foreign welcome to this meeting one of the last of the festival of economics 2017. the subject that we are going to focus on in this session is extremely topical in the world up to some time ago we would have said in the western world but now the problem is extending also to developing countries and the problem is that of obesity and as we are at the festival of economics we want to focus on the uh relation between obesity and economy or economics and the topic will be dealt with by an expert a world expert dr kirsten strombotney i hope i pronounced it correctly it is a norwegian type of family name she is a health economist and works at the american institute of research washington dc the capital city of the u.s and she deals and she has been dealing with this topic for more than 10 years and she tackles the issue from different viewpoints trying also to provide recommendations or guidelines for policy makers you know that obesity is a sort of an epidemic which has uh repercussions on health production longevity so it has a large spectrum impact on many aspects of our life personal and social life so i'll stop here and look at the floor to dr strombotney who will speak about this topic and then at the end of her speech if there is time we will collect some questions thank you i'm sorry this is going to be in english and i'll try to speak as slow as possible for the translators in the back just to give you a little bit of background my name is kirsten strombotney i'm very happy and very grateful to be here with you all discussing obesity i'm going to come at it from the perspective of american obesity and i'll focus as well on italian obesity with the caveat that i'm still learning about the incidence of this disease in your country as well i want to talk about the economics of obesity and what does that mean what do economists have to say about obesity as a topic well we believe that obesity is ultimately the result of a series of dynamic decisions and what i mean by dynamic decisions is decisions over time regarding health behaviors what we eat how much we eat of it how active we are and understanding how individuals make trade-offs between food physical activity and weight gain and weight loss the market forces that influence those actions the consequences of those actions and the role of policy in addressing the consequences are all topics that economists may have particularly useful insights into so just to give you an idea of what i'm going to talk about today i'm going to present some background on obesity with the assumption that not everyone is as familiar with this topic and related behaviors and i'm going to talk about the drivers or what i believe are the drivers of this disease i'll go over the consequences both the financial and the health consequences talk a little bit about economic theory and i promise i won't get too technical or jargony discuss some policy options and then talk about where i think we go for from here both for my country and maybe for your country as well so let's talk what is obesity when we see obesity what are we talking about i'm going to refer to something called bmi which stands for body mass index in adults you measure it by dividing your mass so in kilograms divided by your height squared so you can see this is a chart where how this works is you would take your height so i'll my height is 173 centimeters so it would go over on the chart and then you go upwards you find your weight and then you classify your bmi based on your weight for height right and so in general if you fall in that green bucket we say you have a normal weight if you fall in the yellow bucket we say you're overweight and if you fall in the red bucket that's when we say you're obese there are other ways to measure obesity you could do it by body fat percentage waist circumference waist to hip ratio skin fold thickness this measure is imperfect for a number of reasons but we use it because it's easy to collect data on height and weight in a lot of people now i'm going to talk to you a little bit about childhood obesity today too and we measure childhood obesity a little bit differently and that's because children grow in non-linear ways so for those of you who have children and you've taken them to the pediatrician the pediatrician will show you a growth chart and you can see where your child or how your child is developing in relationship to these kind of growth curves so for children we want to look at weight and height within age and gender categories so it's an imperfect measure again but this is kind of where we're at in terms of measurement so let's let's look at obesity rates in italy you guys are actually relative to most oecd countries have very low obesity rates here maybe about 1 in 10 individuals are obese the oecd average is one in six and you can see in my country it's far worse it's about one in three and this is obesity but when we look at overweight so that was that yellow category i showed you in the first chart italians are about 40 percent overweight so that includes obesity and what you'll what you'll notice for italian adults from this graph you can see in the red line you don't really see the same trends in growth that you see in say the us or england i don't know if that's just because your data doesn't go as far back or if you don't have the same trends but it's ultimately an empirical question these are global prevalence of obesity so let's just kind of look relative to the rest of the world the way to interpret this graph is countries that have darker blue have higher prevalence of obesity and countries that have lighter blue have lower prevalence so for females these are all female specific the world average is about 11 so italian italians actually have a lower percentage of obesity than the world average the lowest would be bangladesh vietnam and then you can see there are pockets of the world that are really problematic the pacific region southeast asia have very high obesity rates as do the americas and the middle east the prevalence and the pattern looks fairly similar when you look at men although you can see if you just compare colors i'll do a quick switch men are generally less obese than women worldwide so i talked about a trend and i want to show you the trend for the prevalence of obesity over time in the u.s and this graph starts in 1960 but if you were to draw this line out to the 1900s it would look relatively stable at about 10 percent and what you'll notice is that in the 1970s and 1980s we get a really big spike in obesity rates in the us so you've probably read the newspaper heard the news stories about different hypotheses for what's driving global obesity what drives the epidemic and what i want to make salient from this graph is any hypothesis that we consider needs to be able to explain that really rapid increase so if you were to say something like obesity is caused by genetics you would also have to be willing to make the argument that something about our genetics changed quite starkly in the 1970s to explain the rise in obesity rates this is another graph and we won't spend too much time here but it shows different um categories of obesity so this light bottom area is overweight over time the darker green is obesity and then the gray is extreme obesity and what i want you to take away from this chart is that the growth in obesity rates are happening at the highest values of obesity and i have one more way to show this again these are different categories of obesity growth rates you can see that it's really extreme obesity that's driving this problem in the us and i'll come back to the geography of italy but i want to show these are graphs i'm going to present to you a series of 25 graphs and they're going to show obesity rates by state over time and what you'll see is that the spread of obesity really looks a lot like a contagious disease or a pandemic so i'll explain in words but just to show you the light blue is going to be under 10 obesity and then as we get into the yellow and reds it's higher rates so here we go so by 2010 you can see that there's no state in the u.s that has under 10 obesity that's that's alarming so i said italians have low obesity rates but that's italian adults when we look at italian children we see a different story so this graph is showing rates of child overweight and what you'll see is that relative to other oecd countries italy is actually not doing great at all second to greece and overweight amongst children and this is particularly problematic because what we know about obesity is once you become obese there's really no going back on average now that can change from individual to individual but what we see in american data is once you move into a different category you really only move up from there we don't see people moving down so when i look at this i think oh italy's in in for some problems in the years to come this is a graph that is from a great paper i was reading this weekend that shows variation in italy and child overweight by province and what you can see is that southern provinces have higher rates of child obesity northern provinces have lower rates and from my basic understanding about italy these would also correlate with very various socioeconomic factors so this conference is about inequalities in health and we see inequalities in obesity we see inequalities in income you can see that the poorest americans have higher rates of obesity than the more wealthy americans although the group for whom obesity is growing fastest this purple group is actually the wealthier american so it is an unequal disease but it does touch everyone the story is a little more nuanced when we break it down by females and by ethnicity so for females we see a pretty typical what you would think to see about obesity as your incoming increases the propensity to be obese decreases for males it's a little bit different we we see that same trend for white males in the us but for african-american and hispanic males we actually see either an inverse relationship or a u-shaped relationship between income and obesity we see disparities by education so these are italian rates of obesity women with poor education here are three times more likely to be overweight than educated women the same is true for men though to a lesser extent similarly italians from southern provinces low-income rural areas are more likely to be obese and obesity is actually was interesting to me and maybe someone in the audience can explain we out we also see higher levels of obesity in women who completely abstain or report abstaining from alcohol consumption so what happened this is all pretty rapid it's pretty scary at least to me the economic argument is that and and i believe economics are at the heart of the obesity epidemic the argument is that economic forces have made it easier and cheaper to consume high energy tasty affordable food and have made it more expensive and i mean expensive and economic costs to be physically active moreover medical advances have lowered the health costs and consequences if not the financial costs that result from excess weight and have perhaps decreased the motivation to diet and exercise so in other words the obesity epidemic is a direct result in changes in relative prices or costs that promote excess food consumption and decrease physical activity so let me show you some data to back up that claim the first claim is that it's cheaper to consume more calories and i'll walk you through this graph in a second but in general when we think about economics one of the basic laws for normal goods is that when prices decrease the quantity demanded is expected to increase and the demand for food is no exception during the past several decades in the u.s food prices have actually been steadily dropping and i know these look like rises but i'll explain why in a moment since 1978 our food prices have dropped 40 percent relative to other goods and services so what's even more relevant is that high calorie foods have become much cheaper than more healthful alternatives so what you're looking in at in this graph is the cpi which is the consumer price index so this isn't inflation adjusted this dark blue line is the cpi for all foods and beverages since 1982 and what you'll see or what i want you to see is that since 1983 when this graph starts the prices of fresh fruits and vegetables all fruits and vegetables fish and dairy products have increased by a hundred and ninety percent 140 percent and a hundred percent respectively but when you look at fats and oils sugars and sweets and carbonated beverages they increase at much lower rates 70 66 and 32 percent respectively we think much of the decrease in these relative prices is the result of food technology that disproportionately affects processed foods so that could be through technology like freeze drying vacuum packing and the discovery and mass production of high fructose corn syrup in addition to falling monetary costs i think that technology has also decreased the amount of time and energy it takes to prepare food so decreasing non-monetary costs are also expected to increase consumption for example you have the widespread availability of the microwave oven has made it even easier for pre-packaged food today 95 of us homes have a microwave that's practically everyone compared to 8 30 years ago we also see decreases in the acquisition cost of food which is supported by the sheer volume of restaurants and cafeterias and snack bars and vending machines this is this is actually a picture from a really great new york times article that was about italy this is a picture from a shopping mall in trentino i think riveta okay this is amazing to me i saw one of these in trento you have vending machines that make pizza this is shocking right these options were not available 20 30 years ago right and much of the increase in calorie consumption when you look at the data on average calorie consumption over time much of that increase occurs between meals so snacks now although the cost of calorie consumption has decreased the cost of expending those calories has increased significantly and i mean the cost in terms of all costs right so consider energy expenditure in the workplace as a result of advances in workplace technology even the most blue-collar occupations i don't know if that word translates blue collar means more mechanical even those jobs have been automated to the point where employees burn very few calories in the workplace this technology allows employees to be increasingly productive and to earn a higher wage as a result but it comes partly at the expense of growing waistlines you know it's it's not only that jobs that burn large numbers of calories are increasingly hard to find but they pay also low wages so it's hard to imagine people would be willing to take a substantial pay cut for a few extra pounds of weight loss one strategy to offset the increase in calories consumed and the decrease in calories expended in the workplace is to increase your leisure time physical activity so this is a graph of gym membership over time in the us with the caveat that gym membership doesn't necessarily mean people actually go to the gym but you can see that increasingly we're thinking about ways to use our leisure time for physical activity however that too requires significant costs when one considers what needs to be given up to engage in that activity right if we're earning more money the opportunity cost of the leisure time is higher we also means we're you know using a host of new technologies which include computers the internet video games television these are all sedentary behaviors that have to be traded off for that physical activity in leisure time and finally the last piece of this argument is that it's just cheaper it's less expensive to be obese right the this too is based on economics it says that a res as a result of advances in medical technology the uh the health consequences of being obese have decreased so there's been a tremendous increase in the medical the pharmacologic and surgical treatments for the risk factors and diseases that obesity promotes which suggests that the health consequences which are one form of the cost of obesity are not as great as they once were for example many drugs and surgical procedures have been introduced over the past 40 years that treat cholesterol high blood pressure you can buy insulin medication the the consequences from having diabetes are less severe and partly these technologies are even subsidized by our insurance companies or by publicly funded health programs so really the costs are decreased and partly as a result of these new technologies obese adults in the us at least have better blood pressure and better cholesterol than they did 30 40 years ago so this discussion is not meant to suggest that obesity is not bad for one's health obesity adversely affects nearly every system of the human body and it greatly increases the risk of numerous health conditions especially diabetes and it's associated with most of the non-communicable chronic diseases including stroke lung disease cancers heart diseases gout arthritis sleep apnea throughout the body moreover the financial consequences are incredible a very conservative estimate of what this costs the u.s from a year-to-year basis is 147 billion dollars most of that or a little more than half of that is the direct medical costs of treating the diseases i showed you on the previous slide the other half comes from lost productivity in the workplace so we know that individuals who are obese earn less money they show up to their jobs less frequently and there are estimates that say being obese and having the conditions associated with being obese make you less productive on the job so what do we do about all this what should we do and what can we do the appropriate policy response really depends on your view of human behavior and our relationship to food right do we choose to be obese how does this story change if we believe that there are addictive components to what we consume to answer this question i want to present to you three different forms three different economic models of the way of looking at human behavior and the way we consume and make trade-offs with respect to addictive substances now when you go to your introductory economics course you learn individuals are perfectly rational we walk around with these kind of utility maximizing functions in our head we you know make perfect trade-offs now we don't actually ever see the utility functions in each other's heads so we have to make assumptions that people are behaving rationally what if they're not that changes the interpretation of how and whether we should regulate obesity related behaviors so i'm going to present to you three models the first is a completely irrational model of addiction the second is a completely rational model of addiction and the third is going to be a host of models in between the first this very irrational model is called the myopic model and in this view of human behavior you would have to think that humans have no forward-looking behavior right we're perfectly obsessed with the donut with the drug with cigarettes with alcohol and that we have an economic terms high or perfectly price inelastic demand for the substance that means i can change the price of the substance and your demand stays the same right in this case if we believe that there are problems with the consumption of the good right we believe there's externalities associated with being obese the appropriate policy response is total prohibition right if you're not responsible to prices then we ban the substance this has unintended consequences saw with the prohibition of alcohol it can create black markets and raise crime rates we also might worry that food sugar fat salt aren't addictive substances for everybody so can you ban it for everybody can you just completely get rid of food and which kind of food what about the evidence does the evidence say that we're actually price sensitive i'm going to show you some price sensitivities for food but first i want to show you some addictive substances so you can get an idea of how they relate to each other so for instance when we look at how your consumption of alcohol changes in response to the price of alcohol we see that for an alcoholic for a very heavy drinker that price elasticity is essentially zero you can change the price and people will consume alcohol in most forms we've seen it in a very extreme case in russia where people will actually resort to drinking know car fluids windshield wiper fluids any kind of alcohol that's a zero price elasticity something like cocaine you see has an elasticity of about negative 0.3 negative point four cigarettes we think are elastic so the consumption of smoking actually responds pretty well to changing prices which may also be a reason why we saw really effective smoking and cigarette taxes in the u.s now food is no different food is generally price inelastic so in economic terms again that means that you can change the price and your behavior change is less than the change of the price i don't know if that's going to be it's not surprising that food is price inelastic right we all need food to survive we all have to eat every day um but you can see that there are differences by the type of food so of all of these the one that you're most likely to give up in response to an increase in price is going to be fast food or food in a restaurant then soft drinks you can see sweets and sugars are fairly inelastic that's kind of about the same estimate we saw for cocaine which is interesting for a host of reasons and then eggs are the most inelastic which is slightly strange to me so if we don't think we're myopic we don't think we're completely irrational with respect to food are we completely rational is it the case that forces in the markets technology have changed our relative prices and it's just more costly to be thin than it is to be overweight right if we believe that humans are completely rational then we would interpret the rise in obesity as a rational response to prices and those include all economic prices right this is the idea that consumers are maximizing their utility with all the costs in mind across the entire life span right if actors are completely rational they respond to incentives and it implies a wider range of potential policy lovers in in response to externalities of obesity right that could include taxing legal penalties informational campaigns etc i'll talk about a couple of these initiatives the one that receives the most attention in our country are food taxes sin taxes kind of as a mean to recuperate costs associated with obesity although a number of state and local governments have recently initiated soda taxes with tax on carbonated or sweetened beverages economists disagree over the extent to which these taxes are appropriate so you might think there's some really important differences about taxing food and taxing say cigarettes alcohol or illicit substances for instance a cigarette is a single substance it's very easy to target but if you want to target a tax at food what do you target do you target total food if you want to reduce calories that seems not right sugar what kind of sugar sugar occurs naturally in many foods it occurs in fruit you get it in dairy products there are added sweeteners if you tax sugar the people change to fake sugar and is that any better for you do you tax soda well if you take soda what's the cross-price elasticity what kind of effect does that have on the consumption of say fruit juice or candy bars these are all really important questions that don't have clear answers but they in the u.s at least soda presents kind of the easiest target there have been many studies showing associations between soda consumption and weight gain and this is what policy makers have chosen to focus on another problem with these taxes are that they could be regressive and what i mean by regressive is that a tax like a soda tax impacts um the poor more than it does the wealthy right the counter argument to that argument is that those are also individuals who may be most likely to benefit from the taxes but that's that's the argument now existing studies are actually show mixed effectiveness and how well these taxes actually address obesity my colleague and co-author eric finkelstein has estimated that you'd need a 40 percent tax on sodas to achieve just a one pound decrease in body weight that 0.6 kilos about per person so that's a really high tax and even when you see changes in purchasing behavior they don't necessarily translate to clinically meaningful outcomes another policy that's popular and has been put forward is the provision of information right so if you believe one of the the problems with obesity is stemming from the fact that people just don't know what's healthy for them or they don't have the appropriate information then the obvious thing to do is provide the public with information it's everyone's favorite strategy it imposes very little cost and people who don't want to use the information don't have to use it right unfortunately it's it's not that effective so for those of you who were in uh professor ashen falter's lecturer yesterday saw that he presented on the um the mc wage actually giving it away so on switch and the way he measures the mc wage is by looking at it the price of a big mac french fries and a soda right and when you go to mcdonald's in the u.s there's a law now that mcdonald's has to post the calories for each of their menu items right so my blockers aren't working very well but basically a big mac french fry and coke is 1200 calories does anyone know how many calories you're supposed to have in a day some people do well this is a big problem with menu labeling is that not many people know so if you don't know what to do with this information it's not particularly useful you'll also see that calories are presented in ranges so if you order what is that a number three the double quarter pounder it could be anywhere from 750 calories to 1400 calories right and we don't see these policies changing purchasing behavior so we certainly don't see them changing weight um there are many reasons for this one is that you may not know how many calories you should consume in a day there have been some great qualitative studies showing that these numbers are hard to interpret people could go into restaurants compensating for other meals you could go into the store already knowing what you wanted these foods could be habit-forming or addictive and mostly the cost of preparing something healthy at home far exceeds the four dollars that you'll pay for over half of the calories that you need in a day right so if you're a single mother you're working all day you need to feed your children you don't have a lot of money this is the cheapest option and the quickest option you don't have to think about preparing the meal go to the grocery store bring it home cook it serve it clean it it's easy and it's cheap and it's high in calories now what if we think our behavior is actually someplace in between completely irrational and completely rational right we're still price sensitive but what if we're just making mistakes and when you talk to real people not economists this seems to jive with our experience of eating food and our experience with sugar and desserts and gelatos and sodas there are a number of models that explain something somewhere in between jonathan gruber who spoke here yesterday has a really great model looking at time and consistent preferences so that's the idea that you would hyperbolically discount into the future we may be sensitive to cues and marketing we may have self-control problems right we may not want to do it but feel compelled to do it and we may make mistakes right and if this is the reality we may want to consider additional policies so we call them libertarian paternalistic policies and the idea here is that you essentially want to help people help themselves right this is a picture of odysseus and he's tied himself to the mass because he knows the sirens are calling and that if he hears them he's not going to have any self-control so he kind of pre-commits to um to binding himself and it's the metaphor that we use for many of these nudge policies or policies that help us maintain our self-control one of these policies is increasing taxes to not just reflecting the externalities of your behavior but also the internalities of your behavior they could include things like changing the default so there are some really interesting studies showing that if you just move let's say you're in a buffet line if you just move the desserts from the end from the beginning to the end people consume less desserts right go figure it shouldn't make sense from a rational utility optimizing perspective but it does make sense from a psychological and human perspective these could include policies like paying people to lose weight so financial incentives and then manipulating how you give them out so through lotteries or sweepstakes and then pre-commitment devices so things like gym membership where you're paying money upfront with the thought that you have to be healthy there's also there's some really fun websites dean carlin from yale has one called stick where you can pay money up front you make a pledge and you say this year i'm going to lose 10 kilos here's 500 and if i don't lose 10 kilos you can donate that 500 to the worst charity i can think of so if you are maybe on the left side politically you could promise to give it to the far right policy and the id far right political party the idea being that that outcome is so horrible you've pre-committed to lose 10k so we actually see in the us a lot of these kind of behavioral nudge ideas popping up so where do we go from here what do we do with all of this we've clearly got an obesity problem it's being driven by technology right and if it is being driven by technologies that help us live better lives we may not be comfortable with rolling back those technologies for the sake of losing weight right first of all we need effective policies unfortunately most of the policies i've presented to you don't show effectiveness in isolation right this may be because we still need to do quite a bit of research onto what's actually causing obesity the relative importance of different behaviors is it what we eat how much we move and is it total number of calories or specific types of calories like carbohydrates or sugar those the real demons in the diet and then we also need evidence-based theories of behavior so i presented three different models of economic behavior to you but from an empirical standpoint it's very very difficult to test those models to test between them the data requirements are incredible and finally i think we need a systemic approach and i i usually hate when people talk about a problem and then recommend a systemic approach because it sounds like a easy response but i want to show you some pictures of what we're dealing with at least in the us and what could be coming your way this is a pharmacy in the u.s this is where we go to get the drugs that are supposed to make us healthy this may actually be an okay pharmacy they're serving some bananas it looks like but you can see that as you approach the checkout it's just temptation this is a sporting goods store this is where you go to buy things to help you be physically active and if you look closely what you'll see is that every checkout counter you can buy candy this is a bookstore this is where you would go to buy books presumably about being healthy also as you walk through the line to check out temptation candy food this is a linen store this is where you go to buy pillows and sheets okay it's ubiquitous right so these are the kind of problems that we're up against the market forces that are incredibly strong in my own personal opinion i think where we should be focusing all of our efforts are on schools and for our children right nobody believes that our children are perfectly rational and that we make kids make utility maximizing decisions with the lifetime consequences of those decisions in mind i think the most promising systemic approach is to target our efforts at banning junk food in school certainly regulating or banning the marketing of food and sugar towards children and that includes on the internet and by television and then providing funding to increase physical activity time in public schools and maybe some of those things would be useful for the italian childhood obesity crisis as well so i think that's my time and thank you very much well i found your presentation extremely interesting and original from my viewpoint for a person like myself who normally deals with health i write for the career de la serre about health well whenever i look at things not from the viewpoint of cause and effects and uh consequences in terms of calories and consequences well i see that everything changes everything takes up more comprehensive dimension a complex dimension and the fact that this presentation has been fantastic in terms of quality well i understand that from the fact that i took some notes about questions and at every slide you already answered my questions so you answered all the questions that i had wrote down so now i'm a bit in a difficulty because i don't know what uh questions to make anyway let's hear if you have questions or comments for our speaker i'm sure she will be happy to answer please go ahead don't be shy you're not shy good afternoon in your opinion depression can have an impact on obesity and if we treat a depression do you think that it might be easier to find another way so that the person can help him or herself to solve the problem thank you so it's it's a nuanced question it's a question that requires a nuanced answer because it's difficult to disentangle the relationship between depression or even psychological stress or various mental health conditions and obesity which one comes first just solving the obesity solve the health dissolving the health solve the obesity um but i think it points to you know the fact that there are a lot of other things that drive our eating behaviors beyond cost right and one of you know one of the the things that i didn't touch on is that there could be kind of multiplier effects given our new environment so it may be that some people's genetics do worse off in this kind of high calorie processed food environment it could be that some people do better or worse given their mental health state so i think it's um it's ultimately an empirical question and i i don't have the the full answer for you well i see a connection between economic factors and obesity both at the time when food is produced i'm thinking of big industrial husbandries and then the push to eat meat and then the excessive use of cereals and then i think monsanto which has a connection with the um buyer and not even obama uh did what he had promised and by the way bayer produces drugs for heart diseases so there are big big companies out there and then we tell people that they have to face off this economic power but it is these big companies which cause obesity and then we tell individuals who work 10 hours they don't have time to prepare food because in western countries there is very little time available to cook while in india they spend four hours in america half an hour so there is no time to cook and on the other hand there is a huge army of economic powers so it also it all seems very disproportionate to me so i think you touched on a lot of issues in your statement one big one which for those of you who were at the panel discussion on friday has a lot to do with the framing of the problem so there's a whole other way to approach this topic which is to think about the political feasibility of policies that may be effective and believe it or not we don't have universal support for these policies in the us and i think it's because of something you said which is there are a lot of people who see obesity as a personal failing right as someone who is irresponsible with their health and isn't making the right choices and in that case what do we really want to do to help those people with their own tax dollars the other side of the story or the the flip side is that we're all victims of the market right and if we're kind of at the whims of companies with big lobbying power and a lot of money who have vested interests in seeing that we're obese and in profiting off our health outcomes that's a very different way to tell the story and it opens up a lot more policy options i think one other thing you touched on is kind of agricultural policies and how those may affect what we eat so one hypothesis that's put forward in the u.s is that we subsidize corn production say and then the idea would be that the subsidizing of the corn makes the ingredients cheaper like high fructose corn syrup and therefore reduces the price of these kind of high calorie high fructose corn syrup products in actuality farm policy at least in the u.s is a lot more complicated than that often times subsidies and quotas and acreage rules will cancel each other out and when you actually look at how much of the price the fructose fructose corn syrup plays so for example a soda actually two cents on the dollar of every soda comes from the ingredients most of it is the price of the aluminum that the soda is served in so yes agricultural policies could play a role the evidence in my opinion hasn't shown that they do this far i hope i touched on all of the elements you listed thank you very much thank you for your beautiful and very clear presentation i have two questions we saw in the beginning a map of the world and so my question is the phenomena that we see in egypt and in the middle east and elsewhere do they follow the same pattern that was followed or that happened in the united states or is there a diff difference and then based on your studies have been have there been cases where there were incentives at tax levels meaning i don't know whether you can deduct the gym fee from your taxes from your taxes has that been done and if so with what effect has this triggered the virtues type of behavior or not these are great great questions the first question about global obesity rates these are harder questions to answer because we don't have the same kind of empirical data for the world that we have not even for italy that we have in the u.s so what i would tell you would be a lot of speculation you mentioned the middle east in particular and one hypothesis that's gaining a lot of traction is that it has to do in particular with sugary beverages or soda consumption because these are areas of the world where alcohol is not consumed in high rates but again that's conjecture and i'm not an expert in global obesity your second question is about financial incentives to lose weight and how effective they are there are so many studies about this and people try to change the timing of the payment if we say we'll give you a hundred dollars per pound or you have a one in ten chance of a thousand dollars or ten thousand dollars per pound what if we pay your favorite chair i mean you can test it in any number of ways but the bottom line is is what we see are really minimal reductions in weight loss that disappear over the long term so even if i can design an intervention that uses financial incentives to help you lose weight even if i see effectiveness in the short term in virtually every study when you follow up a few years later you'll see a return to the original weight or even increases from the original weight so they tend to work while the study is happening and not so much from a long-term perspective at the time a lot of these trials for financial incentives were popular we also kind of started to think about ways that your employer may also incentivize you to lose weight in the u.s a lot of people are insured through their employers so the employer has a vested interest in making sure you're healthy so the employer will offer benefit programs for prevention with with the hope that your health expenditures will decrease or won't be as high one problem with that is that in the us at least we see a lot of mobility between jobs so employers don't necessarily have incentives to invest a lot of money in your health if you're not going to stay at the company for longer than five years so it's a question that many many people are thinking about but as a single strategy for intervention hasn't shown a big promise thank you it was interesting i wanted to ask you you spoke about provision of information and especially in the menu but i was wondering about processed food and packaged food and stuff like traffic light labeling and the relationship with between this type of provision of information and inequalities and then last thing i was a bit disappointed by the name scene attacks because it puts a stigma on it so i i'm pretty sure shared the thought with me but i really don't like to call it syntax that's it thank you we'll call it a pagovian tax for you so the the question is about informational provision of information so the example i gave is about menu labeling which is actually law now in the u.s for restaurants or franchises that have more than 20 locations the obamacare aca law required that they post their calories and largely we've seen that that policy has been ineffective so then what other kinds of provision of information can we think about well you can look at nutrition labeling in the grocery store the evidence shows that people have a hard time disentangling all of the information that's presented you know you get calories fat grams sugar percentage micronutrients i'm not sure exactly what italian nutrition labels look like what's more promising are labels that are kind of heuristics so these could be one you mentioned as a stop stop light a traffic light so just on the cover of the the box have a green light a yellow light or a red light to indicate buy don't buy definitely don't buy the problem with these kind of labels is that it then becomes political how you rate them who gets a gold star who gets the heart approved who's a green light um i spoke a little bit on fridays i think you were there that there are these kind of nutrition wars that exist outside the scope of my presentation and they're really bitter battles between nutritionists who believe that obesity is a problem of caloric imbalance it's like you just you consume too many calories and you don't expend enough in which case if that's what you believe you really want to signal individuals to buy low calorie food options but there's an entirely different camp that believes obesity is a problem of specific calories so sugar carbohydrates calories that promote insulin secretion and fat storage and if this is your belief then you really want to incentivize or signal to the consumer that you should buy low sugar some people believe in low fat right so there's no real consensus from the experts on what it is you should be eating to be healthy and then you add into that all of the kind of vested interests that this woman had asked about and it becomes a a real boondoggle real a little bit chaotic to figure out the best way of signaling healthy food options so it's it's a very nuanced topic i i hello i'm here i think that we also have to talk about the right information and i heard the question about food and depression and i think that this is a different domain in that a number of diseases have some don't have anything to do with that it could be that there is a person with depression who eats a lot and is always hungry and vice versa as well oftentimes i read that good and reliable institute developed a number of not expensive diet in i read in the daily corriere de la serra about a diet which is the smart diet and the oncology institute has approved of it the and there of course we would have a possibility but what is important what i mean is that people have to be told about the various options so information is key i'm sorry i did not understand whether you are criticizing the smart diet or whether you are inviting us to inform people about that i'm sorry i did not understand now i was not criticizing or saying the opposite what i meant is that it seems i understood what you said but i didn't understand the point what i mean is that we should all be informed about the effects of what we eat in terms of making us live longer not develop cancer and i made reference to one article i read in the corriere de la sierra i'm not being polemic i simply asked because i didn't understand fully what you meant i but i think you touch on something interesting which is that there are many diets and many of those diets offer different recommendations that may be at odds with each other i was at the the festival bookstore you can go in the square and there's a whole table that has diet books which which all say you should do different things right so there's one says you should be vegan one says you should eat mediterranean diet one says low fat one says atkins lots of meat and what are you supposed to do with all of this information as a consumer when even the experts don't agree so i think it touches off the question from the side of the room earlier which is it's very difficult to make policy recommendations and can be very dangerous when you don't have the complete information about what it is what the right diet is and whether it's right for everybody if i may i would like to conclude with a personal observation unless there is another question there is apparently another question what is a good diet for a child so what should i eat being a child i think you have to ask luigi the the physician maybe what your parents tell you i will try and give a serious answer i do not know what is a good diet for a child because i'm not a nutritionist i'm a physician but not a nutritionist i think that a child during the age of development needs to have a very varied diet in line with the demand for energy because you you have a growing developing body you use a lot of energy also at basal level and you move more as a child than an adult for obvious reasons so you use up more energy and you should receive the essential nutrients i think that we should all agree on the fact that we all should be educated to go for the right taste if you are taught as a child to appreciate a lot candies and sweets that in the united states you also find in pharmacies then you get dependent in a way you are addicted to that and that is one thing but if you replace sweets with fruit then possibly you will continue eating fruit as an adult so nutritional education is key and that will help us appreciate what is good to our body and not the opposite and diet should be varied and should be also rich rich in reasonable approaches it is very true that diet say different things because there is a market for diets as well this is the reason why you have one name or the other in diet i don't want to mention names because i don't want to be sued but the point is that several studies tell us that all diets work in the short term all diets in the short term means that you eat in an orderly way possibly less than you normally do so they all work in the short term and you say well i did that diet is wonderful and you suggest that a friend doing that but people do not see what happens after one year and after one year you gained again the same weight and perhaps an extra kilo so you see what works in the long term is a sustainable diet which is something that is good for our palate and is in line with our needs normally the diet that works better is the one that we can tolerate better but it's not only a question of rules it's a question of personal decisions it's a question of motivation indeed there is another thing that is oftentimes mentioned some people say sugars are to blame and then it's fats and then it's proteins and nutritionists are told that they never give one final word but i must defend them and i must tell you that studying the effect of see individual nutrients on health is sort of difficult it is very difficult to isolate the effect of one nutrient these are the all the other nutrients that are taken in together with with the first one so it is so that we acquire new knowledge all the time and this is progress trials and errors is the process that we follow in science it is a development it is an evolution we know today that's a too much salt is bad and 20 years ago it was flat and it is it was not a political decision at all simply we did not know 20 years ago that salt was not good today we have to be aware of the fact that also nutritional science evolves and i would like to state once again that the receipt to pick the right diet is something that has to do with being reasonable there is one mistake that we all have to avoid and it is that of always eating the same things that is always wrong you should prefer vegetables and fruit and reduce animal fat and simple sugars that is obvious we all know that i have said that i'm sorry but i know that it was not necessary now i would like to thank so much christmas from botany for her wonderful contribution thank you so much a round of hand for you and uh thanks to the audience uh uh for being here and since tito boheri the organizer of the festival is here he also deserves a hand for organizing this very beautiful festival you