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Obesity: a Public Health Problem?

Posted by tinako on November 8, 2010

Boyd Swinburn

I recently listened to a couple of short podcasts from the Yale Rudd Center, interviews of Dr. Boyd Swinburn, a professor and researcher at Deakin University in Australia.   I really liked what he had to say.

The first podcast was about Public Health, and I’ll give a quick sum-up.  The interviewer, Dr. Kelly Brownell, asks why use public policy to combat obesity – what about personal willpower, personal changes?  Swinburn answers that that public-personal tension exists in many other areas such as tobacco, road injuries, etc., and what we’ve learned is that these problems haven’t been reversed until public policy has been implemented.  People still need to take personal responsibility, but it’s society’s role to give them the best chance to make the healthy choice.  So society makes the healthy choice the easy choice, and then promotes the healthy choice, which is the individual’s responsibility to select.

Swinburn describes the upstream/downstream metaphor.  If you tackle a problem downstream, you’re dealing with diabetes, etc., after they’ve happened, which is very expensive.  We currently invest heavily in downstream approaches.  This will not turn the problem around.  You’re just managing complications of a long-standing problem.  Midstream approaches target the individual.  Examples are seatbelt regulation, or for obesity, examples are motivation and education, “soft policies.”  Upstream interventions deal with the environment, the conditions people face when they’re making their decisions.  Swinburn feels most of the effort needs to be upstream.  This can be changing the physical environment so that it’s easier to be physically active, or changing the food environment.

Upstream interventions might be regulations to ban or restrict junk-food marketing to children, a tax on soft drinks, food labeling.  It doesn’t force people to choose a food, but it makes it easier for you.

Swinburn has done research to find which interventions are most effective, the most bang for the buck.  Brownell asks how Swinburn would evaluate, for example, the effectiveness of a proposed tax on soda.  Swinburn answers that the higher the tax, the higher the price, and the more that would affect behavior.  How directly price affects purchasing is called price elasticity, and it varies depending on the product (as you can imagine, for some products people will pay any price, and for others they cut back when the price rises).  This can be well-estimated based on past data, and now you know how much soda consumption will go down.  With that you can figure how many fewer calories the population will be consuming, and what that will do for body weight.

Swinburn has done this modeling and found that policies are generally pretty cheap and have a broad reach.  Health-promotion programs cost money and have a more limited reach.  Health services costs a lot of money and have a person-by-person reach.  Physical activity programs alone had very limited impact – physical activity is important, but not as important as food.

Public policy at the top of the effectiveness list: restricting junk-food advertising to kids.  It affects all kids, and while the influence on each individual is small, all together it has the biggest impact and the least cost and in fact even saves money.  Programs, particularly promoting active transport, are quite expensive with little impact.

Brownell asks isn’t restricting marketing making a nanny state?  Government intrusion into our lives?  I loved Swinburn’s answer to this.  He says “nanny state” is a flip way to dismiss what should be a serious policy debate.  If you’re talking about children, nannies are a good thing; they care about and try to protect children and support parents.  If government took on those characteristics, our children would be in much better shape.

In addition, we accept more intrusive restrictions in our lives all the time: seatbelt laws, speed limits, DWI, tobacco sales to minors, etc.  In many, many areas we accept restrictions on our “freedom” to do whatever we want, for our own benefit and for the greater population benefit.  In the obesity epidemic, nanny state keeps coming up, but he can’t think of a single proposed regulation that would tell him what he can and can’t eat or whether he has to exercise.  Most of the regulations are targeting the environment, making it easier to make a healthy decision.  It’s much less “nanny state” than many things we already accept.

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