During the debate over health care reform, a lot of people postulated the existence of what I started calling "magic pots of money": large expenses that could be cut, almost painlessly, in order to fund the new health care entitlement. There were a lot of these, from "unnecessary surgery" to "reforming end of life care". But probably my favorite was obesity. Our nation's excess avoirdupois was, it was alleged, costing north of $100 billion a year. And getting bigger all the time! (pun intended). Curb the nation's waistline, and you could achieve the holy grail of health care cost control, while simultaneously making the obese better off.
Like all the magic pots of money, it turned out to be underwhelming. It's very hard to make people thin, especially using the crude tools of public policy. And those crude tools aren't free: they have costs in both money and liberty. The public health experts had tried to argue away the liberty costs on the grounds that people didn't really want to eat fattening food; they were helpless victims, stranded in food deserts, trapped in the predatory claws of Big Food, or betrayed by agricultural subsidies that made bad food cheaper than good. (That last is a favorite of libertarians, who are happy to blame malign outside influences as long as those influences consist of government programs).
This was all wrong, argues a new article from Breakthrough. The "obesity epidemic" is poorly understood, but we have a good idea of what didn't cause it: food deserts, advertising, or agricultural subsidies:
For some foods, the healthier option is indeed more expensive than the less healthy counterpart, but for many other foods, the price between the healthy option and the unhealthy option is more or less equal. Lentils are as cheap as potatoes. Skim milk costs the same as whole milk. Low-sugar cereals are typically no more expensive than high-sugar brands. Many seasonal fruits and vegetables are extremely inexpensive — bananas average just 60 cents per pound.
The evidence shows that “the poor choose their foods not mainly for their cheap prices and nutritional values,” noted Abhijit V. Banerjee and Esther Duflo in Poor Economics, “but for how good they taste.” They quote George Orwell’s observation about poor British workers in The Road to Wigan Pier: “A millionaire may enjoy breakfasting off orange juice and Ryvita biscuits; an unemployed man does not … When you are unemployed you don’t want to eat dull wholesome food. You want to eat something a little tasty. There is always some cheap pleasant thing to tempt you.”
Meanwhile, federal agriculture subsidies appear to increase, not decrease, the cost of unhealthy foods.46 But even so, the impact of subsidies on food costs is negligible. This is because raw ingredients contribute very little to the overall cost of most processed foods. For example, raw potatoes cost 50 cents a pound, while potato chips average $4 a pound. The sugar in a $1.39 Big Gulp soda at 7-Eleven accounts for only a few cents of its cost. For such items, processing and marketing costs are what determine their prices. Eliminating subsidies would have little effect on what consumers pay for them.
The picture painted by advocates of grocery stores and gardens in the inner city was compelling to so many in no small part because it combined an established way of thinking about poor neighborhoods as materially deprived with rising cultural support from middle-class Americans for eating healthier, locally grown foods. This explanation of the obesity epidemic fostered in a highly misleading, and negative, picture of the poor as essentially passive victims of their food environment.
Obese people are choosing to eat the food that makes them fat--choosing from among an array of affordable, low calorie options. Why? Because they are hungry and it tastes good. That doesn't mean that I think obese people are weak, or "don't care about keeping themselves healthy". Weight seems to be largely genetic--it's highly correlated in families, and very highly correlated in identical twins. Obviously, something in our environment has activated those genetics, of course, but it's not a matter of personal virtue; it's a matter of how much your body wants to weigh.
But though overweight people are choosing what to eat in the face of genetic differences in hunger and metabolism, that doesn't mean we can say that they are not making a choice--that in some sense, they would really like the rest of us to take away their pasta and keep them on a diet of cabbage and carrots. Nor that they are victims of a broken food distribution system, or advertising mind control. People are finding and buying the food that they eat out of an array of low calorie options. Any public health crusade which fails to grapple with this central fact is doomed to fail.
As indeed, all of the public health crusades surrounding obesity seem to have failed. Read through the studies on obesity treatment or prevention and you see a large group of very well-meaning people struggling to find some reason for cheer among truly dismal results. One study of I read was touted as showing that "Childhood Obesity Interventions Focused on Environment Pay Off". The payoff? A mean reduction in adiposity of a third of a pound. And that reduction was heavily weighted towards children in the 0-5 range whose parents pretty much completely control their access to food; by the age of 13, even those meager results had largely disappeared. And this was not atypical; most studies show little long-term weight loss from dieting, environmental changes, or exercise programs. If you just cherry pick the studies that seem to show results, you get a somewhat brighter picture, but only somewhat; even the positive studies are pretty underwhelming.
But turning the overweight into victims of Big Food or agricultural subsidies (rather than, say, unlucky genetics combined with the increasing availability of affordable and delicious snack food) made it much easier to mobilize political support for a big public health campaign. Or at least, public health experts thought it would, argues Helen Lee:
Determined to cast the food industry in the role of big tobacco, influential public health scholars set about defining the causes of obesity in ways that they believed would predispose the public to support societal action to bring the industry to account. “The more an issue is framed in terms of involuntary risk, universal risk, environmental risk, and knowingly created risk,” wrote Regina Lawrence in the 2004 issue of the Harvard International Journal of Press/Politics, “the more likely the opinion environment is to be conducive to public policy solutions that burden powerful groups” (emphasis in original).20
They may have won the battle, and lost the war. Lee points out that the strategy was fundamentally misguided: the mobilization against Big Tobacco was not the main reason that smoking fell. Most of the decrease in smoking came before the tobacco lawsuits, and consisted of repeating the observation that smoking gives you cancer over and over and over again.
Such a strategy is unlikely to work with food. People are very much aware that huge helpings of starch and fat will make you gain weight--my great-grandmother knew this, and I'm not sure she even graduated from high school. Which may be why giving people information, like forcing restaurants to put calories on their menus, have shown modest-to-no success in getting people to eat less. (In one study, the number of calories consumed actually went up slightly!)
Instead, it becomes one more excuse to deny the agency of the people we're trying to "help". If you want Cheetos, then it's problematic for me to say that you can't have them. But if a big food processor is making you want Cheetos through a combination of high-tech food engineering and sneaky advertising, well then, it's only justice for us to swoop in and foil their dastardly plans.
Assuming away choice lets public health experts treat people like an epidemic, rather than individuals with tastes. Obviously, that allows us to impose enormous infringements on personal liberty.
But even if you don't care about that, Lee argues persuasively focusing on corporations takes the focus off things that indisputably do work, like encouraging modest exercise. Exhorting people to exercise more is a very thankless task that will be, at best, only weakly effective. On the other hand, if food deserts or corporate advertising are behind your epidemic, it's at leats possible to imagine some sort of centralized solution that could make a significant difference. But this is looking under the lamppost because that's where the light is best, rather than because that's where the keys are likely to be. Apparently, thanks to the experts, that's what we've all been doing for the last few decades.