Incremental Change for Obesity Control: Feasibility, Cost-Effectiveness, and Sustainability

INTRODUCTION – “Radical change” social engineering approaches have a deservedly poor reputation. In the US, alcohol prohibition was an unsustainable “radical change” that entrenched organized crime. Less ambitious interventions that improve people's ability to make decisions do not promise immediate solutions, but may be more sustainable and ultimately more successful. METHODS – Literature synthesis identifying characteristics of policies that are politically sustainable, cost-effective (including the costs of unintended side effects), and lead to long-term changes. RESULTS – Interventions that radically change the environment affect many dimensions of our lives, often beyond the public health context in which they have been. Public health proposals often have a technocratic/authoritarian bent, a notion that is alien to the US institutional environment. Political acceptability requires acknowledging the importance of consumer sovereignty and individual choice. That does not negate the role of regulation. Market failures (externalities, public goods, information problems) immediately call for policy interventions, but research in behavior economics has shown a much broader range of situations where people make suboptimal decisions. It is in this grey zone between psychology and economics where small “nudges” can have meaningful impacts without constraining choice and requiring radical environmental changes. DISCUSSION –A challenging task for policy will be finding the right levers. Both economic and public health/medical perspectives play an important role in the policy process, but often approach policy questions in an incompatible way. Economics and public health perspectives can complement each other, but harnessing any synergy requires an understanding of the other perspective.