Obesity and Paternalistic Policies

INTRODUCTION

At the beginning of August, several Brazilian media outlets pointed out that all schools in Rio Grande do Sul are prohibited from selling soft drinks, candies and snacks. Canteens will have up to 90 days to adjust to the new reality. If the law is not respected by the owners of the establishments, they will have to pay fines that can reach R $ 1.5 million. This measure results from the approval of bill PL 23 2016 authored by Ms. Tiago Simon (MDB) in early July by all MPs present and sanctioned by Governor José Sartori.

Following the slippery path of policymakers and bureaucrats around the world who have used behavioral insights to legitimize strong paternalistic interventions, the justification for Gaucho law is as follows. The following foods contribute to obesity, diabetes, hypertension among other diseases and so should be banned:

Bullets, lollipops, chewing gums, stuffed biscuits
Soft drinks and artificial juices
- Crackers
- Frying in general
- Industrialized popcorn
- Industrialized foods whose calories from saturated fat are equal to or greater than 10% of total calories
- Foods prepared with hydrogenated vegetable fat
- Processed foods that have high sodium content

In addition, the law determines that canteens in Rio Grande do Sul offer at least two types of fruits and / or natural juices daily.

The purpose of this article is to critically examine the arguments of such a measure that relies on two premises. One is that the major cause of obesity involves the consumption of such foods and beverages. The other is that policymakers can and should change the misbehavior of people's choice of food consumption by banning unhealthy foods and mandating the sale of adequate products for a good diet.

To accomplish this task, we invite readers to understand which insights of behavioral economics are welcome to discuss public policies and deal with complex problems, such as childhood obesity in Brazil. However, we draw inspiration from the cautious view of behavioral economist George Loewenstein about the extent of nudges and the need to recognize some of their unintended negative consequences (Loewenstein & Chater, 2017). In our case, the focus will be on critical analysis of the implications of anti-obesity nudges (Hoffer & Nesbit, 2018). In addition, three types of problems - ethical, epistemic, and practical - will be briefly discussed by all of us, sympathizers and critics of behavioral research, to consider.

2. THE PROBLEM OF OBESITY IN BRAZIL

Unfortunately obesity has become in the last decades a chronic disease worldwide. According to the Surveillance Research on Risk Factors and Protection for Chronic Diseases by Telephone Inquiry from the Ministry of Health, obesity among the young population increased by 110% between 2007 and 2017 (Vigitel 2017). Currently, 54% of the Brazilian population on the problem of overweight and obesity already reaches 18.9%. In Porto Alegre, 19% of the inhabitants are considered obese and 55.1% overweight. Childhood obesity affects 9.4% of girls and 12.7% of boys in Brazil and is already above the world average (5.6% of girls and 7.8% boys).

The great commotion results from the fact that obesity is associated with several diseases, the so-called comorbidities, such as hypertension, diabetes, heart disease, depression and cancer. In response to this, the Ministry of Health has set the goal of reducing the increase of obesity by 17.9% in the next year of 2019. The Unified Health System (SUS) estimates spending of almost R $ 490 billion associated with diseases that accompany obesity.

It is worth mentioning that obesity is a disease resulting from a combination of biological, sociocultural, environmental, economic and behavioral factors. However, the finding that less than 5% of obesity cases in the country result from endocrine disorders illuminate that obesity can be a perverse consequence of food choices and limited exercise.

In line with health and wellness policies around the world, Brazil also seems to consider obesity in terms of market failures and behavior resulting from scarce information on nutritional content of foods, externalities, habits of the contemporary world and limited rationality. This line of reasoning brings the contributions of Behavioral Economics to the center of the debate on food health policy (Scharff 2009, Rising 2016).

Some interesting experiments suggest that some nudges expand individuals' information set on food attributes (and the consequences of their overeating), and thus help consumers change their choice behaviors over time. Consumption of soft drinks and artificial juices in Brazil fell 52.8% during the period from 2007 to 2017 (Vigitel 2018). In the same period, the consumption of vegetables and vegetables rose 4.8% and physical exercise in free time grew 24.1%.

3. NUDGES CAN HELP, DO NOT RESOLVE EVERYTHING AND COULD JUSTIFY STRONG PATERNALISM

Since the publication of the bestselling Nudge in 2008, Richard Thaler and Cass Sunstein point out that evidence of behavioral economics can inspire subtle changes in the decision-making contexts of individuals, which serves to help them pursue their best long-term interests. According to Daniel Kahneman (2011), the book is a manifesto for the behavioral approach to politics.

The literature on nudges is vast and has contributed to a promising twist in the design, implementation, and review of public policies that consider individuals as human beings rather than mere concepts of decision-making units that are fully rational and insensitive to contexts, emotional factors, mental models, and preferences social policies.

The numerous nudges that are interesting for the fight against the growth of obesity include reminders, tables of nutritional content, cell phone applications to organize healthy diet, among others. Other anti-obesity nudges involve changes in the default rules, such as changing the location of unhealthy foods in supermarkets and canteens, reducing portions of food, adding salads instead of fries at meals of fast food restaurants, smaller size of sandwiches, dishes and soda cups. There are even programs that use posters containing images of healthy living to influence beverage food choices.

4. SOME CHALLENGES OF ANTI-OBESITY INTERVENTIONS AND THEIR IMPLICATIONS

We will briefly review the evidence on the efficacy of nudges related to the axes of education, communication and information on healthy diet and choice of foods that promote future quality of life and health. According to Brian Wansink, small changes in the architectures of choice are capable of causing people to control their food intake without incurring any dietary effort (Wansink 2004). However, Skov et al (2013) review studies that show that the results of changes in food choice architectures help individuals to eat better are inconclusive. Other studies also suggest that dish size has no significant effect on the total energy (kilocalorie) of a meal (Rolls et al 2007, Libotte, Siegrist and Bucher 2014).

The effects of regulation on food labeling also suggest that nudges need to be examined carefully (and eventually revised). Not always the presentation of the table of nutritional information is done in an informative and well informed way.

Curiously, such a cautious view of the need to better understand the effects of changes in food labeling rules has inspired the National Sanitary Surveillance Agency (ANVISA). With this in mind, a public consultation was opened to provide greater transparency and accept suggestions on how to improve nutrition information to help consumers make better food choices. The idea is to inform potential consumers about the nutrient content that causes negative health impacts. To simplify and avoid confusion or deception, the proposed change in labeling will involve using colors, symbols, and an essay accessible to all.

What about the Rio Grande do Sul intervention, which prohibits canteen vendors from selling delicacies and processed food or beverages? Can we include it in the set of measures called childhood anti-obesity nudges? Our answer is no. This is because nudges refer to measures and policies that do not restrict individuals' freedom of choice. Nudges only illuminate or point to alternatives that can help agents cope with problems such as self-control, procrastination, and other cognitive biases that in turn create obstacles to approximate intentions and actions to promote individual and social well-being.

In a study that tracked 20,000 kindergarten through eighth grade students in 1000 public and private US schools, Jennifer van Hook and Claire Altman (2012) found that children with access to junk food (snacks, sweets, candy, etc.) weighed no more than those who studied in schools without access. This is because 35.5% of the children who studied in schools without a ban were obese and 34.8% were also studying in schools that banned foods considered as unhealthy. Similarly, Jonathan Kropski et al (2008) reviewed the impacts on obesity associated with existing experiences of banning candy sales in schools. They also concluded that interventions are not effective and can not reduce caloric intake.

Let us turn now to the analysis of three problems that accompany both nudges and strong paternalistic interventions (prohibitions). The first is ethical. The second is epistemic, and the third is practical in nature.

It is not easy to lose weight especially when the individual is obese. The task is not limited to the choice of food intake. The growing enthusiasm for interventions to combat obesity does not recognize perverse perils and unintended consequences that threaten the autonomy of choice and human dignity.

Although there are several causes for weight gain in the last 50 years, many of the discussions emphasize behavioral failures and treat overweight people as having less access to information, limited ability to deal with the problem of self-control at the moment of food consumption and low motivation to lose weight. Such a portrayal of the obese contributes to a distorted and prejudiced view of the obese as a "naive hyperbolic dissonant" individual, unable to approximate his own intentions and actions. All this opens space for the acceptance that obesity is the result of a wrong choice of food, which can be corrected. The problem is that some health policies may carry the deleterious effect of disrespecting individuals' food preferences and their ability to manage their own lives. In addition, they inspire the formulation of standards of well-being and quality of life that do not fit everyone.

By restricting adults' freedom to choose what they and their children will eat, politicians and bureaucrats call into question the fundamental value of human dignity and the right of each to be the agent of their own destiny.

To complicate matters, there is always the temptation of bureaucrats to impose their values ​​on what it means to be well informed and have long-term preferences. In a survey involving 1130 adults in the United States, Finkelstein et al 2008, 2011 identified that obese people know the risks associated with obesity. In addition, the view that the obese are not motivated to lose weight is distorted. Individuals suffering from obesity receive lower wages and pay higher health insurance (Bhuttacharya and Bundorff 2009).

The second problem comes to light when we consider the causal relationship between obesity and the consumption of certain foods. We can not underestimate the difficulty of understanding the causal link between obesity and environmental, biological, social and psychological factors. Even politicians and bureaucrats most familiar with nutrition and health problems possess local, dispersed, time-sensitive and social context. Regulators tend to believe that they know health problems more than the people themselves who are the targets of their interventionist policies. This is because they have greater access to information. However, it pays to be careful not to get carried away by the confirmation bias and illusion of control. The technical knowledge of policy makers seems necessary, but insufficient to prevent and combat obesity. Paternalistic interventions stronger than nudges - high taxation of high calorie products or processed foods and ban on sale - neglect unplanned consequences. For example, we can imagine that replacing the consumption of an unhealthy good banned from the market by another healthy food can also have harmful health effects if consumed in excess. There is evidence that prohibitions and taxation did not reduce individuals' caloric intake, but only encouraged the consumption of surrogate goods, not always of high nutritional value (Marlow, 2017). In addition, removing certain foods from the supermarket shelves and cafeteria counters causes losses not only to business owners linked to the production and distribution of goodies, but also unemployment, falling incomes and reduced welfare in the economy as a whole.

The third problem is the practical one. It does not seem to us possible to effectively implement changes in the decision-making behavior of individuals through mere taxation and consumption bans. Such an undertaking would show that policy makers could gather and coordinate all the information necessary to know what the best interests of each individual are. In addition, there is no way to control whether children will stop eating the treats because canteens are barred from selling them. Prohibitions commonly generate the unintended consequence of the emergence of informal trade and higher prices that only reduce the quantity consumed by the poorest, without this implying the change of preferences and individual behavior in a lasting way.

So it is worth examining the nudges on a case-by-case basis and beware of the poor uses that politicians and bureaucrats can make of evidence of limited rationality. This is because Homo sapiens is subject to the mechanisms of fast and slow thinking in both public and private life.

In our view, behavioral economics applied to public policy does not necessarily imply any predilection for "paternalistic inves- tations." Instead; it makes us more humane, humble and aware that it is worthwhile to admit the limits of our rationality and knowledge. May such recognition give us a willingness to put on the white lab coat and then go out to field experiments. Any and all efforts to reform public policies to combat obesity that fail to deliver what they promise are most welcome.

REFERENCES

Bhattacharya, J. and  Bundorff, M.K (2009) “The Incidence of Health Care Costs of Obesity,” Journal of Health Economics, 28, 3, pp.649-658

Finkelstein, E. A., Brown, D.S and Douglas E (2008). “Do Obese Persons Comprehend Their Personal Health Risks?” American Journal of Health Behavior 32 (5), pp. 508–16.

Finkelstein, E.A., Strombot, K.L;  Chan, N and Krieger, J. (2011). “Mandatory Menu Labeling in One Fast-Food Chain in King County, Washington.” American Journal of Preventive Medicine 40 (2): 122–27.

Hoffer, A.J.; Nesbit, T. (2018) For Your Own Good: taxes, paternalism and fiscal discrimination in the 21^st century. Mercatus Center and George Mason University

Hook, van J. e Altman, C. (2012) “Competitive Food Sales in Schools and Childhood Obesity: A Longitudinal Study.” Sociology of Education 85 (1), pp. 23–39.

Kahneman, D. (2011) Thinking, fast and slow, New York: Farrar, Straus and Giroux.

Kropski, J.A., Keckley, P.H and Jensen, G.L. (2008). “School-Based Obesity Prevention Programs: An Evidence-Based Review.” Obesity 16, pp. 1009–1018.

Libotte, E.; Siegrist, M; Bucher, T. (2014) “The Influence of Plate Size on Meal Composition: literature review and experiment,” Appetite, 1, 82, pp.91-96

Loewenstein, G; Chater, N. (2017) “Putting Nudges in Perspective,” Behavioral Public Policy, 1, pp.26-53

Marlow, M. L. (2017) “Government Nutritional Nudges: hope over reality,” Journal of American Phusicians and Surgeons, vol. 22. No.2, summer 2007, pp. 57-59

Rising, C.J.; Bol, N. (2016) “Nudging our Way to a Healthier Population: the effect of calorie labeling and self-control on menu choices of emerging adults,” Health Comunnity, 27, pp.1-7

Rolls, B. J.; Roe, L.S.; Halverson, K.H.; Meengs, J.S. (2007) “Using a Smaller Plate Did Not Reduce Energy Intake at Meals,” Appetite, 49, pp.652-660

Scharff, R. L. (2009) “Obesity and Hyperbolic Discounting: evidence and implications,” Journal of Consumer Policy, 32, 1, pp.3-21

Skov, L. R; Lourenço, S.; Hansen, G.L; Mikkelson, B.E; Schofield, C. (2013) Choice Architecture as a means to change eating behavior in self-service settings: a systematic review,” Obesity Review, 14 (3), pp.187-196

Thaler, R.; Sunstein, C. (2008) Nudge: improving decisions about health, wealth and happiness. New York: Penguin Books

Vigitel Brasil 2017, Brasil 2016 Saúde Suplementar: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico [recurso eletrônico] / Ministério da Saúde, Agência Nacional de Saúde Suplementar. – Brasília: Ministério da Saúde, 2017. 157 p.

Vigitel Brasil 2018, Brasil 2017: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico : estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2017 / Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde. – Brasília: Ministério da Saúde, 2018. 130.: il

Wansink, B. (2004) “Environmental Factors that Increase the food intake and consumption volume of unknowing consumers”. Annual Review of Nutrition, 24, pp. 455-479