Unless you have been living under a rock, you likely have heard the names Ozempic, Wegovy or Mounjaro. Or perhaps been humming the jingle. Rarely has a class of drugs (in this case, GLP-1s) achieved such widespread attention in popular culture and the media, which has people clamoring for them in every doctor’s office in the nation.

And for good reason. What we know is that the efficacy and safety profile of these medications is substantially better than any weight loss drug in the past, while our obesity epidemic has only ballooned. As organizations committed to sound science and holistic patient care, we are encouraged by the benefits of these new therapies for diabetes. The clinical evidence shows that GLP-1s are highly effective for controlling blood glucose levels among patients living with Type 2 diabetes and certain co-morbidities. GLP-1s may even improve heart health for high-risk patients.

To date, the biggest worry with these weight loss therapeutics has been the hefty price tag, ranging from $800 to $1700 per person, per month. Conservatively, these weekly injections could cost the nation more than $100 billion dollars annually. Already, state Medicaid budgets are sagging under the financial burden. In North Carolina, for example, officials dropped coverage of GLP-1s for obesity, noting that two drugs alone would cost about $1 billion over 6 years, and that’s with a nice discount.

As troubling as the cost is, what we don’t know is what should really worry us. Amidst the excitement over patients rapidly shedding up to 15% of their body mass, fundamental questions remain about who should be taking GLP-1s, at what dosages and what the long-term health and economic consequences will be for patients and society. Ultimately, the price paid to people’s long-term health may be more concerning than the price paid out-of-pocket.

With the recent release of the SELECT trial data highlighting limitations of existing published studies of GLP-1s, it is now even clearer that the public isn’t getting the full picture.

Calls for widespread adoption are clearly premature. The stories touting GLP-1s clinical weight loss benefits often leave out that the studies are limited and based on a homogenous population, likely to further exacerbate existing inequities. For example, only 27.7% of the patients in the SELECT trial were women, compared with other trials in which they represented 74.1%. This smaller patient population rightfully leads to questions about the effectiveness in women and others not included in the trial. By only seeing part of the puzzle, we’re left to worry about the missing pieces such as what the GLP-1 cardiovascular benefit for people who are obese but without a prior heart condition could be.

Even more troubling are the unknown long-term effects. In people with diabetes, studies have found an increased risk of pancreatitis for some patients. For individuals taking GLP-1s for weight loss, usually at much higher dosages than for treating diabetes, we simply don’t know what the long-term implications, both positive and negative, will be because few longitudinal studies exist. Too many patients are prescribed GLP-1s for a lifetime without thought as to what comes next.

Pharmaceutical manufacturers will argue that anyone concerned about their weight would benefit from GLP-1s. However, based on the published evidence on weight re-gain, GLP-1s likely require a lifetime commitment to maintain weight loss and associated benefits. Many patients must contend with well-documented side effects such as nausea, diarrhea or the significant loss of lean body mass (ie. muscle) and bone density. Again, those are lifetime side effects. and some patients simply tire of giving themselves a weekly injection.

In a July 2023 study of real-world claims data from 16 million commercially insured members, Prime Therapeutics and MagellanRx researchers found that almost 70% of patients stopped GLP-1 treatment less than one year after starting. When you combine that data with the findings from a recent Journal of the American Medical Association study (in which patients regained two-thirds of the lost weight after switching to a placebo) you have the makings of a dangerous rollercoaster ride. We must consider whether the rider is prepared for the physical and mental implications of a weight-loss rollercoaster. The short-term benefit isn’t worth the long-term costs.

What we do know is that GLP-1s work best in combination with lifestyle modification and that clinicians need flexibility to determine the right combination for each individual. We can scale evidence-based nutrition treatments with proper support to deliver long-lasting results. Health plans, clinical teams, patients and – more broadly – society must deploy a full range of comprehensive population health tools to get the nation back to a healthy weight.

With so many unknowns about GLP-1s, a cautious approach is needed with continued focus on the evidence-based strategies that tackle root causes of obesity, including nutrition and socioeconomic factors. The work of population health is not as sexy as the slender models posting videos on Tik Tok, but it is the proven approach for many struggling with weight issues.

Clinicians and policy makers must resist the seeming quick fix of GLP-1s. Greater attention and resources must be devoted to treating the whole person and patiently evaluating the right and wrong candidates for GLP-1s.

A healthy lifestyle is likely the only sustainable, affordable and safe way to address our obesity epidemic and to deliver long-lasting results. By focusing on the drivers of obesity, we’re focusing on what we do know rather than being surprised by the unknowns.

Even if GLP-1s were free, they are not the magic pill to solve our obesity epidemic.

Ceci Connolly is the president and chief executive officer of the Alliance of Community Health Plans. Sami Inkinen is co-founder & CEO of Virta Health, a telemedicine and behavior treatment company focused on solving our T2 diabetes and obesity epidemic.

Flawed Accounting for the US Health Spending Problem

By Jeff Goldsmith

Source: OECD, Our World in Data

Late last year, I saw this chart which made my heart sink. It compared US life expectancy to its health spending since 1970 vs. other countries. As you can see,  the US began peeling off from the rest of the civilized world in the mid-1980’s. Then US life expectancy began falling around 2015, even as health spending continued to rise. We lost two more full years of life expectancy to COVID. By  the end of 2022, the US had given up 26 years-worth of progress in life expectancy gains. Adding four more years to the chart below will make us look even worse.  

Of course, this chart had a political/policy agenda: look what a terrible social investment US health spending has been! Look how much more we are spending than other countries vs. how long we live and you can almost taste the ashes of diminishing returns. This chart posits a model where you input health spending into the large black box that is the US economy and you get health out the other side. 

The problem is that is not how things work. Consider another possible interpretation of this chart:  look how much it costs to clean up the wreckage from a society that is killing off its citizens earlier and more aggressively than any other developed society. It is true that we lead the world in health spending.  However, we also lead the world in a lot of other things health-related.

Exceptional Levels of Gun Violence

Americans are ten times more likely than citizens of most other comparable countries to die of gun violence. This is hardly surprising, since the US has the highest rate of gun ownership per capita in the world, far exceeding the ownership rates in failed states such as Yemen, Iraq and Afghanistan. The US has over 400 million guns in circulation, including 20 million military style semi-automatic weapons. Firearms are the leading cause of deaths of American young people under the age of 24. According to the Economist, in 2021, 38,307 Americans aged between 15 and 24 died vs. just 2185 in Britain and Wales. Of course, lots of young lives lost tilt societal life expectancies sharply downward.

A Worsening Mental Health Crisis

Of the 48 thousand deaths from firearms every year in the US, over 60% are suicides (overwhelmingly by handguns), a second area of dubious US leadership. The US has the highest suicide rate among major western nations. There is no question that the easy access to handguns has facilitated this high suicide rate.

About a quarter of US citizens self-report signs of mental distress, a rate second only to Sweden. We shut down most of our public mental hospitals a generation ago in a spasm of “de-institutionalization” driven by the arrival of new psychoactive drugs which have grossly disappointed patients and their families. As a result,  the US  has defaulted to its prison system and its acute care hospitals as “treatment sites”; costs to US society of managing mental health problems are, not surprisingly, much higher than other countries. Mental health status dramatically worsened during the COVID pandemic and has only partially recovered. 

Drug Overdoses: The Parallel Pandemic

On top of these problems, the US has also experienced an explosive increase in drug overdoses, 110 thousand dead in 2022, attributable to a flood of deadly synthetic opiates like fentanyl. This casualty count is double that of the next highest group of countries, the Nordic countries, and is again the highest among the wealthy nations. If you add the number of suicides, drug overdoses and homicides together, we lost 178 thousand fellow Americans in 2021, in addition to the 500 thousand person COVID death toll. The hospital emergency department is the departure portal for most of these deaths. 

Maternal Mortality Risks

The US also has the highest maternal mortality rate of any comparable nation, almost 33 maternal deaths per hundred thousand live births in 2021. This death rate is more than triple that of Britain, eight times that of Germany and almost ten times that of Japan. Black American women have a maternal mortality rate almost triple that of white American women, and 15X the rate of German women. Sketchy health insurance coverage certainly plays a role here, as does inconsistent prenatal care, systemic racial inequities, and a baseline level of poor health for many soon-to-be moms.     

Obesity Accelerates

Then you have the obesity epidemic. Obesity rates began rising in the US in the late 1980’s right around when the US peeled away from the rest of the countries on the chart above. Some 42% of US adults are obese, a number that seemed to be levelling off in the late 2010’s, but then took another upward lurch in the past couple of years. Only the Pacific Island nations have higher obesity rates than the US does. And with obesity, conditions like diabetes flourish. Nearly 11% of US citizens suffer from diabetes, a sizable fraction of whom are undiagnosed (and therefore untreated). US diabetes prevalence is nearly double that of France, with its famously rich diets. 

Causes of obesity include: poverty and racial inequity, poor diet, lack of physical activity, prepared foods laden with processed sugar and salt, food desserts, etc. There has been an eerie correlation between the decline in adult smoking and  the rise in obesity; one lethal anxiety reducer replacing another beginning  in the late 1980’s, right around the time our health costs peeled away from the rest of the world vs. life expectancy. Our high rate of obesity undoubtedly contributed to the US  death toll from COVID. More than 70% of COVID casualties among the US population were obese or overweight. Obesity rendered the infected vulnerable to breathing and circulatory problems aggravated by COVID.

Our Appalling COVID Performance

And of course, per capita deaths from COVID in the US, though not the highest in the world, significantly exceeded the death tolls in most wealthy nations. According to the Economist, we lost  between 1.3 and 1.4 million people to COVID., the third most “excess deaths” of any country (after India and Russia).* Our peer group in the rate of excess deaths per thousand during the pandemic included:  Kazakhstan, Greece, Brazil and Estonia.  

Countries that excelled in combatting this pandemic, which had death rates less than one-fifth of ours- New Zealand, Taiwan, Japan, South Korea- seem to share two traits in common: competent governments capable of acting quickly and decisively to manage public health risks and populations that respected both scientific authority and public health mandates. In the US, we lacked both of these things.

* Excess deaths- deviation above the normal predicted level of deaths in a year- may be a better measure of the pandemic’s effects than “official” COVID deaths, due to complexities in attribution of deaths to specific causes and political interference by government

Toxic Libertarianism

During the pandemic, an ethos of F#@ck You Libertarianism took firm hold in much of the US: “My right to go bowling is more important than your right to be disease free! You are NOT the boss of me!” A gross imbalance between individual rights and responsibilities to the society manifest itself in resistance to masking, social distancing and vaccination. The same objections “libertarians” had to COVID precautions apply equally to traffic signals or drunk driving restrictions, which are also abridgements of individual rights in service of a common good. Basic and sensible public health measures became politicized in a tidal wave of social media-fired nonsense; any doofus with an Internet connection became his or her own epidemiologist or virologist. Public health is now, to many Americans, an elitist conspiracy to deprive them of their freedom. 

And the resistance was well armed.  A not-so-well-regulated militia of local citizens armed with semi-automatic weapons and walkie-talkies turned up to reopen the Crash and Burn Tattoo Parlor in Shepherd, Texas in April, 2020. Radical libertarian militiamen were convicted of a plot to kidnap and murder the Governor of Michigan based on her enforcement of pandemic closures! 

Not a Failed Economy but a Struggling Society

The US has certainly not failed as an economy. A recent Economist analysis show us pulling away from our European peers in wealth generation. It had a similar record in productivity growth. So it isn’t a resource shortage that is holding us back. The US is also  not a failed  state; it fought off a coup attempt after the 2020 federal election, and successfully defended the integrity of its election system in the 2022 mid -terms. 

But US society’s performance has been truly cringe-worthy. Start with a base layer of income inequality and the resultant unresolved racial and social class antagonisms, stir in pervasive obesity, widespread depression,  anxiety, and a high ambient level of anger, add over 400 million lethal weapons, flood with fentanyl and then a lethal virus and you are left with the chart which we began this essay. In the inimitable words of  Walt Kelly’s Pogo: “We have met the enemy and he is us”.

Health System Not Blameless

We cannot and should not absolve our health care system of blame; it is 17.3% of our economy. Our pharmaceutical industry, including wholesalers and retailers, lit the match that exploded into the epidemic of opioid addiction and deaths. But other corporate interests have contributed materially to the broader decline in Americans’ health. Our food industry -fast and otherwise-bears a lot of responsibility for the flood of cheap calories and oversalted prepared foods. Gun manufacturers and Second Amendment absolutists have facilitated not only the explosion of gun ownership, but the inability sensibly to restrict their use.   

And we can thank two generations of distracted state and national political leadership of both parties, and an ethos of “don’t worry, the market will fix it”, for abandoning our inner cities and much of rural America  notably the Deep South and “greater Appalachia”. This malign neglect created economic conditions that narrowed life choices, and a marked disparity in life expectancy depending on where you live (see map below). It also helped foster a deep and festering resentment among those who were left behind which found its expression in the election of Donald Trump and in the rioting that followed the George Floyd murder.   

What Isn’t Going to Matter Much

Is our health system too costly both to individuals and to US society? Absolutely. But the forces that push up the demand for care and generate those health costs are deeply imbedded in a poorly functioning society. The current roster of health policy nostrums favored by academia, the policy commentariat and the consulting community – “price transparency”, further shifting of health costs onto strained household budgets, converting Medicare to a voucher program instead of a “service benefit,” state administered hospital price controls and yet another wave of futile technocratic payment system tinkering for hospital and physician care such as that launched by ObamaCare – do not even graze the underlying problem.

What Might Actually Help

There are things we can do that might make a difference. We can create a safe “third place” besides prison and the acute care hospital for schizophrenics and others of danger to themselves or others (and dramatically reduce incarceration rates while at it). We can do a much better job of keeping the mentally disturbed away from firearms. We can break the cycle of revenge-driven shootings by intervening sensibly at the neighborhood level. We can also do a much better job of managing addiction in a humane and thoughtful fashion, by dramatically expanding both the quality and availability of addiction treatment.   

We can raise taxes on salt and processed sugar added to food, and use the money to fund research into food addiction. We can also reduce taxes on fresh fruit and vegetables to make them more affordable to the poor and near poor.

Most importantly, we can dramatically improve our system of social care, particularly support for family care-giving, as Elizabeth Bradley and Lauren Taylor suggested in their outstanding The American Healthcare Paradox. Anything we can do to strengthen American families’ ability to remain together will make a material difference in Americans’ health and reduce pressure on health spending. And even with all the pandemic related extensions of health coverage, 28.5 million Americans still lacked health coverage in 2022, whose costs of care were shifted onto the rest of us.

Fixing Broken Regional Economies

But none of this will matter much unless we can reverse the outflow of public and investor capital from the abandoned localities in our country, both urban and rural, and create dignified and lasting employment for those that live there. Life expectancy differences closely mirror the health of local economies. If the hospital is the largest employer in many of these communities, as it is, that is not an economically sustainable state of affairs. 

It is not random that the lowest life expectancies in the US (fifteen years or twenty years lower than the national averages in some counties) can be founded in regions of the US such as Appalachia and the Deep South that have struggled economically for more than fifty years. Buz Cooper convincingly argued in his brilliant Poverty and the Myths of Health Reform, that poverty and all its sickness-inducing correlates is the most important driving force in the variation in health spending, not flawed payment schemes or oversupply of care system resources.  

Source: US Census Bureau

The country is so big, both in geography and population, that it is difficult to understand or appreciate how things are for others that are geographically remote from us. But travel writer Paul Theroux, in his Deep South, said he found poverty in the American South that was worse than what he has seen in rural Africa.  There are significant health (and political) consequences for this poverty.  

Given the fragmentation, how we can get Americans to actually focus on helping each other may be the most difficult problem of all. It is galling to see totalitarian societies like China use our current troubles to justify stripping their own citizens of their freedom and dignity and abusing their human rights in the name of “social order”.

By the time those who have been damaged by neglect reach the Emergency Department, it is too late to help most of them.  Our present flawed social accounting system blames the health care system for the cost of patching up the damage from all the problems enumerated above. . You do not need a doctorate in sociology to realize that the problems that generate all those health costs lie much deeper. They are soluble problems.  We must use our wealth, ingenuity and boundless American energy to foster a sense of mutual responsibility that transcends racial, ethnic and social class boundaries to fix these problems.   

An excellent NPR report in March, 2023 entitled “Live Free and Die” explored these issues, as did a similarly excellent April, 2023 piece in the Economist. 

Jeff Goldsmith is the President of Health Futures Inc. This first appeared on his substack

By CAITLYN EDWARDS

Obesity treatment is often framed as a race to the bottom — how much weight can someone lose? Five percent? Ten percent? And with recent scientific advancements in anti-obesity medications such as GLP-1s, what about even 15-20%?

Obesity treatment, though, isn’t just about the number on the scale. It’s about moving the needle on biomarkers that really matter to overall health. Seven out of the top ten leading causes of death and disability in the United States today are chronic diseases that have links to overweight and obesity. The metabolic benefits of just 5% weight loss can be life-changing for many people with obesity-related comorbidities. This means that for organizations looking to treat their chronic conditions, obesity care shouldn’t be all about striving for the lowest possible weight.

Indeed, consensus and practice statements from groups including the American Heart Association, the American College of Cardiology, the American Diabetes Association, and The Obesity Society, support weight loss programs that achieve clinically significant weight loss outcomes, defined as greater than or equal to 5% of an individual’s baseline body weight. This number is derived from decades of research demonstrating that even modest weight loss has impacts on physiological health including type 2 diabetes, dyslipidemia, hypertension, and many kinds of cancer.

People who attain just 5% weight loss see the following health improvements:

• Reductions in systolic and diastolic blood pressure
• Risk reductions of developing type 2 diabetes by almost 60%
• Reductions in HbA1c and fasting blood glucose levels
• Greater insulin sensitivity
• Decreased need for newly prescribed diabetes, hypertension, and lipid-lowering medications

Understanding that obesity outcomes include more than just the number on the scale, how can benefit managers and health plan leaders measure success? Here are some things organizations should look for when evaluating an obesity management solution:

N-size of outcomes

While a high weight loss average may sound impressive, it doesn’t tell the whole story. A better measure might be the number of people in a program able to achieve greater than 5% weight loss. The fact is that weight loss averages are easily skewed by outliers.  An exceptionally high average may not be representative of what is actually taking place at the individual level. What matters is that a large percentage of people in the program are able to see clinically significant results.

Emphasis on behavior change

Another way to measure the success of an obesity management solution is by the sustainability of its outcomes — primarily through adopting healthier behaviors. Intensive behavioral therapy is crucial to obesity treatment and can reduce the risk of type 2 diabetes. Support from expert dietitians and coaches can help promote a healthy relationship with food for optimal weight loss.

Through medical nutrition therapy, dietitians create personalized calorie and macronutrient goals to foster weight loss in a healthy, sustainable way. Also, self-directed cognitive behavioral therapy can help people become more aware of underlying thoughts and behavior patterns around food.

Step therapy approach to treatment

Some obesity management solutions avoid medications entirely while others rely solely on expensive GLP-1s. But both of those methods fall short of providing the best care to the most people at the lowest cost possible.

The best obesity management solutions take a clinically rigorous step-therapy approach to treatment. This way, they carefully manage access to expensive anti-obesity medications while achieving meaningful outcomes. Many of their members will achieve clinically significant weight loss through behavior change alone. Some may need a boost from lower-intensity, lower-cost anti-obesity medications to reach their goals. Others, with severe obesity or multiple cardio-metabolic conditions, may require higher-intensity anti-obesity medications like GLP-1s. Treatment levels can be safely tried in succession with needs and costs in mind.

It’s likely only 5-10% of a given population would end up using GLP-1s with this step-therapy approach, while the majority of people would still get clinically meaningful results without such intensive treatment.

Address SDOH to personalize care

One-size-fits-all solutions — like those that insist on a highly restrictive diet — miss the mark on health equity. Not everyone can afford expensive meat-heavy diets and they don’t always line up with people’s cultural preferences. Similarly, a program that simply doles out GLP-1s without helping people manage side effects doesn’t work and will only drain budgets.

The key to unlock improved outcomes is by helping people address SDOH challenges like food insecurity, language barriers, cultural factors, physical environment, and more. A good obesity solution should expand access to bilingual registered dietitians who are trained in dietary considerations and eating patterns for many different cultures and ethnic groups. They can help folks plan meals around limited budgets and specific dietary needs.

Conclusion

Organizations have much to consider when evaluating obesity solutions for their population. It’s easy to be swayed by simple metrics that seem indisputable. But, in the end, outcomes like 5% weight loss and reductions in HbA1c for the majority of an eligible population are what counts. Sustainable outcomes rely on real behavior change, a careful step-therapy approach to medication, and personalized care when it comes to social determinants of health.

Caitlyn Edwards, PhD, RDN, is a Senior Clinical Research Specialist at Vida Health

By STEPHANIE TILENIUS

Well over a third of Americans are obese — and the percentage keeps growing at a staggering rate. Over the last twenty years, obesity prevalence grew from 30% to 42% of the US population and rates of severe obesity nearly doubled. If we don’t make serious changes to our healthcare system, it’s scary to think where we’re headed in a few short years.

The fact is, obesity is far from a cosmetic condition. It can be a devastating disease and was classified as such by the American Medical Association in 2013. Obesity is the leading risk factor for deadly diseases like type 2 diabetes, heart disease, stroke, and at least 13 types of cancer.

If we don’t stop the obesity epidemic in its tracks now, we’re in for a world of hurt. People’s lives, the healthcare system, and, by extension, the US economy could be headed for collapse if we continue to ignore it. Cardiometabolic conditions like obesity, heart disease, stroke, and diabetes cost the US healthcare system upwards of $500 billion a year in healthcare costs and another $147 billion in lost workforce productivity for heart disease and stroke alone.

And yet private and government-sponsored health plans are dragging their feet to address obesity head on. They know most people jump from health plan to health plan every few years, so they’re willing to take the chance that their members with obesity won’t develop high-cost complications soon enough to justify treatment now. And yet treatment could reverse the effects of obesity and downstream chronic disease, saving lives and billions of dollars in the long run.

Referring to how most people with diseases in the US get access to specialized health professionals and treatment, Chief Medical Officer for the American Diabetes Association Robert Gabbay said “Not so for people with obesity: the system forces them to wait and get sicker before their treatment is covered by insurance.”

Forward-thinking employers and pharmacy benefit managers, on the other hand, are taking note of new obesity therapies like GLP-1s. Employers will soon start covering GLP-1s and other weight loss medications because people have longer tenure with employers than insurers and employers recognize that obesity treatment reduces healthcare costs, increases worker productivity, and has the potential to attract and retain talent.

While the cost of many weight loss drugs is steep right now, it’s inevitable that we’ll see prices come down eventually. Just like we saw insulin prices come down to $35 a month, patient advocates and lawmakers will pressure drug companies to lower the cost of weight loss drugs to more reasonable amounts. Too many people need these medications who can’t afford them at their startling price point now. And no one wants to live in a world where lifesaving drugs for the masses are only priced for celebrities to use.

As exciting as they are, however, GLP-1s aren’t going to solve obesity alone.

Healthy food should really be the premier medicine to treat obesity. The trick is how to actually integrate food into medical practice. As of now, the best way to integrate food is through Medical Nutrition Therapy prescribed by registered dietitians. Dietitians can personalize eating plans to help people with obesity make healthy food choices that will impact not just their obesity, but also co-occurring conditions like diabetes, hypertension, and cancer. Some nutritious food delivery systems and SNAP benefits show promise too.

We can’t forget that obesity is also strongly linked to depression and other mental health disorders. The mind-body connection is real with obesity sometimes causing grave changes in brain function and cognitive impairment. Conversely, depression is often thought to be an underlying cause of weight gain. Research physicians like Chris Palmer, MD, argue that “mental disorders are metabolic disorders of the brain.”

People with obesity need more mental health support in order to combat the disease and make effective behavioral changes. Studies show that treating depression and obesity together can bring greater improvements for both conditions.

Initiating and sustaining weight loss often requires a nearly herculean effort for many people. It necessitates learning new coping mechanisms and changing lifelong habits — and even still, genetics and other biological markers can work against those efforts. Nevertheless, no surgery or drug alone can fully cure someone of obesity. Experts agree that weight loss medications (GLP-1s and others) and surgery must be coupled with behavior change for sustained results.

People with obesity need the supportive care of provider teams who can prescribe Medical Nutrition Therapy, weight loss medications, and antidepressants alongside mental health coaching and cognitive behavioral therapy when necessary.

Fighting the obesity epidemic will require wholesale change. We can’t keep dismissing obesity as a personal problem of willpower. Not only is that assumption hopelessly defeating, it’s patently false. Obesity is a medical disease that’s reached epidemic proportions and our healthcare system must directly address it with evidence-based treatments like Medical Nutrition Therapy, weight loss medications, and behavioral health coaching for lasting outcomes. If we tackle obesity with our full arsenal, we have the potential to save millions of lives and billions of downstream healthcare costs.

Stephanie Tilenius is the Founder and CEO of Vida Health

By MERCEDES CARNETHON PhD

This month, we saw historic turnout at the polls for midterm elections with over 114 million ballots cast.  One noteworthy observation regarding voter turnout is record rates of participation by younger voters aged between 18 to 29 years old.  Around 31 percent of people aged 18 to 29 voted in the midterms this year, an increase from 21 percent in 2014, according to a day-after exit poll by Tufts University.

Surely their political engagement counters the criticism that millennials are disengaged and disconnected with society and demonstrates that millennials are fully engaged when issues are relevant to them, their friends, and their families. Why, then, do we not see the same level of passion, engagement and commitment when young adults are asked to consider their health and well-being?

I have had the privilege of being a member of the National Heart, Lung and Blood Institute-funded Coronary Artery Risk Development in Young Adults (CARDIA) study research team. In over 5,000 black and white adults who were initially enrolled when they were 18 to 30 years old and have now been followed for nearly 35 years, we have described the decades-long process by which heart disease develops. We were able to do this because, in the 1980s when these studies began, young adults could be reached at their home telephone numbers. When a university researcher called claiming to be funded by the government, there was a greater degree of trust.

Unfortunately, that openness and that trust has eroded, particularly in younger adults and those who may feel marginalized from our society for any number of valid reasons. However, the results—unanswered phone calls from researchers, no-shows at the research clinic and the absence of an entire group of adults today from research studies, looks like disengagement. Disengagement is a very real public health crisis with consequences that are as dire as any political crisis.

As a public health researcher who has been documenting trends in obesity and heart disease for nearly two decades, a number of frightening patterns have arisen.  One pattern is that three out of every four adults are now overweight or obese and the average age of onset of obesity-related illnesses such as diabetes is falling.  Heart disease and chronic heart failure are developing in middle-age—a time that compromises financial well-being secondary to missed days of work managing illness. The negative implications for caring for growing families and aging parents are obvious.  A frightening harbinger of our future are the children and adolescents who see and feel the impact of these illnesses, but who don’t know how to prevent them because the research studies that have identified risk factors have little relevance to their lives today.

The reason they do not have these answers is related to the second startling pattern that young adults are even more difficult to engage in medical and public health research than their older counterparts. I have led and been a member of many research teams and we are extremely grateful for the retired grandmothers and the reluctant, but willing, grandfathers who donate their time to answer questions about their health and allow us to poke, prod and test them.

Due to their participation, we have identified the major causes of cardiovascular disease in the population. However, our knowledge about the evolution of obesity and cardiovascular disease in young adults is limited to studies that were formed in the 1980s before our social and cultural landscape was dotted with mobile devices, online communications and concerns about safety and privacy.

Young adults certainly have many competing responsibilities, including finishing their education, starting first jobs and building their own families. To saddle them with another responsibility seems unfair.  However, just as participating in our political system is one of our many rights and responsibilities as citizens, participating in our public health system should be, too. Ultimately, the goals of public health are to protect the health of all citizens and promote wellness. The national fervor and debate about health care demonstrate the passion people have for health. We need for young adults to stand together and show up to participate in their health with the same fervor and passion with which they showed up at the polls.

Mercedes Carnethon is the Mary Harris Thompson Professor of Preventive Medicine and Chief of Epidemiology at the Northwestern University Feinberg School of Medicine and a Public Voices Fellow with The OpEd Project.

By HANNAH MARTIN MPH, RD; JENNY BOGARD; WILLIAM DIETZ, MD; ANNE VALIK; NICHOLE JANNAH; CHRISTINE GALLAGHER; ANAND PAREKH, MD, MPH; DON BRADLEY MD

The United States has been facing a mounting obesity epidemic for over a generation, but our health care system has struggled to keep up. Given the complexity of obesity and the pace of curricular change, obesity education for our health-provider workforce is still lacking. There are wide disparities in quantity and quality among programs and disciplines. Similarly, public and private payers have taken vastly different approaches towards coverage for obesity treatment and prevention, which even leaves the most educated providers unsure of what services each patient can access. Because coverage decisions are based partly on what providers are prepared to provide and curricula are based partly on what services are typically covered, these problems reinforce one another. Despite these challenges, several important steps have been taken recently to tackle both sides of the problem. The steps include the development of new Provider Competencies for the Prevention and Management of Obesity and the launch of the My Healthy Weight pledge to standardize coverage for obesity counseling services.

Why We Must Act

In the US, more than one-third of the adult population and nearly one-fifth of the children have obesity. Adult obesity prevalence is projected to reach nearly 50 percent by 2030. Adult diabetes prevalence currently hovers around ten percent and is further projected to affect one-third of the adult population by 2050. Estimates for the total annual medical cost of obesity in the U.S. range from $147 billion to $210 billion, with billions more lost in productivity due to absenteeism and presenteeism. Obesity is also a national security issue. As of 2010, 27 percent of young adults were disqualified for military service due to obesity.

Improving Obesity Education for Health Care Providers

Despite these shocking rates of obesity, fewer than one in four physicians feel that they received adequate training in counseling patients on diet or physical activity. Obesity concepts are underrepresented on medical licensing examinations and substantial gaps in provider knowledge related to obesity care have been recently documented. This is not surprising considering that less than 30 percent of medical schools meet the minimum recommended number of nutrition-related content hours.

The decision to develop interprofessional obesity competencies grew out of two related activities. A 2013 convening and 2014 white paper that we organized and authored on training doctors for prevention-oriented care, established that a major barrier to improving the knowledge base was a lack of clarity on what exactly should be taught. At the same time, a publication by several members from an Innovation Collaborative associated with the National Academy of Sciences, Engineering, and Medicine’s Roundtable on Obesity Solutions pointed to the need for integrated approaches to obesity prevention and management.

These led to the formation of a working group consisting of 24 diverse organizations representing a dozen health professions involved in the care of people with obesity. Over the course of 18 months, the working group developed 10 core competencies for obesity education that include demonstrating knowledge of obesity as a disease and its epidemiology, recognition of bias and stigmatization, interprofessional collaboration, and the need for patient-centered communication and physical accommodations.

To promote the integration of the obesity competencies into training programs, we launched an Innovation Award for Health Care Provider Training and Education to recognize health professional training programs that provide innovative nutrition, physical activity, and obesity counseling education and have incorporated one or more obesity competencies into their curricula. Now in its second year, the Innovation Award recognizes the leadership of inventive educational models from all health disciplines and serves to inspire others with examples of what can be achieved.

Improving Reimbursement for Obesity Services

Payments to providers for counseling in nutrition, physical activity, and behavioral health for obesity are another major barrier to the prevention and management of obesity. Although some health insurers have increased coverage for preventive care services, adequate reimbursement for obesity care is rarely a top priority. A survey of Medicaid coverage of obesity services shows that coverage is highly variable and often deficient across states.

To address the lack of coverage and standardization with the insurance marketplace, we convened over 20 private insurers, large self-insured employers, and state Medicaid agencies to devise a standardized benefit obesity counseling services. These forward-leaning payers collaborated for over a year to develop the My Healthy Weight pledge, which launched in November 2017 and now boasts 11 signatories who collectively cover over 10.5 million lives. Key components of the pledge include covering intensive behavioral interventions and evidenced-based community programs for both adults and children with specified risk factors. While these benefits are currently structured for a fee-for-service payment model, we hope to move towards quality-based payment models for obesity in the future.

Looking to the Future

Moving the needle on the obesity epidemic will require all schools and programs that train health professionals to integrate obesity education into their curricula. To facilitate this effort, we have created a database of curricular resources for educators and will continue to recognize exemplary training programs annually through the Innovation Award. We will also identify and address profession-specific gaps in provider education and training on obesity prevention and management.

To capitalize on the momentum of the founding members of My Healthy Weight and support their continued leadership in this process, we will provide ongoing technical assistance and resources as our first cohort of signatories works to implement the benefit for the plan year 2019. We are also working with additional payers to sign the pledge for the plan year 2020.

The costs of obesity emphasize the need for revising care delivery and the importance of clinical-community partnerships to effectively mitigate the obesity epidemic. These improvements cannot come overnight and will require that educators, students, health care providers, health systems, payers, employers, and governments make obesity prevention and care a high priority.

Hannah Martin, MPH, RD, Senior Policy Analyst, Bipartisan Policy Center

Jenny Bogard, MPH, Founder and Managing Partner, Commonality

William Dietz, MD, Ph.D., Director of Sumner M. Redstone Global Center for Prevention and Wellness, George Washington University

Anne Valik, MPH, Founder and Managing Partner, Commonality

Nichole Jannah, Research Assistant, STOP Obesity Alliance, Redstone Center, George Washington University

Christine Gallagher, MPA, Research Project Director, STOP Obesity Alliance, Redstone Center, George Washington University

Anand Parekh, MD, MPH, Chief Medical Advisor, Bipartisan Policy Center

Don Bradley, MD, MHS-CL, Associate Consulting Professor, Duke University School of Medicine

I was enjoying drinks last week with Jody Holtzman (AARP), Terry Booker (IBC), and Doug Ghertner (change:healthcare) at a wonderful conference sponsored by Oliver Wyman. Jody was waxing eloquent about how every start-up needs a strategy for the senior population, when – after a few too many drinks – I emphatically told everyone at the table that I had the senior market cracked. I had experienced first hand the ills of the American health care system for seniors and had identified the perfect solutions.

My father-in-law grew up on a small, Kosher dairy farm outside of Pennsylvania (insert Jewish farmer joke here). He is 72 years old, he was about 40 pounds overweight, he has been widowed for about four years, and, about 30 minutes after my mother-in-law passed away, he started dating a woman that my wife never quite accepted, which is akin to saying that Russia is watching events unfold in the Ukraine from the sidelines (and to be clear, I don’t condone either position).

In January of this year, he was jumping from a backhoe onto a helicopter pad (don’t ask), fell 6 feet, and shattered his heel. The heel is a terrible bone to break in general (poor circulation) and, in particular, for someone who is older and a bit overweight (my goal is to not use the word “patient” once in this article because we aren’t patients, we’re people).

He flew to LA on a massive dose of pain killers (more suitable for a dairy cow than a person), had surgery at a leading hospital system there, and spent the next 2 months lying on his back (truly) while my sister-in-law sponge-bathed and bed-panned her father back to health.

In mid-March, he was given permission to go home and by early April was building a vault at the Federal Prison in Pueblo, CO (true story) when his foot started to smell.

He came up to San Francisco to live with my wife and me, and after five more surgeries, health care bills totaling tens of thousands of more dollars, 40 hyperbaric oxygen sessions, five more months lying in bed (literally), and one nasty surgical site infection and non-healing wound later, was back on his feet and on his way to Montana to plug an artesian well in northern Montana where the nearest hotel is 90 miles from his job (I wish I was making this up but I’m not that creative).

So what’s the point and what are the solutions:

1. While living with us for five months, my wife (for those who don’t know her, think Kathy Bates in the movie Misery) almost starved him to death. It was unclear what was tougher on the poor soul – the gash around his ankle, the 7 months in bed, or the kale smoothies every morning for breakfast. But … he lost 40 pounds, looks great, feels great, has a fully functional heel (!!), and is now living a healthier and happier life.  While I was a believer before, I am an even bigger believer now in wellness for seniors. The weight loss made a world of a difference. Every senior in the country should come and live with Amy and experience her starvation diet. We could probably turn it into some kind of reality TV show.

2. In August as he was starting to see the recuperation finish line, his girlfriend broke up with him (which is understandable after eight months apart). A couple of days after they broke up, my father-in-law went on J-Date, the Jewish dating site, and posted his profile. I didn’t see the actual profile but I envision the following: “72 year old male, gimpy but recovering, living with daughter, seeks attractive, outgoing female. Must like sleeping in cars on side of road, heavy equipment, and working in close proximity with America’s most dangerous criminals.”  He also posted a pre-starvation picture. He had 180 date requests within 24 hours – I kid you not!  The last month he stayed with us, he had four lunch dates and three evening dates each week, was routinely out until midnight, and slept until 9 am most mornings with a bottle of aspirin next to his bed (and it wasn’t for the foot pain). Our kids aren’t teenagers yet, but I’m pretty confident I am ready to handle their dating adventures now.  I got to peruse my father-in-law’s dating options on J-Date and, if he wasn’t the father of my wife, I would have asked him to take me with him.

Notwithstanding seven months on his back, my father-in-law is really happy. While he had a remarkable and positive attitude throughout the ordeal (and I greatly admire him for that); he’s also happy because he got to spend eight months with his family, he is meeting new people, and he is experiencing new things. Kidding aside, he really had a good time with J-Date, and it has made me realize that the big senior opportunity is in creating happiness. He is healthy and thriving today (after a horrible eight months) because he had a great attitude and because he is happy and engaged with people of all sorts. In the provision of all care, but in particular with senior care, we REALLY have to  cultivate the mind in addition to the body.

3. Pick your hospitals carefully. The infection NEVER should have happened (a huge shout out to Dr. Jamie Bigelow at Dignity Health for getting us to the right place). Big reputation and a famous name on the door does not necessarily equal great care.  As consumers, we need to be educated on what makes for a good hospital (beyond simplistic “Best of” lists), and we need to be provided with clear data to evaluate the places we go for treatment.

4. Approach my wife Amy even more carefully than you pick your hospitals.  I go to sleep each night fearful that she’s going to break my heel to “help” me lose 15 pounds.  But she is not to be trifled with, and, to her great credit, she nursed her dad back to health and even better health than before. This process was stressful on everyone – my father-in-law (obviously), Amy, her sister, his sister, and the whole family. Everyone came together, worked together, and handled it beautifully despite the stress. Everyone showed great respect and appreciation for the family caregivers and for my father-in-law during the process. This is incredibly important and worth remembering in family caregiving situations.

5. Logistics are a bear when dealing with senior care. He was unable to drive while recuperating, and my wife, who, like me, has three young children and a husband too cheap to support her with extra child care over the summer, had to get him to his daily hyperbaric oxygen treatments (please see my next blog on why Uber is actually worth $10 trillion dollars).

So you’re probably wondering what Esther Dyson has to do with this. During the conference, Esther led a wonderful session on “the quantified self.”  About 15 bourbons into the evening, I  challenged Doug to explain to me what is “the quantified self” as I impetuously decided it was an oft used but rarely defined term. Doug gave a wonderful answer, which is that it’s a means to an end and one of many means to that end. We should be talking about awareness. How do we make people more knowledgeable about the implications of their lifestyles and more self-aware about those implications when making daily decisions. The self doesn’t have to be quantified (although it certainly doesn’t hurt). It has to be qualified. Terry then told me I needed to document our conversation for posterity and suggested Lisa’s blog. We were trying to figure out a way to bring it all together when I started to wonder if Esther is on J-Date….

I don’t have a twitter account but try me at #ihopemywifedoesntreadthisblog or #ihopeihaventoffendedestherdyson or #ittakes9hourstogetfromtampatosfandihadnothingbettertodothanwritethis

PS. I hope it doesn’t happen again, but my father-in law is welcome back (sick or healthy) any time he wants, and not just because we had a “captive” babysitter for five months, which was nice. I am in awe of how he and the whole family handled such an extreme situation with grace and I even learned something in the process.

Marty Felsenthal is a partner with HLM . 

Eating advice in the United States has taken leave of its senses. It is no wonder that Americans are perpetually on diets.

It is only in the last 20 years that eating, a task we do quite naturally, has become so complex that you apparently need professional spin from nutritionists and dietitians, or worse, from doctors, on how to do it.

Spend a little time on the web (and especially social media) and your head will spin from all the contradictory healthy eating advice: eat organic…no, wait, don’t waste your money; eat less salt…wait, too little salt might be worse for you than too much salt; don’t eat fat…oh, sorry, eating too little fat will actually make you fat because you’ll eat too many poor quality carbs; eat foods that have a low glycemic index…wait, we meant a low glycemic load, er, well maybe eat foods that are both; eat breakfast every day because it will help you control your body weight except when it doesn’t.

We have the most productive food industry and the safest food supply in the world. Without us, the world’s food supply collapses and lots of people starve.  Food is cheaper now as a proportion of income than it was 100 years ago. Only in America could we look at our easy and cheap access to food and conclude that we have done something wrong.

Where we have gone wrong is in our belief that there are no normative standards for what it means to be a competent American adult. Don’t want to exercise? It’s ok, it’s your choice. Don’t want to trade the $6 extra large bag of chips in your cart for a bag of apples and a bunch of bananas? It’s ok, it’s your choice. Can’t tear yourself away from the soda fountain long enough to consider drinking a bottle of water? Hey, it’s okay, it’s all about you.

If you use Supplemental Nutrition Assistance program (SNAP, which replaced food stamps), you can fill your cart with poor quality calories because, well, it’s only taxpayer money, which you should be able to waste as you see fit.

The modern nutritional mewling that Americans have eating disorders, and they’ve all been duped by the food industry, is the witless maundering of an industry looking to make work for itself and get paid for spouting platitudes. The obesity problem is not only not a disease, it’s not an epidemic. An epidemic is both prevalent and virulent; two-thirds of American adults are not obese, its prevalence varies widely, and you cannot catch it the way you catch a cold.

I learned every useful fundamental thing I ever needed to know about nutrition from my mother, an immigrant with little advanced education: eat a little of a lot of different foods, soda and snacks are bad for you, fruit is always good, and going outside to play is better than watching TV.

I have maintained a healthy body weight for my entire adult life, eating just what’s accessible, sensible, affordable, and tasty. I can walk into any grocery store in America, including the store all the nutritionistas love to hate, Walmart, and walk out with bags of perfectly healthy food.

Our national weight obsession has everything to do with a glaring lack of self-respect and ignorance of basic algebra.

The formula for successful body weight management is unchanged through the millennia: you must balance energy consumed with energy expended.

In fact, here is the world’s simplest eating advice: Eat less. Eat less crap.

Oh, and exercise A LOT more. After a year of doing that 24/7, come back and see me. Until then, closing your mouth will serve multiple useful purposes.

Vik Khanna’s new e-book Your Personal Affordable Care Act: How To Avoid Obamacare, is available now in the Amazon.com Kindle Marketplace and at Smashwords.com. Vik is THCB’s Editor-At-Large for Wellness.

The health care field is in the grip of a standard that drains resources while infusing little back in return. Stuck in a paradigm that was defined in 1893 and never revised with regard for the promise offered by modern information processing, ICD symbolizes many of the fetters that keep the health industries from acting more intelligently and efficiently.

We are not going to escape the morass of ICD any time soon. As the “I” indicates in the title, the standard is an international one and the pace of change moves too slowly to be clocked.

In a period when hospitals are gasping to keep their heads above the surface of the water and need to invest in such improvements as analytics and standardized data exchange, the government has weighed them down with costs reaching hundreds of thousands of dollars, even millions just to upgrade from version 9 to 10 of ICD. An absurd appeal to Congress pushed the deadline back another year, penalizing the many institutions that had faithfully made the investment. But the problems of ICD will not be fixed by version 10, nor by version 11–they are fundamental to the committee’s disregard for the information needs of health institutions.

Disease is a multi-faceted and somewhat subjective topic. Among the aspects the health care providers must consider are these:

• Disease may take years to pin down. At each visit, a person may be entering the doctor’s office with multiple competing diagnoses. Furthermore, each encounter may shift the balance of probability toward some diagnoses and away from others.
• Disease evolves, sometimes in predictable ways. For instance, Parkinson’s and multiple sclerosis lead to various motor and speech problems that change over the decades.
• Diseases are interrelated. For instance, obesity may be a factor in such different complaints as Type 2 diabetes and knee pain.

All these things have subtle impacts on treatment and–in the pay-for-value systems we are trying to institute in health care–should affect reimbursements. For instance, if we could run a program that tracked the shifting and coalescing interpretations that eventually lead to a patient’s definitive diagnosis, we might make the process take place much faster for future patients. But all a doctor can do currently is list conditions in a form such as:

E66.0 – Obesity due to excess calories

E11 – Type 2 diabetes mellitus

M25.562 – Pain in left knee

The tragedy is that today’s data analytics allow so much more sophistication in representing the ins and outs of disease.Take the issues of interrelations, for instance.

These are easy to visualize as graphs, a subject I covered recently.

Figure 1 shows how a patient’s obesity contributes to Type 2 diabetes and knee pain. There are many ways to store this information in ways that a computer program can retrieve and make sense of, including a standard called RDF that is widely used on the Web.

Figure 1. Illustrating contributory factors

In contrast, ICD obscures relationships. The standards do represent a small subset of such relationships; for instance Type 2 Diabetes has 56 ICD-10 codes that list commonly associated conditions. The paucity and gawkiness of such efforts (for instance, how do you represent multiple complications?) just underlines how desperately the health care field needs a different approach.

Wrong-side errors (such as operating on the left side when the problem is on the right) are shockingly common, but it’s still laughable to define separate medical codes for the left and right side, instead of coding left/right as a separate dimension that can be represented in the graph.

Finally, given that the doctor will select the diagnosis that gets the highest reimbursement rather than the diagnosis that best represents the patient’s condition, one can say good-bye to any analytical benefits that supposedly come from the proliferation of ICD codes. The bias of the system toward billing instead of treatment is revealed by the definition of separate codes for the initial encounter and subsequent encounters.

Researchers and analytics firms, I’m confident, will devise standards for representing disease in all its complexity. Health care institutions, eager to cut costs and find the right treatments faster, will use the new systems to track and analyze disease. It’s sad that we’ll be forcing doctors to use at least two parallel diagnostic systems–one tied to the practice of medicine in 1893 and another appropriate for 21st-century data processing.

Among the American public and even some policymakers, it has become conventional wisdom that poverty, a dearth of supermarkets, reduced leisure time, and insufficient exercise are key forces behind the U.S. obesity epidemic.

Conventional wisdom is an unreliable guide, however, and in this case, much of it is wrong: The epidemic actually coincides with a falling share of income spent on food, wider availability of fruits and vegetables, increased leisure time, and more exercise among the general population.

Of course, there are differences between individuals, but we need to explain the change in obesity over time, not why people differ. Some differences in body mass index (BMI) are associated with genetic makeup. But genes haven’t changed in the past 50 years, so differences between individuals don’t explain trends.

Data from a new analysis of this issue indicates that the same argument applies to other characteristics, such as geography. Southern hospitality’s heavy food hasn’t caused the obesity epidemic any more than an active Colorado lifestyle has prevented it. There are differences at a given point in time, but the trend is the same, as shown in the figure below.

Percentage of Population with a BMI Over 25 in California, Colorado, and Mississippi

SOURCE: Calculations based on Behavioral Risk Factor Surveillance Survey; smooth trend adjusted for 2010 demographics.

Increases in obesity have also been surprisingly similar by level of education and by racial/ethnic group, as the following figures show.

Increase in Average BMI Nationwide, by Highest Education Level Achieved

SOURCE: Calculations based on Behavioral Risk Factor Surveillance Survey; smooth trend adjusted for 2010 demographics.

Increase in Average BMI Nationwide, by Racial/Ethnic Group (Men)

SOURCE: Calculations based on Behavioral Risk Factor Surveillance Survey; smooth trend adjusted for 2010 demographics.

Increase in Average BMI Nationwide, by Racial/Ethnic Group (Women)

SOURCE: Calculations based on Behavioral Risk Factor Surveillance Survey; smooth trend adjusted for 2010 demographics.

Across all these characteristics, the striking feature over time is not how different the trends are but rather how similar the weight gain has been, regardless of geography or social group. There are differences between groups—often sizable ones—at any point in time, but addressing such disparities is different from stopping the obesity epidemic.

That no group is immune to rising obesity rates suggests that universal environmental factors are driving the trend. The clearest change concerns food availability and cost. Since the 1970s, there has been a significant drop in the share of income spent on food—yet each food dollar buys a lot more, as shown below.

Food Expenditures as a Percentage of Disposable Income, Total and by Type of Food

SOURCE: U.S. Department of Agriculture data.

Average Daily Per Capita Calories, Adjusted for Spoilage/Waste

SOURCE: U.S. Department of Agriculture data.

As the obesity epidemic has grown and food prices relative to income have dropped, Americans have been eating more of everything, including fruits and vegetables. In terms of macronutrients, most extra calories come from carbohydrates.

U.S. markets have succeeded in largely solving the age-old problem of food scarcity, so the answer isn’t to return to higher food prices across the board. But with the solution to food scarcity contributing to a new threat, Americans need market forces to shift them in a different direction and help stem the obesity epidemic.

Market forces happen on both sides: supply and demand. On the supply side, agricultural policy has historically tried to promote output and improve food security. Undesirable side effects weren’t uncommon. Europe, for example, often resorted to discount prices to eliminate its surplus “butter mountains” and “milk lakes.”

On the demand side, consumers do substantially alter their shopping and improve their diets if motivated by price changes. An encouraging example comes from South Africa, where the country’s largest health insurer implemented a nationwide rebate program for healthy foods. However, even substantial price incentives—in South Africa, a 25-percent rebate—can close only a small part of the gap between recommended and actual diets. In addition, price discounts may improve diet quality, but they may not reduce obesity. (A discount for healthy foods doesn’t mean that people will buy fewer calories overall.)

South Africa isn’t the only country taking action. In Mexico, where the obesity rate now exceeds that in the U.S., policymakers have enacted a tax on sugar-sweetened beverages and energy-dense snack items. Europe, perhaps spurred by swelling obesity rates of its own, is also taking action. Hungary has imposed special taxes on unhealthy foods, while Denmark went back and forth: It implemented a tax, only to repeal it a year later.

Changes in social norms that shift the demand curve could be just as important as policies that affect food prices. There was a time when it was polite to offer a guest a cigarette. Americans today might offer cookies or soda. When they begin to regard junk food as they do tobacco, curbing the obesity epidemic may become more attainable.

Under the influence of conventional wisdom, many policy interventions focus on “positive” messages: Eat more fruit and vegetables. Get more exercise. However, given that fruit and vegetable availability and physical activity have both increased while relative food prices have plummeted and obesity rates have soared, reducing discretionary calorie consumption may be a more promising lever to reduce overweight and obesity.

Roland Sturm is a senior economist at the nonprofit, nonpartisan RAND Corporation and a professor at the Pardee RAND Graduate School.