04/22/2012 11:59 EDT | Updated 06/22/2012 05:12 EDT

DONNER PRIZE FINALIST: Obesity and the Limits of Shame

Can the flattening rate of growth in childhood obesity be credited to public health campaigns -- such as anti-junk food posters in urban high school hallways; recent bans on soda pop machines in some schools; and mandated 20-minute physical exercise regimens in inner-city schools? They may have some impact among some kids, but not much, by all accounts.

Does the prime minister wield too much power? Is our skilled immigration policy in need of major reform? What role do museums play in Canadian society? Could Healthy Living Vouchers help in the battle against obesity? These are the questions posed by the four finalists competing for the $50,000 2011/2012 Donner Prize, the award for best public policy book by a Canadian. The winner will be announced on Tuesday, May 1. We will post excerpts from each of the finalists in advance of the prize, exclusively for Huffpost readers. Today's excerpt is from Obesity and the Limits of Shame by Patrick Luciani and Neil Seeman, with an intro by the authors.

The global public health industry weirdly takes credit for initiatives that have yielded no return on investment on the path toward reducing the burden of disease associated with excess weight and its associated toll on human health and on economic productivity. There is a conspiracy of silence in the public health industry -- and industry it is, abetted by government collusion interested in protocols that are politically expedient rather than data-driven. This government cabal is unwilling to stand up and shout loudly: We need a bold policy solution that improves the already fraying provider-patient relationship, one that incents all parties to try to fashion bespoke regimens to help patients keep to a healthy weight and/or switch course over time. To this end, we need, first with pilot projects in low-income neighborhoods, to embrace a universe of incentives -- we call them 'healthy living vouchers', i.e., otherwise taxable income available to persons 16 years of age and older -- that create a market of (self-regulated) companies to market services ethically to earn a portion of those dollars.

ON MAY 28, 2008, the U.S. Centers for Disease Control and Prevention

published a bombshell article in the prestigious Journal of the American

Medical Association suggesting that rates of childhood obesity in the

United States had leveled off. A reporter for the New York Times wrote:

'It is not clear whether the lull in childhood weight gain is permanent

or even if it is the result of public efforts to limit junk food and increase

physical activity in schools.

Could this be the public health establishment's greatest achievement

since John Snow identified the Broad Street Pump as the source of the

London cholera outbreak in 1854?

After a 25-year hike in child obesity rates, with childhood

diabetes rates shooting straight up and other diet-related complications

on an apparently inexorable climb, here was a story saying that the

obesity epidemic had perhaps reached a plateau; what's more, public

health campaigns and system-level planning may have had something

to do with it -- or so the media storyline went. In North America and

around the globe, the story was the most widely read academic news

item on obesity reported in the major media in 2008. Dr David Ludwig,

director of the childhood obesity program at the prestigious Children's

Hospital in Boston, called it a "glimmer of hope."

Can the flattening rate of growth in childhood obesity be credited to

public health campaigns -- essentially, to scattered pilot projects such as

anti-junk food posters now peeling off the walls in urban high school

hallways; recent bans on soda pop machines in some schools; and mandated

20-minute physical exercise regimens in inner-city schools?

They may have some impact among some kids, but not much, by all

accounts. A recent National Bureau of Economic Research study by

John Cawley, Chad Meyerhoefer, and David Newhouse has found that

while state physical education requirements can make children more

active, they have no detectable impact on teenagers' BMIs or their probability

of becoming overweight. Yet public health advocates will not

give up such 'get moving' approaches: recall the 2010 insight from Jeff

Levi, head of the Trust for America's Health, whose organization found

weight gain escalating across America yet who attributed one statistically

negligible annual drop in the District of Colombia to the expansion

of community recreation centres and public transit -- expansions

that have been taking place in dozens of other states without any slowing

in their obesity trend lines.

Just a year before the JAMA study came out, in 2007, the influential

Institute of Medicine, part of the U.S. National Academy of Sciences,

recommended that junk foods such as potato chips, doughnuts, chocolate-

covered ice cream, and sugary drinks be banned from all elementary,

middle, and high schools. According to the IOM, only through

mandated national standards in every single school in America could

we make a dent in the problem of childhood obesity. So how was it possible

that a year after the IOM announcement, on the heels of the widely

cited JAMA study, the New York Times was speculating on whether

public health bureaucrats had won a major battle by halting the rise in

childhood obesity? Was the public health establishment guilty of self interest

in claiming credit for 'success'?

In statistical terms, the data from the original JAMA study likely

resulted from the fact that all major ascents eventually plateau.

2008 and 2009, violent crime rates reached half-century historic lows in

cities like Los Angeles and New York. It is now generally accepted that

demographic trends -- notably an aging population with fewer young

people in the younger age category most prone to commit violent crime

-- explain the phenomenon of declining crime rates. It is rarely the case

that abrupt statistical changes in the prevalence of social ills -- from

obesity to violent urban crime -- can be attributed to policy rather than

to nature. Americans were all aging at one point and all were growing

taller, but then the rate of aging and the rate of growth ebbed. Did this

signify success in the control of 'height gain'? Even the rise in obesity

has a natural plateau.

That there are ebbs from this peak (as suggested by the JAMA data)

is statistically meaningless. There's a point at which society -- America

being a good example -- won't get fatter, but that should not be

considered "good news." Seldom reported in news articles about the

JAMA study was a quote from the lead author of the report, Dr. Cynthia

Ogden, who thinks that we may have reached "some sort of saturation

in terms of the proportion of the population who are genetically susceptible

to obesity." This is an example of how data can be interpreted

and "spun" in a variety of ways.

For instance, a National Bureau of Economic Research study by Patricia

Anderson and Kristin Butcher concluded that a 10 per cent increase

in the availability of junk food was correlated with about a 1 per cent

higher BMI for the average student. However, the effect of the junk

food appeared strong only for students whose parents were overweight.

Researchers from the Karolinska Institute in Sweden conducted a four-year

study called STOPP (Stockholm Obesity Prevention Project), in the

course of which sweets, buns, and soft drinks were banned from five

schools but not from five others. The proportion of overweight six- to

10-year-olds dropped by 3 per cent in the schools with the ban, while

it climbed by 3 per cent in the schools with no ban. This improvement

was encouraging, but child obesity across Sweden was still rising. A

review of school-based obesity prevention problems in 2008 stated that

out of 14 such studies, the evidence was weak in 10. The authors


"Our ability to draw strong conclusions as to the efficacy of school-based

obesity prevention programs is limited by the small number of published

studies and by methodological concerns. Qualitative analysis suggests

programs grounded in social learning may be more appropriate for girls,

while structural and environmental interventions enabling physical activity

may be more effective for boys. High-quality evaluation protocols

should be considered essential components of future programs."

The only other major "good news" media-reported study to have

appeared in the past few years comes from the NPD Group, a Port

Washington, New York-based market research firm. The story, widely

circulated in the international media in 2009, contended that the eating

habits of American children were changing. "And for a change, the

news is good," celebrated the New York Times. The NPD is one of many

major marketing companies skilled at getting reporters to pay attention

to their sound-bite stories, and when it comes to teens and obesity,

reporters always pay attention. The story in the Science Desk section

of the Times was titled: "Kid Goes into McDonald's and Orders ... Yogurt?"

This is what journalists call a "man-bites-dog" story; as such, it made


The NPD data found that chicken nuggets, burgers, fries, and colas

remained popular with the teenage set, but that consumption of these

foods was declining, whereas consumption was on the rise for soup,

yogurt, fruit, grilled chicken, and chocolate milk. Let's put aside the

fact that there are heavily caloric restaurant yogurts, soups, fruits (say,

with granola), spicy grilled chicken (usually accompanied by cheesy,

crouton-laced Caesar salads), and chocolate milk; are public health

campaigns responsible for this "good news?"' NPD analysts insisted

that the global economic meltdown in 2008 and 2009 (and the resultant

decline in restaurant orders for kids' meals) could not explain the shift,

since the costs of healthier foods are comparatively on the rise. Bonnie

Riggs of the NPD said that "kids' tastes and preferences are changing."

Most parents of teenagers would find this astounding.

Left out of the media stories was the fact that young people between

18 and 24 had been eating more at "fast casual" chains,

which are just as caloric. Fast casual chains had simply lowered their

prices and spruced up their offerings to draw away calorie-craving

customers from Taco Bell, Burger King, McDonald's, and Wendy's. Yet

public health opinion leaders jumped on the story as proof of the power

of big-government social messaging to promote healthy weights.

Leann Birch of the Center for Childhood Obesity told the Times: "The

food industry is always saying, 'We're giving people what they want;

that's why we're giving you chicken nuggets, burgers and fries for your

kids.' That's not really true. If kids are given different options and if

parents make them available and let them choose some of those things,

I think quite often we see you do get shifts in eating."

To be sure, kids' tastes are malleable. Parents are an important part of the equation

because what they feed their kids early on will program their taste buds

for many years to come. And what parents feed their children depends,

to a large degree, on how much money they have to spend on healthy

food. But none of this means that the public health policy establishment

has been somehow responsible for the statistical plateau in childhood

obesity reported by the NPD.