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Think Tank

How Should Policymakers Deal With the Fattening of California?

Most Californians, if they aren’t already fat, probably will be in the next decade or two.

If current trends continue unchanged, at least half the U.S. adult population will be obese by 2030, according to a recent survey conducted by Columbia University and Harvard University researchers. Obesity rates in California have more than doubled since 1990. More than 20% of the state’s adults now are considered obese, according to the Public Policy Institute of California.

California isn’t alone.

In addition to each of the U.S. states, many of the world’s nations are getting fatter as well. Obesity is becoming a problem in low- and middle-income countries, according to the World Health Organization’s Collaborating Centre for Obesity Prevention. The United Nations’ first high-level meeting on non-communicable diseases is scheduled for this month, and researchers say obesity should be high on the agenda.

“Governments certainly need to lead obesity prevention, but so far, few have shown any leadership,” said Steven Gortmaker, professor at the Harvard School of Public Health and co-author of an obesity report published in the journal Lancet last month.

In addition to the personal costs of increased chances of chronic health problems, obesity carries a substantial monetary toll. In 2009, California’s obesity-related medical costs were $15.2 billion — the highest in the country – according to researchers.

Some California companies and communities have embraced parts of a national campaign to promote healthy eating habits and exercise.

Earlier this year, a proposed soda tax effectively fizzled out in the California Legislature. AB 669 by Assembly member Bill Monning (D-Carmel) proposed a one-cent tax for each ounce of sweetened beverage sold in California. The money would have been used to promote healthy habits for kids.

Some health advocates contend that incentives for adopting healthy lifestyles — similar to incentives for not smoking tobacco — could help turn the tide.

What should California do? At the most basic level, there are three courses of action:

  • Educate people about the hazards of obesity and hope they make good choices;
  • Punish bad behavior through taxes or other punitive measures; or
  • Reward good behavior through reduced insurance premiums or other incentives for making healthy choices.

We asked legislators, policy analysts and other stakeholders which course California should pursue? All of them? How? When?

We got responses from:

Promoting Health and Wellness on All Fronts

There is an obesity epidemic in California and across the country that is creating a surge of children with an increased risk of diabetes, heart disease, poor oral health and other preventable chronic conditions. Absent a comprehensive obesity prevention plan, future generations will have a shorter life expectancy and we will all be paying for it.

In response to this public health crisis, I have introduced AB 669, which would place a penny-per-fluid ounce tax on sweetened beverages. Revenue from a sugary drink tax would be directed to the California Children’s Health Promotion Fund and used exclusively to combat childhood obesity by providing resources to local schools and community-based nutrition and wellness programs statewide. Although the bill did not pass this year, it remains active, as support is growing among those who see the bill as a means to pay for the rising costs of the obesity epidemic.

By increasing the price of the biggest contributor to obesity, we not only place the cost of sweetened beverages on par with healthful beverages, we can better inform consumer behavior. An increase in the price of sugary drinks will be a deterrent to those who might consume these drinks in excess, similar to what has been achieved through the implementation of increased taxes on cigarettes.

However, placing a tax on sweetened beverages is not a cure-all to this multifaceted issue. Policymakers will need to leverage the funds generated to develop a broader public health campaign that counters the massive advertising budgets used to market high-sucrose drinks and other unhealthful options directly to children. Additionally, funds need to be dedicated to programs that educate parents and children about healthful choices and inspire lifetime habits of exercise and healthful eating.

There is no silver bullet to avert this crisis, but we cannot afford to sit by while the childhood obesity epidemic overwhelms our health care system and shortens our children’s lives. I have seen families struggle to offer healthful cuisine choices. An abundance of cheap, low-nutrient, high-calorie foods and drinks like soda have become diet staples in rural, low-income and minority communities.

We need to foster environments that make better, healthful choices easier. Our children’s lives depend on us developing innovative and practical approaches to address the health, social and environmental inequities associated with trends of obesity. Government alone cannot do this, but working together we can build a healthier California.

Policymakers Should Address Root of Problem

Today’s obesity crisis was no coincidence. In many ways, it was a well-engineered and forgone conclusion stemming from a food system run amok.

America has not always had a weight problem. In fact, only in the last three decades has there been a dramatic climb in rates of overweight and obese residents. During that same period, we’ve seen the food and beverage industry take an ever-increasing and dominant role in shaping the American diet.

Here’s just one example: where we once had turned on the tap to quench our thirst, the beverage industry now spends billions of dollars to convince us to instead grab a bottle of soda, sugary iced tea, Gatorade, Frappuccino or Red Bull. It spends $500 million a year marketing sugary drinks just to children. And it works!

Consumption of sugary drinks has more than doubled in the last 30 years. Not only are we lining beverage company coffers with each purchase, but we’re also adding dozens of teaspoons of sugar (16 teaspoons per 20 ounce bottle) and hundreds of new calories to our diets.

So I’d suggest that your three categories of policy don’t get at many of the underlying causes of the problem. Policymakers also need to pay more attention to industries that are doing everything in their power to convince us to make the unhealthiest choices, often at the expense of healthier alternatives.

It is naïve and unsustainable to try to fix only one side of the equation. We can educate, cajole and punish consumers until we’re blue in the face, but when the easiest, most attractively marketed and often most affordable choice is calorie-laden junk foods and sodas, what do we think consumers will grab much of the time?

A few years ago, California led the nation by banning junk food and soda from schools. We also led the way in 2009 by passing labeling to put calorie information on menus. Both of these were aimed at helping consumers make better decisions by stripping away the overpowering marketing advantages of the food and beverage industry. In both cases, industry fought us tooth-and-nail because we were undermining their business model of overwhelming consumers with unhealthy choices and incomplete information about their products.

If policymakers are serious about addressing the obesity crisis, they would be smart to look at what has caused the epidemic in the first place and develop policies that put some limits on the runaway marketing of unhealthy products, starting with marketing that specifically targets our children.

Policies To Stem Obesity, Generate Local Revenue

There’s no question that the obesity epidemic — beyond its impact on children and families’ well-being — poses a serious threat to California’s future.

Medical expenses and other costs associated with obesity are putting a major burden on an already overwhelmed health care system. In California alone, the annual cost of health care and lost productivity from obesity and related conditions has topped $40 billion. Lower-income Latino, African-American and other communities of color have the highest rates of obesity but the least access to medical care or preventive services.

The obesity epidemic puts more than our health care delivery system at risk. Businesses suffer along with an unhealthy workforce, and corporate investors are backing away from communities with high rates of obesity and other diseases. Obesity also poses a threat to our military security. Last year, a former head of the California Army National Guard cited Department of Defense statistics showing that more than a quarter of all young adults are too overweight to join the military, urging Congress to act quickly to help reduce obesity rates.

We need to push for policy interventions that not only can stem rising obesity rates but also build new sources of revenue statewide. Local and state policymakers already face a multitude of competing priorities, as they struggle to navigate California’s unprecedented fiscal crisis. So while the economic consequences of obesity have become too great to ignore, the question of how simultaneously to prevent and to finance obesity prevention also looms large.

The most promising solution lies in new fiscal policies — whether that means taxes on products like soda that contribute to obesity (where, like tobacco taxes, the revenue is earmarked for programs to prevent or treat disease), or local government incentives for businesses to rebuild communities with new opportunities for physical activity and access to healthy food.

Local business incentives are an especially powerful way to reshape California communities bearing the greatest burden of the obesity epidemic. Every day, business owners and real estate developers make decisions that have tremendous impact on our health. Local governments can provide incentives for them to establish healthier food outlets, build parks and playgrounds, and create neighborhoods where it’s easier for residents to walk and bike to meet their daily needs.

How? For one thing, by easing the bureaucratic burden for businesses and developers that commit to important features to promote residents’ health — pedestrian-friendly amenities like wide sidewalks and bike paths, or the equipment and know-how corner store owners need in order to stock healthy perishables like fruits and vegetables. Streamlining the process to get a license or get building plans approved, reducing fees or providing zoning exemptions all can make it easier for a developer to move through a project — and more lucrative to locate in a neighborhood in need.

Incentive policies like these are part of the “Health in All Policies” approach in California that more than 19 state agencies are now beginning to promote, taking a cue from European leaders to systematically consider the health impact of all government policy interventions.

As the obesity epidemic threatens to overwhelm our health care delivery system, health care professionals need to work in partnership with the public health community on a holistic approach to the problem. Moving beyond the clinic walls, the health care sector can build support for policies that promote not only residents’ health but also the economy. We have at our disposal an array of policies that can generate resources to sustain our health and our economy, and we need to pursue them now more than ever.

Education Trumps Punishment

California, like much of the rest of America, suffers from an obesity epidemic for which there is no single cause or simple cure. The case for building new models to address this epidemic is based on three principles:

  1. California’s current health status: Poor nutrition, inactivity and lack of exercise now are causing serious health problems, including type 2 diabetes, heart disease, stroke and cancer, and if left unchecked, these conditions will all worsen. Public health will be compromised, the economic impact will grow, and productivity will decrease;
  2. Competing environmental forces: Choices that lead to poor nutrition are often more convenient, affordable and aggressively marketed than healthier options. Opportunities for physical activity are not readily available where people live, work, learn and play; and
  3. Fragmented, uncoordinated efforts to remedy problems: Many countermeasures are being pursued by government, industry, voluntary and philanthropic sectors, but they lack coordination.

How do we work toward lasting behavioral changes? Punish those who have not ultimately made good choices? No! We should focus on promoting wellness and chronic disease prevention in the workplace, community, and our schools.

We need to look at a multipronged solution and examine root causes. This includes improving access to healthier foods; creating more livable, active and safe communities; educating the public about both the problem and its prevention; and encouraging employers to develop wellness programs.

Education, Incentives Are Best Choices

The hot idea in the war on obesity? Taxes.

In Arizona, policymakers are considering a tax on obese Medicaid patients. In Philadelphia, Mayor Michael Nutter launched his second attempt to impose a city soda tax weeks ago. President Obama’s debt commission has championed the idea. In California, Assembly member William Monning (D-Carmel), the Assembly Health Committee chair, introduced a bill in February to tax soda.

It’s not just here. Across the Atlantic, France just levied a soda tax. Denmark’s new tax on fat takes effect in October; and the Swedes are considering a calorie tax.

Among these different tax proposals — the soda tax clearly being the most popular — one common idea emerges: if people are eating too many calories, hit them in the wallet.

But call me a fat tax skeptic. By all accounts, even the most favorable studies argue that dietary taxes have to be very high — in the 18% to 25% range — before they’ll have any real impact on consumers. Even then it’s not clear that people will eat healthier; they may just shift their calories. People may put down the root beer when it’s taxed heavily and pick up the potato chips.

The approach is overly simplistic. Coke isn’t the reason why Americans are too heavy. It’s our entire diet — and lack of exercise.

What then is to be done?

At a time of rising obesity rates, we should emphasize physical education in our schools and better food in their cafeterias.

Washington, D.C., spends billions of dollars subsidizing big business and bad health choices through agricultural subsidies. It’s difficult to ever see the justification for this, but, at a time of record deficits, there is none.

Health insurance needs to move from a model of sick care to one that promotes wellness. That means, yes, incentives for better health choices.

And, finally, we need to practice more restraint in our eating habits.