The New Health Dialogue

A series from The Los Angeles Times this week on the serious health issues -- and enormous healthcare costs  -- associated with obesity contained a curious omission: the concrete steps that state and local governments here in California have taken to mitigate them.

Though largely unaddressed in the LA Times articles, the weight of evidence lies behind the assertion by Dr. Deborah Cohen of RAND that:  “Much obesity is the result of genetics and the environment. Yet we're blaming individuals when the food environment is the problem.”    

What does she mean by the food environment? A report issued by the California Center for Public Health Advocacy (CCPHA) in 2007 showed a strong linkage between the prevalence of diabetes and obesity and a community’s score on the “Retail Food Environment Index.”  This measure of the accessibility of healthy food divides the number of fast food restaurants and convenience stores by the number of supermarkets, produce stores, and farmers’ markets.  These differences in obesity and rates of chronic disease persist when controlling for income and other factors. (My colleague Joanne Kenen also wrote about other aspects of what we can think of as a food environment, as well as changing social norms that affect how we interact with that environment -- our round-the-clock, everpresent access to food, fast food, and junk food).

The importance of the quality of individuals’ food choices has not been lost on California governments.  In July 2008, the Los Angeles City Council unanimously passed an ordinance banning the construction of new fast food restaurants in South Los Angeles.  This economically depressed area of the city has some of the highest rates of obesity in California. 

A study gauging the impact to these regulations, co-authored by Deborah Cohen, questions the effectiveness of this policy intervention. It noted, for instance, that many residents of this area purchase high-calorie, low-nutrient foods such as soda at convenience stores not targeted by this fast food restaurant ordinance.  Larry Cohen, executive director of the Oakland-based The Prevention Institute, urges that “more time is needed before their full impact can be realized,” analogizing these interventions to the no-smoking areas implemented in the 1980s that took many years to have a broader effect.

The RAND Corp. study suggested that menu labeling might be a more effective strategy of reducing rates of obesity -- and consequently of chronic diseases and the growth of healthcare costs to which they contribute.  In 2008, the California Legislature also passed a menu labeling bill (SB 1420 -- Padilla and Midgen) that when implemented will require fast-food restaurants with twenty or more outlets in California to provide nutritional information on their standard items. One analysis of a menu labeling ordinance in New York City “did not detect a change in calories purchased after the introduction of calorie labeling.”  Other researchers (and Joanne has interviewed some for an article she’s working on -- you’ll hear more about it soon) are finding some preliminary signs that menu labeling can have an effect on how and what people eat.

This underscores one of the most perplexing issues in the debate about rising health care costs.  The crisis is immediate, but many solutions may only have an effect over the long-term. 

The savings to be realized from addressing the obesity  trends, however, is substantial.  A recent study issued last year by CCPHA and UCLA estimates that, “if the state of California is able to achieve a modest reduction in the prevalence of overweight, obesity, and physical inactivity of just 5 percent per year for each risk factor, the savings realized would average nearly $2.4 billion per year.”  With this high a potential payoff, one hopes it is possible to muster the political will to take on long-term projects that may dramatically reduce our state’s health care costs while improving the health of the citizens in some of our most disadvantaged communities. 

It remains to be seen whether the political will exists in Washington to address major health care challenges in our nation.  In California, though, a broad group of stakeholders came together over the course of the past year to develop a comprehensive plan to stem rising healthcare costs in the state. This strategy includes addressing everything from the “social determinants” of poor health outcomes, such as lack of access to healthy foods, to the financial incentives that encourage wasteful, and in some cases harmful, care.  These recommendations -- as well as details of how to successfully implement them in California with or without federal health care reform -- will be included in a forthcoming report by The New America Foundation.  Stay tuned.