FROM ISSUE NUMBER 13 ~ FALL 2012 GO TO TABLE OF CONTENTS
The Bloomberg Diet
The rise of obesity presents America with a serious challenge. To understand how serious, consider that a person is deemed to be overweight if his body mass index (a measure of height and weight) is between 25 and 29.9, and obese if his BMI is 30 or more. In the United States today, the average BMI for adult women is about 28.5, and for men, 28.7. According to the Centers for Disease Control, in 2010, more than one-third of adults — 35.7%, to be exact — had a BMI of 30 or greater. As a result of their excess weight, these Americans face a number of health consequences — such as osteoarthritis, depression, heart disease, type 2 diabetes, and increased risks for stroke and some cancers.
Obesity is a health crisis, and since health costs are at the center of our nation's growing budget woes, it is a driver of our fiscal crisis as well. According to the CDC, the United States spends $147 billion a year in direct medical costs to treat obese patients — more than 9% of all health-care spending. Some studies estimate that obesity's share of health spending is closer to 20%. On average, people who are obese spend 42% more per year on health care than do people of normal weight. According to one study, by 2020, health costs will grow by another 20% because of excessive weight alone.
Because of obesity's implications for public health and public finances, improving Americans' weight and fitness is increasingly seen as the purview of government. The most visible example is the anti-obesity campaign being run out of the White House under the leadership of First Lady Michelle Obama. Her "Let's Move" initiative has enlisted federal agencies to promote healthy eating and increased physical activity among children, and her activism led to the enactment of the Healthy, Hunger-Free Kids Act in December 2010. The legislation — which increased funding for federal nutrition and education programs and the national school breakfast and lunch programs — was authorized with a price tag of $4.5 billion. The Patient Protection and Affordable Care Act, too, boosted funding for anti-obesity initiatives.
Many Americans are understandably wary of such intense government interest in very personal decisions — what we eat, how much we eat, and whether and how much we choose to exercise. Some of these concerns are certainly legitimate. So are concerns about how official anti-obesity campaigns treat overweight Americans and shape public perceptions of them. (As a physician, I recognize that any conversation about obesity requires great sensitivity — whether it takes place in the privacy of a doctor's office or as part of a broad debate on public policy.) Above all, Americans are right to be concerned about the effectiveness of such anti-obesity efforts — to ask whether government interventions can really improve citizens' weight and fitness.
Despite these concerns, government efforts to shape Americans' waistlines are likely to become more prevalent, not less so. And because obesity does pose very real dangers to the nation, there are ways in which government can and should be helpful in trying to reduce it. It is therefore worth considering exactly what kinds of government interventions are (and are not) appropriate and effective in the effort to curb obesity. There is a balance to be struck between legitimate measures to improve public health and intrusive, ineffective overreach. The challenge for policymakers is to find that balance.
Fortunately, one government anti-obesity campaign is advanced enough to have produced revealing results and to offer some useful lessons. In the efforts of New York mayor Michael Bloomberg, the nation has an example mostly of what not to do in the effort to reduce obesity. The New York campaign shows how top-down government mandates are doomed to fail — but also points to plausible solutions for officials seeking a better way to keep citizens healthy and fit.
Upon taking office in January 2002, Bloomberg appointed Dr. Thomas Frieden, an epidemiologist specializing in tuberculosis, as commissioner of the city's Department of Health and Mental Hygiene. In that role, Frieden, with Bloomberg's support, banned smoking in the city's public spaces. New laws prohibited smoking in restaurants and bars, new taxes were slapped on tobacco products, and an army of public-health officials was dispatched to enforce the new laws. Not surprisingly, following the crackdown, smoking rates in the city dropped.
Inspired by the success of the anti-smoking campaign, Frieden and an enthusiastically supportive Bloomberg turned their attention to a new project. The administration argued that obesity rates in the city were higher than the national average, and in 2005, Frieden declared that "[o]besity poses one of our most serious health risks." Trimming New Yorkers' waistlines — with an intense focus on diet and exercise — thus became a project for City Hall. Cheered on by Bloomberg, Frieden (who left his post in 2009 to become head of the CDC) and Frieden's successor, Dr. Thomas Farley, embarked on a broad strategy of "public-health interventions." In addition to their fat-fighting aims, these policies were consciously designed to expand the range of accepted government involvement in matters of personal health.
The anti-obesity campaign took a multi-pronged approach. In one respect it drew on New York's anti-smoking efforts, which had succeeded by severely restricting the places in which tobacco could be consumed and by using taxes to drive up tobacco prices and thus reduce demand. Unhealthy food was targeted in much the same way: In the city's own extensive food-distribution chain — to more than a million children in city schools; to New Yorkers in nursing homes, hospitals, homeless shelters, day-care facilities, senior centers, and jails; and in vending machines in city facilities — Bloomberg tightened nutritional standards and cut out junk food. City rules cracked down on the use of trans-fatty acids in the preparation of food in restaurants. More recently, the city has moved to prohibit restaurants from selling sweetened drinks in cups larger than 16 fluid ounces.
Another front in the city's war on obesity was public awareness, involving high-profile (and often controversial) advertising campaigns. In 2009, New York's health department released a striking ad depicting soda being poured out of a bottle and transforming into fat. "Are you pouring on the pounds? Don't drink yourself fat," the poster instructed. Earlier this year, Bloomberg came under fire for a series of graphic ads, including one featuring an overweight, one-legged man alongside large servings of soda. Noting that "portions have grown" along with the prevalence of type 2 diabetes (which, the ad notes, "can lead to amputations"), the poster urges New Yorkers to "Cut your portions. Cut your risk." Asked by a local radio reporter whether the ad was too graphic, Bloomberg responded, "What do you [want to] do? Do you [want to] have people lose their legs or do you [want to] show them what happens so that they won't lose their legs? Take your poison, which do you want?"
Another major component of the Bloomberg campaign has been fitness and exercise. The administration's "Move-to-Improve" program, according to a report of the Obesity Task Force the mayor convened late last year, has (with federal funding from the CDC) pushed "teachers [to] integrate physical activity into all areas of classroom academics." The administration promoted "active design guidelines" encouraging architects and city planners to create "healthier buildings, streets, and urban spaces" and changed building codes to encourage exercise-friendly architecture. Bloomberg's signature effort has been the aggressive promotion of biking, including the reconfiguration of city streets to make New York more hospitable to bicycles. According to the task force, the city's Department of Transportation built 250 miles of bicycle lanes throughout New York's five boroughs in three years.
But the most prominent features of Bloomberg's campaign were those through which the city involved itself directly in New Yorkers' dietary decision-making. With these programs, the city did not ban certain ingredients or mandate exercise. Rather, Bloomberg and his deputies believed that, simply by providing the right resources, City Hall could make people choose healthier food.
Here, the city's policies revealed an assumption that underlies the efforts of Bloomberg and many other public officials seeking to reduce obesity. Too often, public-health advocates suffer from "McVictim Syndrome": the belief that America's obesity problem is caused entirely by outside forces — such as economic injustice and corporate greed — rather than by the preferences and choices of free citizens. Those suffering from McVictim Syndrome assume that the obese have simply been misled by fast-food chains and other "big food" corporations dissembling about the nutritional content and health risks of their products. These public-health officials argue that "food deserts" — urban areas dominated by convenience stores, lacking proper groceries that sell fresh produce — are the fault of supermarket chains. These companies, rather than the residents of such areas, are thus to blame for inner-city obesity. New York City's own literature on obesity often frames the problem in terms of class and race, noting that obesity rates are highest in poor and minority areas. As one press release put it, "non-Hispanic black New Yorkers are almost three times more likely, and Hispanics twice as likely, as non-Hispanic whites to die from diabetes."
This understanding of the obesity challenge drives sweeping (and expensive) policies in which the government, believing individuals have been denied the resources they need to make good nutritional decisions, does everything possible to try to make those decisions for them. Only government can break through the misleading corporate advertising to tell citizens which menu options they should consume; only government, using zoning powers and other regulation, can bring green oases to urban food deserts. This is the thinking behind two of New York's signature anti-obesity initiatives — both of which have, for the most part, failed. It is thus worth examining these programs to see what they tell us about the McVictim approach to combating obesity.
One of Bloomberg's most visible anti-fat efforts has been his attempt to influence New Yorkers' choices while dining out. In 2007, the city enacted a law requiring chain restaurants (those with more than 15 outlets nationwide, or about 10% of the city's restaurants) to prominently display calorie counts on their menus in order to educate diners about their food options. After a battle in court — restaurateurs argued the law violated their First Amendment rights — the calorie-count requirement finally went into effect in 2008; failure to comply could produce a fine between $200 and $2,000. The Bloomberg administration justified the policy by claiming that the calorie labels would result in 150,000 fewer cases of obesity and 30,000 fewer cases of diabetes over five years.
The theory behind the law was that if people knew just how unhealthy their food choices were, they would modify their purchases accordingly. But the evidence seems to undermine that assertion. Since the calorie-count law took effect, five major studies have been published on the efficacy of the program. In October 2009, researchers writing in Health Affairs observed that, in the aftermath of the calorie-count mandate, they "did not detect a change in calories purchased after the introduction of calorie labeling" in low-income neighborhoods in New York. The research group expanded the study a year and a half later, focusing explicitly on teens, parents, and children in low-income neighborhoods — the key demographics targeted by Bloomberg's initiative. But the results, published in the International Journal of Obesity, also revealed "no statistically significant differences in calories purchased before and after labeling" after three years of implementation.
Meanwhile, a study by Stanford University and the National Bureau of Economic Research from January 2010 reviewed sales data from Starbucks coffee shops in New York City. Researchers found that "food calories per transaction fell by 14% (equal to 14 calories per transaction on average)." Beverage calories per transaction "did not substantially change" in light of the new visible calorie-labeling information. Overall, calories consumed by Starbucks customers declined by just 6% per transaction.
On the whole, the evidence indicates that the calorie-count program has had a negligible impact. In fact, the only major study to claim that the new regulation had a significant impact was one conducted by the New York City Department of Health itself. Published in 2009, this internal review found that menu labeling had helped lunchtime customers in fast-food restaurants cut caloric intake by an average of 12.3% — even less than the independent Starbucks study found.
The fifth research team attempted to pinpoint a cause for the failure, seeking to explain why the regulation had not made the significant impact hoped for by city officials. Instead of tracking consumer behavior, researchers from the Columbia University School of Nursing compiled information from 70 menus in a sample of restaurants. They concluded that the problem with the regulation was that patrons would need "complex math skills" to make effective use of the menus as posted — even though the restaurant menus were generally in compliance with the specifics of the city's own regulations.
To the (very limited) extent that the law did reduce New Yorkers' caloric intakes, the restaurants themselves deserve much of the credit. In July 2011, the Economist reported on a study of the law's effects by the British Medical Journal, which pointed to key changes made by the affected restaurant chains. The Economist noted three whose customers beat the city's calorie-reduction average: McDonald's, Au Bon Pain, and KFC. When the law went into effect, these chains expanded their low-calorie offerings, giving patrons more healthy options to choose from. Subway, meanwhile, saw its average calories per sale jump by 133. Though about a quarter of the chain's customers reported having used the calorie labels mandated by Bloomberg, the Economist reported, the period of the BMJ study coincided with Subway's "$5 foot-long" promotion, meaning patrons deciding between a six-inch and foot-long sub could purchase twice as much sandwich for just a little more money. As the article concluded, "If this study confirms anything, it's that food-related decision-making is highly complex and, like other aspects of human psychology, not changed simply by the provision of more information. To make large strides in changing how people eat, more than just labels will be needed."
What is needed, the results of the calorie-labeling program suggest, is for diners to prioritize healthy eating above other considerations, such as cost and taste preferences. When there is bottom-up demand — consumers seeking healthy options on their own and restaurants providing them — caloric intake can decline. But the top-down imposition of calorie labels is unlikely to push people toward food choices they would not otherwise make.
Calorie labels were only one part of the New York campaign. Addressing the city's "food deserts" — and the supposed inability of New Yorkers to get healthy food in their own neighborhoods — was another major priority. To address this challenge, the city's public-health bureaucracy launched two initiatives.
First, city staff worked closely with retailers in a "Healthy Bodegas" initiative, launched in 2006, to improve the quality and nutritional value of food sold in the city's many corner stores. The project focused on three "underserved" neighborhoods — the South Bronx, North and Central Brooklyn, and East and Central Harlem — which, according to the city, suffered high rates of obesity and diabetes. According to a city report, only one in four East Harlem bodegas sells apples, oranges, and bananas, while only 2% of bodegas in Central Harlem sell leafy green vegetables. To counteract this trend, city officials supplied advice, marketing materials, supply-chain contacts, and other services to persuade bodega operators to offer more healthy foods. The city also tried to stimulate demand, pushing community organizations and residents to "support" their local shops in the effort to offer more healthy foods through the "Adopt-a-Bodega" program.
Central to the program was a campaign to make more New Yorkers drink low-fat milk. "In areas of Brooklyn," the city report states, "bodegas make up more than 80% of food stores, with only one in three selling low-fat milk, compared with nine in 10 supermarkets." Switching New Yorkers off of richer milk blends thus became a major target for the city, as Frieden argued that "other than people with rare medical problems, everyone over age 2 should drink low-fat milk — 1% or skim." As part of the Healthy Bodegas effort, the city launched the "Moooove to 1% Milk" campaign, providing participating bodegas with bilingual promotional materials.
What does Bloomberg have to show for these efforts? In some cases, the health department got what it wanted. More bodegas sold more of the desired products, and nearly half of the bodegas surveyed by the department said they had sold more low-fat milk over the course of the 2006-10 campaign. But there is no evidence that this success will translate into reduced levels of obesity. For instance, researchers in Australia recently tracked children who had switched to 1% milk as an alternative to fatty milks. After reviewing the evidence, they concluded that the children simply made up the lost fat and calories from other foods. Though the city reports that rates of childhood obesity have declined slightly since the Bloomberg administration launched its war on fat, there is simply no way of knowing whether pushing 1% milk — or any of the administration's other food-supply efforts, for that matter — can be credited with the change.
The second component of Bloomberg's effort to eradicate "food deserts" had City Hall getting into the grocery business itself. In 2008, working with City Council speaker Christine Quinn and financed with $1.5 million from a private foundation, Bloomberg launched New York's "Green Cart" program. Following the recommendation of the city's "Food Policy Task Force," the Bloomberg administration identified neighborhoods where consumption of fruits and vegetables was low, and where access to fresh produce was allegedly limited. Local Law 9 (which authorized the Green Cart program) worked by lifting caps on food vendors imposed by previous mayoral administrations — but only if the vendors sold fresh produce exclusively, and in only these neighborhoods identified and approved by City Hall. Street vendors would then be licensed and trained to sell fresh produce directly to consumers on city-branded carts. Initially, the city aimed to issue 1,500 permits, concentrated most heavily in the Bronx and Brooklyn.
Treating it almost as an article of faith, Bloomberg insisted: "There is demand for fruits and vegetables in these neighborhoods," adding confidently that "this regulatory change will enable the market to meet that demand." City sources estimated that the initiative would save 50 lives each year. And the cheerful claims made in reports from the city's health department would seem to vindicate Bloomberg, suggesting that Green Carts has been a success. The evidence, however, is not on City Hall's side: At the end of fiscal year 2011, New York had authorized 1,000 Green Cart permits — and roughly half remained unused. More than half of the initial cart vendors had abandoned their permits to other sellers.
An article from earlier this year in the progressive journal City Limits offers insight into why the demand to participate in Green Carts hasn't lived up to expectations. The authors believe the program should be retained, but nonetheless identified a host of very serious problems with its implementation. Vendors have faced opposition and harassment from their fellow New Yorkers, especially from bodega owners and other food retailers who see the carts as competition. Rival street vendors, meanwhile, have undercut business by selling illegally, facing few consequences for operating without permits.
For many vendors, the carts simply are not a viable way to make a living. Indeed, the City Limits investigation showed that the average vendor had an annual net income of only $7,500. Vendors blamed poor planning, excessive regulation, and bureaucratic obstacles on the part of the city. Since the start of the program, more than 4,200 applications have been submitted, but only 640 permits issued. There is just one cart-inspection facility, in Queens, where vendors have to wait several hours for inspections. Tickets and steep fines and penalties await vendors whose carts are in minor violation of city rules. In identifying the neighborhoods where Green Carts could operate, the city failed to account for the lack of produce storage in those areas. Vendors quoted in the City Limits article cited the high cost and difficulty of finding storage in city-approved "commissaries" as major obstacles to profitability.
The response of consumers, too, was less than promised. Unlike many media outlets, City Limits did not simply accept and parrot the city's assertions that the program was a success. Rather, the magazine looked at the health department's data:
From 2008 to 2010, the percentage of residents in Green Cart communities who reported consuming no fruits or vegetables the previous day increased from 17.1 percent to 18.1 percent, while in non-Green Cart neighborhoods, the same number decreased from 10.7 percent to 9.5 percent. During that same period, the number of residents in Green Cart areas who reported consuming between 1-4 servings decreased by 2 percent. However, residents with Green Carts in their neighborhoods [who] reported consuming five or more servings a day increased 1 percent.
In short, the only positive outcome of the Green Cart program to date is that it reinforced the sound dietary habits of New Yorkers who already had sound dietary habits. Meanwhile, those who did not consume fruits and vegetables before the program's launch continued to avoid produce even after the city practically dropped it on their doorsteps. The notion that the increased availability of fresh produce would drive increased demand turned out to be false: Simply offering people healthier food didn't make them choose it.
A QUESTION OF MOTIVATION
The failures of the Green Cart program and calorie-label requirement illustrate the fundamental flaw in the Bloomberg approach to curbing obesity. The McVictim philosophy presupposes that people want to make healthy food and fitness choices, and that only corporate greed and lies stand in their way. It assumes that once government has forced full disclosure and mandated access to healthy foods — by telling restaurateurs how to do business, or implementing costly yet ineffective city programs — citizens' diets will take care of themselves. Unfortunately, these assumptions usually turn out to be wrong — because they fail to understand some of the key reasons why people are obese.
In New York's case, part of the problem is that the public-health officials drew the wrong lessons from the success of the campaign against cigarettes. They saw that public bans, mandates, and other intrusive regulations in fact reduced smoking rates, and thought they could apply the same approach to food. But food and cigarettes are not the same. In the case of smoking, there was actually a problem of misinformation: Many people became addicted before anyone knew of the health consequences.
Moreover, consuming nicotine is always harmful. If a person smokes a cigarette just once — no matter which brand, where it is smoked, or how rarely he has smoked before — he is inhaling poison. Regulating tobacco use thus does not require impossibly complex prudential decisions rooted in endless individual circumstances to determine just how much is too much.
Food is a different matter. Food is not poison, and even unhealthy foods and beverages do little harm to most people if consumed in moderation. And what constitutes "moderation" for food varies wildly from one person to the next, based on a host of factors such as height, weight, age, sex, genetics, and activity levels. While the averages recommended by government agencies can be helpful, anyone hoping to regulate the average meal from Washington (or City Hall) must set rules that are either absurdly arbitrary or hopelessly complex and unenforceable. If the goal is to improve people's dietary choices, mandates are thus poorly suited to the task.
Taxes, too, are a problematic mechanism — and another area in which New York's success with cigarettes does not translate into the realm of food. Like it or not, it is easy for governments to tax tobacco products. They are sold in standardized units, and most smokers grudgingly accept smoking taxes as part of the cost of a habit they choose to maintain. With unhealthy foods, collecting taxes is vastly more difficult. Some Scandinavian countries are experimenting with calorie taxes, but it doesn't take much to see the absurdity of this approach. High-performance athletes consume large numbers of calories to maintain their energy levels, and a calorie tax would punish them for eating the food they need to stay fit. Moreover, fat and sugar taxes are, as a general rule, very unpopular. For example, in 2010 in Washington state, legislators enacted taxes on soda and candy bars. Just months later, residents voted to repeal the levies by a margin of nearly two to one. Only two of the state's 39 counties voted to keep the taxes in place.
This unpopularity points to the bigger problem with the Bloomberg approach to regulating health and fitness. It is not only that the mayoral administration failed to appreciate the differences between tobacco and fat. Rather, they failed to take account of the differences in people's attitudes toward their own behaviors. As Frieden himself has acknowledged, most smokers want to quit. Contrary to the McVictim philosophy, the reason many people are inactive and make poor health choices is not that they lack opportunities to do better. Rather, unlike people who want to quit smoking, they aren't sufficiently motivated.
Consider that many overweight Americans aren't even aware that they have a weight problem to begin with. In an interview in the October 2007 edition of Obesity Management, Frieden noted that, while more than 1.1 million New Yorkers were obese, "only 39% of obese adults correctly say they are ‘very overweight' when asked to describe their weight."
Frieden's observation correlates well with other studies on obesity awareness. For example, a Harris survey in August 2010 found that "30 percent of overweight [Americans] think they're actually normal size, 70 percent of obese people feel they are merely overweight, and 39 percent of morbidly obese people think they are overweight but not obese." Other Western countries have flunked similar surveys. It doesn't help that, as more people become overweight, public standards for what constitutes "normal" weight shift to accommodate the changes. A classic example is "vanity sizing" — smaller numbers attached to larger clothing in a sort of size inflation.
Moreover, even when people are presented with opportunities for healthy eating, they simply choose not to pursue them. In a column on the food-desert issue in July 2011, the Economist explained:
No surprise, then, that neither USDA nor the Institute of Medicine of the National Academies has been able to establish a causal link between food deserts and dietary health. In fact, both agree that merely improving access to healthy food does not change consumer behaviour. Open a full-service supermarket in a food desert and shoppers tend to buy the same artery-clogging junk food as before — they just pay less for it.
This points to a significant reason for the underwhelming performance of the Green Carts and Healthy Bodegas programs in New York. In the city's own review of the bodegas program four years after its launch, under the heading "What We've Learned," city officials seemed to finally bow to reality, noting that "store owners stock what people buy." As the report acknowledged, "community buy-in and support are [therefore] essential to help sustain healthy changes." Until and unless there is demand from a motivated public for healthy foods and healthy lifestyles, there is little that government can do to push them.
By recognizing this basic point, policymakers concerned about obesity can craft much more responsible and plausible solutions. The key is to generate authentic demand among the public for healthy food and healthy lifestyles. As we have seen, such demand can't be stimulated by intrusive top-down mandates or by assuming that the obese are victims of forces beyond their control. A better approach must be based on trusting and empowering people to take responsibility for their own health.
Such an approach starts with education — helping the obese and overweight recognize that they have a medical problem and understand the risks associated with it. Doctors in particular should be more forthcoming with patients about the dangers of obesity. And here, the Bloomberg administration actually got something half-right.
One of the more promising components of the mayor's campaign instituted new rules about testing for hemoglobin A1C — a measure of blood glucose concentration, and thus an indicator for diabetes. Under the rule, medical laboratories that already report infectious-disease results from any blood, urine, or tissue samples they test must now also report the results of any patient's hemoglobin A1C test directly for the department's records. The city, in turn, sends a letter to patients with elevated levels of hemoglobin A1C, "informing them of the test results and suggesting some lifestyle changes," as one Harvard analyst wryly put it. Local physicians also receive updates on their own patients, packaged with recommendations for treatment.
At first glance, this system seems to be excessively intrusive. It is hardly reassuring that the government collecting this information is one of America's most inefficient bureaucracies. There are also legitimate concerns about the precedent the rule sets. Testing hemoglobin levels to identify the obese is not like monitoring a cholera outbreak: Through this law, the city government is responding pre-emptively to a health risk to an individual that, in turn, poses no imminent threat to the broader population. It thereby invites future intrusions by government into very personal aspects of individuals' lives in the name of ill-defined public purposes.
Still, despite these misgivings, this standardized risk reporting is one of New York's more defensible anti-obesity policies. If people face serious health risks as a direct, measurable result of their dietary habits, it makes sense that they be told directly, so that they have the opportunity to change their food-consumption patterns. As mentioned above, a great many people facing health problems because of obesity and excess weight do not even know they are at risk. With this type of program, doctors are notified about the danger facing their patients, and can decide whether to discuss the problems of obesity with those patients directly. If doctors prefer to avoid bringing up the issue with their patients — and clearly many do — the obvious answer is for public-health officials to lobby primary-care providers to change their professional practices. To bring about that change, no new law would be required.
Patient (and doctor) education through programs like standardized risk reporting holds promise, but it is not enough to create the basic conditions under which people will be motivated on their own to lead healthy lives. Policymakers will have to do more. In many cases, they can start by getting government out of the way, clearing the obstacles to healthy lifestyles erected by bad public policy.
For instance, public-health advocates (in and out of government) want to increase spending on awareness campaigns and increase the cost of unhealthy foods through targeted taxes. But they could change prices more directly by ending billions in wasteful federal subsidies for agribusiness and marketing for unhealthy foods. Public-health advocates want to boost spending on infrastructure for public fitness — yet millions of square feet of gym space and playing fields have been locked shut by public-sector union rules, new insurance requirements, and other regulatory barriers. Public-health advocates hope to regulate children's exposure to fast foods, but a better target would be government-provided school lunches, which are often (rightly) blamed for promoting poor health at taxpayer expense.
Other, more proactive policy choices can also promote better health decisions without promoting bigger government. Consumer-driven health care, focused on patient outcomes, would be an important step. Flexibility in insurance plans, for instance, allows for the use of incentives for healthy behavior. In 2005, Safeway implemented a Healthy Measures program, using cash rewards to persuade the company's workers to adopt healthier habits. The plan helped contain costs in the company's self-funded health-insurance plan.
The Affordable Care Act actually included amendments to protect these programs, but regulations still exist to limit their scope and their availability in workplaces across America. With fewer restrictions, this concept could be aggressively expanded — to private insurers, and even to Medicare and Medicaid. There is reason to think such policies would provide people with the necessary motivation to stay fit: Recent studies in the United States and the United Kingdom found that structured incentives were effective in promoting weight loss. In the British study, nearly half of test subjects reduced their weight by 5% or more, and nearly a quarter of the group lost more than 10% in a one-year trial.
Even in New York, some of Bloomberg's aims would have been better served with less government rather than more. In 2011, Manhattan borough president Scott Stringer published a report called Red Tape, Green Vegetables, arguing that New York's private system of farmers' markets would be capable of meeting retail demand for produce in food deserts — if only a long list of regulatory obstacles could be swept away. The report noted that, while Bloomberg's Green Carts roam target neighborhoods as part of an expensive program micromanaged by city officials, grassroots farmers'-market operators "are tackling the same problems that many city officials are trying to address, but they are doing it with on the ground knowledge of the most in-need neighborhoods at no cost to the city" [author's emphasis]. According to Stringer's assessment, the revenue from one year's worth of permits for a farmers market would be 44 times the one-year permit cost of a Green Cart.
Another simple, inexpensive way for public officials to approach the problem of obesity while avoiding excessive legislation is through encouragement and example. After a positive experience losing more than 40 pounds while in office, Oklahoma City mayor Mick Cornett announced that in 2008 he wanted to "put Oklahoma City on a diet." But instead of forcing change through regulations, Cornett led by example and created positive incentives for public participation. Oklahoma City's anti-obesity project gave out free pedometers for participants, subsidized with corporate sponsorships. It published a web site with advice on diet changes and local exercise opportunities. More than 47,000 residents participated in the program and reported losing one million pounds collectively, showing that inspiration campaigns can provide individuals with the crucial motivation to make better choices about their health.
A HEALTHY BALANCE
In 2007, Mayor Bloomberg bluntly articulated his philosophy of government: "We have to tell people how to lead better lives." Though Bloomberg's policies may seem relatively harmless, confined as they are to New York City, there is reason for other Americans to look to the results from the Big Apple with concern. In April of this year, the Washington Post published a flattering article about Bloomberg's Green Carts, noting that the program "is fast becoming a model for other American cities" including Philadelphia, Washington, Chicago, Los Angeles, Madison, and California's Santa Clara County. Meanwhile, the Affordable Care Act includes a provision similar to Bloomberg's calorie-count policy. Restaurants with 20 outlets or more nationwide will be required to include calorie labels on their menus, and information about recommended daily values, as part of federal law.
It is tempting to dismiss such policies completely, arguing that government should do nothing whatsoever about Americans' waistlines. This view represents one extreme, and it is not a responsible position. After all, on an average day, some 685 Americans endure a risky weight-control procedure called bariatric surgery, performed only on the morbidly obese. In other words, Americans spend roughly $17 million every day in an attempt to surgically cure a preventable illness. And this represents but a fraction of obesity's financial toll. The overall drain on public finances is much greater, and obesity's cost in terms of lives and health incalculably greater still. Clearly, some response from government is appropriate.
But the approach embraced by Bloomberg and other McVictim acolytes represents another extreme — one that, as the evidence from New York shows, is not much more effective in combating obesity. Along the way, this approach has the added downside of burdening public budgets with expensive government programs and eroding personal liberty. These policies may also be counterproductive: The more government asserts responsibility for individuals' health choices, the less incentive there is for individuals to embrace such responsibility for themselves. Yet without that sincere motivation on the part of citizens to stay fit, there is little government can do to make people lead healthy lives — as the experiments from New York make clear.
The right balance between government indifference and overzealousness is to create the conditions whereby people can motivate themselves to watch their waistlines. This can be achieved not through bullying or nannying, but rather through education and inspiration. It can be achieved if policymakers understand that the obese are not victims of sinister outside influences, but rather free citizens with the power to choose for themselves what kind of lifestyles they wish to lead. The obesity problem won't be reversed until policymakers start treating them that way.
David Gratzer is a physician and author.