A Question of Scale

Illustration by Brian Cairns.

As a kid, I liked eating. A lot.

I’d sit around and guzzle soda and take down whole pizzas by myself. Other times, I’d eat dinner, then sit around and guzzle soda and take down whole pizzas by myself. My parents implored me to eat better, to go outside, to be more active. But cookies don’t grow in the wild, you know. Back then, eating was easier than being healthy, and I preferred the comforts of my kitchen.

There were consequences. By middle school, I was racing to the locker room so I could change before the older guys arrived, what with their fondness for poking and mocking shirtless fat kids. Once I was safely into my gym clothes, the scariest words on earth were “shirts versus skins.”

Were I back in seventh grade now, I doubt I would feel any less self-conscious, but I certainly wouldn’t be alone. According to a 2009 study by the Massachusetts Department of Public Health, one-quarter of the state’s adolescents weigh too much, about three times more than 20 years ago. And the people who are supposed to be feeding them properly aren’t doing any better: More than half the adults here are overweight, too.

Of course, the “obesity epidemic” is America’s cause célèbre right now. Everyone from Michelle Obama to that annoying British chef on ABC has stepped forward to address the issue. Here in the commonwealth, Governor Deval Patrick put forth a plan last year to deal with the problem. He called for restaurant chains to begin prominently displaying nutrition information, as in New York City. He directed grants to cities and towns so they can come up with local health initiatives. And, in a controversial move, he called for schools to measure the weight and height of first, fourth, seventh, and 10th graders; calculate their body mass index; and send a letter home to their parents explaining the implications.

The whole idea, says state Public Health Commissioner John Auerbach, is to change the way we think about what we put into our bodies. Yet the underlying premise of the governor’s push seems to be that fat people do not know they are fat — and do not understand that the foods they eat make them that way.

As a fat-kid emeritus, I’ll bet you all the Munchkins from here to Hopkinton that Patrick’s plan will not work. The reason is simple: Obesity is not a matter of ignorance. Does anyone really believe there is one overweight kid in Massachusetts who is not acutely aware of how overweight he or she is? No, the challenge isn’t bridging a knowledge gap; it’s closing a behavioral one. And there is only one sure-fire way of getting people to change their behavior: pay them.

Chances are you, too are overweight. Despite Massachusetts’ status as one of the healthier states in the country, the Department of Public Health study found that 59 percent of adults here weigh too much, compared with 40 percent two decades ago. One-fifth of the population is technically obese (meaning a BMI higher than 30). “The increase has been dramatic, and it’s been steady over the last 20 years,” Auerbach says. As a result, the state has seen dramatic growth in diabetes cases, while heart disease, strokes, gall bladder disease, and musculoskeletal disorders also loom large.

These statistics speak to a financial problem as much as a health one. According to the research group RTI International, nearly 10 percent of all healthcare costs can be attributed to obesity. That adds up to $147 billion per year nationally, with each obese person costing, on average, $1,400 more than their fit friends. In Massachusetts, where businesses and governments are already grappling with the nation’s highest family-coverage health premiums, we can ill afford our extra pounds.

Auerbach says that when state officials were formulating Patrick’s plan, they looked for programs that had worked elsewhere. “We didn’t want to simply come up with a list of things that we thought made sense without any evidence that they would be effective,” he says. The BMI letters to parents, for instance, are modeled after ones in a similar program in Arkansas.

Overall, Auerbach says, the goal is to provide a steady flow of information that will change the way people think. The state wants to stigmatize unhealthy habits the same way smoking has been branded as taboo. “That’s what we’re trying to do with eating habits and exercise: begin to change what people think of as socially acceptable behavior by doing a bunch of different activities that will hopefully have a cumulative impact,” he says.

But there’s a flaw in that thinking. For one, eating healthy is a much more complicated problem than giving up cigarettes. Just imagine trying to quit smoking while still requiring at least three cigs a day. Recent reports also indicate that posting nutrition information at restaurants isn’t nearly as useful as it might seem. A study in the journal Health Affairs found that it had no effect on how people in poor neighborhoods ordered their food, while the New York City health department has admitted that ordering habits citywide have changed only modestly, if at all.

That’s not a surprise to Kevin Volpp, a professor at the University of Pennsylvania School of Medicine who studies weight loss. “When it comes to self-harmful behaviors, like behaviors leading to obesity, the problem is not having too little information; it’s more a problem with self-control and behavior,” he says.

In 2008 Volpp completed a study to determine what would work. A group of 57 people — all of whom were seeking to slim down — was divided into three sets. One group wagered a small amount daily and earned matching funds if its members lost weight; another was eligible to participate in a daily lottery of $10 to $100 if members met their weight-loss goals; the third received no incentives. After 16 weeks, those given no incentives had lost an average of 3.9 pounds. Those in the lottery group had lost an average of 13.1 pounds. And those in the daily-wager group had lost an average of 14 pounds.

“When trying to get people to lose weight, we’re basically asking them to do less of the things that on some level they enjoy,” Volpp says. Because the pressure of dieting is constant and the rewards are so long-term, the money helps focus the dieter’s mind on something tangible and immediate. Even small incentives, Volpp says, “change the equation.”

He admits there remains much work to be done, especially with regard to how well people keep off the weight. Yet that hasn’t stopped others from seizing on similar ideas as a means to control obesity — and healthcare costs. One Boston startup that recently moved to New Hampshire, Tangerine Wellness, contracts with companies to operate an on-site weight-loss incentive program for employees. (If sales incentives worked, the thinking went, why not weight-loss incentives?) One client, a small Illinois manufacturing company, reports it has saved 10 percent on healthcare costs annually, or $50,000 to $60,000, since launching the program.

There are other firms like Tangerine out there, such as Denver-based Incenta-Health and Weight Wins in the U.K., which contracted with that country’s National Health Service for a pilot program to help 400 obese Britons lose weight. A year in, the Weight Wins dieters have lost an average of 29.2 pounds, or 13.4 percent of initial body weight.

You might argue that Massachusetts has no business paying people to shape up. But the fact is, we’re already footing the bill. It’s just happening on the back end of the process, in the form of ballooning medical costs.

I don’t expect the state to start paying schoolkids to lose weight tomorrow, but there’s still plenty we could do. Some insurance companies already build in longer-term weight-loss and health incentives. Why couldn’t they implement shorter-term incentives, too? Better yet, Massachusetts could offer tax breaks to firms that participate in a Tangerine-like program, or even run its own pilot program for state employees, modeled on Great Britain’s.

The carrot doesn’t even need to be money — but it’s got to be something, and it’s got to be a hell of a lot more appealing than, say, a carrot (especially without ranch dressing). Cash just happens to be the one thing we know everybody likes. As for me, toward the end of high school I dropped 60 pounds, several belt sizes, and two chins. I didn’t change my diet and start working out because I stopped liking chicken wings or suddenly discovered that Skittles don’t count as a serving of fruit; it happened because my priorities shifted. I slogged through hours of exercise and gave up my weekly double orders of Chinese food because at college I was hoping to finally, you know, attract girls by means other than my gravitational pull. That simply became more important to me than eating whatever I wanted. It had a lot to do with motivation and very little to do with a new world view of food and exercise. Now, if only there were some way to make me less awkward.