Wednesday, December 15, 2010

Tackling Obesity One Step at a Time

Obesity has steadily become a significant problem in modern society, especially in the United States. Note that it is clear obesity is a growing problem even without resorting to statistics which is good because the BMI stat which typically drives obesity identification is flawed in its inability to differentiate between fat weight and muscle weight. While there are a number of reasons postulated for this rampant increase in over-weight individuals, the most disconcerting issue is despite the existence of viable solutions obesity rates continue to climb. It is rational to conclude that there are two chief elements behind this continued expansion of obesity.

The first element involves the psychological reality that most people shy away from the physical exertion required to stay fit. Sadly for these individuals biochemistry has not advanced to the point where weight can be selectively and effectively controlled by simply taking some drug. Even common surgical options like lap bands and gastro-bypass surgeries have not stemmed the problems and have caused there own set of problems. The only proven methodology to avoid becoming obese is proper diet and exercise; however, these elements especially the latter demand effort and time. Note that while there is mounting evidence to suggest the involvement of stomach bacteria in calorie absorption and its role in increasing weight, this research is still in its infancy and has not yielded any therapeutic strategy, thus it is useless to scapegoat obesity with stomach bacteria.

The second element involves proper direction. Unfortunately capitalism has provided an unnecessary obstacle in preventing obesity in that the social environment has been flooded with strategies for dieting and weight control that run the gamut from eating almost nothing but carbohydrates to eating almost no carbohydrates. Most of these various strategies have only a small level of biochemical backing and instead are pushed in effort to make money for the individuals sponsoring or backing the particular diet methodology. The lack of clarity in most of these plans leads to ‘higher than should-be’ failure rates which foster greater frustration in those that fail reducing the probability that they invest their time, money and psyche in future attempts at weight loss.

Another problem related to this second element is availability. More often than is realized even if an individual would prefer to eat healthy food, that food is either supply unavailable or economically unavailable. One of the most noted issues is that of ‘food deserts’, regions (rural or urban) which lack a variety of food selection largely because of a lack of supermarkets or farmer’s markets. While there have been some noteworthy start-up efforts to address this issue, the problem of food deserts seems too large for small entrepreneur-driven individuals to solve without government assistance. If individuals want to get serious about dealing with food deserts and even domestic hunger then state governments need to conduct audits in their states to identify where these deserts are and how to divert food items from more plentiful regions.

Returning to the first element one would inherently think that pride should be a driving element in warding off obesity, but there is evidence to suggest that a number of individuals who are obese or even just over-weight do not view their weight as a problem.1 In those periods when they are concerned the concern tends to manifest as disgust rather than an affront to pride; this disgust can lead to rash short-term crash dieting instead of long-term change in behavior, which commonly results in long-term failure. However, if weight is not viewed as a problem any form of self-motivation to address weight becomes less likely including issues surrounding overall health and physical well-being, thus such a reality demands a secondary strategy. For most a form of familial intervention is also not a likely option based on this same psychological premise. With these two effective options no longer available a new incentive must be provide to drive motivation to live a healthier life.

The best form of incentive is typically some form of monetary award. Unfortunately indirect or future awards, largely those that can be calculated from healthy behavior, do not motivate effectively. The uncertainty of the future forces probabilistic arguments instead of direct yes/no arguments. For example one can make the rational argument that eating a certain assortment of food may reduce the probability of acquiring cancer by x%, but most people want a more definitive response, ‘if food x is eaten then I will or will not get cancer’.

Another problem is the incompatibility with probability figures in a deterministic reality. Getting cancer is a deterministic yes/no issue, so one seems to save the same amount regardless of what their personal cancer percentage turns out to be. Basically one does not receive more money for a lower cancer percentage, just a greater probability of receiving any money (through savings by not having to treat the cancer); this concept is rather confusing and further makes it difficult to see the benefit from a financial perspective. Finally the fact that this savings occurs over the course of a lifetime and not in an immediate lump-sum further reduces its usefulness as an incentive. Note that when does a lottery winner ever take the lifetime annuity option over the lump-sum option? With these incompatibilities with typical human psychology it is not difficult to understand why people still have difficulties undertaking healthy actions even when the resources to facilitate them are available.

With the ineffectiveness of arguing ‘you should do this because it will reduce your probability of getting cancer, macrodegeneration, osteoporosis, etc.’ a more direct incentive is required. Typically most argue that the most effective incentive is cash. Not only is the distribution of cash immediate, but it is also flexible. However, that flexibility is also a problem. Most people would like to assume that individuals would use capital in an effective manner that most helps their existence, but if such a contention were true a vast majority of the people that are in debt would not be in debt. The inability to predict what an individual will do with a monetary award creates inherent complexity with such an incentive program, especially when individuals have a wide variety of resources available from which to select. For example it is easier to predict what a person in Somalia will do with 30 dollars than a person in the United States. Therefore, distributing cash in any type of incentive program with the single target goal of improving societal physical health through weight loss seems inefficient.

With the elimination of cash as a possible option, the award mechanism for incentive will most likely take the form of a ‘gift’ card. However, to ensure a restricted flexibility, the ‘gift’ card would only be useable at certain retailers. In fact if one were willing the best possibility would be to establish a retailer designed specifically for interaction with these ‘gift’ cards. By establishing a specific retailer, the government can control the role of supply and production. For example if so desired the supply of merchandize could only include items that are manufactured in the U.S. by U.S. companies. The interaction medium for this retailer(s) must include both an online and an off-line component because not everyone who would take advantage of the program would have online access. The off-line component can be something as simple as mail order involving the U.S. Post Office.

Now that the general incentive agent has been established, the next element is how the individual would acquire this incentive. The overall goal of this program is to stem and hopefully in time reverse the growing rate of obesity in the U.S. The hope is that eventually the program would pay for itself by reducing the amount of money spent in healthcare by increasing overall societal health. The spending reduction should be seen in both Medicare payouts and private insurance payouts as well as through increased tax revenues by increasing production through reduction of sick days and other health related circumstances that lead to missed or unproductive work days. There are two chief elements that influence overall health which can be affected at a reasonable certainty and level of effort, food consumption and exercise. Due to the reward element of this program as well as lingering consistency questions involving the availability of food supplies, using exercise as the defining element seems to make more sense.

One may argue that exercise in a vacuum is not an appropriate strategy to drive good overall health. On its face this opposition is understandable, but there is value in exercise regardless of food consumption on two levels. First, the obvious benefit is that any amount of exercise can neutralize some of the ill effects from improper eating. Second, the less obvious benefit is biological memory. While still in its infancy there are theories which suggest that individuals who frequently exercise have a higher level of something (maybe fat-burning enzyme activity), even beyond simple muscle mass correlations, which control weight gain. On a related side note it is possible that this theory and the role of stomach bacteria may be associated with each other in that greater exercise increases efficiency of energy use, which decreases the demand to absorb calories which selects for stomach bacteria that absorb fewer calories. Thus the more exercise an individual performs the better his/her body is able to control weight even while resting. Finally the application of exercise is important because something needs to be done to address the overall weight problem.

If exercise will be the evaluation medium what method will be used for the evaluation? In the past such a program would commonly demand a participating individual to travel to a specific location, a special gym for example, where activity could be tracked by volunteers. However, computers have eliminated this change of venue demand where more simple aspects of exercise such as distance traveled, rpms, heart rate, etc. can be measured, tracked and saved where ever the device is being used. Not having to travel should significantly increase the probability of both participation in the program and continuation with the program. The requirement of this vital stat information demands the use of some form of machine. The machine in question needs to be simple while also involving a methodology that allows for ample heart rate increase. In effort to limit stress on the body it seems that an elliptical machine would be superior to a treadmill.

The elliptical machine used in this program would be specially designed with a microchip that documents the use of the device and would be used to determine rewards. The rules governing the payout need to be transparent and clearly stated. Three salient factors would demand a clear fixed unambiguous incentive price, an age limit and personal identification. The following is one possible example describing the use of the device:

Acquisition of the device is dependent on receiving a physical from a participating physician. The reason for this element is that it would be unfair to set a standard baseline on the device without taking into consideration the current physical health of the participant. For example to hold someone that is 350 pounds to the same exercise demand as a 185 pound individual is counter productive. The standard of measurement will use a rpm floor and because of the potential volume of participants there needs to be a ceiling on how much exercise will be counted towards the overall program over a given time period. The ceiling is required to control the total cost of the program as well as protect individuals from overzealous exercising which would be detrimental to overall health in attempt to acquire more monetary rewards. The machine should visually and audibly inform the user when this limit is reached and should reset at 12:00 am each day. One possibility for the limit would be 45 minutes at or above the rpm floor in a 24 hr period. One point of discussion would be whether the individual would have to maintain the appropriate speed at or above the price floor for the entire 60 seconds or if just the average rpm over that 60 second period would have to be at or above the rpm floor to be given credit for 1 minutes of exercise under the incentive program.

The rpm floor is designed to ensure appropriate benefit from the exercise so the monetary incentives awarded are driving the accomplishment of the overall goal. Basically one should have to actually physically push his/her body for the time spent exercising to count towards incentive, no ‘dogging it’; otherwise the entire point of the incentive program is meaningless because once again it only resorts to an individual’s pride as the driving factor and as stated that strategy is clearly not working. Establishing the correct rpm floor is one of the principle reasons a physical is required before an individual can acquire this device. Pursuant to this rpm floor the device will have a kill-switch after some amount of time (10-12 months) where an individual will have to have another physical in order to recalibrate the floor. As inefficient as it would be to expect a 350 pound individual to meet the rpm requirements assigned to a 185 pound individual, the same goes for an individual that was once 350 pound continuing to meet that rpm requirement even though he/she now only weighs 290 pounds.

The incentive price should be tied directly to the total minutes exercised at or above the specific assigned rpm floor. Initial blind thought sets an incentive price of 2 cents per minute. This rate would establish a reward of 90 cents a day and $328.50 a year. Some may argue on its face that such an incentive is too small to facilitate meaningful exercise. The counterargument is that the overall level of work required to acquire these funds is so insignificant that the seemingly small value can be viewed as appropriate. For example because the device is at the participant’s home there is an improved probability of multi-tasking in that one could be exercising and watching television, reading a book, listening to music or even having a conversation. The primary reason for establishing a meager value is concern regarding the sheer volume potential of the program. Suppose 200 million elect to participate in this program and hit 50% of their total potential as a group, such a scenario would result in 32.85 billion dollars in incentives per year.

Finally each individual should have a specific ID code that recognizes that individual, especially if only one elliptical device is distributed per household. One could argue that there could be unscrupulous behavior regarding this ID code where a healthier individual could exercise at an easier rpm floor. While true, a ‘safety measure’ could be established where if an individual did not noticeably improve while in the program after two physicals that individual would be blacklisted from the program permanently.

Overall while the idea presented above still have some more specific details to flesh-out, it is obvious that something needs to be done about the growing weight problem in the U.S. and individual pride clearly is not enough of a driving factor.

1. Powell, T, et, Al. “Body Size Misperception: A Novel Determinant in the Obesity Epidemic.” Arch Intern Med. 2010; 170(18): 1695-1697.

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