Cash for clunkers, cash for lowering obesity rates

The raging popularity of the cash for car clunkers program gives rise to an even more striking potential for cash incentives to deal with the world’s biggest problem. For the incentive of $3500 to $4500 individuals are buying new cars at an unprecedented rate for about 8 miles per gallon improved gasoline efficiency. Even with 750,000 clunkers taken off the road with a total cost of $3 billion, it is unlikely to have an impact on earth’s global warming. For perspective, the 60 million gallons of gas saved per year from this program is less than one half of one percent of the 140 billion gallons consumed.
 
But obesity is the planet’s number one public health problem. Turning our attention to over 70 million obese Americans, with significant involvement among children, is imperative. In the United States, the financial burden for obesity reached $147 billion in 2008, with medical spending for obese individuals more than $1,400 per year than their normal weight counterparts. Yearly updates from the Center for Disease Control have shown unstoppable, runaway increased obesity prevalence from 1991 through 2008 with an overall more than doubling, and in certain states such as Alabama, Tennessee, and Mississippi current rates exceeding 30%.
 
On the other hand, the benefits of being trim for preventing age-related diseases have crystallized. A recent study published in Science on monkeys followed for over 20 years, randomized to either a caloric restriction diet (30% less than normal) or the regular monkey diet, showed a striking improvement in not only survival, but also freedom from diabetes, cancer, heart disease, and brain atrophy. So nearly 100 hundred years after Rous' 1914 observation that avoiding high caloric intake in rats improved survival, we have strong evidence that avoidance of obesity has across the board health benefits in primates (like human beings!), not just yeast, worms, fruit flies, mice, and rats.
 
We know that one of the most dreaded complications of obesity is diabetes (also known as the “diabesity” epidemic) and that weight loss of about 12 pounds reduces the incidence of diabetes almost 60%. There have been many studies of providing cash incentives for weight loss. In a recent randomized trial in JAMA, veterans randomized to 2 different cash incentive programs lost 13-14 pounds at 4 months compared with controls receiving no incentive. Many other similar studies have documented that with cash incentives of $300 to $800, striking degrees of weight loss can be promoted. So with the health care cost crisis, isn’t it about time to consider an incentive to avoid obesity? The cash for car clunkers program amounts to an incentive of $500 per year per car trader, assuming an ownership of the new car for 8 years, which is in the same ballpark.
 
In Japan, where obesity is far less common than in the United States, there are aggressive programs to deal with the problem. As of last year, companies are required by law to have their employees age 40 to 74 undergo annual waist measurements. If the companies cannot comply and reduce the incidence of obesity, they face significant governmental penalties and fines. In contrast, in the United States, the Americans with Disabilities Act of 1990 not only prohibits an employer from making health inquiries but also for providing compensation incentives. The Health Insurance Portability and Accountability Act (HIPPA) of 1996 pre-empts the ability to reward for attaining a lower body mass index or waist-to-hip ratio. So in the United States there are significant constraints to providing cash for people clunkers program.
 
Beyond such embedded restrictions for employers in the US, we are now at the highest level of unemployment in decades, which likely will exacerbate the obesity epidemic with diminished physical exertion, depression, and unhealthy diets. And what about the people who work hard at maintaining a healthy lifestyle with proper attention to diet and exercise–shouldn’t their efforts be rewarded in some fashion? Presently they are paying premium taxes to treat obesity and its multiple medical complications.
 
Faced with the economic crisis and undeniable need for health care reform, it is time to get serious about the country’s most significant and pervasive health condition. Adopting Japan’s policies to guard against obesity seems attractive, but why not go well beyond that? We invest in more fuel efficiency and alternative energy supplies, but why not invest in innovation for prevention of obesity? Simple wireless devices, such as a disposable skin-adhesive “band-aid” which tracks all calories consumed and expended throughout the day, displayed via a smart phone, would be a reasonable approach and prototypes are being pursued. Pharmacologic agents, which to date have been largely unsuccessful in achieving durable, significant weight loss without side effects, could be developed with priority and incentives. More potent derivatives of resveratrol or the sirtuin family of proteins may hold promise. Now that we know many of the common gene variants for susceptibility to obesity, it will be someday be possible to individualize a strategy based on what gene and pathway is involved in a particular person. But today it would be highly attractive to encourage people to trade themselves in for a new trimmed down model, with much less fuel consumption, and a healthier planet at reduced cost. Our bodies are worth far more than our cars.