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Obesity is becoming a defining issue in the United States.
So many children are now overweight that "adult"
diabetes is an epidemic that foretells long-term suffering
of individuals and enormous medical costs for the nation.
Two-thirds of adults are now overweight, and the rate continues
to increase. It has taken the federal government a couple
of decades to decide obesity is a problem, but the government's
strategy is now becoming apparent.
The House of Representatives recently passed the "Personal
Responsibility in Food Consumption Act." The law would
prohibit lawsuits holding restaurants liable for their customers'
obesity. Last month, a Department of Health and Human Services
representative objected to the World Health Organization global
strategy to combat obesity by stating that the administration
insisted on emphasizing personal responsibility instead of
policy changes. On the day of the announcement that obesity
and inactivity are now rivaling tobacco as the No. 1 cause
of death, the Department of Health and Human Services began
a public service ad campaign to encourage people to move more
and eat less. One clever TV spot encouraged people to take
the stairs to help them lose their "love handles."
These three apparently separate government actions define
an approach to what is quickly becoming the most deadly and
most costly health problem in the country. It is clear that
the main strategy - perhaps the only one - is to promote personal
responsibility for eating and exercise choices. Much can be
said in favor of this approach.
Paraphrasing a recent statement from the president of the
National Restaurant Association, it is obvious that everyone
can freely choose whether, what, when, where and how much
to eat. We also decide every day whether and how much to exercise.
Encouraging more healthful choices does not restrict any freedoms.
As a health psychologist, for years I have studied programs
to teach people behavior change techniques that help them
make more healthful choices. There are many programs that
significantly help people improve their lifestyles. Over the
years people have reduced their fat intake, and there have
been small increases in exercise levels and fruit and vegetable
intake, proving the population can change.
It sounds like everyone agrees that helping people make more
healthful choices is the way to go, so the government's strategy
should be endorsed.
But there is another side of the argument. Although teaching
behavioral change skills can be effective, many of us who
develop and study these programs for a living have realized
a number of limitations.
First, although many well-designed programs have significant
effects, even the most motivated participants do not change,
and changes generally are modest.
Second, most people do not want to participate in programs
offered by work sites, health care organizations, schools
and the Internet. Behavior change takes effort, and people
prefer to use machines that promise "exercise without
effort," pills that make unsubstantiated claims and fad
diets.
Third, the biggest problem is that most changes don't last.
About 50 percent of exercisers drop out after a year. Diets
go back to normal after programs end. Success rates five years
after behavioral obesity treatments are usually in the single
digits.
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Even though we have been promoting physical activity since
the 1970s, only about 12 percent of adults claim to do regular
vigorous exercise, and about 30 percent admit they do no structured
activity. A consensus is developing among health scientists
that the obesity problem is so widespread that programs promoting
only personal responsibility will never be sufficient to control
the epidemic.
Why does the personal responsibility approach not work better?
To begin with, food choices are not entirely free. From birth,
humans have biologically based preferences for sweet and fat
foods, and these both drive consumer demand and constrain
choice. The food industry is built around these preferences.
Not only are sweet and fatty foods vastly cheaper than nutrient-rich
fruits and vegetables, but they are almost the only foods
that are advertised. Take a look at the food ads on children's
TV sometime and try to find an ad for something that is not
sweet or fatty. It is clear to most of us that children are
not able to make rational choices about foods, so foods ads
can be considered exploitation. In an area of soaring childhood
obesity, this is no longer acceptable.
Although individuals do need to take responsibility for what
they put in their mouths, what about the responsibility of
food companies? Is it responsible to heavily promote foods
of low nutritional value to children and adults? Doesn't this
make it more difficult for people to make healthful choices?
But people have free choice when it comes to physical activity,
right? No one is chaining us to easy chairs, but a wide variety
of companies spend a great deal of money to make it easy for
us to be sedentary and difficult to be active. The billions
of dollars spent on ads for TV shows, movies, DVDs, computer
games, professional sports, cars and computers tell us how
great it is to sit.
How many ads are there encouraging us to take responsibility
to be active? Very few. When some people want to go out and
take a walk, they find tree-lined sidewalks, well-lit trails
and attractive parks. But when too many Americans go out their
doors, there are no sidewalks or trails, the streets are filled
with fast traffic, there are few safe street crossings and
the parks are run-down.
Numerous studies show that people walk less in suburbs built
on the assumption that people would drive everywhere. We have
invested trillions of dollars to maximize the convenience
of auto travel, with very little consideration given to making
our streets safe and attractive for pedestrians. When we design
for pedestrians, we find people walk more.
We know eating and physical activity are not driven only by
personal responsibility. We have created environments that
make it difficult to make healthful choices. A national strategy
that addresses only part of the problem is likely to fail,
and the stakes for failing to control obesity are too high.
We need to motivate and help people make healthful choices,
but we also need to create environments that make the healthful
choice the easy choice.
We have a long way to go on both of these goals. The nation
cannot afford to politicize the debate over personal versus
societal responsibility for eating and physical activity.
Individuals, families, community and faith-based organizations,
corporations, and governments all must take responsibility
for contributing to the solution of this national problem.
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