Challenging Dogma - Fall 2011

Friday, December 23, 2011

Fat Chance the ‘Fat Tax’ Will Have a Much of An Impact: Critiquing a Proposed Public Health Intervention- Gillian Hurwitz

The Problem:

Over the past 20 years there has been a dramatic increase in obesity in the United States and it appears the trend is continuing (1). The Center of Disease Control and Prevention reports that 33.8% of Americans are obese (1). This is particularly alarming because obesity is a risk factor for major causes of death, such as: various cancers, diabetes and heart disease (2). From an economic standpoint, obesity accounts for approximately 9.1% of medical spending in America and The US Centers for Disease Control and Prevention approximate that over $147 is spent annually on direct and indirect costs of obesity (3).

Given the pervasiveness of this ‘obesity epidemic’, there has been an impetus from public health professionals, economists, politicians and community-based groups to implement interventions to help mitigate the problem. In fact, First Lady Michelle Obama is especially disturbed that “we [Americans] are spending outrageous amounts of money treating obesity-related conditions like diabetes, heart disease and cancers”, so she has taken action and is spearheading a campaign aiming to reduce America’s obesity rates (3). Mrs. Obama seeks to create change through a government-subsidized program called “Let’s Move,” offering American families information about how to live a healthy lifestyle.

The aforementioned campaign is merely one of many interventions seeking to resolve the growing problem of obesity in America. Interventions are often multipronged to address the multifaceted, complex, interplay of factors leading to obesity. It has been postulated that the affordability and abundance of unhealthy foods in America is one of the major reasons waistlines are expanding (3).

In 2004, the Danish government introduced a ‘sugar tax’ and anecdotal evidence suggests that this tax has been successful in decreasing cardiovascular disease rates (4). This prompted Denmark to introduce another tax-this time on foods containing more than 2.3% saturated fat, and American legistators are considering bringing this Danish policy to America (4). Federal tax policy has a longstanding history of attempting to proscribe unhealthy behaviors like smoking and alcoholism, and obesity is no exception. The basic tenet of the proposed ‘fat tax’ is that increasing the price of foods high in saturated fat would deter individuals from purchasing and consuming these goods, which, in effect, would have a beneficial health effect.

Upon examining this intervention from a social behaviorist perspective, it is evident that a ‘fat tax’ is not a viable approach to addressing America’s obesity crisis. This paper will address how the ‘fat tax’ disregards the Theory of Psychological Reactance, fails to take into consideration that modest taxes may have little to no effect on behavior change and neglects to acknowledge that a ‘fat tax’ is a stigmatizing, regressive policy.

“Reverse Psychology”: Psychological Reactance Theory

One behavioral explanation for the likely shortcomings of implementing a ‘fat tax’ in America is psychological reactance. Psychological reactance occurs when one perceives a threat to their freedom and seeks to restore that threatened freedom (5). This theory continues to be extensively studied in the field of consumer psychology. Clee and Wicklund, renowned consumer psychologists, describe reactance as one’s increased motivation to own a house that has recently sold despite the availability of numerous similar houses on the market, solely based on the fact that the sold house poses a threat to one’s perceived freedom of choice (6). Consumer research suggests that consumer’s perceived freedom can be curtailed by barriers including “product shortages, discontinuations, long waiting lines and other limitations on availability”, which, in turn, make the individual increasingly motivated to obtain the product (6). In fact, reactance can actually cause a net positive change in desirability and attractiveness of the hard-to-obtain item (5).

These concepts are especially relevant with respect to the ‘fat tax’ because it suggests that the tax may in actuality negate its intended effect. The government is seemingly rationalizing that making unhealthy foods more expensive will reduce their desirability and accessibility, but Reactance Theory posits that consumers will be more motivated to obtain fatty foods if they perceive a threat to their freedom via a tax aiming to limit product accessibility.

Interestingly, when anti-obesity spokesperson, Michelle Obama, was asked about whether the United States needed a ‘fat tax’ similar to that of Denmark, she answered, “folks don’t like people telling them what to do. They don’t need the government telling them what to do”(7). The First Lady’s sentiments are congruent with psychological reactance theory- mainly that perceived freedom is an imperative component of an individual’s cognitive processes and actions. According to this model, if the government implements a ‘paternalistic policy’ similar to that of Denmark, it may actually be detrimental. After all, personal choice, autonomy and individualism are core American values (8).

“The Price is Right”: A Steep Tax required for Behavior Change

Numerous studies explore the extent to which alterations in food prices affect food purchasing/food consumption. One of the most extensive meta-analyses to date concluded that small taxes or subsidies were not likely to result in a substantial decrease in obesity prevalence (9). In order to achieve a significant consumer effect (9), the tax would likely have to be steep- an untenable notion to many policy makers and government officials.

Danes currently pay $1.29 extra per pound of fat (10), but is this amount enough? Research finds that even a ten percent ad valorem tax on fatty goods will reduce fat consumption by less than one percent and even a fifty percent tax reduces fat consumption by just three percent (11), which is hardly a noteworthy public health effect.

The proposed policy also raises another apropos question: is it possible that feelings of psychological ownership could moderate the association between the effect of the ‘fat tax’ and consumer purchasing patterns? Research suggests that if one feels possessive tendencies toward an object, the object becomes highly meaningful and manifests itself in one’s “self-concept” (12). In turn, the object becomes increasingly valuable and research suggests that one is willing to put a greater dollar value on something of which they perceive ownership toward (13). Therefore, if an individual perceives ownership of fatty foods because consuming fatty foods is engrained in their “self-concept”, they will likely not be deterred by an added tax on high-caloric foods.

The Case of Wrongfully “Framing” the Issue:

The major premise of framing theory is that an issue can be viewed from many perspectives and can, therefore, be construed in many ways (14). Specifically, Chong and Druckman describe framing as “the process by which people develop a particular conceptualization of an issue or reorient their thinking about an issue” (14). As a health-related construct, being obese has often been framed as a result of poor life decisions. There is a longstanding belief that obese individuals are responsible for their own condition in large part due to an alleged “lack of self control” (8) and this belief is perpetuated by the ‘fat tax’, which is premised on the “fault based paradigm” that obese individuals require the government to intervene because they have cannot resist succumbing to the temptations of food. Rogge and colleagues describe this insidious pattern of ongoing denigration and marginalization toward this demographic as ‘civilized oppression’ (15).

Framing the issue in this manner can be injurious to the psyche of obese individuals because not only does it create a perpetual cycle of perceived self-blame and stigmatization, but can trigger severe depressive symptoms (16). Self-blame among obese individuals as a result of the frame upon which the ‘fat tax’ is based would, therefore, impede upon individuals’ motivation to actively engage in efforts to lose weight and may actually worsen their overall well-being.

“Stuck in Reverse”: The Proposed Policy is Regressive

Another major flaw of the proposed ‘fat tax’ is that it is regressive in nature. Financially disadvantaged Americans would absorb a disproportionately greater burden of the tax compared to the rest of Americans (11). The proposed levy on foods containing high levels of saturated fat would not only dig deeper into the pockets of already suffering Americans, but may also exacerbate the condition that led financially disadvantaged Americans to be obese in the first place (8).

The ‘fat tax’ is unethical because it defies the principle of vertical equity, which states that low-income houses should pay less than high-income houses (8). The issue of vertical equity is completely relevant to the ‘fat tax’ because food should be more affordable for lower income individuals, but the ‘fat tax’ would make food more expensive for this demographic. Proponents of the ‘fat tax’ refute arguments that the policy is unjust by claiming that equity is irrelevant with respect to “sinful taxes” (ie. goods such as fatty foods, alcohol and cigarettes) (8); however an important distinction ought to be considered. Whereas cigarettes and alcohol are “luxuries”, food is essential to survival, therefore it is unethical to defy the principle of vertical equity and make food more expensive for marginalized demographics, such as the ‘fat tax’ purports to do.

My Intervention:

In order to ameliorate the flaws of the proposed ‘fat tax’ policy, I would implement a drastically different, innovative campaign to address the obesity problem in America. As was previously stated, we must be mindful that adiposity is a complex problem requiring a multitude of interventions working concurrently to achieving a common goal, and this was the basis upon which I conceived of the idea for my campaign.

The “Every Step you Take, Every Meal You Make” campaign, would be a government-subsidized intervention aimed at encouraging all Americans to lead a healthy lifestyle. More than 23 million Americans live in “food deserts”- areas that are more than a mile from supermarkets offering fruits, vegetables and whole grains (17). This is undeniably one of the primary factors contributing to obesity because these Americans are forced to purchase convenient, unhealthy foods or pay marked-up prices for scarce, hard-to-obtain healthy foods. Evidently, a concerted effort ought to be put forth to eliminate “food deserts” by making food more accessible and affordable.

Another principle goal of the campaign is to reinforce little healthy decisions that Americans make on a daily basis. For instance, preparing a healthy family meal, walking to school and choosing to purchase an apple instead of a candy bar for snack should be applauded. The campaign would offer an online health tracking device for all Americans, where meals consumed, physical activity and grocery lists could be recorded and the campaign would incentivize healthy daily decisions by periodically sending small rewards (eg. coupons, kitchen supplies, exercise gear) to campaign participants.

Availability of Food: A Means to Countering Reactance:

As was previously mentioned, when an individual perceives a threat to their freedom, they attempt to re-establish the threatened freedom (5). In the context of the ‘fat tax’, the psychological reactance model posits that it if one perceives the government as attempting to limit their freedom to food high in saturated fat by making them more expensive, the saturated foods will become more desirable. Evidently, implementing a ‘fat tax’ will not curb obesity and may actually exacerbate the obesity problem because limiting fatty foods increases their desirability.

Instead of limiting access to “fatty foods”, we should target the “food desert” problem and make healthy foods readily available in all communities. The “Every Step You Take, Every Meal You Make” campaign would strive to make healthy foods more available by supporting community garden initiatives, bringing farmer’s markets to isolated communities and providing people with bus routes/walking routes to stores that offer healthy food. Additionally, the campaign would seek to encourage large-scale supermarkets to participate in “food save programs”, donating healthy vegetable, dairy and grain products to “food desert” communities. Ideally, community service students or volunteers would willingly offer to deliver these donated goods. This aspect of the campaign would be modeled after the Boston University Student Food Rescue Program, which organizes 21 weekly food runs to underserved communities thanks to contributions from donor sites (to learn more about the program click here: Empirical evidence suggests that these interventions would be productive because increasing the availability and promoting the consumption of healthy food products, increases the consumption of these items (18).

Additionally, the “Every Step You Take, Every Meal You Make” program would encourage people to make healthy choices using the principles of the Psychological Reactance Model. Research suggests that one of the ways to counter psychological reactance is to enhance one’s feelings of autonomy and self-determinism (19). Upon increasing the availability of healthy foods, advertisements appealing to an individual’s free-will would be produced, conveying the message: “You have the option of choosing the type of food you eat, so why not make it a healthy food?”

The Price is Right for Healthy Foods:

One of the major shortcomings of the ‘fat tax’ is the fact that raising the price of fatty foods is not an effective purchasing deterrent. This could be due to numerous mediating factors, such as psychological ownership and brand loyalty, but if increasing the price of fatty foods does not significantly affect purchasing power, would lowering the price of healthy foods affect consumer behavior and, in turn, weight loss?

Interestingly, an emerging body of literature supports the notion that prices of fruits and vegetables are positively associated with Body Mass Index (BMI). Sturm and Datar discovered that alterations in children’s weight were closely associated with the price of fruits and vegetables (20). They found that one standard deviation increase in the price of fruits and vegetables increased the child’s BMI by 0.09 to 0.18 units over a two-year period (20). This compelling research suggests that if we make nutritious foods more affordable people will lose weight.

In addition to increasing access to healthy foods through some of the campaign objectives previously discussed, the “Every Step You Take, Every Meal You Make” campaign would attempt to make nutritious foods affordable. Working harmoniously with legislators, campaign officials would lobby for government subsidies on healthy foods through the presentation of compelling empirical data suggesting that this would be a powerful mechanism for improving the health of Americans.

Making fruits and vegetables accessible and affordable will help remedy the obesity problem in America and perhaps even change the mindset of Americans to the point where they eventually take ownership of fruits and vegetables and consuming healthy foods becomes a part of their “self-concept”.

Reframing the Issue:

One of the most damaging downfalls of the ‘fat tax’ proposal is that it is predicated on the belief that obese people are to blame for their obesity. One of the underlining axioms of Public Health is that it is more efficacious to have a small impact on a large number of people than it is to have a large impact on a small number of people, therefore in order to curb the problem of obesity in America, a macro-level intervention ought to be implemented. This rationale is reflected in a promising body of literature, which points to the fact that large-scale obesity interventions that focus on environmental factors contributing obesity are more effective than interventions targeting individual behavior change (21). Interventions aimed at mitigating environmental factors contributing to obesity, such as targeting the “food desert” problem, have been proven to be more effective and to have less of a stigmatizing effect on obese individuals (22).

Instead of being predicated on an accusatory rationale like the “fat tax”, the “Every Step You Take, Every Meal You Make” campaign, would focus on maximizing the health of all Americans. This is based on the logic that it is especially impactful to make a small influence on many individuals. Additionally, this intervention focuses on remedying the ubiquitous “food desert” issue, and based on the aforementioned research findings, this environmental-based intervention will have a de-stigmatizing effect, which will, ultimately, enhance the intervention’s efficacy.

Some may argue that the “Every Step You Take, Every Meal You Make” campaign is inherently individualistic, as even the title suggests that the onus is on you to exercise and eating nutritiously. This is true to an extent: the campaign title seeks to inspire confidence that individuals can achieve personal successes with minor daily achievements (eg. engaging in a physical activity or cooking a healthy family meal). The name of the program was intentional in the hopes that it would create a framing effect: establishing an internal locus of control. Research suggests that when one has an internal locus of control, perceiving personal responsibility for an event’s occurrence, and they achieve a success, it will have a reinforcing effect (23). Therefore, the “Every Step You Take, Every Meal You Make” is framed in a positive way that encourages individuals to take responsibility for minor successes with respect to their health.

Progressive Effect vs. Regressive Effect:

Another flaw of the ‘fat tax’ is that it is regressive and would penalize financially disadvantaged Americans. Making healthy foods affordable and accessible, as the “Every Step You Take, Every Meal You Make” campaign aims to do, will have a reverse-regressive effect. Since “food deserts” tend to take place in low socioeconomic geographic areas given the significant correlation between poverty and obesity (8), abolishing “food deserts’ will have the greatest effect on this demographic. Thus, instead of placing the burden of the ‘fat tax’ on financially disadvantaged Americans, poor obese Americans would have increased access to nutritious, affordable foods. Though my intervention may have a disproportionately greater impact on a subset of Americans with a low socioeconomic status, the supportive nature of the campaign aspires to encourage all Americans to maximize their well-being, and thus, can be considered a ‘progressive’ campaign for all Americans, unlike the regressive ‘fat tax’.

‘Fat Tax’: Glutton for Punishment?

Implementing a ‘fat tax’ in America is superfluous, imprudent and would, ultimately, be ineffective at decreasing the pervasiveness of obesity in our society. Attempting to dissuade individuals from consuming high-caloric foods may create a reactance effect and lead to an increased consumption of the “demonized” good. A ‘fat tax’ would be seemingly futile at deterring consumer behavior unless the tax rate was extreme- something few politicians would willingly do. In addition to being useless, the ‘fat tax’ would likely have detrimental effects. The way in which the policy frames obesity is intrinsically flawed and though a ‘fat tax’ may seem moderately logical in theory, in practice it would be regressive and debilitating to financially disadvantaged Americans.

On the contrary, we need to introduce a progressive campaign embodying principals set forth in the “Every Step You Take, Every Meal You Make”, which facilitates the positive personal growth of all Americans, while inhibiting the growth of their waistlines. Accessibility and affordability of healthy food is undeniably an issue at the forefront of the obesity crisis and needs to be addressed. Additionally, positively-framed interventions aiming to de-stigmatize obesity and focusing on reducing environmental risk factors will likely be the most efficacious.

Obesity will continue to pervade social, economic, political and medical discourse and effective public health interventions are desperately needed to discontinue the obesity trend in America. The call to action is now: the continued rise of obesity does not solely impact those inflicted with the condition, but it has a direct straining effect on an already stressed American medical system. Policy makers ought to critically review empirical evidence before they decide to implement imprudent policies like the ‘fat tax’.


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