How Obesity in America is not a rational choice

Author: Tricia Goh

Research Head: Ashwin

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My 600-lb Life. The Biggest Loser. My Diet is Better than Yours. Reality television in the United States has thrived on documenting the lives of the obese and their journey towards weight loss.

Is obesity such a rare phenomenon in the U.S.? Why is it that these reality series consistently attract millions of viewers?

According to the Centers for Disease Control and Prevention (CDC), an individual is considered to be obese if ​​their weight is higher than what is considered healthy for a given height, with the Body Mass Index (BMI) measure being used as a screening tool.

Shows about obesity are not piquing the interest of Americans because they want to know what it’s like to live as an obese person. In fact, the National Health and Nutrition Examination Survey in 2017-2018 found that 42.4% of the U.S. population aged 18 and above are considered overweight (Hales et. al, 2020), which makes about 2 in every 5 Americans obese.

What is more worrying is that obesity rates have been on the rise, increasing by about 50% from 30.5% in 1999 to the current 42.4%. Severe obesity rates have also undergone significant increases, doubling from 4.7% to 9.2% in the same time period.

Obesity in America is not something that should be taken lightly, or seen merely as a source of entertainment. It needs to be seen as a pervasive, serious, and costly disease.

Why is obesity such a rampant problem in the U.S.?

There are two main causes of obesity – genetics and behaviour. However, according to CDC, genetic changes in human populations occur too slowly to be responsible for the obesity epidemic. Hence, we can tie the increase in obesity rates to behavioural causes.

Behaviours that contribute to obesity can include physical activity (or lack thereof), dietary patterns, medication use, and other exposures.

For every 3500 calories not burnt off, an individual gains 1kg of weight. Hence, to prevent excessive weight gain, it is vital for an individual to balance the number of calories consumed from foods and beverages (calories in) with the number of calories the body uses for activity (calories out).

Workforce transitions from hard labour to a more corporate lifestyle is one of the major culprits. In the 1960s, more than 50% of jobs included moderate physical activity. However, by the 2010s, this number has fallen drastically to less than 20% (Church et. al., 2011) The move towards a more sedentary lifestyle has led to less calories burned, with researchers estimating that work-related energy expenditure has decreased by more than 100 calories per day.

To combat this loss of work-related energy expenditure, Americans could follow federal guidelines for physical activity, which is 150 minutes a week of moderate-intensity exercise or 75 minutes of more vigorous activity. However, only 1 in 4 Americans are actually abiding by these recommendations.

If Americans are not increasing their calories out, they could reduce their caloric intake.

Unfortunately, the average American consumes more than 3,600 calories daily, which is a 24% increase from 1961, when the average was 2,880 calories. Consumption of added fats also skyrocketed by around two thirds over the same time period.

Part of the reason why there is such a great increase in caloric intake is the rise in fast food consumption. Research published by the World Health Organization found that a rise in fast food sales correlated to a rise in body mass index (De Vogli, Kouvonen & Gimeno, 2014). This is because fast food tends to be high in calories, sodium, and unhealthy fat, but low in nutrients.

​​Fast food is a signature component of the American diet. Research found that from 2013 to 2016, 36.6% of adults consumed fast food on a given day (Fryar et. Al, 2018), with an estimated 11.3% of total daily calories being attributed to fast food.

With too many calories being consumed, and not enough calories burnt, the U.S. now faces a war with obesity.

Obesity is associated with many other medical conditions, including insulin resistance, glucose intolerance, diabetes mellitus, hypertension, dyslipidemia, sleep apnea, arthritis, hyperuricemia, gall bladder disease, and certain types of cancer. Obesity is also related to health issues such as coronary artery disease, heart failure, cardiac arrhythmia, and stroke. (Pi-Sunyer, 1999)

Obesity does not only cost an individual their health, but also brings along economic costs.

There are direct costs and indirect costs from treating obesity and obesity-related conditions. Direct costs manifest in the form of payments for outpatient and inpatient health services (including surgery), laboratory and radiological tests, and drug therapy.

In 2005, the U.S. spent $190 billion on obesity-related health care expenses. The number has increased to $260.6 billion in 2016 (Cawley et. Al, 2021) In 2015, treatment for obesity-related illnesses in adults took up 7.91% of the United States national medical expenditures, marking an increase from 6.13% in 2001. More so, estimates foresee the total healthcare spending on obesity to be 9.1% (Leyd & Carlson, 2018)

Obesity is a disease that can be curbed if an individual takes action to care for what they consume, unlike other diseases like Alzheimer’s Disease, or cancer. Cecchini and Fassi (2015) found that prevention initiatives for obesity may produce a significant decrease in the use of health care services and expenditures, with savings on obesity-related expenditures becoming significant when implemented over a long period of time. The magnitude of the direct costs of obesity causes medical resources to be diverted from more pressing, and less preventable issues, creating another growing concern related to obesity.

For indirect costs, they refer to resources forgone as a result of a health condition, such as increased insurance premiums and days missed from work – which are a cost to both employees (in lost wages) and employers (in work not completed). It is estimated that with the current increasing trend of obesity, the loss of economic productivity could be as high as $580 billion annually by 2030.

The costs of obesity, whether direct or indirect, have snowballed to a concerning amount. Currently, CDC acknowledges that there is no single or simple solution to solve the obesity epidemic. They provide the following strategies to prevent and manage obesity: State and Local Programmes, Community Efforts and Healthy Living.

The focus of these solutions is to encourage better nutrition and support active lifestyles in order to curb obesity. They work at different levels, ranging from statewide to individual, to send the message that “policy makers, state and local organisations, business and community leaders, school, childcare and healthcare professionals, and individuals must work together to create an environment that supports a healthy lifestyle.” (CDC, 2020)

It can be hypothesised that one of the underlying economic justifications for the increased obesity rates and weight gain is that consumers are maximising their utility given their fixed preferences.

Rational consumers choose how much of a good to consume based on their budget and utility, which is the amount of satisfaction they receive from consuming a good. Rational consumers will always seek to maximise their utility given their fixed budget.

Over the last few decades, consumer incomes have steadily increased and consumption has increased accordingly, leading to a rise in caloric consumption. It is not just an increase in consumption of fast food that has caused this spike in calorie consumption, but in general, an increase in consumption of all food.

Solutions are hence drafted and pivoted towards the rational consumer, hoping to change their fixed preferences. For instance, state and local programmes include the High Obesity Programme (HOP), which focuses on providing healthier alternatives for food. This would, if successful, influence the food preferences of individuals in the programmes, causing them to change their utility function. With this change in the utility curve, the rational consumer would then eventually use their fixed budget to consume a different basket of goods, this time including more healthier options that would help stem obesity rates from rising further.

However, economist Frederick Zimmerman (2011) proposes that obesity is not a rational choice. Rather, he posits that the cause for rising obesity rates is the influence of food-producing companies, which attempt to drive consumers’ tastes toward fatty and high-calorie foods.

Food marketing is ubiquitous. A study has found that 69% of popular movies from 1996 to 2005 included brand placements of foods or beverages. Around 50% of the product placements were for sugared beverages or snacks, with the vast majority of the remaining placements being for fast food or casual dining.

An analysis of several areas of food marketing led Zimmerman to conclude that the explosion in the power and reach of marketing, particularly for snacks and sugary beverages, is likely to be a more plausible reason for the increase in obesity rates.

For America to effectively target its obesity problem, there is a need to focus less on the individual’s personal responsibility. Rather, interventions should be made for marketers, and limit their ability to influence the food choices of consumers.

An example that the U.S. government can draw from is Singapore’s banning of advertisements on sugary drinks. While sugary drinks may only be one part of the obesity epidemic, any step is better than no step at all.

Singapore’s ban on advertisements for sugary drinks stemmed from their government’s decision to crack down on the rising diabetic rate in Singapore. The ban, which will apply to "the least healthy" sugar-sweetened beverages, will cover all media platforms including print, broadcast and online. Not only so, sugary drinks would also be required to display a colour-coded, front-of-pack nutrition label to list nutritional quality and sugar content.

Implementing advertising regulations to influence consumer choices, and raising consumer awareness of what goes into their food and drinks could potentially be one of the most powerful tools in the war against obesity.

An informal survey conducted by TODAY Singapore found that some drinks with the highest sugar content are products that many consumers did not manage to guess are heavily sugar-laden. As such, consumers continue to consume these beverages regularly under the guise that they are “healthy enough”. This is in line with Zimmerman’s theory that due to advertising, many individuals’ tastes are being driven to the unhealthy.

A complete ban on advertising for any major contributing factor of obesity, such as fast food, or sugary beverages, may seem like a radical move. However, it may just be the move that the U.S. government needs to take in order to push out the message and make it known that the war on obesity is a major issue that needs to be combated right here and right now. A consistent message that “processed snacks and sugary beverages cause obesity” has to be clearly stated across all media platforms and companies to rewire and change people’s eating habits.

References

Cawley, J., Biener, A., Meyerhoefer, C., Ding, Y., Zvenyach, T., Smolarz, B. G., & Ramasamy, A. (2021). Direct medical costs of obesity in the United States and the most populous states. Journal of managed care & specialty pharmacy, 27(3), 354–366. https://doi.org/10.18553/jmcp.2021.20410

Cecchini, & Sassi, F. (2015). Preventing Obesity in the USA: Impact on Health Service Utilization and Costs. PharmacoEconomics, 33(7), 765–776. https://doi.org/10.1007/s40273-015-0301-z

Church, T. S., Thomas, D. M., Tudor-Locke, C., Katzmarzyk, P. T., Earnest, C. P., Rodarte, R. Q., Martin, C. K., Blair, S. N., & Bouchard, C. (2011). Trends over 5 decades in U.S. occupation-related physical activity and their associations with obesity. PloS one, 6(5), e19657. https://doi.org/10.1371/journal.pone.0019657

De Vogli, Kouvenon, A., & Gimeno, D. (2014). The influence of market deregulation on fast food consumption and body mass index: a cross-national time series analysis. Bulletin of the World Health Organization, 92(2), 99–107. https://doi.org/10.2471/BLT.13.120287

Fryar D.C, Hughes P.J., Herrick A.K., Ahluwalia, N. (2018) Fast food consumption among adults in the United States, 2013–2016. NCHS Data Brief, no 322. Hyattsville, MD: National Center for Health Statistics. https://www.cdc.gov/nchs/data/databriefs/db322-h.pdf

Hales M. C., Carroll D. M., Fryar D.C, Ogden L.C. (2020) Prevalence of obesity and severe obesity among adults: United States, 2017–2018. NCHS Data Brief, no 360. Hyattsville, MD: National Center for Health Statistics. https://www.cdc.gov/nchs/data/databriefs/db360-h.pdf

Leyd, L. M., & Carlson, E. R. (2018). The Impact of Obesity on United States Health Care Expenditures. J Obes Weight Loss, 3(009).

Pi-Sunyer F. X. (1999). Comorbidities of overweight and obesity: current evidence and research issues. Medicine and science in sports and exercise, 31(11 Suppl), S602–S608. https://doi.org/10.1097/00005768-199911001-00019

Zimmerman. (2011). Using marketing muscle to sell fat: The rise of obesity in the modern economy. Annual Review of Public Health, 32(1), 285–306. https://doi.org/10.1146/annurev-publhealth-090810-182502