Does Obesity Kill?

There is so much noise these days about obesity that it can be hard to figure out what’s important about the issue and what’s not. To try to keep track, I sometimes divide the obesity issue into three questions.

1. Why has the U.S. obesity rate risen so much? Many, many answers to this question have been offered, most of them having to do with changes in diet and lifestyle (and, to some degree, the changing definition of “obese”). There is an interesting paper by the economists Shin-Yi Chou, Michael Grossman, and Henry Saffer that sorts through many factors (including per capita number of restaurants, portion sizes and prices, etc.) and concludes — not surprisingly — that the spike in obesity mostly has to do with the widespread availability of very cheap, very tasty, very abundant food. They also find that a widespread decline in cigarette smoking has helped drive the obesity rate. This seems very sensible, since nicotine is both a stimulant (which helps burn calories) and an appetite suppressant. But Jonathan Gruber and Michael Frakes have written a paper that calls into doubt whether a decrease in smoking indeed causes weight gain.

2. How can obese people stop being obese? This, of course, is the question that sustains a multi-billion-dollar diet and exercise industry. A quick look at Amazon.com’s top 50 books reveals just how badly people want to lose weight: there’s Intuitive Eating: A Revolutionary Program That Works, The Fat Smash Diet: The Last Diet You’ll Ever Need, and Ultrametabolism: The Simple Plan for Automatic Weight Loss. All these books make me think of the argument that every story in human history, from the Bible up through the most recent Superman movie, is built from one of seven dramatic templates. (FWIW, Superman and the Bible are plainly cut from the same template: baby Superman and baby Moses are both rescued from certain death, sent off by their desperate parents in a rocket ship/wicker basket, and are then raised by an alien family but always remember the ways of their people and spend their lives fighting for justice.) This seven-template theory is even more true of diet books. They are pretty much all the same idea with some scrambled variables. Perhaps the weirdest variable yet is the olive oil/sugar water “diet” put forth by Seth Roberts in The Shangri-La Diet, which we have written about a few times on this site.

3. How dangerous is obesity? This is, to me, the toughest question of all. The conventional wisdom holds that obesity is like a huge wave that is just starting to break across the U.S., creating an endless swamp of medical and economic problems. But there is a growing sentiment that the panic over obesity is a worse problem than obesity itself. Among the proponents of this view is Eric Oliver, a political scientist at the Univ. of Chicago and the author of Fat Politics: The Real Story Behind America’s Obesity Epidemic. Oliver argues that the obesity debate is rife with lies and misinformation. According to his publisher, he shows “how a handful of doctors, government bureaucrats, and health researchers, with financial backing from the drug and weight-loss industry, have campaigned to misclassify more than sixty million Americans as ‘overweight,’ to inflate the health risks of being fat, and to promote the idea that obesity is a killer disease. In reviewing the scientific evidence, Oliver shows there is little proof either that obesity causes so many diseases and deaths or that losing weight makes people any healthier.”

Well, even if Oliver is right, and putting aside for a moment Questions 1 and 2, obesity seems to be the culprit in at least 20 recent deaths. Last October, a tour boat carrying 47 elderly passengers sank on Lake George in upstate New York, and 20 of them died. Now, according to a National Transportation Safety Board report, this happened because the boat was badly overweight since the tour company used outdated passenger-weight standards to determine how many passengers the boat could safely carry. (Here is the NTSB’s press release announcing the report; the report itself isn’t online yet, but will probably show up here eventually.)

So even though the boat wasn’t over the passenger limit, it was very much over the weight limit. And when the tourists crowded to one side of the boat to take in the view, disaster struck. According to the New York Times‘s report, the tour company had been using the old standard of 140 pounds per passenger — which the NTSB had already warned was no longer valid, and which N.Y. Governor George Pataki has now updated for New York State, setting the new average-passenger weight at 174 pounds.

The legal wrangling, documented here, has already been intense, with everybody looking to blame everybody else for the accident. The tour group has called the accident “an act of God”; others blame a company that modified the boat; there has also been talk that the captain was drinking. Now it seems only logical that someone will step up to try to sue McDonald’s for putting all those extra pounds on the passengers in the first place.


JanneM

You have to distinguish between obesity levels, I think, and also look at health, not just morbidity. For the very obese - the Shamu-of-the-boardwalk set with 30 or 40 kg overweight or more - there is very little doubt that it is downright dangerous. Those people really are eating themselves to death.

For the moderately obese the morbidity may not change all that much (it does, but not a whole lot), but that does not mean there's no negative effects. Living as long as other people but with an array of lesser health problems still means quality of life is worse, more lost work due to sick days, and still "burdens" the health care system with an array of health problems (perhaps more so than someone with the good grace to go quickly in a massive coronary).

The real debate is where to draw the line between normal weight and obesity, and there I believe critics may be right that the current focus on a fairly arbitrary BMI limit may not be the right way to do so. THere's also good indications that the overall level is probably too low.

The better measuse is probably fat proportion, not mass. Also, there should probably be separate limits not only for men and women, and for different ages but perhaps for different body types as well. The downside is of course that unike BMI this is not something you can measure yourself with any accuracy.

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magmalux

At last, another perfect opportunity to sue a fast food chain for the decadence of the American eater. Burger King, anyone?

mackmalloy

Hello,

I enjoy the blog. Regarding possible causes of obesity, there's one cause I don't see mentioned much in the news, but I think may be quite important. It has to do with the design of modern cities. In many post-WWII cities and developments particularly out west, the residential areas are kept separate from commercial districts, and sidewalks connecting the two are either non-existent, unsafe, or unattractive when compared to roads. Thus, this encourages driving instead of walking. In contrast, traditional urban environments like Manhattan offer wide sidewalks and numerous routes to choose from.

The CDC did a great study on this a while back that can be read here:
http://www.cdc.gov/nccdphp/dnpa/physical/health_professionals/active_environments/aces.htm

Of course, this phenomenon doesn't explain everything by itself, and it is just another piece of the puzzle.

Jeremy Cherfas

Going to the idea of definition, I vaguely remembered an argument about the Metropolitan Life tables -- which were the basis of most recommendations -- being biassed because they were based on mortaility figures from people insured. That is, they ignored the (possibly very fat) people who were turned down for cover.

I can't dredge that up, but there's an interesting article at http://query.nytimes.com/gst/fullpage.html?res=9A03E2DF1138F935A3575BC0A963948260&sec=health&pagewanted=print

cvillouta

I'm not American, but I used to travel there.

Is worth to mention that when you walk in American cities, you can see a higher proportion of "fat people" in the streets compared to other countries (Europe, Asia, Latin America).

It is not a scientific study, but one of the most striking issues that I saw in the movie "Super Size Me" was the people who worked in the Mc Donald's restaurants .... all of them were incredibly fat !

christopher

For a unique and incredibly Occam's-Razor-like explanation of the cause and effects of obesity, have a look at "Lights Out: Sleep, Sugar, and Survival," by T.S. Wiley and Bent Formby.

Of particular interest is the coincidence of disease and obesity in modern times with certain concomitants of our modern, industrial, technological age. These simple but unexpected causes in our environment are purportedly wreaking havoc on our bodies whose evolution up to now isn't capable of dealing with the relatively sudden changes.

Incredible thesis, assembled from an enormous amount of corroborating, respectable, mainstream-approved research from the NIH and many others. (Fully one third the book is footnotes.) Very much worth the read.

Wyatt

Obesity does kill, and as Ruth Kava of the American Council on Science and Health recently noted, it is especially dangerous for women to be very obese. She writes that according to JAMA, "middle-aged and older women at the more extreme upper levels of body weight have significantly increased risks of death, cardiovascular disease, and type 2 diabetes."

Check out her article: http://www.acsh.org/factsfears/newsID.789/news_detail.asp

And as far as lawsuits against McDonalds, there is a good new report showing how foods cannot be treated like cigarettes in litigation: http://www.acsh.org/news/newsID.1356/news_detail.asp

Rob Donoghue

Ok, so the boat sinking thing is making for good headlines, but given the other weight factors, like the installation of a heavier canopy and larger engine in 1997 ( Insurance Journal) as well as additional ballast (Washington Post) it seems that using this as a pointer for obesity (as opposed to for the wide ranging breakdown of regulations it represented) is just taking an easy shot.

SuperRob

I was thinking about this subject all weekend, and I'm trying to figure out why it's so expensive to eat healthier these days. I was going through a Jack-In-The-Box drive-thru the other day, and noticed that their new "Chicken Chibatta" sandwich comes in two versions: Spicy Crispy (breaded and deep-fried) and Grilled. Other than the preparation on the chicken, the sandwiches are otherwise identical.

It's of little surprise to anyone (sadly) when I tell you that the price of the fried version is $4.39 and the price of the grilled version is $5.99. I have to assume a level of demand is causing the price differential, considering that the fried version must be a higher cost item for the restaurant. I know it's beyond most corporations to have a conscience, but it seems like they are placing a price premium on the less costly item and I can't see that demand is the entire cause. Someplace, it's been decided that the healthier sandwich is a higher value item, so they should price it higher, despite there being far more room for profit.

You see this mentality everywhere ... most notably bottled water made from cola companies, where the water is essentially the same water that goes into making the cola. Despite far more cost going into making the cola (sugar, caffeine, etc.), it sells for half the cost of the water. Wouldn't you want to drive people to the item that costs you less to make, to increase your profits? I understand the "value added" business model, but it's become ridiculous when you are leaving money on the table.

It's everywhere ... foods that cost more to make (and are unhealthy for you) are selling for pennies on the dollar, and when you are on a limited budget, those are the foods you're stuck with. It's almost like a tax on the poor, forcing them to choose unhealthy foods because they cannot afford to eat better.

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Dr. Funk

This is a great post. Well done.

One thought that occured to me is that a cause of obesity may be the increased quality of available health care. The decision to eat excessively boils down to a tradeoff between the pleasure of eating and future health costs. It may be that people just no longer care as much about the 5 years they chop of their life, given that it's the difference between 85 and 80 instead of 80 and 75.

So basically, if you assume a diminishing marginal return on life expectancy and rational behavior, you should find that as other factors increase life expectancy, people substitute away from health and towards other goods.

zbicyclist

SuperRob said: "You see this mentality everywhere … most notably bottled water made from cola companies, where the water is essentially the same water that goes into making the cola. Despite far more cost going into making the cola (sugar, caffeine, etc.), it sells for half the cost of the water. Wouldn't you want to drive people to the item that costs you less to make, to increase your profits? I understand the “value added” business model, but it's become ridiculous when you are leaving money on the table."

SuperRob has some good points, but ... It's not true that far more cost goes into cola than into water. Packaging costs are the same. Transportation is the same. Marketing costs as a % of sales may (or may not) be higher. The water has to taste good without the addition of flavoring, and therefore may require more filtration or purification. The ingredients in Pepsi or Coke are cheap (sugar being the most obvious case).

Even when we get to tap water in restaurants, there is more cultural tradition than cost-based logic. The tradition of serving the customer unlimited ice water free in restaurants, but charging $1.50 for a glass of cola with ice is just that ... a tradition. The glass (and the washing), the ice, the server's labor are all pretty much the same, and the 12 ounces of soda has a high markup. [That's why many restaurants can offer free refills on soda.]

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Derek Scruggs

In China, most adults are slim and some are rail-thin. I saw only a couple people there that I could've described as obeses, and they were tourists.

However... their kids are much more likely to be fat. I have a niece and nephew in China and they are both overweight. The niece in particular. She's only six years old and her mom has her on a diet!

Here's the thing - they both walk a *lot*, way more than the average American, or even the average New Yorker. They live on the 7th & 8th floors of their respective buildings and there are no elevators. The one thing that's different from them and their parents is they eat a lot of fast food - mostly McDonald's and KFC - and drink a lot more soft drinks.

I read somewhere that the average Chinese person consumes 10% of the sugar of the average American. I bet that ratio changes radically if you only count people under the age of 18.

SuperRob

zbicyclist said: "SuperRob has some good points, but … It's not true that far more cost goes into cola than into water ... The water has to taste good without the addition of flavoring, and therefore may require more filtration or purification. The ingredients in Pepsi or Coke are cheap (sugar being the most obvious case).

OK, but they're still additional ingredients. Think of it this way ... what is easier for a soda plant to do, get their water or the bottled water from a second source (or process it separately), or to use the same water for the bottled water that you use in your soda? It's the second , and while it may be in reverse (using the bottled water in the soda), it just makes sense from a cost perspective: Add the filtration to the process before you diverge the lines.

So in that case, to make the soda, you're adding ingredients to the water, and no matter how cheap those ingredients are, they're still a cost. Thus, they're selling the higher cost item at a lower price, and that's just insanity.

I'd love for someone from a soda company to prove to me that this is not they way they operate, but I'm almost certain they can't.

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JanneM

The boat accident may well not be due to obesity, but in Sweden about ten years ago, it was the main cause of an aiplane accident.

The local council of a medium-sized town was going to a conference in Stockholm, and boarded a commuter airplane to do so. Of course, politicians at the level of a mayor and councilmen tend demographically to be male and middle-aged, and with a sedentary job, more than a little overweight. The captain (somewhat foolishly) used the then-current average passenger weight to calculate takeoff weight. During takeoff, as the plane tilted to lift, the tail hit the tarmac (it was too heavy, and too many heavyset people were sitting towards the back), and ended up crashing onto the strip again, killing more than half the passengers.

Eric Boyd

Regarding point #3, there is increasing evidence that it's not the weight per-say which is damaging but rather the calorie consumption necessary to gain and keep the weight. Caloric Restriction (CR) studies on animals have shown increased lifespan, and early results in humans are also promising.

Obesity is just the inverse effect - the increased risks of cardiovascular disease, type 2 diabetes, and other major killers may just be the symptoms of an actual shortening of lifespan due to metabolic overuse. Although I've never seen any studies on this, I think it's also plausible that this explains the difference in average lifespan between women and men. Perhaps you two should whip out your famous stats analysis and have a field day?

ron

Part of the confusion rest on when you became obese, your pre-obesity health, and the reason for your obesity. A blanket statement that obese people are unhealthy is probably not true and is at least incomplete. However, any obesity does complicate other health problems, usually resulting in slower recovery from almost any surgery and aggrevates the effects of a hospital stay. Obese patients are more likely to develop respiratory problems from a prolong hospital stay, any surgery on the chest and abdomen, as well as any medical problem that limits mobility. Not to mention the effect on medical staff of transporting, turning in bed, etc (don't ask) of the growing number of morbidly obese patients. This is based on 20+ years as a respiratory therapist prior to my economic career. However, before we adopt too sanctimonious a position on the obese we should examine our own behaviors, driving without a seatbelt, high fat diets, smoking, rock climbing, alcohol, driving a car without helmet (most head injuries are from auto crashes)taking a bath without slip proof tubs. Let he who is without bad or dangerous habits throw the first low cal muffin.

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daedalus702

The few European posters betray a distaste for fat rather than a desire to analyze the issues at hand.

Janne says that very obese people are "eating themselves to death." Another European poster talked about all the fat people he sees in the US.

How enlightening. We knew Americans were fatter on average than Europeans. That's the point. So if you go to the US -- wow -- your experience will probably confirm this. A poster said that all workers at McDonalds are fat. Well class is inversely related to obesity, so there you go.

I'll get in the spirit of the commenters. Each time I have gone to Europe I am surprised at how lazy everyone is; sitting there on there long lunch breaks with nothing to do.

??????

harichinnan

I visited America last winter and when I came back my parents were stunned. I put on an extra 8 kg. I had two American meals(NOT from McDonald) and I cooked dinner myself.

The reasons I would hazzard a guess are
1. Every food had cheese
2. Ice creams came in 3$ giant packs as against 10 cent packs in India.
3. $1 Chocolates as against 10 cent chocolate bars in India.

In India everything comes in small packs. Rs 5 or 10 cents is a magic number. You get chocolates, coke, cakes, almost everything at a Rs 5 price range.

In most cases I never wanted a $3 ice cream. But since I didn't get a smaller pack, I bought the bigger one and ate the full.

I should say if they have to bring any kind of regulation to check obesity, bringing a small size or say '20 cent' pack option on chocolates, coke etc would be the most effective.

bigjohnomfg

I agree with harichinnan. The other day i was buying food at mcdonalds and, i never saw this before but, i realized that a regular cheeseburger costs 99 cents plus tax and a double cheeseburger costs 1 dollar ?! For an extra slice of meat all you have to pay is 1 cent?

improbable

SuperRob said: “You see this mentality everywhere … most notably bottled water made from cola companies, where the water is essentially the same water that goes into making the cola"

Isn't this an example of trying to divine how much the a drink is worth to each customer, and then selling it to them for that much? (There's a name for this I've forgotten.)

Like selling crippled computer processors at half the price: it's cheapest to manufacture just one kind, but if you only sold one you'd lose either the bulk market or the most profitable discerning buyers. The unfortunate consequence here, of course, is that the less discerning buyer gets not last year's computing speed, but worse health.