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Illustration of a man's waist with a tape measure around it.
Illustration by Robert Samuel Hanson

Your Loss is Your Gain

Should people get paid for shedding weight and pursuing a healthier lifestyle?

What can governments do to fight the escalating, and costly, health problems associated with the obesity epidemic sweeping North America and other developed countries?

The policies that have been tried so far – public education campaigns, additive bans, and taxes on high-fat and sugary foods – haven’t put a dent in the problem, say Massey College fellows Neil Seeman and Patrick Luciani. If anything, they argue in their new book, XXL: Obesity and the Limits of Shame (University of Toronto Press), some of these approaches waste valuable resources and even may have exacerbated the crisis.

What’s driving the epidemic is a complex and interconnected list of factors that includes inactivity, the widespread availability of high-fat foods, city design that leaves us dependent on cars, and society’s unique genius for creating technologies that make life easier but also more sedate. It’s exceedingly difficult to isolate a single cause and effect, the authors say. Every obese person has their own story and their own struggle. “If we’re going to think seriously about obesity, we have to attack the problem at the individual level instead of using population-based approaches,” says Seeman. “These haven’t provided significant results.”

The authors’ alternative? “Healthy living vouchers,” which would reward people for purchasing health-related goods and services such as nutritious, low-fat food and gym memberships. Participants would be required to work with their primary health-care providers to develop a regimen geared at achieving long-term weight reduction. “It’s a preventative care model,” says Seeman, who has fought his own diet battles. “Everyone would take advantage of it.”

Currently, about two-thirds of Canada’s $230-billion health budget is directed to chronic disease treatment. Seeman and Luciani propose allocating between two and four per cent of Ottawa’s annual spending – $5 billion to $10 billion – to healthy living vouchers. Everyone over 16 would be entitled to participate, not just low-income people or those facing obesity problems. “The voucher is available to everyone because we want to encourage a sustained relationship between individuals and their doctors.”

The authors argue that their system would provide individuals with a direct financial incentive to improve their eating habits, their fitness level and their overall health. The vouchers would also engage market forces to allocate the resources needed to combat the obesity epidemic, rather than relying on government to determine the best approach.

Yet the system could also face nagging regulatory and political issues because it involves the transfer of hundreds or possibly thousands of dollars to every Canadian.

Seeman acknowledges that health spending could actually rise in the short term if the voucher system prompts patients to spend more time with their primary health-care providers (although the proposal would allow individuals to devise health plans with non-physicians). Another potential headache: determining which services and products should be included in the voucher program. Such a system may be vulnerable to special pleading. For those living in poor neighbourhoods with no fitness facilities, for example, the authors note that vouchers should be permitted to defray the cost of transit to gyms. But then why not gas costs, if they choose to drive?

Despite these objections, the authors argue that the obesity epidemic has become so pressing that governments have no choice but to be bold in searching for solutions. “The return on investment will not necessarily be seen in year one,” Seeman says.

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