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James R. Knickman

James R. Knickman

Posted: December 14, 2010 09:25 AM

If ever a challenge vexes us in the public health world, it is how to take on the obesity epidemic. Obesity is the pathway to a wide range of health maladies we face, including heart disease, diabetes, kidney disease--and the economic malady of high health care costs.

I admit that I have been a fan of many ideas that might make a difference, even if I am not entirely convinced there is evidence that the intervention alone will have a noticeable impact on the obesity challenge.

Take the soda tax, for example. I have written about how such a tax would be a helpful step and have been impressed with the passion Health Commissioner Richard Daines at the state level and Commissioner Tom Farley at the New York City level (as well as the New York State Association of County Health Officials) have brought to this issue.

But, lately I have been having some second thoughts. I am not doubting that a soda tax would be a positive force in a campaign to address the obesity challenge. My concern is that such a tax might only make sense if it is in fact part of a larger campaign of initiatives to make a meaningful dent in the problem. I think we need to start thinking bigger and more systematically rather than trying to do things increment by increment.

A soda tax would have just a small impact on the problem. Optimistic estimates are that it would reduce consumption of 20 calories per day. And, we are not absolutely sure people wouldn't replace soda by eating or drinking something else with similar worthless calories.

Of course, we know soda taxes will have more of an economic impact on the poor than on the wealthy. I would find that less troubling if there were assurances that any revenues from the soda tax would be invested in additional prevention activities that would help reduce obesity rates among hardest-hit communities (the most recent proposal by the State government was to use the soda tax revenues to help the hospital system).

A soda tax would be more palatable if we put it on a menu of initiatives that taken together would add up to a real campaign to make a measurable, meaningful impact on people's health. More of the public might see the sense of each element because they would have more confidence of the real impact of the set of initiatives.

Here is my list of items that we should put in the campaign to address this epidemic (and all of these have some evidence that they can work):

  1. get rid of every soda machine in schools;
  2. seriously revamp school lunch menus;
  3. adopt standard requirements for recess, physical education, and other physical activities in school (and go the extra mile with similar standards for child-care programs);
  4. get insurers to start paying for meaningful diabetes prevention programs that focus on helping people improve eating and exercise (the YMCA is piloting such a project in New York State and elsewhere and UnitedHealth Group is committed to begin reimbursing for it);
  5. establish joint-use agreements that would allow community members to use gymnasiums and other school-based recreational facilities outside of school hours, to provide additional opportunities for students and community members to be more physically active;
  6. start a campaign to have every large employer have an on-site wellness program that encourages physical activity and good eating habits;
  7. extend menu-labeling laws to all eating establishments across the State; and
  8. grow the smallish initiatives of New York City to get fruits and vegetables available in our low-income neighborhoods.

The next step in the public health field's interest in reducing obesity should be to outline the elements of a campaign and to push for a multi-pronged approach done in real time. This issue is too important for us to tinker around at its margins.