The Growth in Obesity-Becker The weight of the average male and female began to grow sharply around 1980 not only in the United States but also in all other developed countries. When average weight grows, the rate of obesity-usually defined by a biomass index (BMI) of over 30- grows at a much faster rate. As Posner indicates, two of the important causes of the increase in weight and obesity are the rapid decline in the price of fast and fatty foods that began about 30 years ago, and the growth in sedentary activities, mainly driven by the expansion of television, and the development and spread of personal computers and the Internet. Posner believes that consumer ignorance of the health consequences of their eating and sedentary activities also contributed significantly-particularly since lower educated persons have the highest incidence of obesity. I am doubtful, however, if ignorance of these effects has been important. Poor information is a last resort crutch that economists are increasingly relying on to explain consumer behavior that they fail to explain in other ways. For example, "behavioral economists" are arguing that many consumers run up large credit card debts in good part because these consumers are not aware of the level of interest payments, and that poorer borrowers took out mortgages during the housing boom years of a few years ago because they could not calculate the difficulty of meeting monthly payments. In both these cases, virtually no evidence is presented to support this thesis. In the eating case, most reasonably well-executed studies find quite small effects on eating patterns of providing nutritional and other information about foods. Continuing with an emphasis on the relation between obesity and low education, Posner argues that heavy discounting of future consequences induced many less educated teenagers and adults to overeat relative to the adverse consequences on their future health once cheap fast foods became available. Perhaps insufficient attention to future health consequences has been important; although many other possible explanations are available for why more educated persons eat smaller quantities of fast foods and get more exercise. Another change, however, also emerged around 30 years ago that provides a fully rational forward-looking incentive to pay less attention to the future health consequences of overeating and weight gain. I am referring to the beginning of the age of blockbuster drugs that help control blood pressure, cholesterol, and erectile dysfunction, help treat if not cure various cancers, and provide other protections against some serious health consequences of being overweight. The expectation of even further progress in the future, such as in treating the worst aspects of diabetes, would rationally reduce present concern about weight gain and the future consequences of heavy eating of rich foods and low levels of exercise. This argument does not presuppose that persons with less education and even the more educated are keenly aware of these developments in drug therapy, or that they could articulate this as a reason for their eating patterns. All that is required is that most people have a loose awareness of the growth of drug therapy for many diseases, and that such awareness helps relax their concerns about gaining weight. To me that is a reasonable presumption that would producen rationally heavy "discounting" of the future health consequences of becoming obese. Another argument made for public policy to discourage obesity is that obese individuals make demands on the health care system that raise the cost of this system to others. This argument is not persuasive to the extent that it relates to private health insurance. If obesity makes as large demands on medical care as claimed by the Centers for Disease Control and Prevention study cited by Posner, it would be in the self interest of insurance companies to charge significantly higher premiums to overweight persons since that would better align their revenues to the cost of treating obese persons. Moreover, it is easy to use weight as a determinant of insurance premiums since weight is easily measured in any physical exam required to get insurance. That private insurance companies do not use weight as a premium determinant means either that they do not consider the effects of obesity on their cost to be that large, or that they are afraid they will be accused of discrimination if they do use weight as a criterion. Perhaps the health bill in Congress would make it easier for insurance companies to punish overweight persons relative to thin ones. Since taxpayers finance Medicare and Medicaid, these organizations do not have the same incentives as private insurance companies to penalize overweight persons for their excess weight. The cost imposed by overweight persons on public expenditures has been one of the justifications for taxes on fast foods and soft drinks since these are important inputs into weight gain. However, such a tax would be inefficient, perhaps highly inefficient, because it targets all persons who eat fast foods and drink sodas, yet most of these persons do not become obese. It is akin to taxing the sale of wines and liquor to reduce drunk driving, even though most drinkers do not drive drunk and cause accidents. This distinction between taxing inputs into drunk driving and taxing drunk driving explains the tendency to heavily punish people who are drunk, especially when they cause accidents. The corresponding approach with regard to weight would be for Medicare to institute surcharges for very overweight persons (or discounts for thinner persons) and for Medicaid to impose various costs on obese persons who use their services, such as requiring them to spend time at educational classes on the control of weight, or to pay a fee for any Medicaid services they receive. Such charges and fees probably would run into strong political opposition, but they point the way to more appropriate ways to discourage obesity that causes medical problems that utilize public funds.

Comments

[Anonymous]

Your argument is intriguing. And I agree that it is increasingly becoming a crutch to blame "lack of information" on any seemingly irrational action of lower-income people. However, I think an argument can be made that imperfect information at least CONTRIBUTES to rising obesity among the poor. After all, on a small income, most poor people have the ability to eat healthier food and perhaps they are myopic towards their future health.

Also, I mainly think people are getting fatter because as we get richer, people have to do manual labor less, and food is that much cheaper. It is a sorry, but in my opinion trivial, consequence of everyone getting richer and lifting people out of poverty.

[Anonymous]

it seems the advertising arms don't think that us already knowing something a billion times over is reason to stop telling us repeatedly.

'big macs are delicious & convenient'/'bigs mac are bad for you' are both pieces of information that should fall under the 'does not qualify for lack of information' defense.

but, one actually has a tremendous amount of resources devoted to it.

[Anonymous]

Another determinant of obesity must be lack of time. Poorer individuals probably have to work longer hours (or more days), and thus may resort to unhealthy fast food meals. A standard worker who earns a comfortable living works normal 40 hour work weeks, and thus has time to buy healthier foods and prepare them adequately. Along the same line of thought, they would also have more time to devote to exercising and other weight-loss techniques.

[Anonymous]

"virtually no evidence is presented to support this thesis". Really? I know this would be a revolutionary breakthrough in analytical tools for an economist, but why not ASK PEOPLE why they took out the mortgages and test whether they actually understood the mortgage terms fully? In a country where a recent poll says 58% of Republicans don't believe Obama was born in America, I think it's safe to say that ignorance is not a rare commodity round these parts.

I think discount rates, derived from actual utility functions, are the major explanation for obesity, like Posner. But then again, I don't need to use any quotation marks when I talk about behavioral economists.

If your drug prediction hypothesis is correct, why is it that only the poor and uneducated folks are betting on breakthrough medical treatments? Are these guys, the ones who know basically nothing about science, really in the best position to be predicting biomedical innovations? I'd expect more fat postdocs at the NIH...

[Anonymous]

"Poorer individuals probably have to work longer hours (or more days), and thus may resort to unhealthy fast food meals. A standard worker who earns a comfortable living works normal 40 hour work weeks, and thus has time to buy healthier foods and prepare them adequately."

I don't know how you're defining "standard" or "comfortable", but the folks I know that make the most money work MORE hours and days to earn the money and opportunities they want. Granted I'm 26, college educated and highly ambitious which no doubt influences my perceptions. Perhaps this ties into Posner's point about the less intelligent folks and their personal discount rates. I expect to be paid off down the road for my efforts, which is why I'm willing to invest my time now.

I'll also add that the time periods being discussed roughly correspond to the proliferation of strength training, which increases BMI as measured due the density of muscle mass relative to fat. There are better metrics to identify obese people than BMI and before I'm charged a higher health insurance premium, I'd like a better distinction to be made between "obese" as measured by fat composition and by BMI.

[Anonymous]

"I don't know how you're defining "standard" or "comfortable", but the folks I know that make the most money work MORE hours and days to earn the money and opportunities they want."

Granted, you have a point here; obviously one who works more hours will make more money. But in comparison, a chef at Ruby Tuesday's would have to put in much more work (and perhaps search for a second job) to even come remotely close to the same standard of living as an accountant, for example. Comparing differences between an accountant who works a 40 hour week and an accountant who works a 50 hour week is negligible, as they belong to the same (or extremely similar) social class.

Thus, either the poorer individual would have to work more hours to afford the same "healthier" meal choices as the richer person, or they would have to dedicate more time to work, thus losing the time required to purchase and prepare the healthier foods.

[Anonymous]

A Pigouvian tax on calories and/or fat would seem less intrusive.

[Anonymous]

A number of US laws (eg. Americans with Disabilities Act and Health Insurance Portability and Accountability Act) limit employers in their ability to charge different premiums based on health status. Federal agencies have interpreted these laws to preclude charging higher premiums to obese employees. These laws and their current interpretation have limited the growth of wellness incentives in employer health plans. Thus, the effort to clarify the law in the current healthcare reform debate.

[Anonymous]

This time period roughly corresponds to women returning to the workforce in great numbers. Has anyone considered the impact of the loss of a primary homemaker responsible for cooking meals, grocery shopping and family nutrition?

Jennifer

[Anonymous]

So, Americans are responsible for their own health ? Well, I thought that was the governments job - I mean, that's why we're having this big national debate about health care right now, right ? So, maybe if Americans didn't have so many obesity related illnesses (diabetes, heart disease, etc.), then health care costs wouldn't be skyrocketing ? And maybe if our national addiction to drugs and alcohol and their related health care costs could be reduced, then maybe overall health care costs would rise at a more normal rate ? So, maybe if Americans were a more responsible people, then maybe our freedoms wouldn't be so costly ? Wow, what a thought !

[Anonymous]

"Granted, you have a point here; obviously one who works more hours will make more money. But in comparison, a chef at Ruby Tuesday's would have to put in much more work (and perhaps search for a second job) to even come remotely close to the same standard of living as an accountant, for example."

I understand your point, however a lot of people are considered "8-5" employees and don't receive overtime pay for the extra 10-15 hours they work. Instead they receive additional opportunities down the road. Of course an accountant makes more money than a cook at Ruby Tuesdays! Why else would the accountant sacrifice resources to get a better education? Again, I think this is related to the personal discount rate question.

Finally, it doesn't cost as much money as some people think to eat healthy. Whole grain rice, chicken, beans, and green vegetables are relatively inexpensive and the cornerstones of healthy eating.

[Anonymous]

Hi Prof. Becker--

I used to be a student of yours, and now I really enjoy reading your blog. One tiny request, can you please double space in between paragraphs? I read the blog in Google Reader and it is so hard to read with all the paragraphs munched together. Thanks!!!!

[Anonymous]

Great article with many insights into obesity.

We are doing what we can. We use soccer and health workshops to combat obesity in inner-city Chicago public schools.

Follow us on Twitter: Twitter/AmSCORESChicago

-America SCORES Chicago

[Anonymous]

the last commenter has a good issue that we are doing what we should do!

[Anonymous]

The long-term benefits of preventive care are immeasurable and it is definitively a surer bet.

Moving slightly out of context, I do agree that obesity does pose a major health problem but I feel this is just one of the possible causes. There are several variables that can leads to serious health problems like smoking or drinking.

Successful health care measures should be taken at a holistically level targeting most possible causes.

[Anonymous]

Becker's posts have become practically unreadable because of the lack of paragraph breaks. Please add an extra line break between paragraphs.

[Anonymous]

I think Becker is right that poor people have less time to exercise and cook well. Low income people work an average of 2500 hours a year. Assuming the average work week is 40hr/week, then on average, poor people work 1.2 times more.

A large of amount of poor people actually work two jobs, so we must also consider that they spend a significant amount of time commuting.

[Anonymous]

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[Anonymous]

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[Anonymous]

Dr. Poster and Dr. Becker,

I can believe I am about to correct two of the smartest people in the world, but I think you would both completely change your mind on this issue if the two of you read the following article and book.

The two of you seem to be simply repeating conventional wisdom. For example "eating fat makes you fat" and "lack of exercise makes you fat". Do you actually have evidence for this?

Did people not eat fat and not exercise before 1980?

What exactly changed in 1980.

The following article and book presents much more scientific evidence as to what happened after 1980 than either of you do in your essays here.

Read and be enlightened.

Dr. Becker at least got one thing right, the obesity trend started in 1980. Find out why here.

http://www.nytimes.com/2002/07/07/magazine/what-if-it-s-all-been-a-big-fat-lie.html?sec=health

http://www.amazon.com/Good-Calories-Bad-Gary-Taubes/dp/1400040787

Where did I get the audacity to challenge the conventional widsom here? I read the information at the links. But what really got me going was what I found out from my wife's boss. My wife is an assistant dean at one of the top 5 medical shcools in the country. They were once ranked 2nd behind Harvard in U.S. News and world report. At a social event I found out the dean had lost 40 lbs. by dieting. His diet consisted of eating meat and fat, aka The Atkins Diet. Please read the article and book. A spoiler: What happened in 1980 is the government began encouraging the eating of carbohydrates with their new food pyramid and by many other means and demonizing the eating of fat. The article and book are very convincing and all the evidence is laid out in convincing detail by a very credible writer. And no it is not Dr. Atkins. A very Chicago school ending: The Govt. caused the obesity epidemic.

[Anonymous]

I don't know if either of you read "Marjorie Morningstar". One of Marjorie's suitors is queried about why an older comedian (on a cruise ship ) would marry a much younger woman. Suggestions include to deny advancing age , to rescue the woman from an insipid life etc. Marjorie's friend suggested he married her because he wanted to 'sleep with her'.(These were simpler times.)
Maybe people are eating more because food tastes good , and is readily available. I don't have to wait to eat-just drive through BK, McD's etc.
And a little about Atkins.(I was in NYC for an Atkins meeting and watched him slip and fall.)
Yes,it causes weight loss .It restricts total calories.So, it causes weight loss.

[Anonymous]

Why are many poor people overweight?
Answer: Because the government and society enables it.
There are loads of health problems that follow from obesity, something which is within the power of the individual to control. An obese person can easily develop a disability, which in turn, can qualify them for government subsistence. Also, an employer who wants to require their workers to be fit and sets reasonable milestones for fitness can face a very expensive discrimination law suit.
We do not have any incentives for people to stay in shape or to go for preventive care. Why not give tax incentives for wellness? If you were 10 pounds overweight and knew you could get a $1,000 tax credit if you lost and kept off the weight - would you do it? This would also foster and support preventive care by physicians. The focus now is overwhelmed due to a lack of preventive care. BTW- the problem is not preventive care expanding life spans, this has happened due to tackling disease and making society safer. The problem is the lack of preventive care triggers costly care early in a persons life, making their life very medically expensive. Add to that the expense due to loss of productivity and we have a huge seive of resources busting out of our country, something that could be prevented if we did not enable it and provided incentives for people to take care of themselves.

[Anonymous]

I agree with your assumption that insurance companies are hesitant to charge premiums
by weight. The potential public demand for
legislation and the use of another
"prexesting condition" would be
counterproductive. However, employers and
insurance companies do offer incentives and
discounts for starting and maintaining
healthy lifesytle choices, such as
smoking cessation and exercise programs.

If/when we have government directed
healthcare, must ensure these types of
incentives are used. Under the current
Senate bill, I believe there is a
prohibition against financial incentives for lifestyle changes. I am not sure why this
was added, but I hope that clause is struck before enactment.

[Anonymous]

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[Anonymous]

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