On why shaming won’t stop obesity, why vouchers might, and losing 80 pounds

Neil Seeman is director of the Health Strategy Innovation Cell at the University of Toronto. In XXL: Obesity and the Limits of Shame, he and co-author Patrick Luciani argue that public health campaigns have contributed to the obesity epidemic.

Q:&  Why haven’t governments come up with any effective public policy to halt the rise of obesity?
A: Obesity is a deeply complex, extremely individual challenge. So if the policy doesn’t embrace individualized solutions, if it enforces the existing model of health care which doesn’t champion autonomy and outcomes, it’s not going to work. We’ve got to craft an obesity policy that recognizes the meta-theme of the research of the past 30 years: top-down, one-size-fits-all solutions, which then rely on information campaigns to nudge people into action, don’t work. We’re facing a perfect storm: an epidemic of obesity, which is a significant driver of chronic illness, and rising median age of the population. So we need to think more creatively.

Q: How much money is spent on obesity?
A: It’s hard to say exactly, but we spend about $200 billion on health in this country annually, and 60 to 70 per cent of that is eaten up by chronic illness. Obesity is a significant driver of 60 per cent or more of that chronic illness. There are also severe knock-on effects in the private sector: about $30 billion of annual costs in terms of productivity losses related to obesity in the work force.

Q: You write that public health campaigns in Western countries focus on banal messages telling people to eat more fruits and vegetables, or messages that shame fat people. Why doesn’t either approach work?
A: People hear these mass-market carpet bomb messages and don’t absorb them. They’re too generic. And they can also backfire. The data show that sometimes healthy living reminders, especially if they use shock language, actually wind up getting people to eat more.

Q: Won’t the stigma of obesity, and the possibility of shaming, disappear if half the population is overweight?
A: That’s what I would’ve thought too, but it’s not the case, largely because people discount their own weight issues. The research shows that moms who are obese don’t consider themselves or their children obese. The majority of Americans, despite being overweight or obese, actually think they’re in good to excellent physical condition. It’s a weird cognitive dissonance. Interestingly, in the most obese nations, places like the U.K., there’s actually a heightened tendency to want governmental policy to shame the obese.

Q: Isn’t policy just reflecting a widespread feeling that fat people are responsible for being fat?
A: It’s a symbiotic relationship. This culture of mocking the obese does find its way into policy, because knowing there’s acceptance of shaming creates an appetite to use it as a tool in a public health campaign. One reason for the embrace of shock tactics is political expediency. There’s an absolute urgency sensed by governments around the world, that they have to be seen to be doing something. That something can either be an odorized “dialogue” such as the one Canada is embarking on in the context of childhood obesity, or it can be hard-hitting messages.

Q: A lot of people say, “Well, shaming got people to stop smoking.”
A: With smoking we had to go through a cognitive evolution to understand the science, to understand there was a correlation between smoking and cancer. Until the late 1960s, doctors in white coats were sporting for tobacco companies. Whereas with obesity, we’ve known since we were children that drinking soda and scarfing down potato chips is bad for us. Secondly, with the graphic warnings around smoking, there is clear evidence that they did have an impact, though there’s some debate around how much. But putting a poison symbol on fatty food won’t work.
Q: Why doesn’t seeing how much fat there is in a burger deter people from eating it?
A: A lot of people simply don’t know what these numbers even mean. The only people who change their order from the mayo-slathered hamburger to the salad are those already committed to healthy living.

Q: You lost 30 per cent of your body weight while working on this book. Were you obese?
A: Yes, I was about 80 lb. overweight. I had been suffering from depression, and taking certain anti-depressant medications clearly had an impact on my weight. I then had a number of events occur which led me to become more active as I escaped my depression. One was striking up a friendship with an immigrant from Kenya who was training to become a UFC fighter, and he became my personal boxing coach. So I became an amateur boxer. It’s less colourful than it might sound! The point is that for me, as for everyone else who’s obese or overweight, the solution was extraordinarily individual.

Q: How did you personally frame being overweight: as a health issue, a psychological issue, or a moral failing?
A: As a moral failing and a psychological issue. There was frustration because I think of myself as an educated person, a rational person, and yet I was irrational in the face of food. The research shows that we’re all irrational when it comes to the consumption of food—but we’re irrational in our own, unique ways. That’s why anti-obesity policies aren’t working, they treat the senior citizen and the child in a poor district as being the same.

Q: So is most of the public health research, which focuses on systems rather than individuals, a waste of taxpayers’ money?
A: Within academe more broadly, not only within public health, there’s a bias in favour of research that hews to politically fashionable ideas. For example, the ideas that more green space, more bike lanes, more calorie posting are going to attack obesity. A particularly pernicious trend within Canadian academe is the animosity toward the private sector and toward private-public partnerships.

Q: What should their attitude be toward, say, McDonald’s?
A: There should be a recognition that partnerships are essential. To say otherwise is really absurd. Millions of people eat at McDonald’s every day. But for the Canadian academic even to go to a conference where a McDonald’s spokesperson is speaking—you’re undertaking a deep risk for your career. In the U.S., there’s an understanding across the political spectrum that private-public partnerships are not nasty, but in Canada we invest taxpayer dollars in research that vilifies the private sector. Any producer of sodium-enriched food, for example, can do a lot in terms of educating researchers and government around the futility of certain top-down regulations, like the mandatory legislated sodium content, or the idea that we need 12 variables listed on each food package.

Q: As you point out, we’re “fatigued by fat news” and people know that obesity is bad for you, medically. How do you get them to act?
A: We’re all suffering from information overload. There’s a growing tendency simply to tune out the noise and run back to a source of trust: our primary care provider. We still invest great trust in our primary care provider and, increasingly so, whether the person is a physician or a nurse practitioner or a traditional Chinese medicine practitioner. So it’s extremely important that the solution embrace the relationship between the primary care provider and the individual. We need them to work together on a sustained healthy living agenda with real outcomes that are measurable. We need to re-architect our entire biomedical and health care system in order to invest more money in that relationship. That’s the way we break through with obesity. In order to do that, we’ve come up with this idea called the Healthy Living Voucher.

Q: What could the average Canadian do with an HLV?
A: People really do want to have meaningful choice. With educational vouchers, the outcomes have been very positive and measurable, especially for low-income families. HLVs would open a similar universe of choice so that people could customize options to manage their weight. A gym membership, nutrition classes, cooking lessons, counselling, hip-hop lessons—the options that you could use your HLV for should be very large in number. And in order to apply the voucher the person needs to satisfy certain conditions, like close interaction with his primary care provider whether by Internet or one-on-one, to determine if the HLV is working to improve or help maintain healthy living. The primary care provider can measure outcomes on a quarterly or annual basis.

Q: So you stop subsidizing ineffective public health campaigns and give that money directly to individuals, and they take charge of their own health. Realistically, do you think governments would support HLVs?
A: Yes I do, by dint of the enthusiasm we’ve seen across the political spectrum, from the left to social conservatives.

Q: Even for a universal voucher system, where you’re giving them to people who can afford the gym membership anyway?
A: The costs of a rich person being obese affect the tax dollars of a middle-class person, so we’re all in this together. We’re all paying for each other’s obesity and chronic illness in a health care model like Canada’s. And healthy living is a moral right. It’s like education. We should all, rich or poor, have equal opportunity to live a healthy life.