Tax Obesity?

Should we tax obesity? Although it's an older study, this article resurfaced on my twitter feed today. The focus is on how we can use taxes to modify behavior, including sin taxes on such things as cigarettes and alcohol. The author, Dr. Gruber, does point out that taxing obesity is trickier than these other specific items, and first makes a case for sugar-sweetened beverages.

In my opinion, there are good reasons to tax sugar-sweetened beverages. We should not tax sugar-sweetened beverages because of obesity. Sugar-sweetened beverages are not good for anyone, regardless of weight. Personally, I think these policies should be targeted to industry, not individual purchasers.

The next, idea, however, is "ultimately, what may be needed to address the obesity problem are direct taxes on body weight". As Dr. Gruber points out, it's hard to imagine this in federal tax policy, but we already do it through employer-sponsored insurance. Many others have made many arguments specific to employer-based health insurance, so let's think about this from a broader idea of "tax" of any form.

What is the motivation of a tax on obesity, be a tax on wages to the IRS or through health insurance premiums? In economics, the concept is that taxing something discourages consumption. This worked well for cigarettes--as taxes increased, consumption declined. (We'll set aside the much more complicated issues surrounding cigarette taxes.)

The problem is that most "sin taxes" target a behavior or an item. Taxing obesity would be taxing a characteristic. What would we need in order to actually implement an effective tax on obesity?

• We would need to be able to target the tax, so we would need to be able to measure obesity. This measure would need to be easy to obtain and have a clear tie to the health issues we are concerned about. BMI is easy to obtain, and I guess people could report it on their 1040, but it is not clearly tied to health issues. In fact, the only measures tied to health issues are the existence of health issues. 

• A tax would only be effective if it addresses something changeable. So, we would have to assume a perfect correlation between individual behaviors and weight. So, by changing a specific set of behaviors, you would lead to the exact desired weight. Of course, we know that doesn't happen.

• A tax would also only be effective if it doesn't induce other risky behaviors. What good is a tax on cigarettes if everyone began to smoke an equally dangerous alternative? By taxing a specific weight, wouldn't the motivation be to do anything to reach that weight?

We can't tax obesity, because there is nothing about it that is taxable. Yet, this idea is regularly raised, in the popular press and in science. Obesity is a characteristic. There are no other characteristics I can think of that we tax. We do tax behaviors, but not what people look like. We also don't tax diseases. We tax cigarettes, but we don't impose a tax  when someone is diagnosed with lung cancer.

There are plenty of ways to leverage policy in order to improve obesity. Taxes aren't one. Taxing health insurance is not one. Health insurance is actually an important tool to help people obesity improve their health--why would we restrict that?We can only address obesity be recognition of what it is and by using policy to support individual efforts to improve their health, not to punish them.

The Stigma of Childhood Obesity

Some colleagues and I recently received a rejection of a letter to the editor of JAMA. When we saw this cover, we were immediately struck by the child in the middle, and decided a letter was needed. I guess I shouldn't be surprised by the rejection, given that JAMA recently rejected another piece of mine on how stigma pervades the medical and scientific communities that work on childhood obesity. (That piece, however, was accepted by another in the JAMA family, JAMA Pediatrics, and will be published July 1.)

The refusal to engage in the discussion is as informative as the original point we were trying to make. Below is the image on the cover, which should link you to Dr. Zylke's description--my apologies to those who can't access it freely. I think our letter was appropriate and true.
 



 

Dear Dr. Zylke,

It was with great excitement that child health researchers came across a special issue of JAMA focused on child health last week.  Unfortunately we found this issue’s cover alarming.  The illustration promotes the stigmatization of obesity that has not only pervaded popular culture, but, as so clearly demonstrated here, the research and medical communities, as well.
   
On the cover, we instantly saw a portrayal of an obese child with a large soda-an image that managed to meet all three criteria for defining pejorative images from the Yale Rudd Center for Food Policy and Obesity at Yale University media guidelines.¹  While you say this image tried to portray “problems stemming from social or environmental issues,” the use of a picture of an individual child with a large soda to reflect the high prevalence of obesity among children is stigmatizing in that it recognizes the individual behavior without also recognizing the larger environmental roots.  

Far more disturbing are the subtleties apparent in the image.  The fact that so many people in the scientific community must have looked at this obese girl—with an awkward facial expression, unflattering clothing, and avoiding the world—as an honest representation of childhood obesity is truly disheartening.  Social constructs of disease place responsibility on different individuals, assigning blame in ways that portray children as either victims or perpetrators.² On this cover, nearly all these children are either promoters of their own health or “victims” of their diseases, except this child, who is shown as a perpetrator of hers.  

In your description of the cover’s more idyllic images, you quote Norman Rockwell: “I paint life as I would like it to be.” We would like to offer up another of Mr. Rockwell’s quotes: “Right from the beginning, I always strived to capture everything I saw as completely as possible.” The narrow, incomplete and negative view of the obese child so painfully portrayed on the cover demonstrates the narrow, incomplete view that many people have of obese children and obesity itself. 

If we only focus on the doubt and difficulty of changing individual behaviors, we will not reduce the prevalence of obesity as significantly as if we address systemic factors.  Continual perpetuation of stigmatizing images of obese children reinforces beliefs that obesity is a problem driven only by individual behaviors. Such stigma serves to dehumanize obese people, and may even serve to perpetuate obesity itself.³





Asheley Cockrell Skinner, PhD

Stephanie E. Hasty, BA

Eliana M. Perrin, MD MPH 

References

1.         Yale Rudd Center for Food Policy and Obesity. Guidelines for the Portrayal of Obese Persons in the Media. 2012; http://www.yaleruddcenter.org/resources/upload/docs/what/bias/media/MediaGuidelines_PortrayalObese.pdf. Accessed May 9, 2013.

2.         Herek GM, Capitanio JP, Widaman KF. Stigma, social risk, and health policy: public attitudes toward HIV surveillance policies and the social construction of illness. Health Psychology. Sep 2003;22(5):533-540.

3.         Puhl RM, Latner JD. Stigma, obesity, and the health of the nation's children. Psychological Bulletin. Jul 2007;133(4):557-580.

Inertia

A Forbes article from earlier this month tries to dispel the myth that doctors will only increase their (uncompensated) work burden if they are willing to communicate with patients via email. Personally, I communicate with my physicians via email--I actually go so far as to nearly use that as a criteria when choosing a physician. But I think this form of communication is important for a far greater reason.

The power differential in the doctor-patient relationship is a key factor in how a particular patient's care will proceed, as I've written about before. Email has the benefit of being a low-pressure method of communication, one that doesn't require confident, direct interaction. Many individuals, no matter their background, find it difficult to speak openly with their physician, to ask questions, to be sure they are sharing all of the information and history they should. But email provides an opportunity for the patient to carefully consider what they want to say, and to do outside the pressure of the exam room. Patients may share information--some which might be critical to providing the best care--that might otherwise be left out or simply overlooked.

As technology becomes more and more integrated into all aspects of life, including medicine, health care will have to embrace these changes. People are embracing them. We can't let inertia prevent improvements in care.