The Weight of the Nation: How Many Rounds Ahead for This Public Policy Fight?

Paul E. Terry, PhD

I expect the next 10 years of policy debates, action, and inaction concerning how to curb our obesity epidemic to be an accelerated version of the last 30 years of public policy related to fighting tobacco.

This week’s HBO documentary, The Weight of the Nation, landed a flourish of solid blows against the wrong-headed notion that obesity is simply about lack of will power. The broadcast is based on the report “Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation.” It’s the product of an extraordinary, even historic coming together of the Institute of Medicine, the Centers for Disease Control, and the National Institutes of Health. The report and the documentary make one point exceedingly clear: Obesity is a multifaceted problem that will require multifaceted solutions.

Like our decades-long campaigns against tobacco, these experts emphasize how confronting obesity will require that we confront the very nature of our obesogenic environment by rethinking our approach to food production and today’s overwhelming supply and unfettered access to unhealthy food choices, especially among our youth. Accelerating enactment of policies to reverse this trend is the right vision, but this is just round one. Today’s reactions to regulations concerning food are a shrill echo of those of tobacco users in the 1970s. (What do you mean I can’t smoke whenever and wherever I want?) To be sure, there will be those who point out the basic differences between a deadly addictive substance with no social value and food, which is a requirement of life. But, as Gary Taube, my favorite food science journalist, argues this month in Newsweek, even the high-powered experts behind The Weight of the Nation will fail if they keep pushing the same tired arguments. 

In Taube’s article, “Why the Campaign to Stop America’s Obesity Crisis Keeps Failing,” he cuts to the chase. This fight isn’t about vilifying food and harping about calories in and calories out. It needs to be about the part of the nutrient, fat, and hormone interaction that’s not really controversial. Our hard-to-avoid and nearly impossible-to-resist access to sugars and refined grains is why countless of our children have Type II diabetes for the first time history and why they may be the first generation with a shorter life span than their parents. The solution is a policy no-brainer: limited access to junk food with easier access to healthier proteins, complex carbs, and rich, leafy green vegetables.

No one dedicated to public health will be claiming a victory anytime soon in the fight against tobacco, but some bruising lessons from what has been a glacial but winning strategy are clear. Foremost among them is to brace for the many rounds ahead. As much as health advocates are hoping to create the urgency to enable knock-out punches against the current supply chain, the economic and political forces against rapid change are simply too powerful. One needs to look no further than the First Lady’s “Let’s Move!” campaign to be reminded of the foibles and complexities of public/private partnerships for effecting change. The last year has witnessed public displays of industry cooperation and, at the same time, millions of dollars of lobbying against healthy changes to school lunches.

Another lesson from the tobacco battles is perhaps the hardest to absorb. The work of individual behavior change and social policy change must be concomitant.  When I read the chapter of the “Accelerating Progress in Obesity Prevention” report on Health Care and Work Environments, I found the recommendations to be tepid at best. For example, companies “should consider” the use of financial incentives for healthy choices and should “provide access to healthy foods and beverages.” Hello!?! I might have found this interesting advice in 1970, but progressive companies have been doing this for decades. They are now elevating their work in employee wellness to embrace the best of behavioral economics for positioning food choices, and are using game-theory-caliber incentive schemes to drive healthier choices. What’s more, the most effective programs are striking a shrewd balance between encouraging participation in offerings such as health coaching at the same time they work on building a culture of health that better enables sustainable behavior change.

Finding the right balance between individual and social responsibility is a must if this is to be a fair contest rather than a bloody rumble. In a prior post I wrote about how my IT colleagues were making access to “Greasy, Globby Doughnuts” way too easy. George, our chief technology officer, good naturedly refers to that article as “Doughnut-gate” here at StayWell.

Regulating food can come across as insolent with respect to some of our core values. This is not only a debate about liberty versus responsibility, perhaps our strongest-held values; I would argue that the tension runs even deeper than that. Food policies touch on primal rituals of social connectivity and our basic needs for comfort and security. Before I submitted the “Greasy Donuts” piece I asked for a review by Rob, the person in IT who had brought the doughnuts in that day. He said he understood the points in the article and also wrote me back a very thought-provoking essay of his own. While he acknowledged that he had “absolutely no anguish” over refraining from bringing in more doughnuts, he also wrote about the incontrovertible relationship between the demands of the workplace and the need for colleagues to come together in mutual support over food and drink, especially when under stress. Rob’s smartly grounded feedback is why I ended my Doughnut-gate essay with the question, “What workplace policy maker can wield endless demands on one hand and reprove a simple pleasure like comfort food on the other?”

So, while my initial reaction to the The Weight of the Nation is that it’s too tepid for my tastes, perhaps the authors have some wisdom or patience I’ve yet to find in my own approach to fighting for health. Still, if we lose in early rounds of the fight, we can always find renewed energy from knowing we’re on the righteous side of the ring.

A terrific advantage I personally enjoy as I consider strategy for the many rounds in the battle ahead is that one of the leading minds in the population health management movement occupies the office next door to me. With respect to the IOM recommendations that policy makers should consider incentives, Dr. David Anderson, chief health officer at StayWell, recently wrote that “the horse is out of the barn” on the use of workplace incentives for health.  In David’s essay on “Health Care Reform 2012: What Congress Giveth… the Supreme Court Taketh Away?” he argues that there are enough systemic differences between the ACO and the HMO models that the market is now “intrigued by the prospect of a delivery system with incentives truly aligned to improve population health.”

David and I are heading out after work to debate George and Rob about The Weight of the Nation. Though our food choices may vary, our beverages of choice are predictably similar and are sure to keep the conversation lively.

Paul E. Terry, PhD, is CEO of StayWell Health Management.

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