Case Report on Socio-Economic Aspects of Obesity

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Introduction

Current research in obesity addresses determinants of health, specifically access to health care, social circumstances, individual risk or behavioral factors, the physical environment, and genetic predisposition to obesity.

When one or more of these factors are isolated, traditional health care policy becomes focused on changing individual risk factors, either through eating better, increasing exercise or physical activity or increasing changes in behavior using traditional measures like taxation. The outcome measure is generally a biomedical marker of change such as the BMI.

Population Health seeks to step beyond the individual-level focus of mainstream medicine and public health by addressing a broad range of socio-economic factors that impact health on a population level, such as environment, social structure, resource distribution, etc.  Obesity is a result of this complex web of inequities and disparities and therefore needs to be addressed with a multi-strategic approach that is multidisciplinary and multi-sector, ranging from targeting individuals to groups to sectors.

The following represents current research findings from economists who have studied the socio-economic aspects of obesity with the intent of informing clinicians, policy makers and health care leaders with an interest in controlling the obesity epidemic.

Behavioral Change Studies

One area of research focuses on behavioral changes used to affect individuals’ behavior as it relates to making healthy choices. Those health choices include weight loss, exercise programs and purchasing healthy food. Attempts to live healthier lifestyles often fail for a variety of reasons. The following will address innovative strategies to help individuals in the healthy lifestyle process.

Edington’s 1   program of Health Management in the Workplace was able to quantify various high risk health behaviors and criteria such as alcohol consumption, high blood pressure, high cholesterol, smoking, safety belt use, stress and other factors. These behaviors and physical characteristics were quantified in categories of low, medium and high risk. Edington calculated costs to the employer associated with these behaviors. These costs effected businesses in the form of increases in medical and pharmacy costs, workman’s compensation costs, and employee absenteeism. Cost effectiveness can be achieved by employers enacting a variety of programs that include improved work environments, health risk appraisals, nutritional awareness programs and physical fitness programs.

Crawley and Price 2  looked at various worksite programs that aimed to help employees lose weight. Many employers recognize the value in having healthy employees. These researchers looked at two distinct types of financial reward weight loss programs:  steady quarterly earned rewards and rewards earned via bond after achieved weight loss.  The authors concluded that financial rewards had potential but lack the effectiveness of traditional medical approaches. A major problem identified in both approaches is the drop-out rate of employees in the treatment groups. A key point to further research is the design and implementation of an effective work program that will address attrition rates.

Zheng 3  examined the relationship between food prices and body weight of individuals over fifty. His research concluded that raising the price of calories or fat will have little effect on weight, except in the poorest segment of the population. He concluded that “sin taxes” would not cause significant population weight loss. The higher prices only affect the poor while other groups absorb the additional costs.

Chameides explored the relationship between farm subsidies and obesity. As taxes on bad foods have proven ineffective in battling obesity, subsidies on good food are also not as effective as once believed. This was perhaps of benefit in post depression US; however this abundance has resulted in over production of fructose corn syrup. This by-product is used as a food sweetener in an ever increasing list of foods. Data from the Centers for Disease Control and the American Obesity Association show that there is a direct correlation between the increase in the number of pounds of high fructose corn syrup consumption and the rate of obesity in the US.

Income & Insurance Effects Research

Current research investigates the correlation between obesity and income / insurance factors. One such study was done by Meltzer and Chen. 5   Their data showed that as the “real minimum wage” in the United States declined, individuals and families have limited healthy choices of food to consume. Individuals choose more fast food restaurants because these meals are relatively cheaper. Fast food meals, high in fats and calories, contribute significantly to obesity.

There is considerable interest in the relationship between income and obesity. Ver Ploeg, Mancino, and Lin 6  researched the relationship between food stamps and obesity. The BMI of four groups were studied over time.  These groups consisted of food stamp participants, eligible non-participants, low-moderate income groups and moderate-high income groups. Since 1976 there has been an increase in the average BMI of all the income groups with the exception of the food stamp participants.  Since 1988, data shows a leveling of that group’s BMI, however, it must be noted that other factors beside income must be considered. Within those “economic” groups there were varying differences based on race. Across all economic categories Non-Hispanics had the largest BMI increases, followed by Non-Hispanic Blacks, with Mexican Americans showing the least increases.

Research by Gregory and Ruhm 7  focused on BMI and wages. Their research showed that increased BMI has more of a negative impact on the earnings of women than of men. Their research also suggested that other factors in addition to an increased BMI may be significant. Their data showed that earnings peaked below the clinical threshold of “obesity” or even “overweight.” They suggest that other factors such as “physical attractiveness” could be responsible for the observed relationship between BMI and wages.

One of the most controversial researched topics is that of moral hazard. Bhattacharya, Bundorf, Pace, and Sood 8  explored the issue of whether having health insurance negatively effects BMI. They found that being insured leads to a greater body mass index and a higher probability of obesity. This bolsters the argument that individuals with insurance have less of an incentive to reduce their own risk by living a healthier lifestyle. These researchers acknowledge that similar studies have led to different conclusions. They also suggest a peak or saturation point where having even more insurance has no effect on body weight.

Impact of Contextual Factors

The possibility that relationships between socioeconomic factors may be more observable in the US than in other developed nations has been hinted at by researchers who have noted that a contextual relationship between income-inequality and health found in the US is not found elsewhere. 9   Intriguingly, this may point to a situation where residents of the US are particularly susceptible to the contextual determinants of health at the neighborhood level or may suggest that macro-level processes currently make the US a very different place to live compared with other developed nations. 10  The impact of contextual factors such as supermarket availability, determinants of physical activity, neighborhood quality, environmental factors, recreational amenities and non health consequences including self esteem and educational attainment are warranted given the potential importance of these issues and their effect on obesity.

Changes in nearby fast food availability were not associated with gains in standardized body mass index among children, however, changes in supermarkets and convenience stores were. 11   There is less accessibility to supermarkets in low-income neighborhoods, with fewer supermarkets and more small independent grocery stores available to residents. These independent stores tend to charge higher prices than supermarkets and are also less likely to stock healthier versions of standard foods.

Determinants of physical activity and individual behavioral change can occur only in a supportive environment with accessible and affordable health food choices and opportunities for regular physical activity.

Overall neighborhood quality is not a particularly strong determinant of children’s bodyweight outcomes, however, one specific neighborhood characteristic: the perceived lack of police protection, is a significant determinant of such bodyweight outcome, and may also be associated with the specific sedentary activity of television watching. 12   Public health efforts may benefit from policies directed toward improving both actual and perceived neighborhood safety.

Determinants of health (personal behavior, social factors, received health care, and the environment) disproportionately affect the poor. Strategies to improve population health must focus on this underserved population.  Concurrently, it is important to note that there are large numbers of people who, although they could not be described as socially excluded, are relatively disadvantaged in health terms.  Preventive and other interventions could produce major improvements in their health, and proportionate savings to the health care system. There is a growing consensus that effective intervention to address the obesity epidemic requires a multi-strategic approach involving all levels of society—both for the population as a whole and for the individual.  This relates to ensuring a balance in intervention strategies along the continuum that stretches from individualized health care (downstream investments) to the introduction of policy and legislation that affects whole populations on a macro level (upstream investments). 13   More upstream intervention is required to tackle the obesogenic environment.

Decreasing the prevalence of obesity in a population requires modifications in the environment to facilitate individual behavior. The built environment near the home is a good target for public policy because the neighborhood environment may be more responsive to legislation than either the home or the school. Among the recreational amenities changes in the number of nearby baseball fields, kickball fields, and volleyball courts were associated with BMI reductions. 14

Among a nationally representative sample of young American adults who were in the age range of 21 to 26 in 2001-2002, body weight has an independent impact on self-esteem which affects a host of personal outcomes including education, test scores, and health status. Specifically, being overweight or obese has a negative influence on the probability of having high self esteem for females (both white and black) and for black males. 15   There is no evidence of an impact of body weight on self-esteem in the case of white men. In general, children who are overweight or obese have achievement test scores that are about the same as children with average weight. 16

Conclusion

Obesity is part of a complex web in our society that requires new strategies for research, methodology, and interventions. A multilevel perspective offers insights about the limitations of relying exclusively on free markets and free choice to deal with obesity. Biology, advertising, food pricing, and other socio-environmental factors conspire to shape and influence preferences by changing the accessibility and availability of food and physical activity opportunities.  Neoclassical economic theory promised that allowing individuals to pursue their individual passions and desires with a minimum of constraint would lead to aggregate prosperity. However, this theory may be flawed in the case of food and activity preferences. If humans have built-in biological propensities at odds with their environment, top-down approaches may be needed to achieve population obesity prevention goal.

The Commission on Social Determinants of Health gives public health leaders the framework for policy development, implementation, monitoring, and evaluation which can support the policy-making and review cycle.

The time has come for a critical reexamination of what has not worked and how to improve efforts.  The spirit of change will require the synergy of grassroots mobilization and top-down policy change.

Above all, it is imperative that a concerted effort be applied by clinicians, policy makers and health care leaders with a desire and political will to transform our vision for health and usher in a new paradigm that will elevate population health, eliminate health disparities, and achieve the goal of health equity.

References

  1. Edington D. Health management as a serious business strategy. Presentation to the WEA Trust. The University of Michigan Health Management Research Center. 2009.

  2. Crawley J, Price J. Outcomes in a program that offers financial rewards for weight loss. National Bureau of Economic Research Working Paper 14987, Paper presented at the National Bureau of Economic Research Conference on Economic Aspects of Obesity, Louisiana State University, November 10-11. 2008.

  3. Zheng Y, Goldman D, Lakdawalla D. Food price and body weight among older Americans. Submitted as a dissertation in September 2008, Pardee Rand Graduate School, Santa Monica CA.

  4. Chameides B, Corn subsides: how congress is short changing our health. Static HYPERLINK http://st4tic.worldpress.com/2008/04/25/corn-subsides downloaded April 2, 2009.

  5. Meltzer D, Chen Z. The impact of minimum wage on body weight in the United States. Presented for the International Health Economics Association 2007 6th World Congress Explorations in Health Economics Paper. 2008.

  6. Ver Ploeg M, Mancino L, Lin B. Food stamps and obesity: ironic twist or complex puzzle? Amber Waves, Feb 2006.

  7. Gregory C, Ruhm C. Where does the wage penalty bite? National Bureau of Economic Research Conference Working Paper No. 14984, Issued May 2009.

  8. Bhattacharya J, Bundorf M, Pace N, Sood N. Does health insurance make you fat? Presented at the National Bureau of Economic Research Conference on Economic Aspects of Obesity, Louisiana State University, November 10-11, 2008. Research in progress.

  9. ynch JW, Smith GD, Harper S. Is income inequality a determination of population health? Millbank Quarterly 2004;82:5-99.

  10. Cummins S, Macintyre S. Food environments and obesity—neighborhood or nation? International Journal of Epidemiology 2006;35:100-104.

  11. Powell LM, Chaloupka FJ. Economic contextual factors and child body mass index. National Bureau of Economic Research Working Paper 15046. Department of Economics and Institute for Health Research and Policy, University of Illinois at Chicago. Prepared for National Bureau of Economic Research Conference, Baton Rouge, LA, Issued October 2008.

  12. Sen B, Mennemeyer S, Gary LC. The relationship between neighborhood quality and obesity among children. National Bureau of Economic Research Working Paper 14985. Department of Healthcare Organization and Policy, University of Alabama at Birmingham. 2008.

  13. Swinburn B, Egger G. Preventive strategies against weight gain and obesity. Obesity Reviews 2002;3:289-301.

  14. Sandy R, Liu G, Ottesmann J, Tchernis R, Wilson J, Ford OT. Studying the child obesity epidemic with natural experiments. National Bureau of Economic Research Working Paper 14989, Department of Economics, IUPUI. Issued October 2008.

  15. Moran N, Tekin E. Obesity, self-esteem and wages. National Bureau of Economic Research Working Paper 15101. Long Island State University and National Bureau of Economic Research, Issued November 2008.

  16. Kaestner R, Grossman M, Yarnoff B. (2008). Effects of weight on adolescent educational attainment. National Bureau of Economic Research Working Paper 14994. University of Illinois at Chicago and National Bureau of Economic Research, Issued May 2008.