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Why Worry About Obesity?


Elizabeth Kolbert's review of a half-dozen new books on obesity is gracefully written, entertainingly paced, and well worth a read -- it is, in other words, a New Yorker article. But it doesn't draw much in the way of conclusions. More than likely, all the explanations she finds in these books are responsible for the uptick in obesity: We have bodies built to make the most of scarcity and an economy that is dedicated to maximizing an incredible abundance. We bought fewer calories when calories were expensive and we buy more of them now that they are cheap. We eat because we can, and because it feels good, and because it provides a quick reward on days when that's what we need.

I feel like I should say a word on why I'm writing so much about obesity and other chronic illnesses related to diet. It's not because I think there's a great professional future in being a scold, or because I'm planning on entering the lucrative world of publishing with Paternalist Weekly. It's because I've reluctantly come to the conclusion that we won't be able to avoid the fiscal crisis being driven by health-care costs simply by changing the health-care system.

That's not to say that we can't change a lot of health-care spending by reforming the system. But we can't change enough of it. What you see in the Congressional Budget Office graph atop this post is that the growth in health-care costs is not accounted for by an aging population or simple excess cost growth. It's other factors. More precisely, it's what Peter Orszag and the CBO call "technological change."

Technological change means new and more expensive treatments for illnesses. We develop a lot of those. Then we use them. And that costs money. A lot of it, in fact. Enough that it could eventually overwhelm our economy.

We're not going to stop developing those treatments, nor should we. We're not going to stop trying to give people access to lifesaving medicine, nor should we. We can cut costs somewhat by reducing the incentives for overtreatment and wasteful treatments and by negotiating better deals with providers. We can increase the value we're getting for our dollar with better evidence and electronic health records and more primary care. But that won't be enough.

As we keep getting richer, scientists and medical researchers will keep inventing things that can help us get less sick. That's exactly what you'd expect a wealthy society to spend its time and money doing. And if we keep getting sicker, we will keep having to use more and more of these new medical inventions. And that can only happen for so long until we go bankrupt. It would be good to avoid that point, at least so far as we're able. The key to that will be keeping our usage of the medical system at a manageable level. If we develop a lot of treatments but don't need to use them that often, that's quite a bit cheaper. That, however, will require reducing the prevalence of expensive, chronic diseases related to diet. Neither I nor anyone else has a good answer on how to do that. But it's an answer we need.

By Ezra Klein  |  July 14, 2009; 12:13 PM ET
Categories:  Health  
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Why do you miss the obvious point that in order to give people incentives to be more healthy you would charge people more for health insurance that are putting themselves more at risk? As long as healthcare is free to everyone then there is very little reason for people to not smoke or to keep their weight down. It costs more for healthcare of people who make unhealthy choices- why on earth should they pay the same amount for health converage as people who make healthy choices? At least we both agree that this is a fundamental problem with healthcare reform.

Posted by: spotatl | July 14, 2009 12:43 PM | Report abuse

Great points, Mr. Klein. I particularly agree that there should be financial incentives to be healthy, and also to live a lower risk life. We see this in life insurance and auto insurance, but not health insurance.

While it's strange to think of this, we currently have a pace of innovation that can't be immediately accessible to most people on earth. This is largely because the prepaid health care systems of the world place the incentives only on life saving quality, not price. On the other hand, if you look at a procedure that is generally not covered by insurance, such as Lasik, there is downward consumer pressure on price.

The challenge for government comes in creating this consumer driven innovation in a non market environment where the downward pressure on price is only a negotiation tactic. Multiple payers allow there to be a balance of offerings for those that would prefer a particular treatment, versus those who would ask their doctor to find the most cost effective way to heal them.

We need to get rid of this situation where many doctors and patients have no idea about the costs of the treatments they embark upon.

Posted by: staticvars | July 14, 2009 12:56 PM | Report abuse

A good place to start would probably be with relative pricing. Fresh fruits and vegetables reduce the likelihood of developing many costly illnesses? Then subsidize those in size. Maybe have it so that there is an 80% discount on all produce. Pay for it with a flat tax on everything else in the supermarket.

You could administer the subsidy program with a card, which would work like a supermarket's regular card (or it could even be incorporated into the supermarket discount card which most chains already have). Perhaps we could get insurance companies on board to set rewards for certain levels of fruit and vegetable purchases (perhaps, for example, $0.50 off the monthly premium for every pre-subdizied dollar value of produce purchases).

There are separate issues, such as the importance of individual taste vis-a-vis relative prices, and the general availability of produce - or lack thereof - in certain areas. On that second item, I will note that under this scheme, stores which have weak or non-existent produce sections will end up subsidizing those which have much better produce sections.

That all being said, I don't see a good reason not to start implementing the above ideas or similar ones.

Posted by: justin84 | July 14, 2009 1:09 PM | Report abuse


My problem with financial disincentives for self-inflicted health problems is that it's like telling a man who fell in a well that no one will help him out because he shouldn't have been there in the first place.

It would seem to me to be better to put the disincentives (higher taxes on unhealthy foods, etc) before the need for medical care happens. Ezra's talked about the problems with defining unhealthy vs healthy food before, but I think the general idea of making the costs proactive instead of reactive is better.

Posted by: Asherlc | July 14, 2009 1:11 PM | Report abuse

I'm a vegan, non-smoking gym rat. While I'd love to have cheaper health insurance (actually, I live in England and don't have to pay a cent) I'd like even more to be able to buy cheaper food.

Or at the least know that my carnivorous friends were paying more for their non-healthy food (as they do, incidentally, in England--meat cost much more than in the US).

Government subsidies for broccoli, and an end to cattle grazing free on federal land would be a start.

Posted by: KathyF | July 14, 2009 1:25 PM | Report abuse

I don't care how someone gets healthy- there are many roads to the same path. Basically you are trying to say that people are too stupid to make good choices so you have to limit their choices for them. Personally I eat Taco Bell at least once a week for lunch because I can get a tasty meal for $1.50. I drink at least a case of diet soda every week and I rarely if ever drink water or fruit juice. I go drinking with my friends a few times a week. But I am also in good shape because I get out and excercise at least 4 times a week. Set the incentives and let people get there however they want to. I just don't see the point of trying to micromanging people's diets. If you don't like the PR of charging overweight smokers more to cover their healthcare then charge less for inshape non-smokers. But at some point people have to care about how much healthcare they consume otherwise they have no incentive at all to limit themselves.

The reason that people don't eat a ton broccoli isn't the cost- is that its not particularly convenient and it doesn't taste as good as the other available food. (And I say this as someone who drops by the local farmer's market a couple times a week)

Posted by: spotatl | July 14, 2009 1:50 PM | Report abuse


The thing is we don't fully understand obesity. The wealth obesity hypothesis is compelling in its simplicity but it does not explain several issues in the data.

The most obvious is that it does not explain the inverse relationship between obesity and income in the cross-sectional data. That is, while over time the West has grown wealthier and fatter, if you take a slice in this time period wealthier people tend to be thinner.

You might retort, well vegetables are expensive. Ok, but we are moving to a different paradigm now. We are at least saying that composition of foodstuffs is important and that relative prices of food is important. This is a different mechanism from the basic more wealth equals more calories.

We also now need to explain the mechanism behind vegetables or whatever your preferred "healthy" food is. How is it that foodstuff composition effects weight gain.

I gave a bit of a critique of some of your earlier posts here:

However, there is much more to this topic. The simple fact is that we don't know for sure why people get fat.

Intuition might tell us, "well its because they eat to much" and it is of course true that an excess calorie balance is a necessary condition of gaining weight. Though, thats true for all weight gain not just fat.

However, we don't know if people get fat because they eat too much or if they eat too much because they are getting fat.

I know that sounds strange when you first here it but follow me. When children grow taller they are gaining weight. It must therefore be the case that they have a positive calorie balance.

However, it seems silly to think that they grow taller because they eat a lot, and adolescents do eat a lot. No, instead we think they eat a lot because they are growing taller.

So which way does it go with obesity. I tend to think people eat a lot because they are getting fatter. I also tend to think that fat deposition is enhanced by some characteristic of modern western diets. However, its not clear what that characteristic is. I suspect it is related to the high glycemic load of western food and its effect on insulin. But, I am not sure. I don't think anyone is.

Posted by: karlsmith | July 14, 2009 1:52 PM | Report abuse

"we dont know for sure why people get fat."

we may not know why everyone gets fat. i believe that there are metabolic problems that result in obesity, but for the great majority of people, i think it is crystal-clear why people get fat.
if i started eating meats at dinnertime, fried foods, dreadful snacks, krispy creme doughnuts for breakfast, i would be fat in a month. do you have to have an advanced degree in nutrition to figure this out?
does the average person not put on weight after thanksgiving and christmas? does the average person not gain weight after a week of careless and unhealthy eating?

Posted by: jkaren | July 14, 2009 2:07 PM | Report abuse

every week, i read peoples comments, saying that it is costly to eat in a healthy manner.
this simply is not true.
it does not have to be costly to eat healthy.

Posted by: jkaren | July 14, 2009 2:10 PM | Report abuse


Tastes and preferences certainly do matter. At some level though, cost plays a dominant role. You state that you go to Taco Bell to get a tasty meal for $1.50, especially when a even the cheapest healthy option (say a salad) is priced $4-$5 more. However, if those amounts were reversed - that you could get a sizable salad for $1.50 and the Taco Bell meal set you back $6.50 - you might decide to frequent Taco Bell more rarely. Maybe you wouldn't give up every Taco Bell meal for a salad, but it wouldn't appear to be nearly the bargain it currently is. If the relative pricing was $0.50 for the salad and $20 for the taco bell meal, Taco Bell would probably close its doors within a month.

You do have to significantly change the relative pricing for it to make any serious impact - changing the salad from $6.50 to $6.00 and the Taco Bell meal from $1.50 to $2.00 probably won't do a whole lot.

Definitely agree with the point that there should be price incentives in the form of discounts for those with healthier lifestyles.

Posted by: justin84 | July 14, 2009 2:14 PM | Report abuse


you said that broccoli doesnt taste as good as other available food.
that is a very subjective statement.
years ago, i would not have chosen vegetables over other foods. but now, i couldnt imagine eating a basket of greasy french fries that had been covered with salt.
when people start eating fresh fruits and vegetables, there is a new appreciation for natural flavors and textures.
you dont have the kinds of cravings that candies and sweets dont feel stuffed and uncomfortable or suffer the kinds of gastric after-effects that processed foods cause.
the body knows what to do with "real, living" food.
it does not sit and putrify in the gastro-intestinal tract for days.
SAD diets simply are not healthy for your heart or your gastro-intestinal tract. anyone interested in learning more can read about natural hygiene diets as a place to re-educate themselves about healthful, natural eating.

Posted by: jkaren | July 14, 2009 2:20 PM | Report abuse

"a food can start off as a food, but by the time it is cooked, pasteurized, synthesized, extracted, homogenized, adulterated with additives and devitalized by processing for commercial use and storage, it is rank poison."
~~~~dr. sidwa

Posted by: jkaren | July 14, 2009 2:32 PM | Report abuse

Jkaren- my girlfriend and I cook at her house as often as our schedules will allow. Maybe thats 3 times a week if we are lucky- sometimes our schedules don't line up enough to even have 1 meal together in that manner. Do you realize how hard it is to keep fresh produce stocked at her house in order to be able to put together a meal in that fashion? With 2 people we just don't consume enough to constantly eat fresh food without stopping by the store every time. Fresh food simply is not as convenient. I'm someone who actually has a favorite cookbook and it doesn't take much for me to try a new recipe but it take work to eat fresh food. Broccoli costing a third as much would not increase my consumption of it AT ALL.

And if you want to place out a plate of broccoli next to a plate of frenchfries and see which one people choose when both are free I think I'd be willing to put a large sum of money against the broccoli running out first. I think its rather clear which one people think tastes better.

Posted by: spotatl | July 14, 2009 2:35 PM | Report abuse


american people choose the french fries, because it is what they have become used to.
there are many cultures where people enjoy the flavors of vegetables, legumes, potatoes, rices and grains, with healthful herbs and seasonings...and they are not filling their plates with synthetically processed, ultra-sweetened, addictive food imitations.
and i dont have any difficulty going to the market once a week, and having a whole supply of fruits and vegetables in the refrigerator, staying fresh.
the only exception to that may be bananas and certain berries and lettuces.
broccoli, cauliflower, zucchinis, eggplants, carrots, onions...potatoes, yams....apples, oranges, tangerines....
they all stay very well, and you can pick fruits that are in various stages of ripening, like pineapples and i imagine you could make it through the week.
i only suggest this, because i do it myself.
and there are inexpensive, canned vegetables as well.

Posted by: jkaren | July 14, 2009 2:47 PM | Report abuse

karl smith

the metabolism of children is different from adults.
when they are growing taller, there are many changes that are occurring in their body.
i dont have studies, but i am often in rooms of people who are almost all overweight, and they are eating as if there is no tomorrow.
when you walk through most of the aisles in a supermarket, is it any wonder that people are struggling with obesity?
yesterday, there was a post about the food at the cheesecake factory. many of the people who would eat dinner there, are eating similarly the next day.....or worse, starving themselves the next day and eating twice as poorly the day after, when they are hungry and feeling deprived.
the SAD diet in this country, is making people sick.

also, many people who eat in an unhealthy manner, are receiving poor nutrition from their food choices, which causes them to eat more, because their body is craving nutrients that they are not receiving on their poor diets, even though they are eating excessively.
i worked with a wonderful nutritionist.....and he said,
"when you convert to eating in a healthy manner, your body will gradually go to its correct wieight."
the body has its own intelligence. we may not believe that to be true....but the miraculous system that supports our lives, knows what it needs, if we start paying attention and regarding our bodies as living, sacred entities that deserve to be treated as temples instead of garbage pails.

Posted by: jkaren | July 14, 2009 3:00 PM | Report abuse

"As long as healthcare is free to everyone then there is very little reason for people to not smoke or to keep their weight down."

Well, that's an assertion. There are potential benefits of greater access -- doctors still hold positions of authority, and you shouldn't discount the impact of someone in a white coat behind a desk telling you to shape up or ship out.

staticvars: I think there's room for market elements. The recent Dutch reforms still need more time before they can be judged, but the regulated multi-payer element has included incentives for weight loss and quitting smoking.

On the other hand, there are problematic elements to a "lower risk life". If you're un- or underinsured in the US right now, the risk of twisting your ankle while jogging or damaging a tendon while playing soccer might make you risk-averse.

Posted by: pseudonymousinnc | July 14, 2009 3:28 PM | Report abuse

Some questions:

1. Where is ""technological change." on the graph? (Am I blind?)

2. It seems to me that here is a good place for some graphs from the calculator. Where are they, Ezra?

3. I have read that there are no savings from improving lifestyle (fat, drinking, smoking) because all you do is to have people live longer during which time they still get sick and they still have the big end of life expenses. Is this correct?

4. Australia seems to have similar lifestyle problems. Why do they (like everyone else) have better outcomes (life expectency, life expectency after 60, birth weight, infant, mortality, etc., etc., etc.)?

Posted by: lensch | July 14, 2009 5:41 PM | Report abuse

jkaren -

"i am often in rooms of people who are almost all overweight, and they are eating as if there is no tomorrow."

There is no question that eating a lot is a necessary condition of becoming obese. The question is, is it the CAUSE of obesity.

For example, not eating as many calories as your body expends is a necessary condition of loosing weight. But, do we think that people who suffer from AIDS loose body mass because they're just not eating enough?

""when you convert to eating in a healthy manner, your body will gradually go to its correct wieight"

To some extent we all agree on this. Baring the failure to produce leptin or some other major disorder most people will not be able to sustain obesity on a diet of salad vegetables and chicken breasts over a period of years. This much seems clear.

But, what is it about salad vegetables and chicken breasts that cause the body to mass waste. This is important because most people are not going to eat salad vegetables and chicken breasts. We need to isolate the key variables so that people can achieve healthy weight eating the most realistic set of foods.

Posted by: karlsmith | July 14, 2009 8:52 PM | Report abuse

to karlsmith:
this is important because most people are not going to eat salad vegetables and chicken breasts."

well, i am a vegetarian, so i am glad people are not going to be eating chicken breasts! besides, animal products take a long time to digest in the gastric tract...any food that remains in there at our body temperature, for very long, is not so healthy for us, as it breaks down into waste and gases, and sticks around for too long. would you like to leave a chicken breast in 98.6 temperature for a couple of days?
but why, why wont people be enjoying lots of salad vegetables and fresh fruits?
if people would just try to enjoy the natural and healthful taste of fresh fruits and vegetables, and give their bodies a chance to adjust to digestion without discomfort, and feeling satisfied, without cravings....they would find a world of enjoyment, with lots of choices...different choices for each season! no boredom!
just think of all of the delicious fresh fruits and veggies that are available to us in this summer season.
why dont people enjoy a nice ratatouille of eggplants and zucchini, or a ripe, summer peach?
i can almost promise people that their bodies would feel light and satisfied with healthier choices.
and i really believe that if people would try a life style like this, they would feel so much better ,that when a bag of salty french fries appears, or a jelly doughnut....people would begin to prefer the fresh and sweet flavors of nature's bounty!!!!!
fruits and veggies will go through your system like small vacuum cleaners, performing a spring cleaning, and your body will thank you!

Posted by: jkaren | July 14, 2009 9:16 PM | Report abuse

I think what everyone is thinking but nobody is saying is that we need to tax the fat to pay for health care reform.

Posted by: billbrann | July 21, 2009 10:40 AM | Report abuse

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