Health policies for obesity: how to get there!

A recent study presented the perspective of a ‘citizens' jury’ assembled from diverse groups of citizens in Australia, on the use of policies for preventing obesity in children.¹ The jury made recommendations for ‘health promotion and education, regulation of food marketing, food taxation or subsidy and a parliamentary inquiry’. This study is only one of the numerous calls for action to address the global challenge that obesity presents. There is hardly any disagreement about the need to curb obesity and its adverse health effects. However, from the unabated global obesity epidemic, it is evident that prevention or treatment strategies that can effectively combat the epidemic are lacking. Lifestyle modification with or without pharmacology or surgical treatment form the cornerstone of current approaches for obesity treatment. However, these approaches have two major limitations. First, the treatment outcome is grossly inadequate for a vast majority of individuals, and second, it is inconceivable to deploy these highly individualized and resource intensive treatment approaches for 600 million people affected with obesity worldwide (http://www.who.int/mediacentre/factsheets/fs311/en/). Considering the challenges in treating obesity, its prevention instead sounds like a better alternative. However, reports that demonstrate successful prevention of obesity are virtually nonexistent. It is apparent that we need new strategies to effectively treat as well as prevent obesity en masse. Population level health policies may be one such approach. Such policies hold the promise to reach a large number of individuals and to influence their body weights, which is untenable with currently available treatment approaches.

This special issue addresses the potential for health policies to influence obesity. It is titled, ‘Health policies for obesity. Are we there yet?’ The issue contains invited commentaries from four research groups. These are independent articles and not point-counter points or debates. The topics include the discussion about how health policies could potentially influence obesity,² and challenges in developing policies that are effective and their intended and unintended consequences.^{3, 4} Finally, Richardson et al⁵ outline a process for developing effective health policies.

Peeters² seems generally in favor of health policies to combat obesity, and, makes several excellent points. She emphasizes ‘policy making’ and ‘policy evaluation’ as two separate aspects. She also notes that implementation of impractical policies is unrealistic and cites examples of the futility of promoting fruits and vegetables consumption if they remain prohibitively expensive, or promoting public physical activity when a community lacks safe public places. As indicated by their title, Binks and Chin cover ‘the challenges in developing effective health policies for obesity’.³ They acknowledge the need to reach out to larger proportion of people, but argue that health policies have thus far shown ‘minimal to modest impact’ and may be ‘detrimental to personal autonomy and empowerment’. Alternately, they profess the use of non-regulatory means to achieve change. Binks and Chin caution about clearly distinguishing between the objectives for a policy for prevention vs treatment of obesity. Lusk⁴ outlines the economic aspects of health policies for obesity. In economic terms, he addresses an age-old conundrum about the right of an individual to make legitimate lifestyle decisions. This is often countered by arguing that in a society, someone else may have to pick up the share of a person’s ill-health. In response, Lusk states that ‘it may not be fair that the public insurance forces individual A to pay for individual B’s medical bills, but redistributing the burden has no aggregate economic consequence’. He further argues that those affected with obesity also bear many ‘direct and private’ costs due to obesity. Finally, Lusk outlines that health policies to influence obesity prevalence can have tradeoffs with personal and economic freedom and technological progress.

Taken together, in this special issue, Peeters sees substantial potential in health policies for combating obesity. Whereas, Binks and Chin³ caution against yielding to pressure to ‘do something’ and enact health policies based solely on intuition, good intention and emotion, but without thorough consideration or evidence. Furthermore, Lusk⁴ urges us to consider whether the magnitude of change expected from health policies is meaningful, as it can be influenced in many ways in real life. For instance, the policy for taxing soda expects obesity reduction by reducing soda consumption. This reasoning ignores the reality that many non-soda replacements such as milk, juice or beer could replace the soda-calories. These three very thoughtful and well developed commentaries make several excellent points. Health policies seem to have a potential to impact obesity. However, considering the resources needed in developing and implementing a health policy, it is imperative to consider the evidence for efficacy, and intended and unintended consequences before implementing policies and to evaluate post-implementation impact. Richardson et al⁵ present such a methodical approach to first examine the development of scientific evidence for health policies for obesity and then discuss how such evidence could be generated.

Obesity is a complex and chronic disease that does not yield to simplistic sounding solutions. Addressing obesity may need concerted efforts on many fronts. HIV-AIDS is an example of a chronic disease that is addressed at multiple levels, including active research for better prevention and treatment strategies, patient care, education, social reforms and policies. Similarly, health policies may play an important role in combating obesity in conjunction with other approaches. The field of health policies has had some notable successes such as food fortification policies or in smoking reduction. The optimism is that similar success could be achieved in obesity control. However, the differences are also worth noting. In general, food fortification approaches are policies of ‘addition’ and not deletion or removal of food, or taxation. Not much of decision making was expected from people, who could simply continue using fortified salt, bread or milk. Tobacco policies have a singular message: Do not smoke. Of course, one could live without tobacco, not food. So, unlike smoking cessation, food cessation cannot be a message. A food policy equivalent for tobacco policies would have been policies favoring certain brand of cigarettes over other, limiting smoking to say half a pack or instead of full, or selling packs that contain only three cigarettes and so on. Instead, the decision making is binary, limited to smoking or not smoking. Obesity related health policies around food require substantial decision making, which may need accompanying education.

It is reasoned that formulating a policy around obesity or even public discourse on the topic may elevate visibility for the topic. Nonetheless, it is hard to justify any departure from evidence based scientific approach in identifying health policies for obesity. Future considerations should include feasibility, efficacy, and intended and unintended consequences for the population targeted by a health policy. Intended objectives of a potential policy need to be carefully defined. For instance, a change in behavior or purchase habits of certain foods are not surrogates for obesity reduction, unless demonstrated otherwise. A policy that leads to an increase in the purchase of fruits and vegetables should not be assumed to impact obesity. To consider this policy useful for obesity, evidence is needed to verify that the greater purchase of fruits and vegetables led to their greater consumption, which in turn displaced higher calorie alternatives and resulted in a sustained and meaningful negative energy balance, and that obesity was actually impacted. Considering the resource mobilization involved, it is hard to justify implementation of policies for a specific purpose without supporting evidence. It is also important to consider the effect of policies on those who are not the intended target. As outlined by Dhurandhar and Thomas⁶ ‘by mandating change, public health policies may influence every individual in the population, independent of their personal risk to-benefit ratio. Therefore, substantial justification is needed to propose a new health policy’.

As stated,⁶ ‘there are no universally accepted criteria for the quantity and quality of evidence required to warrant a public policy around a health issue’. However, the four thoughtful commentaries of this Special Issue collectively underscore the need and potential significance of health policies for obesity, outline the pitfalls to avoid and provide a foundation to develop feasible, sustainable and beneficial health policies for obesity.