Wednesday, October 31, 2012

Ontario Pediatrician Recommends Taxation Based on BMI

Last Friday I participated in a call-in show on CTV Newsnet regarding the role of government in obesity prevention policy. A well-known Toronto paediatrician – Dr. Mickey Lerner, joined me.

While I knew from my pre-interview discussions with CTV that Dr. Lerner and I didn’t see eye to eye on everything and that Dr. Lerner felt willpower and education are the keys to success, I was beyond dismayed when Dr. Lerner, on National television, stated that he thought that rather than tax sugar-sweetened beverages, that we should tax obesity. He stated that he thought it would be wiser for Canadians to be asked to enter their BMIs on their tax forms and be levied taxes proportional to their weights than to unfairly penalize those who aren't overweight with soda taxes.

I was appalled.

Putting aside the fact that the consumption of sugar-sweetened beverages is no healthier for skinny folks than fat ones, as I’ve blogged about before, even if obesity were purely an individual’s problem, even if the research that suggests that weight and health are not in fact mutually inclusive or exclusive were wrong, even if over the course of the past 50 years we’ve truly suffered an epidemic loss of willpower and that we’re lazily and gluttonously choosing not to try, even then medicine is not about blame.

And that’s what made my blood boil.

So just for kicks I decided to spend a few minutes of my time today compiling a list of other folks we could target with higher taxes.
  • Folks who don’t complete their course of antibiotics and require further MD or hospital visits.
  • Folks who stop their antidepressants too soon and crash, go on disability and require regular MD followups.
  • People who never bother going to MDs who later require any number of procedures or hospitalizations as a consequence of waiting too long to address a treatable condition (like the non-compliant diabetic who receives a triple bypass and 6 years of dialysis).
  • Anyone who’s non-compliant with their medications for a chronic condition (like the teen with asthma who requires multiple ICU stays because they don’t bother with their puffers)
  • Athletes who don’t respect their injuries and end up damaging something bad enough to require surgery
And then of course there’s the new lifestyle section
  • Folks who don’t exercise the minimum 150 recommended minutes a week
  • Folks who consume more than 1,500mg sodium a day
  • Folks who don’t consume 5 or more servings of fruits and vegetables a day
  • Folks who consume trans-fats
  • Folks who have desk jobs and don’t take the time to ensure they get up to minimize their sedentary behavior based risks
Heck, if we decide that taxation should be determined on the basis of how well we look after our medical conditions and live our lives we could kiss our deficit goodbye in a hurry because I'd bet there's barely a person alive who consistently follows through with completely clean and healthy living.

Taxing products that are themselves unhealthy to consume is no doubt the responsibility of any government. But taxing people with excess weight because in theory they might have gained their weight eating those products? That's just hateful or misinformed stereotyping of a condition that has dozens if not hundreds of causes and it ignores the fact that scales are absolutely terrible tools to measure health. I know skinny folks who live incredibly self-destructive and unhealthy lives that cost the tax payers huge sums of money, and folks who are fat who live healtheir lives than me and cost the system nothing.

During the call-in show there were many callers who agreed with Dr. Lerner, and while they might not be expected to know any better, the same can’t be said about the good doctor.

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  1. This makes me sad.
    There are so many 'thin' people living on junk food who happen to have a metabolism and body type that makes it harder for them to gain weight, while there are others eating clean and exercising who are still not considered 'thin'. Not to mention BMI does not take muscle weight into account.
    I am a five foot nothing woman who runs regularly, weight trains and eats pretty clean. I still struggle with weight and also carry more muscle than the average woman, making it so even wearing a size 5 my traditionally calculated BMI hovers at the overweight mark. Does that make me less healthy overall than the woman who stays thin without trying and makes no effort to eat healthy or be fit enough to run down the block?
    What a rediculously unrealistic and simplistic view for a doctor to hold.

  2. Anonymous7:24 am

    Sounds like the perfect starter for the anorexia epidemic.
    Yoni, where do you get your graphics!!? You must have a designer on staff. I love it!

  3. Why make the poor corporations suffer the stigma of a "fat tax" when we could make overweight people feel even more stigmatized. The "willpower and education" argument is a sure sign that someone is a corporate shill.

  4. AMEN!!

    Thank you for this.

  5. I'm disgusted with Dr Lerner's thoughts on obesity but I'm also not surprised.
    If you go to any online news article about obesity and actually read through the comments section, the vast majority are still blaming overweight and obese people. Almost everyone talks about having the willpower to resist junk food and the need for more education!!! No one wants to admit that junk food is bad for everyone and that weight isn't the be all and end all for health!

    It almost seems like the general public needs to be educated about the role their environment actually plays on their health. Maybe we should make it mandatory for everyone to read your blog? :)

  6. Steve8:58 am

    I wish I had seen that. Is the video online?

    1. I'd asked if they could put it up which is why I've waited until today to post....but since still not up figured it wasn't going up.

  7. Sandra9:32 am

    Here, here! Please HEAR! Thank-you for being the voice of reason. The saddest part of this is that many of the patients I work with have internalized these damaging messages and are full of self loathing.

    1. Anonymous1:26 pm

      Agreed. It's so unfortunate. As if 2/3 of the population lost all their willpower rather than lifestyle changes being the primary factor!!

  8. Yoni, I regularly start my day with reading your blog post as I make my morning coffee. Today's post is a great example of how poorly educated about weight our very own health care practitioners are. The public who are not "in the know" generally take a doctor's word for the gold standard when it comes to anything health. To think that someone with so much power of persuasion with the public is spewing such ignorant garbage really makes me upset. Many of us who work in the area of health and health research know of the many flaws of BMI and how poor of an indicator of health it is on an individual basis. This is expecially true in children, where they grow at such a rapid pace and each child on their own unique pace. It becomes very difficult to accuretly classify children based on weight or BMI. I would assume a paediatrician of all people whould know this and have the limitations of BMI highlighted to him everyday. I am part of a research group looking to develop a health screening tool for children that will replace the use of BMI and give simple method to a more accurate indication of the health needs of the child. Plain and simple BMI does not work on an individual basis and there is no way that his idea for taxation works.

  9. Rhodia9:37 am

    Actually, the things that you posted, such as not taking meds, would be more reasonable to tax than taxing obesity. Not taking meds is a behaviour and is more under a person's direct control than obesity. Obesity is not a behaviour.

    I am overweight (BMI 27) and my husband is not (BMI 22.5), but I dare Dr. Lerner or anyone else to say that he is automatically healthier than I am. I exercise 6-10 hours per week (and that doesn't mean just walking), he does no exercise. I eat 7-10 servings of vegetables and fruits per day, he eats about 3-4.

  10. That story hurts. I can't believe there are educated people out there who believe that tripe. BMI or weight means nothing! I'm borderline "overweight" because I have a lot of muscle from daily exercise - running, yoga, weight training, etc. I eat very well too. My body could never squeeze itself into a size BMI 20-22, I know that for sure.

  11. Not to mention there are some muscular, fit people with high BMIs since BMI doesn't take into account body fat. And lots of unhealthy 'normal' body weight people too!

  12. These kinds of public policy solutions for obesity are simply dehumanizing. A BMI tax is just as bad as a soda tax.

    Imagine a casual acquaintance (say, a coworker) at your office who is overweight. I know they are overweight. They know they are overweight. Even though I see them every day, I would not to presume to tell this person how to live their life, let alone use force to to tax them directly (or indirectly via their food). I don't know their problems, I don't know why they are overweight, and I really don't know how to help them.

    If there were someone I knew really well, perhaps a very good friend or close family member, then I may feel free to talk about their weight to them in as loving and gentle manner as possible. This can only happen when there is a deep, pre-existing relationship with a lot of trust and love - and even then it would be rough.

    If I wouldn't use force to compel a casual friend or loved one into eating better, why would it be acceptable to use the same coercive tactics on a total stranger? That is why I use the word dehumanizing - they treat people like objects, or something else. Obesity is a very personal problem that public policy advocates really ought to refrain from trying to solve.

  13. Hilary3:01 pm

    Not to mention, BMI is a far from perfect judge of health, one could be in perfect health and still overweight or even obese (though these cases are few a far between). Not to mention those who are overweight, and have no desire to be skinny, does this mean we should force them to be so? What measures would go into place to ensure people aren't lying about their height and weight once they find out it is more expensive to be so? How about the body builders and those who are just naturally bulkier? Would we tax those who are anorexic or are underweight? Ugh, the whole thing is pathetic, appalling, and down right wrong. How about we spend are time trying to HELP these people and not penalize them. Before any of this goes down, you better believe we would need the utmost solid data saying negative reinforcement actually works.

  14. "....even if obesity were purely an individual’s problem, even if the research that suggests that weight and health are not in fact mutually inclusive or exclusive were wrong, even if over the course of the past 50 years we’ve truly suffered an epidemic loss of willpower and that we’re lazily and gluttonously choosing not to try, even then medicine is not about blame".

    I've been critical of you in the past, so credit where it's due. If people grasp nothing about why the 'obesity' crusade is so off kilter, this about sums it up for me.

  15. It is an interesting idea to levy taxes based on the health of an individual, but hard to implement and control, I would imagine. There are other places looking into a soda tax - New York City being one of them. Do you feel that this decision is more likely to be made with the health care system in Canada being publicly funded?

    1. Not a chance. Our government hasn't been interested in health for quite a while now. Shortsighted no doubt, but they seem to only have term length vision.

  16. I 100% agree with the overall message in this article – taxing obesity is pretty silly (and offensive).

    One thing seemed off to me though:
    "Putting aside the fact that the consumption of sugar-sweetened beverages is no healthier for skinny folks than fat ones."

    For a skinny ("unattractively thin") person ... wouldn't consuming more calories potentially be a good thing?

    I mean when I was very skinny and eager to get bigger, healthier and more athletic my struggle was consuming ENOUGH calories. That was what was holding me back (although at the time I didn't know it) and my I-want-to-get-stronger training was taking me nowhere simply because I wasn't in a calorie surplus.

    Wouldn't adding a Coke to my diet have been beneficial? It's just extra sugar calories after all, which, combined with an overall balanced diet, would have helped!

    Someone who is obese ("a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health") wouldn't benefit from extra calories in their diets though, no?

    Am I missing something?