Wealth of nations is health of nations

Abstract

We are inundated almost daily with reports about the rising prevalence of obesity. The pandemic is forecasted to greatly increase the incidence of diabetes and its complications, as well as a whole host of other conditions. If you believe the media, Armageddon will come either in the form of obesity-related disease or climate change. Not to make light of serious matters, the problem with these reports is that they are rather long on the devastating complications of obesity but rather short on the viable solutions. The recently published Canadian guidelines on the management of obesity are a laudable attempt at providing solutions (1). Arguably, however, they do not go far enough. Regular objective assessments of obesity by physicians followed by individualized, largely lifestyle, therapy guided by multidisciplinary teams as advocated in the report will clearly call attention to this problem, but this is not enough. The recommendations are of little comfort to the large segments of the population who do not regularly see or even have access to a primary care physician. Global problems require global solutions, and the only tool with any real teeth is legislation. Antiobesity educational campaigns, while necessary, are much too passive and are drowned out by the myriad of advertising campaigns of nutritionally poor foods. Such commercial speech is still free speech and is constitutionally protected. But how do we use this awkward, blunt instrument to fashion tangible change in behaviour and health status? The application of public health law, health policy and litigation to address the problem of obesity was reviewed by Mello et al (2) in the New England Journal of Medicine. The report is a frank, in-depth discussion of historical failures and future proposals. It does not minimize the challenges faced by legislators. Combating constitutionally protected forms of commercial expression is only one adversary, but public attitudes are an even bigger problem. Nonetheless, while some previous health policy measures have failed, there has been a greater public recognition of the dangers of obesity, which may promote the change that would have been unacceptable just a decade ago. In this sense, I will admit that perhaps the media scare campaigns have been worthwhile. The report is at once a review on the specifics of health policy for obesity and a paradigm for health policy on a more general level. Analogies between successes in curtailing smoking in western countries and similarly targeting obesity are drawn. There is a limit to these similarities. There is no ‘second-hand’ effect of nutritionally poor foods. Furthermore, such foods are more frequently consumed by those with lower socioeconomic status, for whom policies such as increased taxation would be extremely unwelcome. However, the lesson learned from antismoking policies seems to be that they are most socially acceptable when targeted toward children and adolescents. These same policies become infringements on adults’ freedom of choice, and the same may well be true for antiobesity policies. Governments are listening. The recent ban of transfats in New York is also in effect in Philadelphia and Denmark. It seems as if it was overnight that the idea of transfats entered the lexicon of the average Canadian. However, despite calls for an outright ban in Canada, current guidelines only call for the voluntary labelling of food. It is encouraging to see that at least in the United States longstanding food preparation methods have changed with relatively little resistance. Health policy as a means of changing population health status has had many successes in the past, which makes it an attractive tool for contemporary problems. Vaccinations, folate fortification of cereal for the prevention of neural tube defects and fluoridation of drinking water are some notable examples. However, the law cannot be expected to completely change behaviour. It must follow, and indeed, its success depends on changing cultural ideologies. As such, change cannot be measured in years, but rather in generations. Selected sites Canadian Medical Association Journal CBC Ontario Health Promotion E-Bulletin Canadian Heart and Stroke Foundation Health Canada