Charles Shoopak
Global Medicine and Disease
D. Oshinsky
March 23, 2021



The Weight of the Problem
Measuring the Effects of Obesity in America


America has known it has had a weight problem for some time. Over 25 years ago, the New York Times declared “Obesity has reached epidemic proportions.” 1 The paper pointed to the rising rate of Americans who were more than 20% over their desirable weight. http://google.com This qualification for obesity had risen alarmingly during the 1980s, expanding from one quarter of the U.S. population to one third.2 After citing these statistics, the editorial went on to delineate some important truths. Rising obesity had occurred too quickly for this to be based on genetics. Our genes could not have evolved substantially within that timeframe to cause the added pounds. Dieting usually fails, people are either unable to shed pounds, or to otherwise sustain meaningful reductions in most cases. Research money spent on obesity was lacking. What has happened since? Obesity rates nearly doubled,3 dieting continued to fail, 4 and all the while, research money devoted to obesity grew to over $1 billion a year.5 This greater expense with poorer results, also matched the story of increased healthcare expenditures by the US in general.

The billion dollars a year now spent on grants for obesity research represents no more than 2.5% of the government's total NIH (National Institute of Health) $41 billion budget.6 Still this compares favorably with higher priority fields, being within the same order of magnitude, expressed in billions, of what the NIH awards for Alzheimer's at $2.2B, cardio vascular disease, $2.4B, and cancer research, $6.5B. Cancer, of course, includes the multitude of diseases characterized by “pathological hyperplasia," 7 i.e. any affliction of unremitting cell proliferation. All told, all NIH funding represents less than 25% of total biomedical research in the US, 8 9 around 2% of federal discretionary spending, and a little less than 1% of the US annual total of $3.8 trillion in healthcare spending. Thus federally funded obesity research consumes only about .025% of annual healthcare spending in the US.

In contrast to the relatively small amount spent on research, the added cost due to the extra load on the US healthcare system caused by obesity, is in the range of 5 to 10% of total healthcare spending,10 Projected onto current figures, the lower estimate amounts to about $190 billion per year of $3.8 trillion in annual health care expenditures. Yet a considerably larger estimate comes from a study which attempts to account for understated BMI due to self reporting. It uses a method that considers the BMI of a family's oldest child, deriving a figure for the cost of obesity to the country at $315 billion in 2010, $382 billion in 2020 dollars, or 10% of total health care spending, 27% of annual spending by the public as per household survey data (MEPS).11 The study also gives evidence of large cost savings per individual if potentially small reductions in BMI, on the order of 5%, could be achieved. Given the difference between the upper and lower estimates of total costs, 10% down to 5%, it would seem an area that warrants further study to determine the true figure. Knowing the cost of obesity has obvious policy implications, especially for informing the proper allocation of healthcare dollars. Another consideration in prioritizing and allocating money, is that unlike the quest to find a cure for cancer, or Alzheimer's, but similar to smoking, suicide, drug abuse, and accidents (falls, automobile), there is no need of a medical breakthrough to effect treatment.

How much has obesity spread, or increased, why is it considered an epidemic? From 1980 to 2016 the percentage of Americans 20 to 74 years of age, who were overweight or obese, grew from 45.8% to 79%.12 Worse still, the distribution of the overweight and obese became significantly skewed towards the obese, the opposite of what it had been before. The CDC data from which these statistics were compiled also show that during the preceding twenty years, from 1960 to 1980, overweight and obese levels had remained stable. 13 14 This meant that in 1980, only 34% of those with a BMI over 25 were obese, as 66% above that threshold were merely overweight. But by 2016 the 66 – 34 split had reversed, and just 39% of those with a BMI over 25 weren't in the higher obese tier. The obese, with a minimum BMI of 30, came to dominate the numbers, the split had become 39 – 61, the overweight segment now vastly outnumbered by the obese. These were the numbers of a public health crisis.

The resulting health effects of increased obesity include greater risk for cardio vascular disease, diabetes, certain cancers, and total mortality.15 The number of deaths attributed to obesity was conservatively estimated to be around 100,000 for the year 2000 (111,909 95% confidence interval [CI], 53 754-170 064). 16 From the year 2000 through 2016, obesity increased from 35.9 to 48% of the population,17 so the mortality figure would in all probability be significantly higher today. In 2004, a minor scandal erupted over misinformation issued by the CDC purporting to show that 400,000 deaths were caused by obesity.18 The incident provided fodder and helped give rise to obesity deniers, or doubters. As one example, Freakonomics author Stephen Dubner later in 2010 devoted a podcast to “Is America's Obesity Epidemic For Real?" 19 It featured U Chicago political science professor Eric Oliver. Oliver authored a book in 2005, “Fat Politics, the Real Story Behind America's Obesity Epidemic." 20 In his book, and for Dubner's program, he used the story of the retracted 400,000 death rate to support his premise, that the notion of an obesity epidemic is wildly out of proportion with reality, a product of what he terms “the health-industrial complex.”

That the health effects of obesity could be in dispute today would likely come as a surprise to the general public. The rising number of those classified as overweight or obese has been the subject of a great many news stories, for decades. In most of this coverage of the obesity epidemic, it is a given that obesity is harmful, a cause of ill health, a risk factor in major disease, and a harbinger of early death. But the reality is that these effects depend on your definition of obesity. Greater levels of obesity do show significant effects on life expectancy.

To address concern over the claim, that being overweight or moderately obese did not produce adverse health effects, one recent study defended the idea that obesity caused harm, by raising the issue of years lived free of disease. CVD (Cardio Vascular Disease) was the affected condition in this report.21 It stated:

“These results provide critical perspective on CVD associated with overweight and obesity and challenge both the obesity paradox as well as the view that overweight is associated with greater longevity.”

In this context, the obesity paradox refers to evidence by others that overweight individuals have better CVD outcomes than those of normal weight. In discussion, the authors further alluded to this phenomena:

“While health hazards of obesity have long been recognized, recent studies have spurred controversy about the specific relationship between overweight status and mortality.”

The report showed that being overweight or reaching a low level of obesity was still strongly correlated with more years of CVD at the end of life. Thus while one would not necessarily die sooner from being overweight or moderately obese, they would still experience years of declining health brought on by the disease.

Some of the controversy surrounding the severity of the obesity epidemic is caused by the classification system used. The technical divisions of normal weight, overweight and obesity, are today defined by the measurement of BMI, or Body Mass Index.22 BMI is the weight of the subject divided by the square of their height, using the metric system, kg/m2. A measurement of 18.5 to 25 is considered normal, below that figure, underweight, over 25, overweight; 30 and above is considered obese.

The intuitive understanding of BMI is that by dividing the weight by the height, the greater weight of someone over six feet doesn't automatically have them categorized as overweight. The squaring of the number is because taller humans are often larger. Otherwise weight could be estimated from height with a single multiplier. An additional metric of waste circumference would be very helpful, but is not widely used.23

Obesity itself is divided into three classes, I, II, and III, for BMIs equal to or greater than 30, 35, and 40, respectively. Class III obesity, a BMI of 40 and above, is often referred to as morbidly obese. These distinctions can become important in two ways. First, dividing the population into segments makes it easier to monitor the distribution of the population that is overweight and obese. Normal weight is considered BMI 18.5 < 25, overweight 25 < 30, Obese I, 30 < 35, Obese II, 35 < 40, and Obese III, 40 and above, also termed morbidly obese ( '<' used to connote a range up to the figure on the right). Secondly, it's useful to observe the differences in health effects among the groups.

For example, estimates of YLL (Years of Life Lost) give insight into why the rise in morbid obesity is so alarming, and also explains part of the debate over observable effects. For obese levels II and III, BMIs greater than 35 and 40 respectively, depending on the demographic, the YLLs average around 3 and 8 years respectively.24 This is rather significant considering that smokers on average give up only 10 years of life expectancy. The fact that overweight and obese 1 groups don't show significant YLL or small negative numbers (they live a year or two longer than normal weight) does not mean they don't suffer any health effects. As noted earlier, the risk factors are still present for greater incidence of diabetes, CVD, and even some cancers. In this case, what doesn't kill you can still lead to serious pathologies and disability.

Since BMI is the all important yardstick for measuring obesity, it would be useful to have knowledge of what the more consequential upper tiers entail in terms of weight. For someone whose height is 5' 9”, they would need to be 237 lb to 270 lb for the Obesity II level, BMI 35 < 40, and over 270 lb for Obesity III, BMI > 40. For a person who is 5' 3”, the corresponding numbers would be 197 lb to 225 lbs for II, and then over 225 for III. Available tables showing distributions up to the year 2016 indicate 19.1% (10.5% II, 8.6% III) or almost 1 in 5 people fall within that range, with a BMI > 35.25

Back in 1994, returning to the editorial when the Times first decried the emerging epidemic, obesity at that level, BMI > 35, did not exceed 8.1%. Attempting to provide context, the paper at that time, stated the obvious, and then dismissed the notion, stating:

“Some evidence suggests that Americans have been eating more and exercising less. But the true causes of the epidemic remain unknown.”

Actually, this is at least the proximate cause of the epidemic, eating more, exercising less. The reason why we are eating more and exercising less, is perhaps generational. Although the growth of obesity did not begin until the 1980s, and although labor saving devices, the less active suburban lifestyle, TV dinners, taking the car everywhere instead of walking, and white collar jobs replacing physical labor, came decades earlier, perhaps it took near a generation for the effects to show themselves, to weigh in. Perhaps it was a new generation, born mid century, tempered by Dr Spock, undisciplined by the post WWII peace. Whether boomer, Gen X-ers or Millennials, 3 hours a day of TV or alternate screens, were bound to take their toll.

In a book describing the biological explanation of the obesity epidemic, The Evolution of Obesity,26 authors Michael Power and Jay Schulkin propose that due to an abundance of food and a physiology tuned to scarcity and intermittent famine, there is no mystery why people are putting on pounds. To explain why everyone isn't overweight, they point to genetic diversity, as a stable 21% in the US are still left in the normal weight range. There are probably some helpful genetic traits that assist in keeping trim.

What can be done? Studies have shown that diets don't work. But that is not to say that weight loss is futile. What is really meant by diets are useless, is that the traditional mechanisms for losing weight do not work. Both of the two contrarians cited in this paper, Traci Mann, the food lab researcher, and Eric Oliver, the political observer, feel the situation will resolve itself, but in manner left to individual choice. What Mann emphasizes most, is that nothing should be left to one's willpower.27 This means never expecting to have food available and not eat it. Yet, if people are unable to change their eating habits, then the obesity epidemic will only pass when a new generation learns to avoid the disadvantages of living in a world awash with sugar, and topped with whip cream.

A pill is also in the making. There is a professor at Harvard, David Sinclair, a longevity researcher, who is running clinical trials of substances that may be able to fool your body into thinking it has exercised, or that you are on a diet.28 This is because longevity therapies attempt to mimic the actions of calorie restriction, a proven way (in mice at least), to lengthen lifespan and healthspan. The tests are run for diabetes because aging is not considered a disease, and the FDA would not approve drug trials for anti-aging remedies. Obesity, however was granted official disease status first in 2013. Researchers in aging would very much like to attain that status for their field. Yet the success of finding a safe pharmacological substitute for a healthy diet and exercise is by no means guaranteed. The benefits of such may also turn out not to be additive. There has been some evidence that drugs intended to mimic healthy behaviors may cancel out the benefits produced by activities like exercise.

Back in the 1930s, the FTC tried to halt the sale of a dangerous obesity cure, a product named Marmola sold by the Raladam Company.29 When the company took their case to the Supreme Court and won, a new law was passed banning such drugs based on false advertising to the consumer, vs previous prohibitions only in regard to unfair competition. Thus, ever since, the consumer is protected from false claims for products that promise to cure obesity through the wonders of modern science. This is reassuring in light of the money being spent on research and marketing for such products, which include natural supplements, that don't require FDA approval. But whether a drug surfaces first for diabetes, or obesity, if all goes as planned, we will be able to have our cake, and eat it too.




1

"Trimming the Nation's Fat" Editorial, New York Times, 11 Dec. 1994, Sec. 4, p. 14 www.nytimes.com/1994/12/11/opinion/trimming-the-nation-s-fat.html

2

"Trimming the Nation's Fat" Editorial, New York Times, 11 Dec. 1994, Sec. 4, p. 14 www.nytimes.com/1994/12/11/opinion/trimming-the-nation-s-fat.html [ibid]

3

Cheryl D. Fryer, et al. Prevalence of Overweight, Obesity, and Extreme Obesity Among Adults Aged 20 and Over: United States, 1960–1962 Through 2015–2016.” Table, Centers for Disease Control and Prevention, 15 Sept. 2018, www.cdc.gov/nchs/data/hestat/obesity_adult_15_16/obesity_adult_15_16.htm

4

Traci Mann, et al. "Promoting Public Health in the Context of the ‘Obesity Epidemic’: False Starts and Promising New Directions", Perspectives on Psychological Science : a Journal of the Association for Psychological Science, U.S. National Library of Medicine, Nov. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4654677/

5

Estimates of Funding for Various Research, Condition, and Disease Categories (RCDC), Filter with 'obesity', National Institutes of Health, U.S. Department of Health and Human Services, 20 Feb. 2020, report.nih.gov/funding/categorical-spending#/

6

Budget, National Institutes of Health, U.S. Department of Health and Human Services, 29 June 2020, www.nih.gov/about-nih/what-we-do/budget.

7

Siddhartha Mukherjee, The emperor of all maladies: A biography of cancer. P 15, New York, New York: Scribner 2010. https://www.simonandschuster.com/books/The-Emperor-of-All-Maladies/Siddhartha-Mukherjee/9781439170915

8

Bluestone, J., Beier, D., & Glimcher, L. (2018, January 12). The NIH is in danger of losing its edge in creating biomedical innovations. Retrieved March 22, 2021, www.statnews.com/2018/01/03/nih-biomedical-research-funding/

9

Harris, R. (2015, January 13). U.S. funding of health research stalls as other nations rev up. Retrieved March 22, 2021, www.npr.org/sections/health-shots/2015/01/13/376801357/u-s-funding-of-health-research-stalls-as-other-nations-rev-up

10

Economic costs, Paying the Price for Those Extra Pounds. (2016, April 08). Retrieved March 22, 2021, Harvard T.H. Chan School of Public Health, www.hsph.harvard.edu/obesity-prevention-source/obesity-consequences/economic/

11

Cawley, J., Meyerhoefer, C., Biener, A., Hammer, M., & Wintfeld, N. (2015, July). Savings in medical expenditures associated with reductions in body mass index among us adults with obesity, by diabetes status. Retrieved March 22, 2021, www.ncbi.nlm.nih.gov/pmc/articles/PMC4486410/

12

Prevalence of Overweight, obesity, and extreme obesity among adults aged 20 and Over: United States, 1960–1962 Through 2013–2014. (2018, September 05). www.cdc.gov/nchs/data/hestat/obesity_adult_15_16/obesity_adult_15_16.htm

13

Flegal, K. (2010, September). ScienceWatch, Katherine Flegal Discusses the Prevalence of Obesity in the US. archive.sciencewatch.com/ana/st/obesity2/10sepObes2Fleg/
Note. Not the source, but Flegal also makes a similar remark about skewness
here and in 14.

14

Bartoshuk, L. (2010, January 01). The "obesity epidemic", interview with Katherine Flegal. www.psychologicalscience.org/observer/the-obesity-epidemic See also Fig 1. therein.

15

Hruby, Adela, and Frank B Hu. “The Epidemiology of Obesity: A Big Picture.” PharmacoEconomics vol. 33,7 (2015): 673-89. doi:10.1007/s40273-014-0243-x www.ncbi.nlm.nih.gov/pmc/articles/PMC4859313/

16

Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess Deaths Associated With Underweight, Overweight, and Obesity. JAMA. 2005;293(15):1861–1867. doi:10.1001/jama.293.15.1861 PubMed site: https://pubmed.ncbi.nlm.nih.gov/15840860/ JAMA site: https://jamanetwork.com/journals/jama/fullarticle/200731

17

Prevalence of Overweight, and extreme obesity among adults aged 20 and Over: www.cdc.gov/nchs/data/hestat/obesity_adult_15_16/obesity_adult_15_16.htm

18

Kolata, G. (2004, November 24). Data on deaths from obesity is Inflated, U.S. agency says. www.nytimes.com/2004/11/24/health/data-on-deaths-from-obesity-is-inflated-us-agency-says.html

19

Dubner, S. (2019, November 22). Is America's obesity epidemic for Real? (Ep. 2). freakonomics.com/podcast/freakonomics-radio-fat-edition-is-the-obesity-epidemic-for-real/
Guest Dr. Ezekiel Emanuel, academic and health policy advisor, urged government action.

20

J. Eric Oliver Fat politics: The real story behind America's obesity epidemic. New York: Oxford University 2006 Press. p12 https://global.oup.com/academic/product/fat-politics-9780195313208?cc=us&lang=en&

21

Sadiya S Kahn et al. “Association of Body Mass Index With Lifetime Risk of Cardiovascular Disease and Compression of Morbidity.” JAMA cardiology vol. 3,4 (2018): 280-287. doi:10.1001/jamacardio.2018.0022 https://pubmed.ncbi.nlm.nih.gov/29490333/

23

Ian Janssen, Peter T Katzmarzyk, Robert Ross, Waist circumference and not body mass index explains obesity-related health risk, The American Journal of Clinical Nutrition Volume 79, Issue 3, March 2004, Pages 379–384, https://doi.org/10.1093/ajcn/79.3.379

24

Finkelstein EA, Brown DS, Wrage LA, Allaire BT, Hoerger TJ. "Individual and aggregate years-of-life-lost associated with overweight and obesity" Obesity Vol 18, Issue 2 p 333-339, Silver Spring, 2010 Feb;18(2):333-9. doi: 10.1038/oby.2009.253. Epub 2009 Aug 13. PMID: 19680230. See Table 2, https://onlinelibrary.wiley.com/doi/full/10.1038/oby.2009.253

25

Normal weight, overweight, and obesity among adults aged 20 and over, by selected characteristics: United States, selected years 1988–1994 through 2015–2018 https://www.cdc.gov/nchs/data/hus/2019/026-508.pdf

26

Michael L. Power & Jay Schulkin (2013). Evolution of obesity. Baltimore: Johns Hopkins Univ Press. https://jhupbooks.press.jhu.edu/title/evolution-obesity

27

Traci Mann Secrets from the eating lab: The science of weight loss, the myth of willpower, and why you should never diet again. (New York, NY, Harper Wave, an imprint of HarperCollins), Chapter 6, The Myth of Willpower Pub site: https://www.harpercollins.com/products/secrets-from-the-eating-lab-traci-mann?variant=32208024436770 Author's site: https://www.secretsfromtheeatinglab.com/

28

David Sinclair and D.M. LaPlante, Lifespan: Why we age - and why we don't have to, (New York, Simon & Schuster), 26 Pub site: https://www.simonandschuster.com/books/Lifespan/David-A-Sinclair/9781501191978 Book site: https://lifespanbook.com/

29

Arthur Kallet and F.J. Schlink, 100,000,000 Guinea Pigs, Dangers in Everday Foods, Drugs, and Cosmetics, (Vangaurd Press, 1932), 70
https://en.wikipedia.org/wiki/100,000,000_Guinea_Pigs


Note: Though not used as a source for this paper, the Wikipedia entries "Obesity in the United States", and "Epidemiology of obesity", provide useful references, including charts and maps, covering the obesity epidemic from a demographic and geographic perspective within the US, and from a global perspective as well.

	US        https://en.wikipedia.org/wiki/Obesity_in_the_United_States
	Global https://en.wikipedia.org/wiki/Epidemiology_of_obesity#United_States
	


April 2, 2020 The paragraph on annual spending caused by obesity was modified to clarify that higher estimates for obesity costs, of 27% from the Cawley paper 11, reflected a percentage of spending from survey data (MEPS), comprising roughly only half of total annual healthcare spending. The dollar figure, $315 billion given by Cawley was added, as well as the projected percent of total healthcare costs, 10%. The 10% figure was then used in discussing the range of upper and lower estimates, 10% down to 5%, vs previously given 27% down to 5% to 10%. A 2007 working paper based on 2003 data, to reconcile household survey gathered data (MEPS Medical Expenditure Panel Survey) with national healthcare cost estimates, can be found here:
https://www.meps.ahrq.gov/data_files/publications/workingpapers/wp_08006.pdf
Thomas M. Selden and Merrile Sing Aligning the Medical Expenditure Panel Survey to Aggregate U.S. Benchmarks Agency for Healthcare Research and Quality 2007.