Everybody knows obesity is a problem, and that it's inflating medical costs that are gradually bankrupting our nation. But I think most people have a misguided sense that obesity is the result of fast-food using poor-quality ingredients and somehow tricking people into eating them. For example, I saw this article on BoingBoing talking about the uproar over the high calorie count in McDonald's new oatmeal.
Basically, it has "as much sugar as a Snicker's bar and as many calories as a hamburger". That sounds really alarming, but it made me wonder: how many calories does oatmeal normally have? What could McDonald's have possibly done to take something good and make it bad? So I did some research on oatmeal, only to eventually find that the BoingBoing commentators had done a lot more.
To make a long story short, the McDonald's oatmeal is totally fine. The oatmeal itself is mostly normal, and most of "extra" calories really come from them adding a bunch of dried fruit (which is hardly an atrocity) and adding brown sugar and cream by default (which is commonly done at home anyway). So... false alarm.
Again and again I think people overreact when it comes to the "quality" of fast food. Yes it's made fast and in high volume, but even with the freshest possible ingredients on hand I think the results would come out looking, tasting, and nourishing about the same. For example, In-N-Out arguably uses the freshest ingredients of any fast-food burger joint, and to compare:
McDonald's hamburger = 100g serving size, 250 calories, 9g fat
In-N-Out hamburger = 243g serving size, 310 calories, 10g fat
(Incidentally, the standard In-N-Out burger comes with a spread that adds another 80 calories and 9g of fat. But I'm going with the mustard/ketchup option to compare more equally to McDonald's.)
So the McDonald's burger has 2.5 calories/g, while the In-N-Out burger has only 1.3 calories/g. But both have about the same fat. What gives? My sense is the difference has nothing to do with the quality of the ingredients, and everything to do with In-N-Out putting heavy, water-filled veggies (lettuce, onion, tomato) on while McDonalds doesn't. I don't have the data in front of me, but I bet if you took all the veggies off the In-N-Out burger (or added an equal amount of veggies to the McDonald's burger) -- basically assembling them the same way -- you'd get largely the same results.
In other words, both use more or less the same quality ingredients, with essentially the same nutrition, despite McDonalds being demonized as the culinary antichrist while In-N-Out being some kind of organic savior.
In my opinion, the problem with McDonald's (or any other fast food chain) isn't that their food is so much higher calorie than if you were to fix it yourself. Rather, the problem is they cater to a customer base who is actively looking for high-calorie, high-fat food. Said another way, given a fully-stocked kitchen (and the willpower and expertise to actually cook), I wager most people would basically fix something as bad or worse than McDonald's, intentionally.
This is somewhat reinforced by this study that suggests that NY's "label the calories as big as the price" plan is failing to produce results. I'll admit, I thought the plan was a good one, and I'm disappointed it didn't work. This suggests people know they're eating crap food (even if composed of reasonable-quality ingredients), but simply don't care.
So where am I going with all this? I think the solution can't just demonize the quality of fast food ingredients (because they're fine) or emphasize how many calories people are buying (because they don't care). And it's not enough to highlight the long-term effects of those decisions; those are already pretty apparent and non-motivational.
Rather, we need some way to identify people who are on a bad long-term path and create short-term consequences. And by "we need" I mean "given that our country is being bankrupt by vast medical insurance programs with out-of-control cost increases driven by health epidemics such as obesity, taxpayers should demand" that something be done to prevent people from taking actions that leave us on the hook for massive medical bills down the road.
Similar to how people with good driving records and safe-driving courses get lower insurance premiums, I think we should do the same for Medicare/Medicaid. Create programs where people can earn better care by making healthy choices. Granted, healthy people need less medical care so it doesn't make sense to give them *more* of it as a reward for needing *less* of it. But what if healthy people got tax credits and prioritized non-emergency care. Shorter waits, nicer rooms, more choice. Everybody still gets the same quality of medical attention (for better or worse), but people who actively maintain healthy lifestyles are rewarded with status, convenience, and comfort.
Furthermore -- and this is the most important point -- it should be made very clear to you which "service tier" you're in at all times, creating an *immediate* positive consequence for healthy actions that normally only have long-term effects. So everybody who does nothing is lumped into the "standard" tier; you needn't do anything special. But you should be constantly encouraged to upgrade to the "premium" tier by just demonstrating healthy decisions. How exactly that is done is obviously a big question, but some ideas:
- Get credit for healthy-eating, healthy-lifestyle training courses
- Demonstrate participation in preventative care programs
- Get regular checkups to certify you haven't been abusing drugs
- Wear an electronic patch that measures caloric intake and expenditure
- Join a gym and hire a certified trainer who reports activity to your doctor
And so on. Every problem has a ton of complications, don't get me wrong. And it'll be a horribly political process to decide what's "healthy". But perhaps something like this can start to gradually steer us in the right direction?
Admittedly, that won't be enough. Not even remotely close to what's needed to actually get things under control. But it might be a step in the right direction of preparing people to resume individual accountability for their health given we probably have little choice but to vastly scale back coverage (perhaps starting with reducing end-of-life care, which is estimated to take roughly 30% of Medicare's budget), followed by probable rationing of key medical resources. (Read here for a hyperbolic freakout session about kidney rationing, which obscures a few good ideas under a heap of total garbage.)
Ultimately, I'm all for reducing government involvement in a lot of things. But it will mean *reducing*, not eliminating. I think we should provide a *minimum* level of universal healthcare, recognizing that it's simply not possible to give maximum care to everybody. And we should eliminate barriers that prevent private insurance health plans from operating at maximum competitive effectiveness.
At the end of the day, very expensive or end-of-life treatment is a luxury for the rich, just like helicopters and fast cars. Whether we like it or not, that's just the way it is. But like helicopters and fast cars, they're terrible investments on which only the rich should waste their money. Instead, we should focus on expanding coverage of inexpensive, early-life care to everybody because it's an investment in society that's returns dividends to us all. And that's what the government is there to help us do.
-david
7 comments:
http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande?currentPage=all
Wow, Tyler, that's a fantastic and truly inspirational article. I'm 100% in favor of that, and it's awesome that Obama's healthcare plan is endorsing it.
It seems to me that that sort of "hotspot analysis" is largely independent from (and complementary with) the other options I suggested, so I say we try them all and see what works -- though if it really can obtain 25% reductions in total spend while *increasing* care to everyone, then obviously that's the one that will win. Go team!
I remember seeing an ad on the tube in London for private health insurance (which is not a necessity but a luxury there because they publicly provide it) that gave a 20% discount on premiums if you went to the gym twice a week. It's super easy to track as well. Give people an RFID fob for their keychain that you swipe to get into the gym, tie it into the health insurance systems and you're done.
Imagine if health insurance companies had an API so that grocery stories could get in on that action too and report what you buy using your Safeway card. Although I'm not sure what's in it for Safeway to implement it, but I'm sure there's some business angle.
So my wife is telling me I'm wrong because I didn't account for the patty sizes potentially being very different, and that I didn't mention that there's far more to nutrition than calories alone (and that had McDonalds used something like steel-cut oats, even at the same calorie count it'll be digested in a much better way). To which I responded:
1. You're right that the size of the patty is the key question. I can't find super reliable data on either, but this source suggests a McDonalds standard patty is 1.6 ounces:
http://www.scribd.com/doc/2606654/mcdonalds-burgers
While an In-N-Out patty is 2 ounces:
http://www.dmagazine.com/Home/D_Magazine/2011/March/How_In_N_Out_Burger_Will_Change_Dallas_Fast_Food.aspx
Taken together it suggests:
McDonalds = 9g / 1.6oz = 5.6g fat grams per ounce
In-N-Out = 10g / 2.0oz = 5.0g fat grams per ounce
So again, pretty close. So close that I think we'd need more precise measurements to really know for certain, but it sounds like McDonald's is (say) 10% worse than In-N-Out in terms of fat-per-beef-ounce, but certainly not something dramatic like double.
2. I agree there's far more to consider than just calories. And I agree that they could offer different ingredients with more nutrition with the same amount of calories. (And there is a huge menu to consider, and this analysis could be totally different on -- say -- fries instead of burgers and oatmeal.) But I don't see that the beef a McDonald's burger uses is dramatically different than the beef we would use. Furthermore, while I agree steel-cut oats might be better, my point is the rolled oats they use are no worse than the rolled-oats anybody else uses.
All I'm trying to say is too much attention is put on this myth that fast-food uses terrible ingredients. And I push back on that because I think that myth is damaging. To say "McDonald's burgers are unhealthy" is to suggest it's not the burger to blame, but McDonalds. But the problem isn't McDonalds -- the problem is burgers. Burgers are burgers everywhere, and are more or less equally bad for you whether prepared at McDonalds or your own kitchen.
Sure, if you fix smaller burgers at home, or use leaner meat, or dramatically change the recipe to be unlike McDonalds, then it won't be so bad. But the recipe is to blame, not the cook.
I just think fast-food is too convenient a villain to blame for our obesity epidemic. Fast food doesn't make us fat; fatty foods do. And they're more or less equally fatty regardless of whose kitchen they come from.
-david
I would actually disagree with Michelle. I think the *only* meaningful metric for the "healthiness" of food, in the context of an obesity epidemic is calorie density.
No one is dying in the US from scurvy or vitamin deficiencies. I have never seen a study that can distinguish people based on wether their diet is "healthy" versus "unhealthy" assuming all other factors are the same (total calories consumed, amount of exercise, etc). Maybe this would manifest if you compared a diet crafted by Lance Armstrong's trainer to an all-potato diet, but that's not what we're talking about -- we're talking about a whole foods diet versus a diet consisting of half-safeway and half-mcdonalds.
I might be wrong, though. The thesis of Gary Taubes' "Good Calories, Bad Calories" seems to be essentially that the obesity epidemic is caused primarily by the demonization of dietary fat and the following substitution of much-more-damaging carbohydrates and starches in place of fattier-but-healthier food. It's supposed to be a good read with a lot of evidence behind it, but I haven't read it.
Regardless, I think that it's a fantastic idea to try to incentivize health, but it seems like it will be really, really hard to do. If actually being healthy isn't going to motivate you, what will? What's more appealing to an American than looking like a movie star? A tax credit? For instance -- David, what would get you in the gym twice a week? A 20% health insurance discount? I doubt it. I don't have any good ideas, either. I wanted to suggest "gamifying" health, but there are plenty of actually competitive things you can do at the gym if you want to try and accumulate points, and I'm thinking of things like basketball and racquetball. Those seem like they'd be just as appealing as Farmville, but apparently they're not.
So, I agree with you on the quality of food issue. But calories have gotten so cheap and tasty that it's really hard for people to overcome their biological desires for the sake of long term health. We used to be able to do this just because there wasn't nearly so much food sitting there ready for us to eat at almost no cost. It's analogous to telling people to have sex only in committed relationships because it decreases their risk of sexually-transmitted diseases. It's hard to do.
We could implement a carbohydrate tax, but it'd never fly because it'd be treated as the government dictating the lifestyle of the poor.
Pardon any incoherence in this comment. I haven't gone back through and edited it like I sometimes do.
If you could measure my "health" and show me that going to the gym twice a week actually improved it in some meaningful way, I could be convinced.
Like, if there was some implant that measured my blood chemical levels and overall activity, and if it told me "Dude, you eat bad and are too lazy; shape up" then I'd do it.
But right now I feel I eat pretty well and am generally active, so I don't really feel the compelling need to go "above and beyond" to achieve a level of short-term fitness that (in my limited experience) provides no short-term benefit, and that I doubt I'd do right or sustain long enough to achieve meaningful long-term benefits.
The overwhelming success of score-based game mechanics to me speaks to an innate desire to quantify and improve things. And if there were symbolic "prizes" such as tax breaks and medical perks, I think I'd probably buy into it (at least enough to bring me up to "healthy", assuming I weren't already in that classification).
I think the saying "Eat well, Stay Fit, Die Anyway" sorta captures it: the end result is pre-determined (barring Singularity, of course) and the long-term benefits of short-term sacrifice (in my case time, more than anything) are so nebulous so as to be non-motivational.
But if we created immediate, short-term benefits to taking meaningful actions to improve your long-term health, maybe that'd work.
Or maybe not, hard to say. Which is why I think your article on hotspot analysis is way better than my proposal.
Oh god, singularity discussion.
The guy in the article seemed to actually be having some measure of success with his system, it sounds like it could work, even on a bigger scale. I'd love to see that take off. I had read that a week or two ago and when I saw your article, I had to go look it up so I could share it, it was just too applicable.
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