Is Obesity a Public Policy Problem?

9 Min Read

Aug 01, 2004


Anthony Wellever


Key Points

    • In Kansas, the cost of obesity attributable medical expenditures totals $657 million per year, at least $143 million of which is paid by the Medicaid program.
    • Obesity is a public policy issue because its health costs are born by society at large and because weight bias affects the ability of obese people to participate equally in the political, social and economic life of their society.
    • Between 1999 and 2003, thirty state legislatures adopted 79 separate policy initiatives that target obesity and physical inactivity.
    • The greatest number of state bills had to do with improving school-based physical education. Sixteen bills instructed the state department of health or a newly created commission to study the topic of obesity and to make recommendations.


The Centers for Disease Control and Prevention (CDC) announced in February that obesity will overtake tobacco use as the leading cause of preventable death by 2005. Next year, obesity will be responsible for the deaths of an estimated 500,000 Americans. These deaths will come from a variety of diseases resulting from obesity, such as heart disease, diabetes and some forms of cancer.

The direct physiological causes of obesity are known and simple. People gain weight when they consume more calories in the form of food and drink than they expend in their physical activities. But an individual’s weight also is determined by a combination of genetic, metabolic, behavioral, environmental, cultural and socioeconomic influences.

Obesity is certainly a public health problem, but is it also a public policy problem that demands attention?

Bar chart: Increase in obesity among Kansas adults increasing.

Some argue that public health problems, by definition, are public policy problems because they affect the welfare of the entire population. Others claim that the aggregate of individual behavior that does not affect the health of others is not sufficient to raise a public health problem to the level of a public policy problem.

On the other hand, certain health issues such as sexually transmitted diseases and diseases caused or exacerbated by secondhand smoke may become public policy issues if policymakers perceive that the prevalence of the behaviors is a danger to the public. Because obesity is not a communicable disease and its direct impact on the health of others is limited, many policymakers claim that the “obesity epidemic” requires no public policy intervention.

Personal behavior rises to the level of public policy, some claim, when it negatively affects a group or class of individuals. Such may be the case in regard to obesity. Consider the social consequences of obesity in the following circumstances:

Obesity-related social costs

On average, annual health care expenditures of non-elderly obese peo­ple are more than one-third greater than people of normal weight. In Kansas, the cost of obesity-attributable medical expenditures totals $657 mil­lion per year, at least $143 million of which is paid by the Medicaid pro­gram. If current trends continue, one dollar out of every five spent on health care in the year 2020 will be spent on obesity-related conditions.

While many economic and non-economic costs of obesity are born by over­weight individuals, some of the economic costs of obesity related to health care are shifted to others. Just as healthier people subsidize the care of those who are less healthy and who consume more health care services, people who are not obese pay higher health insurance premiums to subsidize care provided to obese members in their health plan and those without health insurance. Medicaid expenditures, financed by tax revenues, are greater than they would be if the obesity rate of beneficiaries was lower. Obesity lowers profitability of businesses and may lower productivity, employee pay raises and benefit expansions.

Bias and discrimination

Clear evidence exists of pervasive bias against overweight people across key sectors including employment, education, health care and housing. The power of negative attitudes (bias), in some cases, may produce unreasonable actions (discrimination) against overweight people.

No federal laws exist currently to protect obese individuals from discrim­ination. Michigan is alone among states in prohibiting employment dis­crimination on the basis of weight. A handful of cities have adopted ordi­nances that include weight in their def­initions of unlawful discrimination.

Overweight and obesity are associated with lower incomes and lower levels of educational attainment, but association is not the same as causation. How much of the association results from overweight people being unfairly denied opportunities at school, at work and in the medical system? To what extent is overweight a cause of lower income and lower education? Certainly, other explanations exist for the relationship between obesity and income and education, but we may be mistak­en to think that the explanations flow in one direction only.

Racial and ethnic disparities

African Americans and people of Hispanic origin living in the U.S. have a higher prevalence of overweight and obesity than White Americans. One possible explanation is that low-income minorities are subject to envi­ronments in which low-cost, energy-dense foods composed of refined grains, added sugars and certain fats are more readily available than more nutritious foods. Unequal access to health education and treatment ser­vices may exacerbate obesity and its accompanying health conditions in some minority groups.

Certainly, not all members of a par­ticular minority group are overweight. Because obesity has a tendency to aggregate in families, however, there may be a genetic component to obesity susceptibility. Recent research concludes that genetics play a “large part” in susceptibility to obesity. This stream of research suggests that a number of genes, each with a small effect, contribute to an individual’s susceptibility to obesity. Obesity, like many other health conditions, is caused by the interaction of genetics and environmental conditions.

Some argue that indigenous people in premodern societies developed a biological adaptation that allowed them to cope with alternating periods of feast and famine. The so-called “thrifty genome model” allowed them to store fat when food was plentiful as a hedge against starvation in times of famine. The genes, which were once important to survival, now no longer serve a function. In fact, they have become harmful, because fat, originally stored for famine situations, is not used up. Additionally, many have traded a more active lifestyle for one that is more sedentary.

Ultimately body weight is determined by individual behavior, but the same behaviors can affect individuals differently. Many minorities may be disadvantaged by their genetic predisposition, poverty and the environments in which they live.

The role of public schools

One approach for reversing the epidemic of obesity is to concentrate on obesity prevention in children. Learning healthy behaviors at a young age will accrue benefits throughout the life-course of an individual.

As quasi-governmental organiza­tions, public schools have a duty to protect the health and safety of the children in their charge. As learning institutions, schools should attempt to remove barriers to performance within their control that allow children to optimize their potential. Offering instruction in good health habits (balanced nutrition and physical fit­ness) and reinforcing the lesson by providing an environment that supports healthy eating and physi­cal activity fulfills both duties.

Legislative efforts

Because obesity is influenced by multiple factors, policy solutions to reduce its prevalence are not immediately evident. To find out what policymakers in other states are doing about obesity prevention and treatment, policies recently passed by state legislatures were examined.

Between 1999 and 2003, thirty state legislatures adopted policies that target obesity or attempt to increase physical activity. Seventy-nine separate policy initiatives passed by state legislatures were identified during the period. In 2001, Surgeon General David Satcher issued a report, Call to Action to Prevent and Decrease Overweight and Obesity, calling for increased recognition of obesity as a major public health prob­lem. Since that time, the number of obesity-related laws has increased substantially. Sixty-three percent of the bills passed during the five-year period related to obesity were passed in 2002 and 2003.

Pie Chart: Obesity-related bills passed in State Legislatures (1999-2003), 79 bills were passed in 30 states during the period.

The greatest proportion of bills (28 percent) had to do with improving school-based physical education. Approximately 20 percent instructed the state depart­ment of health or a newly created commission to study obesity and make recommendations to the legislature. The third most frequent state action (17 percent) was a resolution encouraging citizens to lose weight and become more active, urging state agencies to undertake obesity-related programming, or proclaiming an obesity prevention-related day, week or month. Fewer bills targeted general physical activity and school food programs. Insurance regulations, generally mandating that surgical procedures endorsed by the National Institutes of Medicine for the treatment of morbid obesity be offered, were passed in three states.

Obesity is a clear threat to the public’s health. Some environments, such as schools, may unwittingly promote the consumption of empty calories by their competitive food policies. In inner cities and isolated rural areas, food stores that sell fresh fruits and vegetables may not be accessible. In suburbs and rural areas, there may be no sidewalks, walking trails or bike paths that encourage physical activity. The environment and some of the other factors that influence obesity may be altered positively by public policies that target the population as a whole rather than individuals. Legislatures in thirty states have recognized the importance of this issue and have begun to take action.

Quote: On average, annual health care expenditures of non-elderly obese people are more than one-third greater than people of normal weight.

State legislation is not the only avenue of public policy open to those who want to reduce the prevalence of obesity in Kansas. State government administrators, communities, school boards and employers around the nation have also focused their attention on population-based initiatives to limit and control the obesity epidemic. The actions they have taken to date do not represent the full spectrum of possibilities. But they are a start.

Research for this project was funded by the Sunflower Foundation: Health Care for Kansans.

About Kansas Health Institute

The Kansas Health Institute supports effective policymaking through nonpartisan research, education and engagement. KHI believes evidence-based information, objective analysis and civil dialogue enable policy leaders to be champions for a healthier Kansas. Established in 1995 with a multiyear grant from the Kansas Health Foundation, KHI is a nonprofit, nonpartisan educational organization based in Topeka.

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