CH.16 PUBLIC HEALTH ENEMY NO.2 AND GROWING: POOR DIET AND PHYSICAL INACTIVITY

Allcott, Lockwood, and Taubinsky put forward a set of principles for designing such taxes

1. Focus more on minimizing the harmful effects of sugary drinks, and less on minimizing sugary drink consumption itself. Many people enjoy unhealthy behaviors such as drinking soda or eating steak and dessert. The goal is not to deprive people of enjoyable activities, but instead to limit them to a level that balances the pleasure against the harm. This means a tax on soda may be more appropriate than, say, a ban. 2. Target the policies at the people who incur the most harm. For example, this may involve stronger policies related to sugary drink consumption by children. 3. Tax grams of sugar in these beverages rather than ounces of liquid. It is, after all, the sugar that is harmful. For example, Philadelphia's tax applies to regular and diet sodas equally, and excludes fruit juice, even though diet soda is far less harmful (or not harmful) and fruit juice is generally just as unhealthy as soda. In fact, there is little or no evidence that fruit juice is healthy—a common misconception among parents. 4. Implement the taxes over as wide a geographic area as possible. Evidence indicates that taxes imposed at the city level cause some people to simply purchase their soda outside city lines. A state-level tax, for example, reduces this problems.

Confronting the Obesity Epidemic

Costs of treating the diseases caused by overweight and obesity are estimated to account for as much as 20.6% of total U.S. medical expenditures and may have reached as high as $190 billion annually from 2000 to 2005. Approximately half of these costs are paid by Medicare and Medicaid (the government health insurance plans), and the other half by private health insurance and by individuals. The health consequences of obesity are serious, and the ineffectiveness of simply advising people to change their diet and exercise habits has led to the acceptance of more drastic measures. Bariatric surgery, which involves reducing the size of the stomach through implanting a gastric band or by surgically removing or bypassing part of the stomach, has been found effective in helping obese people to lose weight and to control diabetes. The National Institutes of Health suggests that bariatric surgery may be appropriate for obese people with a BMI of at least 40 and for people with a BMI of 35 together with serious coexisting medical conditions such as diabetes. However, it warns that there are risks associated with the surgery and people must be prepared to change their habits afterward. Also, some people regain some of the lost weight. An effective diet pill might be a less drastic approach than bariatric surgery in helping people to lose weight. In recent decades, the Food and Drug Administration (FDA) has been reluctant to approve weight-loss drugs because of fear of side effects. A drug combination called fen-phen introduced in the 1990s had to be removed from the market because it caused heart valve problems and pulmonary hypertension. More recently, the FDA has concluded that obesity has become such an important public health concern that pharmaceutical approaches to controlling it are badly needed and need not be risk-free. In turn, in 2012, it approved two new drugs: Belviq works by activating a part of the brain that controls hunger; Qsymia is a combination of an appetite suppressant and a drug that was approved to treat epilepsy and migraines. An older drug, orlistat, works by inhibiting the absorption of dietary fats. The FDA approved it at a lower dose as the brand-name product Alli, for over-the-counter sales. Orlistat may have unpleasant gastrointestinal effects and on rare occasions has been reported to cause liver damage.

Physical activity and health

Dieters who are physically active are more likely to lose fat while preserving lean mass. This combination not only promotes a healthier distribution of body weight (a lower WHR), but also helps people avoid the weight-loss plateaus that can result from dieting. Because lean mass burns more calories than fat burns, a dieter who loses muscle mass will end up with a higher proportion of his or her weight consisting of fat; thus, the individual will need fewer calories to maintain the new weight, making it more difficult to lose additional pounds. Exercise clearly protects against cardiovascular disease, as demonstrated by both epidemiologic studies and biomedical evidence. The Framingham Study found, as early as the 1970s, that the risk for both men and women of dying from cardiovascular disease was highest among those individuals who were the least physically active and that more activity was associated with lower risk. Exercise offers protection against both heart disease and stroke. Several studies have indicated that inactive men and women are more likely to develop high blood pressure than those who are active, and that moderate-intensity exercise may help reduce blood pressure in people whose pressure is elevated. Type 2 ("adult-onset") diabetes is related to weight gain in adults, especially weight gain distributed in an "apple" shape, a consequence of insufficient physical activity. The high prevalence of obesity among Americans contributes to the ranking of diabetes as the seventh leading cause of death in the United States—though this is probably an underestimate because many cardiovascular deaths have diabetes as an underlying cause.

Promoting Physical Activity

Employ the ecological model, intervening at numerous levels of influence Remove environmental barriers and provide places to exercise Suburban lifestyle is to drive everywhere Add sidewalks, walking trails, bike paths Pedometers increase physical activity and reduce BMI and blood pressure. As with most attempts to change people's behavior, the most effective approach to promoting physical activity is likely to employ the ecological model, intervening at a number of levels of influence. Efforts to motivate individuals to be more active must be combined with interventions that make the physical and social environment more conducive to physical activity. In part because research on the effectiveness of these interventions is difficult to do, most studies have focused on short-term changes in exercise behavior. Very little evidence suggests that any program has had long-term success in increasing physical activity among significant numbers of people. Many organizations and federal agencies recommend that healthcare providers counsel their patients about physical activity. However, the evidence is mixed as to whether such counseling actually motivates individuals to exercise more. Studies of the effectiveness of counseling find that counseling practices of primary care physicians are highly variable, ranging from a brief recommendation to be more active to a referral for intensive counseling by health educators. Somewhat more effective are community-wide campaigns that include improving access to places for physical activity and using group settings to help people set individual goals, teaching skills for incorporating activity into daily routines, and providing social support to people trying to adopt healthier behaviors.

Body Mass Index (BMI)

From a public health perspective, obesity is usually defined more precisely in terms of body mass index (BMI). BMI is calculated by dividing a person's weight in kilograms by the square of his or her height in meters.

Youth Obesity

In 2005, the Institute of Medicine published a report called Preventing Childhood Obesity: Health in the Balance. Calling childhood obesity a "critical public health threat," the report recommends steps that federal, state, and local governments should take to make prevention of obesity in children and youth a national priority. These recommendations include developing guidelines for advertising and marketing of foods and beverages to children and giving the Federal Trade Commission authority and resources to monitor compliance. The report notes that "more than 50 percent of television advertisements directed at children promote foods and beverages such as candy, fast food, snack foods, soft drinks, and sweetened breakfast cereals that are high in calories and fat, low in fiber, and low in nutrient density." It also recommends that governments should develop and implement nutritional standards for all foods and beverages sold or served in schools. In recent years, food and beverage companies have invaded schools with vending machines selling unhealthy drinks and snacks, fast food in school cafeterias, and special educational programs and materials accompanied by advertisements for fast food and junk food.

How much exercise is enough, and how much do people get?

In 2006, the Department of Health and Human Services decided that guidelines for physical activity should be developed, similar to the dietary guidelines. Separate guidelines were developed for children and adolescents (60 minutes or more daily of physical activity) and adults (150 to 300 minutes per week of moderate-intensity activity or 75 to 150 minutes per week of vigorous-intensity aerobic activity). Evidence shows that television and computers may be important factors in children's physical inactivity. A number of studies have found that childhood obesity is positively associated with time spent watching TV. The American Academy of Pediatrics issued new guidelines for children's media consumption in 2016, lowering the advised level.

Calorie labeling

In May 2018, a provision of the Patient Protection and Affordable Care Act went into effect that requires restaurants in the United States with at least 20 locations to post calorie counts on their menus. That includes the calories in popcorn at movie theater chains and the calories in drinks at bar chains. The effectiveness of providing this additional information may be relatively limited—but more study of these policies is needed and perhaps different implementations may prove effective. Unfortunately, the Donald Trump administration has been working against these policies. While the calorie labeling law went into effect in 2018, that occurred only after the administration delayed the implementation at the behest of the restaurant lobby. As part of its renegotiation of the North American Free Trade Agreement (NAFTA), the Trump administration has also pushed to limit the ability of United States, Canada, and Mexico to include health warning labels on packaged foods that are high in sugar and fat.

Sin tax

Like cigarette and alcohol taxes, soda taxes are a sin tax—a tax that raises the price of a product that is harmful to oneself and others—in an attempt to discourage consumption of that product.

Promoting healthy eating

Nevertheless, public health advocates have attempted to apply the ecological model of health behavior to create a social environment that favors healthier eating. For example, making nutritious foods more readily available—intervention at the community and institutional levels—should encourage people to choose their foods more wisely. The food industry is responding to many consumers' concerns about weight and health by providing a greater choice of low-calorie foods. Many restaurants offer "heart healthy" selections on the menu, with labels guiding customers to these choices. Worksite and school cafeterias may also provide healthy food choices, including salad bars. While such measures do not guarantee that people will eat a healthier diet, they remove barriers that make it more difficult for people to do so. Enhancing self-efficacy and providing social support are ways of promoting healthy eating at the level of the individual and his or her family and friends. Social support is provided when a whole family is willing to adopt a diet together, as well as by group programs such as Weight Watchers. Self-efficacy can be improved by "point of choice" postings of nutritional information, which can help shoppers who are concerned about the nutritional content of food but do not know how to make wise choices. Several major campaigns using point-of-choice postings have been conducted by supermarket chains in collaboration with health advocacy organizations such as the American Heart Association, but the results have been mixed. Other approaches to enhancing self-efficacy and adherence to diets include demonstrations of healthy cooking methods and practice in calculating portion sizes. The success of the public service announcements of the 1960s, together with later bans on cigarette advertising in the broadcast media, in reducing smoking prevalence inspired a number of media campaigns to promote more healthful eating. One such campaign was California's "5-A-Day" Campaign for Better Health, which attempted to increase fruit and vegetable consumption among state residents to five servings per day. Another problem with the "5-A-Day" approach is that fresh fruits and vegetables are relatively expensive and are often unavailable in poor neighborhoods. Fast-food restaurants, by contrast, are inexpensive and are often concentrated in low-income neighborhoods. Moreover, U.S. government policy subsidizes industrial agriculture, which produces high-calorie commodities at the expense of more nutritious produce. Food advertising focuses predominately on processed foods, which are more profitable for the industry. A number of proposals have been made to tackle the obesity epidemic with tools similar to those that proved successful in the "tobacco wars." In addition to the educational campaigns such as the "5-A-Day" fruits and vegetables initiative, they include requirements for food labeling and advertising to carry information on calorie, fat, and sugar content and prohibitions on making misleading health claims. Fast-food restaurants would also be required to provide nutritional information on packages and wrappers. The nutritionist Nestle has proposed placing taxes on soft drinks and other junk foods to fund "eat less, move more" campaigns and perhaps to subsidize the costs of making fruits and vegetables more widely available.

Taxing Sugar Sweetened Beverages

Notably, consumption of sugar-sweetened beverages significantly increases the risk of type 2 diabetes. Because the sugar in these drinks is more rapidly absorbed into the bloodstream compared to sugar in solid foods, they are particularly effective at promoting diabetes. These health burdens fall disproportionately on lower-income households.

Psychological issues

Obesity in children also tends to cause psychological problems such as depression, anxiety, social isolation, and low self-esteem. Children who are worried about their weight may adopt diets that affect their physical as well as their psychological health, and they are at increased risk for eating disorders such as anorexia and bulimia. Obese children are less likely than thinner ones to complete college and are more likely to live in poverty.

Dietary Guidlines for Americans (DGA)

Since 1980, the U.S. Department of Agriculture and the U.S. Department of Health and Human Services have reviewed the recommendations every five years and have released reports called Dietary Guidelines for Americans.

Overweight

The National Institutes of Health and the Centers for Disease Control and Prevention (CDC) have agreed on a definition of overweight as a BMI between 25 and 29.9, obesity as a BMI of 30 or greater, and severe obesity as a BMI of 40 or higher. Most studies show that weight-associated health risks begin to appear at a BMI of about 25, and rise more significantly above 30, with the risks increasing in proportion to the severity of an individual's obesity.

Epidemiology of Obesity

There are significant racial differences in the prevalence of overweight among women: 80.6% of non pregnant black women are overweight, compared with 64.6% of white women. Among men, the difference is reversed: 70.6% of black men compared with 75.2% of white men are overweight. The health effects of overweight and obesity are also less marked among blacks. The optimal BMI has been calculated to be 23 to 25 for whites, but is 23 to 30 for blacks. The risks of excess weight are known to be higher for Asian populations, so the BMI cutoffs recommended by the World Health Organization are lower for them. Socioeconomic status has a significant influence on the prevalence of obesity. College graduates of both sexes are thinner than men and women with fewer years of education. The difference is especially significant among females: Those with less than 12 years of education are nearly twice as likely to be overweight as female college graduates.

National health and nutrition examination survey (NHANES)

Today, poor diet and physical inactivity are ranked among the top two factors identified as leading actual causes of death in the United States. Many studies have shown that weighing too much increases people's risk of cardiovascular disease, diabetes, most kinds of cancer, and a variety of other diseases. Getting people to lose weight, however, seems to be even more difficult than getting them to quit smoking, although many of them want to be thinner. According to the 2013-2016 National Health and Nutrition Examination Survey (NHANES) 56% of women and 42% of men are trying to lose weight, most of them unsuccessfully.

Waist-to-hip ratio (WHR)

While being fat is bad for people's health, the distribution of fat on the body makes a difference in the health risks. Obesity researchers distinguish between apple-shaped people and pear-shaped people, and they have found health risks to be greater for those individuals shaped like apples. People who gain weight in the abdominal area, as men usually do, have a higher risk of cardiovascular disease and diabetes than do people who gain weight in the hips and buttocks—a pattern more common in females. Fat distribution is measured as a waist-to-hip ratio (WHR), with the waist measured at the smallest point and the hips at the widest point around the buttocks.

Diet and nutrition

epidemiologic studies show that breast and colon cancer risks are greater in populations who eat diets high in meat and low in fruits and vegetables. Diet is a major factor in development of type 2 diabetes, which is often brought on by obesity and which can usually be controlled by careful eating. Osteoporosis, a debilitating disease of the elderly, especially white women, is likely to become increasingly common because young women are not getting enough calcium, best obtained in dairy products. Federal surveys suggest that one important cause of increasing obesity, especially in children, is increased intake of sweetened beverages. The proportion of calories that the average American obtained from soft drinks and fruit drinks more than doubled between 1977 and 2001 and remains high. According to the researchers, reducing soft drink and fruit drink intake "would seem to be one of the simpler ways to reduce obesity in the United States.

Surgeon generals call to action to prevent

its purpose was to develop a national plan and to forge coalitions of governments, organizations, and individuals to promote healthy eating habits and adequate physical activity, beginning in the childhood and continuing across the lifespan.

Obesity

obesity is a complex condition, influenced by genes as well as by many individual and social factors that include eating and exercise patterns. While being overweight has a health impact in itself, a person's disease risk may also be affected independently by dietary patterns and the amount of physical activity, whether or not he or she is overweight. Public health advocates, therefore, seek to promote healthier eating patterns among Americans, to encourage them to exercise more, and to reduce the percentage of people who are overweight.

Sugar sweetened beverage tax

the relatively worse health effects of sugar in liquid form compared to solid form, have increased calls for a sugary drink tax. Although the Maine legislature passed a tax on sugar-sweetened drinks, the law was subsequently repealed by voters. Chicago also passed a soda tax that was quickly repealed. However, in 2014, Berkeley, California, became the first U.S. city to pass a law taxing sugary drinks—and it has stuck. As of 2019, six additional U.S. cities—three in California, plus Boulder, Philadelphia, and Seattle—have implemented a sugar-sweetened beverage tax