consumption, is not unlike virtually all of our other product choices. High prices stifle demand, while lower prices stimulate it. Also recommended are direct government incentives to encourage farmers to plant and produce a much wider variety of such foods, and, greater variety encourages more people to try them, as offering greater varietal choice is inherently more appealing. Simultaneously, offering these foods at lower prices than were previously available stimulates demand for these healthful foods.
It is known that most of our food preferences are learned in the home and/or culturally influenced, so most food preferences can be modified and changed. One excellent means to facilitate this is by making more interesting and appealing choices available at very attractive prices. In addition to an increase in supply, that naturally lowers prices, the plan recommends offering farmers direct government subsidies to additionally reduce their price and hence further increase the purchase appeal of more healthful foods. In the past federal government farm subsidies have averaged only a miniscule 4% to support the production of fruits and vegetables. This is vastly inadequate.
This plan also calls for the government to improve access to fresh and wholesome foods in the “food deserts” of some of our urban, high-poverty centers. In many, or at least some, highly urban settings there are no, or few, modern supermarkets that offer a wide array of ultra-healthy fresh produce. Yet, it is exactly these disadvantaged, high-poverty populations that are most prone to obesity as they are least able to resist the temptation of low price, low food-quality, super high-calorie ultra-processed foods and “junk foods,” which better fit their limited food budget. Low nutrition-value ultra-processed foods and“junk foods” do have a very innately pleasing palatability, but it is also their ubiquitous availability, at very attractive prices, that has driven their becoming a staple “food of choice” for so many families, especially among lower socioeconomic populations.
These efforts address supply issues that make highly healthful foods more widely available, while also making them less expensive and more widely accessible to a broader swath of American society. But the government can also play a productive role in helping people to thwart the cravings and impulses that drive us to eat unhealthfully. This is the demand side of the equation.
A plan based on utilizing the science of “memetics” will be very powerful by creating memes, via advertising and other media, to counter the impulses that drive behaviors promoting unhealthful eating and immoderate overeating. The approach advocated is firmly grounded in brain science, psychology, advertising principles and common sense. Memes are defined as an idea, represented by words or images, whose message is spread like a virus from person-to-person. They are effective as these memes can become deeply embedded in our psyche and unknowingly influence our opinions, our attitudes, our beliefs and subsequently our behaviors. This behavioral influence is exerted in a manner that people see as emerging naturally from their own conscious mind, not having been forced upon them by the government and this makes them powerful and effective.
Many of us who overeat do so because we are not aware of any easy and effective means to break the physical-emotional impulses we all experience that virtually compel us to consume “junk food” or to eat an additional portion of an unhealthful high calorie, low nutritional quality food, i.e., to overeat. A tool is needed to break this momentum in the very moment when we experience an impulse to eat unhealthfully or to overeat. Once initial hunger is satiated, or at least partially satisfied, further eating is often prompted by purely emotional impulses. These impulses can feel compelling, but yielding to them does not have to be inevitable.
I propose a technique called, “Take 5,” a tool developed by this article’s author, in collaboration with Harvard Medicine/Mass General Hospital neuroscientist, Dr. Rudy Tanzi. It is an effective method to break the momentum of impulses.12 Propagating a Take 5 meme and embedding it in the consciousness of the American public will help to disrupt and break the impulses that drive immoderate and unhealthful eating. Unlike the government obesity-related messaging of the past, that merely recite the negative health consequences of being overweight, Take 5 messaging embodies a “call to action.” It reminds us, and reinforces in us, the need to stop, pause and think, before we respond. The Take 5 tool is now available in the public domain. It is not proprietary and may be freely used by anyone.
The Take 5 technique works by helping people adopt a more healthful diet lifestyle by prompting them to do what their conscious mind knows should be done anyway, i.e., pausing before acting impulsively. While it is a multi-step procedure, it can be initiated via a very simple process. Almost everyone knows the common meaning and intent of the words, “TAKE 5.” It means to take a pause, step back and think, before we act, that is, before we respond. We very often do not do this, not because we are unaware that it makes sense and is the right thing to do, but, because in the “heat” of the moment when we experience a strong impulse to eat or overeat, we very simply do not think to pause first. The reason we do not think to do this, i.e., to pause, is partly because we have no easy tool, or prompt, we can call upon to remind us to do just this, and the emotion of the moment overwhelms us. Take 5 is a highly effective tool to address precisely this issue.
All we need to do, is to tell ourselves, (“Your Name”), TAKE 5, that is, I would tell myself, “Ken, TAKE 5.” That’s it! By telling yourself to Take 5, you remind yourself to pause for five minutes and allow time to make a conscious and deliberate decision to eat, or not eat, the food you may be craving. A simple reminder to do what you consciously know you ought to do, will often be enough to make us pause and allow the impulse to dissipate. Science suggests that most cravings are fleeting and dissipate in a short period of time and quite often do not return.13
It may sound obvious and simple, but, telling yourself to “Take 5,” acts as a highly effective natural disruptor to defuse the impulses that we otherwise so often yield to and allow us to think before we act.
Government-sponsored advertising and promotion will help make Take 5 a meme, and the saliency of this meme will greatly increase peoples’ likelihood to pause, before yielding to an impulse. The Take 5 tool will help to reduce consumption of high-calorie, obesity inducing ultra-processed foods and “junk foods” in particular, and our propensity to overeat in general. This can, at a minimum, help to curb weight gain and the onset of obesity and, over time, facilitate weight loss and reduce obesity.
The Take 5 tool and the overall proposed plan is not a panacea, it is not perfect, it will not always work for all people or for anyone all of the time. But it will work and it will help to address the obesity-based pandemic plaguing our country. A fulsome federal government program to address both the available supply of healthful foods and simultaneously providing tools to reduce the impulse to eat and overeat unhealthful foods, can make a difference. This difference can result in both highly significant cost savings to individuals, families and society overall, while also improving our collective national physical health and mental well-being.
One strength of this proposal is that implementation does not have to be everywhere and all at once. This program be tested and experimentally validated to determine how useful and productive it is, before deciding whether or not to roll it out on a national basis.
The obesity crisis, on both an individual and societal level, is real, increasing and incredibly costly, in monetary and psychological terms. It demands to be addressed and it is truly a national issue that is appropriate for a national entity, namely, the federal government, to tackle. It is far too important to not address the obesity crisis head on. The government cannot successfully mandate that people engage in healthful eating practices, but it can most definitely facilitate such behavior and provide incentives, via increased availability and lower prices, to encourage it. Vaccinating the public will ultimately control and end the devastating coronavirus health crisis, now we need an ambitious and efficacious plan to control the virtual obesity epidemic that we are currently experiencing, an epidemic that poses an ever-increasing threat to our individual and societal health and well-being.
Ken Derow, MSIA
References
1over the past sixty years the rise in obesity: https://www.cdc.gov
2Given that the obesity rate has grown substantially over the past twenty years: https://www.cdc.gov
3a major survey by a leading nationally recognized hospital: Newsroom.ClevelandClinic.org, “Americans Concerned about Their Weight….
4humans have a significant bias that severely discounts future events or potentialities: thedecisionlab.com, “Why do we value immediate rewards more than long-term rewards?”
5obesity-related expenditures amount to over 200 billion dollars per year: brookings.edu, “Obesity Costs Evident as the State Level”
6from 1775 to 2020, it is estimated that the US wartime deaths: statista.com, “Number of United States military fatalities in major wars 1775-2021”
7In 2019 alone, total US deaths equaled 2.8 million: https://www.cdc.gov, “Mortality in the United States, 2019”
8the government budgets about 720 billion dollars dedicated exclusively to national defense: en.m.wikipedia.org, “Military budget of the United States”
9US obesity level by just five percent (from about 42% to 43%: https://www.cdc.gov, Prevalence of Obesity and Severe Obesity Among Adults…”
10Psychologists and behavioralists know that if environmental conditions change, we are likely to adapt our behavior to account for those changes: psychologytoday.com, “Want to Change Your Habits? Change Your Environment”
11These ideas, termed the Self-Determination Theory: positivepsychology.com, “Self-Determination Theory in Motivation: Why Intrinsic Motivation Matters”
12I propose, a technique called, TAKE 5 that is described in my book: Ken Derow, “A transformative diet lifestyle in the era of the coronavirus”; to read entire description of the Take 5 technique, read Chapter 2 of the book, Amazon.com
13 WebMD.com, Food Cravings: “Why they strike, how to curb them,” Katherine Kam; Mlive.com, “How long does a food craving last? “Less time than you might think,” Sue Thoms, 4.3.2019