It's time to shut up about "the cost of obesity."

The state of the universe.
Feb. 14 2008 3:21 PM

Abolish the Fat Tax!

It's time to shut up about "the cost of obesity."

Read William Saletan's "Human Nature" column on obesity and genetics.

Illustration by Robert Neubecker. Click image to expand.

Barack Obama and Hillary Clinton may differ (slightly) on health-care policy reform, but at least they agree on how to pay for it. At a December debate in Iowa, Obama announced that "if we went back to the obesity rates that existed in 1980, that would save the Medicare system a trillion dollars." We might chalk this up as mere Obambast, another of the Senator's blowy promises. But Clinton mirrors the claim on her own Web site: "Medicare could save over a trillion dollars over 25 years if obesity among seniors could be returned to levels in the 1980s."

Daniel Engber Daniel Engber

Daniel Engber is a columnist for Slate

Some fact checking revealed that their numbers (apparently taken from this RAND Corporation study) were a bit off. According to Eric Finkelstein, a widely cited authority on the economic cost of obesity, they should have said the savings would be $200 billion. One of his own studies claims that Medicare and Medicaid lay out an additional $39 billion of taxpayer money every year for obesity-related diseases. This figure—which translates to $175 for each of us, enough to buy a très petit iPod Nano—has led lawmakers to view fat people as a cash cow. If we rein in those profligate heavyweights, the thinking goes, we'll save billions in taxpayer money. A Mississippi lawmaker cited the financial strain on the state's Medicaid program when he proposed a bill making it illegal for restaurants to serve obese customers. After Gov. Schwarzenegger's recent claim that obesity costs California $28.5 billion per year, politicians have tried to force restaurants to list calorie counts on their menus.

But a pair of new epidemiological studies reveals that these attempts to wring money out of the obese are misleading and misguided. Worse, the obesity cost estimates used to justify them are a danger to public health.

The first paper, published by a Dutch team in the journal PLoS Medicine, challenges the basic assumption that fat people are more expensive to treat. It's true that if you compare two people of the same age and wealth, one slim and the other obese, you can expect the fatter one to have more chronic diseases like diabetes and hypertension. The fatter patient will also make more visits to the doctor, buy more prescription drugs, and otherwise ring up higher medical bills in a given year.

But this analytical approach—used routinely by Finkelstein and other obesity number crunchers—ignores one important fact: Obese people have shorter life spans. Since the elderly are by far the costliest patients, it's possible that early deaths save taxpayers money in the long run. In fact, fatal diseases almost always return net-cost savings to public health care. Smoking, which causes a host of particularly deadly conditions, turns out to be especially cheap—which is to say, government attempts to curb nicotine addiction have actually cost the United States money. (Niggling mental disorders and musculoskeletal diseases tend to be more expensive.)

That's how the numbers played out in the Dutch study. If we somehow figured out a way to "cure" obesity—with a pill, an injection, or a law like the one they're proposing in Mississippi—we'd increase the burden on taxpayers. More people would make it to old age, hastening the Social Security crisis and pushing up the costs of Medicaid. Indeed, the analysis in PLoS Medicine revealed that lifetime health expenditures were highest for healthy-living people of optimum weight.

This finding has sent some anti-fat crusaders into retreat. Neville Rigby of the United Nations' International Obesity Taskforce has now admitted to the Associated Press that "the benefits of obesity prevention may not be seen immediately in terms of cost savings." He had a different take in 2004, when he wrote in USA Today that "obesity costs the U.S. $125 billion a year in health and other bills that it can ill-afford. … [T]he result is higher taxes and health bills and an economy that suffers."

But the health economists are undeterred. The PLoS paper looks only at the direct costs of obesity—i.e., the amount spent on specific medical treatments. That leaves out a huge volume of indirect costs to society—unemployment, missed days of work, and lowered on-the-job productivity. According to Finkelstein, these losses add up to more than $40 billion a year: One-third of that comes from absenteeism (people are too sick or lethargic to come to work) and the remainder from something called "presenteeism" (people at work are too fat to get anything done). Finkelstein's firm, RTI International, has even designed a downloadable Obesity Cost Calculator to help business owners figure out how much money they're losing to lard-butt staffers. (RTI also happens to serve a client list that includes some of the biggest names in the weight-loss industry.) Other economists have framed the issue in terms of trendy issues like global warming or the energy crisis. (Click here for more.)

Meanwhile, a plague of ridiculous productivity-cost estimates in other spheres diminishes the obesity sticker shock. If we believe that extra pounds result in $40 billion of lost business, what are we to make of the claim that negativity in the workplace costs a whopping $350 billion? Spam e-mails eat away another $20 billion, and even the NCAA college basketball tournament costs us $3.8 billion. With all these other numbers floating around, the cost of obesity loses all meaning.

But these estimates are more than meaningless—they actually make the problem worse. A second study, published in the American Journal of Public Health on Jan. 30, looked at the relationship between body image and health. The authors compared people of similar age, gender, education level, and rates of diabetes and hypertension, and examined how often they reported feeling under the weather over a 30-day period. It turned out that body image had a much bigger impact on their health than body size. In other words, two equally obese women would have very different health outcomes, depending on how they felt about their bodies. Likewise, two women with similar insecurities would have more similar health outcomes, even if one were fat and the other thin.

These results suggest that the stigma associated with being obese—feeling fat—is a major contributor to obesity-related disease and ill health. This would account for the strong association between body-mass index and depression (especially among women), and the high rates of morbidity and mortality that ensue. Sure enough, racial and cultural subgroups with more moderate attitudes toward obesity seem to experience more moderate health effects. Overweight and obese African-Americans, for example, are much less vulnerable to weight-related illness—even among women who are 5 feet 5 inches and 250 pounds.

Politicians love to throw around cost-of-obesity numbers as support for fat-prevention programs, overeating legislation, or, in the case of Sens. Obama and Clinton, massive health-care reform. These shocking statistics are also supposed to guilt-trip consumers into pursuing a healthier lifestyle. Putting on weight is as much a social decision as a personal one: When we overeat, we're killing both ourselves and the economy.

This chew-and-screw narrative feeds on itself. First, it inflates the numbers by ignoring the real effects of an aging population. Then it promotes bias by supplying phony evidence that heavy people are lazy, useless, and a drag on the nation. This in turn makes anyone who thinks he's a little chubby feel even fatter, which worsens his health and lowers his quality of life. As a result, he spends more money on medical bills and more days at home crying into a bowl of ice cream. And guess what? All of this only increases the cost of obesity!

We're all interested in the most efficient ways to extend life spans and improve our quality of life. But the rhetoric of wasted fat dollars does little for our health; the claim that obesity costs the government $1 trillion is absurd at best and self-fulfilling at worst. Instead, the presidential candidates should pledge support for a federal ban on weight-based discrimination. If we stop blaming fat people for our problems, they might start feeling better—and start saving us money.