The case for naked paternalism in the war against obesity
The well-known statistics on American obesity were anecdotally confirmed for me on a recent layover in Canada, when I was struck once again by how easy it is to tell Canadians from Americans. Those who headed for the "American passport holders" line looked lumpy in all the wrong places. Those who headed for the "Canadian passport holders" line, on the other hand, were of a very different breed. One might hazard to call their appearance "healthy."
You would be wise and correct to point out that my observation suffers from both sample size bias - a passport line is not a statistically significant cross-section of anything - and confirmation bias, since Americans have a well-known reputation for plumpness. But this is a case where casual observation reflects a fundamental truth: Americans are remarkably fat and getting fatter, even though we are obsessed with asking ourselves, why?
The scale of our bigness -- 34 percent of Americans are obese, compared to 24 percent of Canadians -- is made more striking by the scale of our efforts to combat it. America spends more money per person than any other country on "health care" (yes, I put that in quotes), while achieving worse outcomes than most of our peers in almost every conceivable dimension. The trillions we spend relative to Canada (about twice as much, per capita) do not make it any harder to tell Canadians from Americans in the immigration line.
But the bridge between America and Canada can be found in an unlikely place: Japan.
DIETS AND DICTA
See, I am solidly in the "American" group when it comes to personal body maintenance - always trying to lose those last 35 pounds - and yet a funny thing happens to me every time I spend a summer or a couple of years in Japan. Within a couple months, I drop to a healthy weight. I begin to look (though not necessarily to dress) like a Canadian. This might be what one would expect, given that Japan has the lowest rate of obesity in the developed world. Books with titles like "Japanese Women Don't Get Fat" may sound smug and condescending, but, as in comedy, there is often truth in smugness.
Why are the Japanese so slender? There are three reasons, and none of them has to do with genetics. One is the traditional Japanese diet, which is heavy on fish, vegetables, and rice. The second is Japan's mass-transit-centered urban design, which encourages Japanese people to walk a lot more than Americans. But the third factor is paternalism. Japan's government takes an active role in combating any hint of an upward trend in fatness.
In 2008, Japan's diet passed a law designed to combat "metabolic syndrome," which is known to Americans as "pre-diabetes." The so-called "Metabo Law" requires overweight individuals, or individuals who show signs of weight-related illnesses, to go to dieting classes. If they fail to attend the classes, the companies that employ them and/or the local governments of the areas in which they live must pay fines to the federal government. In addition, companies with more than a certain percentage of overweight employees are fined directly.
Americans, of course, would never submit to this sort of violation of personal liberty. Where Japan places an emphasis on enforcing personal responsibility by government or corporate mandate, the U.S. prefers to encourage responsibility by forcing people to live with the negative consequences of their actions. But in this case, it is clear that the two different value systems have led to radically different outcomes in terms of the health of the populace. Japan has succeeded in keeping its people largely thin. America has not.
THE YOGURT RULE
It is time for a rethink of our approach to public health, specifically with regards to obesity. No, it is not possible to use the government to fight fat while adhering to a perfect libertarian ideal; however, it is not possible to do anything while adhering to a perfect libertarian ideal, so let's just start from the notion that we live in a world where outcomes matter along with ideals. I believe that it is possible to change our public health policies in ways that preserve our basic values of personal liberty while significantly improving health outcomes.
One example of such a policy is food labeling. Much is known about which foods contribute to obesity. Added sugar has received much of the attention in recent years, thanks to the work of Robert Lustig. But high fat content is also, fairly obviously, a risk factor for fat. So here's an idea: Let's force high-sugar and high-fat foods to be labeled with the sentence "This food contributes to obesity," while putting an opposite label on fresh foods, vegetables, etc. Large, visible, color-coded labels in grocery stores will allow people to make informed choices quickly and easily. Along similar lines, high-sugar and high-fat foods should be labeled "not healthy for children," so that parents - who probably don't want to be saddled with an obese child - can avoid these foods.
(Random note: Perhaps you think that Americans already know perfectly well which foods are healthy and which aren't. Well, you should wake up and smell the yogurt. Most Americans I know think yogurt is healthy, but most low-fat yogurt that you buy at the grocery store is packed with so much sugar that a single cup contains the entire Japanese recommended daily allowance of 20 grams!)
Another idea is a tax on sugar and fat, coupled with a subsidy for healthy, low-fat low-sugar foods like vegetables. A recent study in the British Medical Journal found that taxes of 20 percent, when paired with subsidies for healthy food, were highly effective in reducing obesity. These taxes should apply to restaurants too - the fact that McDonalds' "extra value menu" is a cheaper dining option than a home-cooked meal cannot be good for America's waistlines.
A third idea is to use the education system. America is afflicted with the culture of the "clean plate club," which encourages people to overeat. Parents who grew up with this culture will tend to pass it on to their children. Just as our schools teach children to read and write and do math, we should teach them how to eat healthily. And the secret to healthy eating habits is very, very simple - eat only until you are no longer hungry (or "80 percent full" as the Japanese say), and put the rest in the fridge for later. When you think about it, this rule is infinitely more useful for a child's future than, say, the difference between an igneous and a sedimentary rock.
Policies like product labeling, "sin taxes," and health education are no different than things our government has been doing for the last six decades or more. They are violations of "liberty" only in the most technical sense. Unlike the intrusive meddling of the Japanese state, these policies allow the individual the freedom to be fat; but, unlike our current, spectacularly failed policy regime, they allow people much more freedom not to be fat. We do things differently from Japan, and even from Canada. But this doesn't mean that we have to do them worse.
Government paternalism is in some sense a last resort, but it has worked wonders in the realm of public health in the past. Hand-washing regulations, sewage treatment regulations, cleanliness education, and other such paternalistic initiatives brought us out of the cesspool of the Middle Ages into the clean, safe, mostly disease-free paradise in which we now reside. Fat, though not contagious, is no different in terms of its ability to cripple and kill our citizenry, and the epidemic has reached emergency proportions. And not just because the Canadians are laughing at us behind our backs.
The American people must become healthy again. It's time to bring in the government.
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