Fast and Supersized: Is the Answer to Diet by Fiat?

When the world was a simpler place, the rich were fat, the poor were thin, and right-thinking people worried about how to feed the hungry. Now the rich are thin, the poor are fat, and right-thinking people are worrying about obesity.

—The Economist, December 13, 2003

Can the state make people conform to a healthy diet and active lifestyle? Can it at least help them conform? Public health advocates have a wish list of governmental interventions they would like to implement to reduce obesity rates. To economic conservatives, however, state action over obesity is tantamount to diet by fiat, and it is an unwanted intrusion. "Government should not help citizens look after themselves," argued The Economist in the editorial from which the epigraph to this column is drawn: "People are constantly torn by the battle between their better and worse selves. It's up to them, not government, to decide who should win."

One question, then, is whether people have free will and should bear responsibility for their own behavior. More on that later. First, consider the sobering statistics. The proportion of overweight adults (65 percent) and children (15 percent) has more than doubled since 1980.¹ A sedentary lifestyle and poor nutrition is a high risk factor for chronic diseases, leading to some 400,000 deaths each year.² Indeed, the United States is experiencing an "epidemiological transition" from infectious to chronic diseases, such as heart disease, diabetes, and cancer, as the leading cause of morbidity and mortality. Obesity resulted in $75 billion in medical expenses in 2003, half of which were borne by the public through Medicare and Medicaid. Obesity-related conditions also affect businesses because they lead to lost productivity, paid sick leave, and more expensive health and disability insurance.³

Since behavior is heavily influenced by environment, many public health advocates support active environmental interventions to reduce the consumption of high fat and high calorie foods and increase physical activity. In addition to such "direct" interventions, they also support indirect regulation through the tort system.⁴

The informational environment.

The public is bombarded with information encouraging inactive lifestyles and the consumption of unhealthy foods. The food industry has an annual advertising budget of $33 billion, including more than $3 billion for fast foods and $1 billion for McDonald's alone, while the National Cancer Institute spends only $1 million a year to encourage people to eat fruits and vegetables.⁵ Public health advocates support restrictions on advertising, particularly when it is deceptive and when it targets children. They also call for tough labeling requirements that require fuller and clearer disclosures of nutritional content on packaged foods and restaurant menus.

The built environment.

Health officials can provide information about healthy lifestyles, but if individuals live in poorly designed communities, their health will suffer. Many urban environments lack safe, open, and green spaces to facilitate recreation and physical activity. They also lack easy access to inexpensive, nutritional foods. Convenience stores and fast food outlets may vastly outnumber grocery stores where people can buy whole grains, fresh fruit, and vegetables. At the same time, suburban sprawl facilitates reliance on automobiles and discourages walking or cycling. To reduce these adverse affects, public health advocates recommend changes in zoning, building regulations, and housing codes, all of which have been approved by the Supreme Court as a proper exercise of the police power. These laws can help create environments conducive to healthier lifestyles.⁶

The educational environment.

Since almost all young people are in school and over half eat one meal in school, the Surgeon General has identified school-based programs as a major way to reduce obesity. Unfortunately, schools now frequently offer the "competitive foods" sold in snack shops, vending machines, and school cafeterias. Offering competitive foods brings revenues of at least $200 million annually into school systems' coffers.⁷ But it also ensures easy, affordable access to unhealthy foods, suggests implicit school endorsement of food brands, and promotes development of early patterns of unhealthy eating among students. Public health advocates recommend stricter federal and state regulation of the food available in schools. The U...