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.