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| Age-adjusted prevalence of overweight and obesity among U.S. adults, age 20-74* |
Given the realistic fiscal limits of funding the U.S. health care system, it is important that resources be directed towards the most cost effective measures to improve the public health. Public attention towards reducing the prevalence of obesity is one area that promises significant benefits if it can be achieved. Obesity is associated with significant health risk and increases the prevalence of diabetes, hypertension, cardiovascular disease, gallbladder disease and arthritis. Over the past few decades, the prevalence of obesity in the United States has progressively increased with the proportion of persons with a BMI of >25.0, rising from 47.1 percent in the 1970s to 66.2 perent in 2004 and doubling of the levels of obese persons with a BMI of >30.0 from 15 percent to 32.9 percent, respectively. There is much debate as to the cause of this epidemic, including the increase in consumption of high caloric food and drink and the reduction in physical activity. Likewise, there is much debate over the solution and means of both prevention of the development of newly obese individuals and the means of helping already obese individuals to reduce their body mass index.
An effective solution must be firmly based in a realistic understanding of physiology, human nature and an understanding of the economic impact of public policy on both industries and individuals.
First, consider the reality of human physiology. The human body is designed to sustain periods of plenty and periods of scarcity as occurs in the normal seasonal cycles of nature. We are therefore designed to eat whenever food is available and to store excess calories for use as energy when food is unavailable. Therein lies the first problem -- food is rarely unavailable in American society.
Furthermore, the human body operates as efficiently as possible. Since the most efficient source of energy is to burn carbohydrates, these will always be consumed by the body first. Excess calories not immediately required for consumption will be stored as fat for later use. Herein rests the problem: as long as there is sufficient dietary consumption of carbohydrates to meet our caloric expenditures, we will not use stored fat reserves.
Next, consider human nature. The development of self discipline is a challenge for most people. Virtually everyone has some areas of life in which they have difficulty with self control. While self discipline should be nurtured, it is time we accepted the fact that for most people, perpetual self discipline in a social environment that does not support healthy choices is extremely difficult.
Finally, consider the economic factors which influence our dietary choices. On the industry side, fat, sugar and salt are added to food primarily for two reasons, to satisfy consumer preference and to prolong shelf life. Both of these factors (high consumption and prolonged shelf life) contribute to the ability of the food industry to offer these foods at a lower price. On the consumer side, the affordability of these foods as well as societal norms and acquired taste preferences contribute to increased consumption, particularly in lower socioeconomic populations.
In view of these considerations, public policy should be directed towards supporting healthier consumer choices with regard to diet and exercise. One important aspect should include financial subsidies for fresh foods and taxes on highly processed foods, particularly those containing excessive amounts of fat and refined carbohydrate. This would remove some of the existing economic barriers to making better dietary choices for both industry and consumers. Just as we would not expect the population to individually boil or filter their water supply in order to provide clean water, it is unrealistic to expect the population to regulate diet and exercise through solely individual efforts. Exercise could be encouraged by local and regional planning and government subsidies for neighborhood walkways and "no drive" areas in central business districts. Similarly, employers and schools should be encouraged to remove foods that contribute to obesity from vending machines and cafeterias and replace them with healthier choices to help people increase dietary compliance and develop healthier food preference. Public policy should focus on ways of aligning financial incentives with health-promoting behavior for both communities and individuals.