The Economics of Obesity Poverty, Income Inequality, and
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Tahereh Alavi Hojjat
Center Valley, PA, USA
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more justice, equality, and the general welfare
– Tahereh Alavi Hojjat
Foreword
In 1958, the celebrated economist John Kenneth Galbraith noted that
“more die in the United States of too much food than of too little” [1].
Unfortunately, this is truer today than it was 60 years ago. We are
finally beginning to understand how prescient these words were. Over
the last decade, there has been an increasing awareness of the obesity
epidemic. President Barack Obama issued a proclamation in August
2015, designating September as National Childhood Obesity Awareness
Month. The year 2015 also marked the 5-year anniversary of the “Let’s
Move!” campaign by First Lady Michelle Obama. Yet this recognition is
not entirely new. As early as 1968, Senator George McGovern began
efforts to create the United States Senate Select Committee on Nutrition
and Human Needs. Initially created to study the issue of hunger and
malnutrition, it quickly began focusing on national nutritional policy to
tackle obesity-related diseases. About half a century has passed since
that time and we still continue to struggle with this issue. In fact, the
prevalence of obesity has more than doubled from 15 percent in 1980
to about 34 percent in 2006 [2]. In order to have solutions, we must
first understand the problem. Why is there an obesity epidemic? Who is
affected by obesity? More importantly, what does income inequality
and poverty have to do with it?
In The Economics of Obesity: Poverty, Income Inequality, and Health,
Dr. Tahereh Alavi Hojjat addresses these issues head on. She outlines
the shift in obesity rates that has occurred among the poor and the
affluent. Much of this is related to the widespread availability of energy-
dense foods – foods rich in fat content and lower in water content. We
tend to consume the same amount of food by weight per day and not
necessarily the same calories. As a result, we eat more energy-dense
foods by weight than we would of the less processed, less energy-dense
foods. These energy-dense foods have become the driving force for not
just the obesity epidemic, but also the changing distribution of obesity
by income and wealth. In this powerful book, the author makes the
compelling case of why obesity in the developed world
disproportionately affects the poor, and how socioeconomic factors and
income inequality continue to drive this trend.
As a physician, I am intimately familiar with the consequences of
obesity. It increases rates of many serious chronic illnesses like
diabetes, high blood pressure, high cholesterol, heart disease, and
stroke. It is also linked to increased rates of osteoarthritis and a poorer
quality of life. Obesity is also associated with the increased risk of dying
from all causes. The insidious detrimental impact of obesity for
individuals cannot be overstated.
As an oncologist, I also recognize the impact that obesity has on
increasing cancer risk in our society. Obesity is a well-recognized risk
factor for the development of multiple cancers including uterine,
colorectal, breast, pancreatic, and others. The National Cancer
Institute’s SEER (Surveillance, Epidemiology, and End Results) database
estimates that approximately 4% of new cancer cases in men and 7% in
women are due to obesity. In fact, depending on the cancer type, the
rates may be much higher.
Much has been written about the economic causes of obesity and
some has been written about its cures. None perhaps offers as
comprehensive a treatment of these issues as the author provides in
this book. Dr. Tahereh Alavi Hojjat describes the serious nature of the
threat we face, not only to our health but also to our society. She
meticulously outlines why the obesity epidemic, at its core, is an
economic issue – one that is heavily shaped by poverty and income
inequality. It is significantly cheaper and easier to consume energy-
dense junk food than to prepare a home-cooked meal. Yet as we see,
this is not simply a result of poor individual choices. In the context of
poverty, it may be fait accompli.
As we see throughout the book, the obesity epidemic is a result of
our increased demand for energy-dense foods coupled with public
policies that encourage this behavior. We see how the principles of
supply and demand hold true in promoting the obesity epidemic,
especially for those living in poverty. As Chair and Professor of
Economics at DeSales University, Dr. Tahereh Alavi Hojjat is uniquely
qualified to explain how we can, and must, decrease the demand for
energy-rich foods. Decreasing the demand requires changes in the
micro-level decisions involving multiple stakeholders – individuals,
parents, healthcare providers, and nongovernmental organizations,
among others. Yet we have to put these stakeholders in a position to
succeed. In Chap. 10, we learn some specific ways government policies
can decrease the supply side of the equation – such as decreasing
subsidies for energy-dense foods and shifting the focus to healthier
options.
There continues to be increasing attention paid to the obesity
epidemic by the government and more specifically by CMS (the Centers
for Medicare and Medicaid Services). In 2009, as part of the American
Recovery and Reinvestment Act (ARRA), Congress passed the HITECH
(Health Information Technology for Economic and Clinical Health) Act –
supporting the concept of implementing electronic health records
(EHRs). Notably, part of the information in the first phase of
implementation was documenting body mass index as a discrete field.
As the old adage goes, you cannot manage what you cannot measure.
But once having measured it, the next steps are much less clear.
Nutritional counseling may check off a quality metric but without
affordable access to healthy food options, the low cost, energy-dense
foods will continue to be a fallback.
Since the publication of the first edition of this book, the COVID-19
pandemic has laid bare the consequences of income inequality, not only
in terms of access to care but also rather the underlying risks that
contribute to the morbidity and mortality from the infection. It is
unfortunately clear that structural inequalities dramatically worsened
during this pandemic but perhaps should not be surprising. In the last
10 months, it is clear that risk factors for higher infection rate and
greater fatality rate include black race, obesity, and socioeconomic
conditions. These are all inextricably tied to one another and the
solution ultimately will lie in addressing the root cause of these issues.
On a personal note, as an oncologist, this is an epidemic that we
must address urgently. The oncologic burden of obesity continues to
rise. If we can tackle the obesity epidemic, we can decrease not just the
widely recognized health complications but perhaps also reduce the
cancer burden on our society. Our microbiome is the sum total of the
bacteria that reside in our bodies, often commensurately. This is
profoundly impacted by our diet, and there is growing evidence that
diets high in animal protein, refined sugars, and processed foods can
lead to dysbiosis (an unhealthy imbalance between healthy and
unhealthy bacteria in the gut). Dysbiosis has been consistently liked to
obesity, heart disease, diabetes, and cancer, among others. As the
science of nutrition matures, I hope that we will be able to see past the
diet fads that surround us and be able to deliver a consistent message
of what constitutes a healthy diet to the public. In a worldwide study
published in The Lancet Oncology, Dr. Arnold and colleagues estimated
that 481,000 new cancer cases in adults in 2012 were attributable to
obesity [3]. As Benjamin Franklin famously wrote, an ounce of
prevention is worth a pound of cure. In the case of obesity, an ounce of
prevention is surely worth much more. We also need to do a better job
in training our next generations of physicians and providers on how to
provide treatment for obesity. Pediatricians are having to retrain
themselves to combat adult diseases previously not seen in pediatric
populations on an unprecedented scale. The training should be started
in medical school and continued through residency.
Dr. Hojjat lays out the challenge before us – the burden of the
obesity epidemic on the poor is both an economic challenge and an
ethical imperative. The current rates of obesity are not sustainable if we
are to remain a productive healthy society and control our healthcare
costs. We must do better. From a public policy perspective, this is the
Holy Grail: better health, lower cost. The author lays out specific
concrete steps our political and civic leaders must take to address the
policy issues that contribute to this cycle of poverty, income inequality,
and obesity. We can only hope our leaders have the strength to listen
and the wisdom to act.
References
1. Galbraith JK. The Affluent Society. Boston: Houghton Mifflin
Company; 1958.
2. Centers for Disease Control and Prevention. Prevalence of
overweight, obesity and extreme obesity among adults: United
States, trends 1960–62 through 2005–2006, [Internet]. Available
from https://www.cdc.gov/nchs/data/hestat/overweight/
overweight_adult.htm.
3. Arnold M, Pandeya N, Byrnes G, Renehan P, Stevens GA, Ezzati PM,
Ferlay J, Miranda JJ, Romieu I. Dikshit R, Forman D, Soerjomataram
I. Global burden of cancer attributable to high body-mass index in
2012: a population-based study. Lancet Oncol. 2015;16(1):36–46.
https://doi.org/10.1016/S1470-2045(14)71123-4
Usman Shah
Preface
When my father visited the United States from our homeland of Iran for
the first time, he was struck by many stark differences between the two
regions. One observation that surprised him was the vast presence of
obesity in a country that is deemed to be a leader in progress around
the world. How could a country so educated be so uninformed about
decisions related to their health? He also could not help but notice the
correlation between obesity, poverty, and race. My father was not
unique in making these observations—other relatives’ first visits
yielded similar remarks.
As an economist, my father’s observations sparked curiosity in me
as to how this health crisis affects our economy. Furthermore, when I
began developing a new course on global economic issues at DeSales
University, I delved into a range of books, articles, podcasts, and social
media to increase my understanding of poverty and income and wealth
inequality in the United States. The Wilkinson and Pickett work, The
Spirit Level: Why Greater Equality Makes Societies Stronger [1], helped
me to connect the dots between these issues. While simply using
“Evidence-Based Politics,” the authors examined the causes of the
differences in life expectancy and health inequalities in peoples at
different levels of the social hierarchy in modern societies. The focal
point was to understand why health gets worse at every step down the
social ladder, so that the poor are less healthy than those in the middle,
who in turn are also less healthy than those further up on the social
ladder. Looking at data, Wilkinson and Pickett [1] concluded that there
is a point at which countries reach a threshold of material living
standards, after which the benefits of further economic growth are less
substantial. When that happens, the “diseases of affluence” become the
“diseases of the poor” in affluent societies. Diseases like obesity, stroke,
and heart problems, which were more common among the better-off
members in each society, have reversed their social distribution to
become more common among the poor. In the book, The Forgotten
Americans: An Economic Agenda for a Divided Nation [2], leading
scholar of poverty and inequality Isabel Sawhill enacted a keen analysis
to learn who the forgotten Americans are. In her analysis, she offers a
proposal for a better society that is consistent with American values
such as the certainty of work, family, and education. I noticed that
privileged children have safety nets to break their falls if they stumble
and helping hands to lift them back up. In contrast, disadvantaged
children are simply out of luck without much support to move up.
There are many ways to view the obesity issue. From a dietary
perspective, the global increase in weight gain is attributable to a
number of factors including a shift in diet toward increased intake of
energy-dense foods that are high in fat and sugars but low in vitamins,
minerals, and other micronutrients. In addition, trends toward less
physical activity are occurring due to increased access to
transportation, increased urbanization, and improved technologies.
These factors are changing forms of living and work into those that
support a more sedentary lifestyle. Given these universal trends,
obesity ultimately becomes a problem for all peoples and ethnic groups,
affecting people at every income level.
The COVID-19 pandemic represents an unprecedented social and
economic disruption in the modern history of the world. There is no
doubt that the economic impacts of the COVID-19 pandemic will
continue to affect people’s health, incomes, education, jobs, and poverty
level into the future. COVID-19 has confronted Americans with two
crises – a public health crisis and an economic crisis. Moreover, these
crises have had more impactful distributional consequences than any
economic event in recent history, but the pandemic and its broader
economic and health consequences are disproportionately impacting
low-income families and Black Americans.
During this period so much attention was paid to design policies to
mitigate economic recession, while less attention has been paid to the
role of wealth and income in determining a household’s ability to buffer
the pandemic economic shocks. Job losses occurred disproportionally
within the low-skilled and low-income families and small businesses.
Furthermore, access to the Internet and remote learning became a new
norm and much more challenging among low-income families. The
under-connected households have been faced with an even larger set of
digital barriers to allow their children to attend school and for adults to
work from home.
I hope that this new norm provides a lesson to many governments
and policymakers around the world to pay more attention to the social
welfare and to compel reallocation of resources to improve the
productivity and safety net of the nations. Excessive focus on the short
term is a growing problem in the United States. It is time to pay more
attention to long-term success rather than short-term gains; doing so
can mean resolving many social issues including health, income, wealth
inequality, and poverty. A Blanchflower and Oswald [3] study warns
that Americans are gradually becoming less happy. Without any action,
those at the bottom of the US economic and social hierarchy could lose
hope about their own lives. As those at the bottom become unhappy
people who may not invest in their own long-term well-being, it could
be dangerous for the society as a whole.
The focus of this book is to uncover and better understand the
economic factors of obesity, concentrating on the groups of people most
predisposed to this health issue. We can say that poverty and the
environment, along with unequal distribution of income and wealth,
are unquestionably part of the equation. More data and research on
income distribution, social mobility, and on health and social problems
has been collected, with an updated snapshot of the relation between
poverty, income inequality, and obesity. Additionally, how poverty,
income inequality, and obesity relate to one another will be tested.
Evidence will reveal troubling long-term social consequences for our
society, to a greater degree than many other global concerns currently
in the spotlight. Yet, in countries like Japan and the Scandinavian
countries, substantial improvements in the quality of life for the vast
majority of the population have been seen. Signs of a hopeful, healthier
future are, therefore, possible.
We need to change the way people see their own societies in which
they live. We need to voice the way that people may support the
necessary policies and political changes. We are not the first to
advocate for a healthier society while living with increased healthcare
costs that grow at unsustainable rates. We certainly will not be the last
to encourage policymakers to provide a supportive environment for
parents and their children to make wise choices in their living and
eating behaviors. Obesity can be and must be confronted for the
betterment of the entire population.
References
1. Wilkinson RG, Pickett K. The spirit level: why greater equality
makes societies stronger. New York: Bloomsbury Press; 2009.
2. Sawhill I. The forgotten Americans: an economic agenda for a
divided nation. New Haven: Yale University Press; 2018.
3. Blanchflower DG, Oswald AJ. Unhappiness and pain in modern
America: a review essay, and further evidence, on Carol Graham’s
Happiness for All? [Internet]. J Econ Liter. 2019; 57(2):385–402.
Available from: https://doi.org/10.1257/jel.20171492.
Tahereh Alavi Hojjat
Center Valley, PA, USA
Acknowledgments
I would like to acknowledge the help of all the people involved in this
book and those who inspired me to write about this topic, more
specifically, to the reviewers that took part in the review process.
Without their support, this book would not have become a reality.
First, my sincere gratitude goes to Ms. Sieglind Gatewood for her
invaluable comments and copy editorial work regarding the
improvement of quality, coherence, and content presentation of the
chapters. I thank DeSales University for full support and
encouragement to complete this work. I am grateful to our librarians,
Michele Mrazik Grasso and Katie Quirin Manwiller, for their research
assistance in this process.
I appreciate the love and encouragement of my family members,
Mehdi, Varta, Rata, Kenneth, and Cy Auby.
I am responsible and accountable for the information included in
this work; all errors are my own.
