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.

Treat the Obesity First?

So, I've been struggling with an internal debate about the new guidelines from the Endocrine Society about treating obesity and comorbidities.That's why I'm late to this party.

On the one hand, I think recognition of obesity as something that can and should be treated is great. On the other, I worry that putting obesity--defined here solely by BMI--above actual health problems is a risky, dangerous proposition.

The Good

It's refreshing to see guidelines for obesity treatment that view medications as positive and not as last-resort efforts. Of course, these are the guidelines for "Pharmacological Management of Obesity".

There is a clear recognition of the array of factors that cause obesity. 

The Bad

The labeling of individuals with obesity is clear from the start. Throughout the document, individuals are referred to as "obese patients" while diabetes is "patients with diabetes", not diabetics. The first and most important step in treating obesity appropriately is recognizing it as a disease, not a characteristic of the person.

One of the only recommendations they make based on the highest-quality evidence is that lifestyle modifications be included in all obesity treatment. I'm not pretending for moment that lifestyle modification is NOT useful, but it doesn't work long-term. A wide variety of reasons exist for this, from an unsupportive environment to metabolic changes occurring as a result of weight loss. The evidence is just not that good.

Successful treatment is defined only as weight loss. If someone stays at exactly the same weight, but show clear improvements in health, have we failed?  If weight loss occurs and there are no improvements in comorbidities, have we succeeded?

Health, not weight

I suppose my greatest concerns are with the media reporting of the guidelines, more than the guidelines themselves. Most articles report, and the lead author comments, that the "new paradigm" is the "treat the obesity first, then the comorbidities". I think the message should be "treat the obesity along with the comorbidities" and that's actually closer to what's in the actual guidelines.

Treating obesity is something that we absolutely, 100% need to do, and do more effectively. However, I can't overstate my opinion that we must view everything through the lens of health. Obesity is not simply size.

Oh, Splenda, I can't even

This morning I ran across this little beauty. My initial reaction is that it’s just more of that unconscious weight bias inherent in our society. Today, though, I found that I didn’t like the negative connotation that implied. I think of all the things I’ve learned in my life, and I wouldn’t want people judging me on my actions about something before I knew better. We need a way to describe our society that captures the unique difficulties faced by people of size or with obesity while not demonizing those who are thin.

Some of this alteration to my thinking came from my 15 year old daughter, who has very passionate opinions about the social justice implications of the heteronormativity of our society. (Would anyone think less of me if I admitted I don’t think I’d heard the term “heteronormativity” until she taught me?) What I really like about the term is that it gives an explanation for the difficulties experienced by those who do not fit into traditional gender roles and heterosexuality. But while identifying heterosexuality as a societal norm, it does not imply that heterosexual individuals have done anything “wrong”.

I realized this matters a great deal in how we perceive weight bias. Underlying the terms we use—thin ideal, thin-obsessed, weight bias—is some level of assumption that thin is bad or that individuals are responsible for the things they say. Just like obesity, the truth is a much more complicated picture. It’s acceptable for Splenda to say “This packet has been approved for swimsuit season” not because Splenda wants to stigmatize people and we’ve simply allowed it to happen, but because our society just assumes that thin is what people are always striving for. 

In order to shift the view from “people with obesity are stigmatized” to “we need to recognize the societal roots of our beliefs”, we need a better term. Heteronormativity does not suggest that those of other sexual orientations aren’t stigmatized—of course they are. But it recognizes that stigma as rooted in a deep societal construct. By understanding what underlies stigma related to sexuality, we can consider how best to alter that stigma and lessen the strength of society’s heteronormativity.

We can do the same with obesity. If we better understand what underlies the stigma experienced by people with obesity, and accept it as a societal construct—let’s call it “thin-normativity”—then we can better isolate where stigma is rooted in individual prejudice and where it’s instead the unsurprising result of a thin-normative society.

After all, if we want people to understand that obesity is a complex issue and not simply the fault of individuals, don’t we also need to understand that weight bias is a complex issue and not simply the fault of individuals?