"There was a fat boy in our street. People called him fatso", observes the main character in Kieron Smith, Boy, a novel by James Kellman narrated from the point of view of a child from the time he is 4 to almost 13. Through his eyes, we see a picture of life in Glasgow in the 1960s – and get an idea of the changes taking place. At the time, obesity was unusual enough to draw attention. Yet now more than a third of Scottish 12- year-olds are overweight, a fifth are obese and over one in ten severely obese. The statistics for adults are even worse, with almost two-thirds of men and more than half of women overweight. The situation is better in the other OECD countries, apart from the United States, but obesity is a concern almost everywhere, in the OECD area and beyond.
Many deserve credit for the contents of this book, but two deserve it above all: Michele Cecchini and Marion Devaux, whose tireless efforts have given substance to the work presented herein. Michele’s work is behind the analyses of the impact of prevention strategies discussed in Chapter 6, while Marion’s is behind all of the statistical analyses presented in Chapters 2 and 3. Without them, this book would not have been written.
Obesity is a major health concern for OECD countries. Using a wide range of individual-level and population data from OECD countries, this book presents analyses of trends in obesity, explores the complex causal factors affecting the epidemic and develops an assessment of the impacts interventions to combat the problem. The book provides new information on what prevention strategies are most effective and cost-effective, discussing the respective roles of individuals, social groups, industry and government, and the implications of these findings for the development of policies to address one of the largest public health emergencies of our time.
Introduction: Obesity and the Economics of Prevention
Unprecedented improvements in population health have been recorded in OECD countries during the past century, thanks to economic growth and to public policies in education, sanitation, health, and welfare. Yet industrialisation and prosperity have been accompanied by increases in the incidence of a number of chronic diseases, for which obesity is a major risk factor. This chapter looks at the impact of obesity on health and longevity and the economic costs that obesity generates, now and for the future. It examines the role of prevention in mitigating these effects and presents a case for how an economic perspective on the prevention of chronic diseases linked to lifestyles and obesity can provide insight into better ways of addressing the obesity epidemic.
Promoting Health and Fighting Chronic Diseases: What Impact on the Economy?
From a welfare economic perspective, the most relevant cost concept is the value individuals attribute to health in general and chronic disease in particular, elicited for example by analysing how people act or how they answer certain questions related to real or hypothetical situations involving a trade-off between money and health. It turns out that the social welfare benefit of health is much higher than the other more conventional (but incomplete) measures, and far too high to be ignored in public policy decisions (Viscusi and Aldy, 2003; Usher, 1973; Nordhaus, 2003; Costa and Kahn, 2003; Crafts, 2008). This value also captures the intrinsic value of health, a feature not shared by the other concepts.
Obesity: Past and Projected Future Trends
Obesity has risen to epidemic proportions in OECD countries during the last 30 years. In this chapter, the development of the epidemic is discussed in the light of evidence from a range of OECD countries. After a comparative overview of current obesity rates in OECD and selected non-OECD countries, the recent obesity epidemic is set in the context of historical developments in height, weight and body mass index (BMI). Using BMI as the reference measure to identify individuals who are overweight or obese, a detailed analysis is presented of how rates have grown in OECD countries in the past 30 years, accounting for differences in the likelihood of obesity across birth cohorts. The final section of this chapter presents OECD projections of further growth of overweight and obesity rates in the next ten years in adults and children.
The Social Dimensions of Obesity
The social impacts of obesity are addressed in this chapter in terms of the concentration of obesity in certain population groups and of the consequences of obesity on labour market outcomes. The first part of the chapter provides evidence of disparities in obesity along demographic characteristics, such as age and gender, as well as social dimensions, such as education, socio-economic status and ethnicity. Differences in the likelihood of overweight and obesity among groups defined along those dimensions are presented and discussed, and comparisons across OECD countries are made in the size of social disparities in obesity. Evidence is also presented of social disparities by socio-economic status and ethnicity in children, based on data from four OECD countries. The second part of the chapter contains a comprehensive review of the existing evidence of disparities in labour market outcomes between the obese and people of normal weight. The final section presents ample evidence of a disadvantage suffered, particularly by obese women, in employment, earnings and productivity.
The Size and Risks of the International Epidemic of Child Obesity
In many developed economies child obesity levels doubled between the 1960s and the 1980s, and have doubled again since then (Lobstein et al., 2004). By 2005, one third of all US children were affected by excess body weight, and children in other developed economies have been following the US pattern. Even in emerging and less developed economies, child obesity prevalence levels are also rising (Wang and Lobstein, 2006), especially in urban areas where the need for physical activity is lower and the opportunities for sedentary behaviour and access to energy-dense foods and beverages far greater. As child obesity is strongly predictive of adult obesity and of chronic disease, the child obesity epidemic has been described as "a massive tsunami" (Ludwig, 2005), and "a health time-bomb" (Chief Medical Officer, 2003).
How Does Obesity Spread?
The obesity epidemic is the result of multiple, complex and interacting dynamics, which have progressively converged to produce lasting changes in people’s lifestyles. Remarkable changes in the supply, availability and prices of food in the second half of the 20th century, in line with major changes in food production technologies and marketing approaches, decreased physical activity at work, and changes in labour markets and conditions heavily influenced lifestyles and contributed to the obesity epidemic. This chapter explores some of the key determinants of health and their role in the obesity epidemic. The question is addressed of whether the changes that fuelled obesity and chronic diseases are simply the outcome of efficient market dynamics, or the effect of market and rationality failures preventing individuals from achieving more desirable outcomes. Social multiplier effects (the clustering and spread of overweight and obesity within households and social networks) are shown to be especially relevant to the formulation of effective policies to tackle obesity.
Are Health Behaviors Driven by Information?
Some people might choose unhealthy behaviors because they lack complete information about the health consequences of their choices. If so, the provision of information should be an effective approach, and might be a cost-effective approach, to encourage healthier behaviors and promote public health. Empirical health economics research on the role of health information provides several instructive lessons.
Tackling Obesity: The Roles of Governments and Markets
In most contemporary societies, we look to governments to protect and even increase public welfare. Whether through regulation, taxes, or education, or some combination of these, governments can play a significant part in affecting the choices we make and the outcomes that result from those choices. Governments in the OECD area have taken a broad range of actions in recent years to improve nutrition and physical activity, reacting to a growing concern about increasing obesity rates, particularly in vulnerable population groups. This chapter examines these actions and analyses the scope for, and potential consequences of, government intervention in the context of obesity prevention. It also looks at the response of the private sector to challenges related to food and physical activity in the current epidemic of obesity.
Community Interventions for the Prevention of Obesity
Community settings offer a unique set of opportunities to reach various individuals and groups at the local level (WHO, 2007) and are a necessary complement to the implementation of high-profile, macro-level policies. Members of a community share cultural or ethnic backgrounds and are exposed to the same environmental determinants. The rationale of acting at the local level is its capacity to facilitate cross-sector efforts (King and Gill, 2009). Within a community, there is a potential to mobilise human resources such that different dynamics and synergies translate into better possibilities to "partner, collaborate, expand and enrich" an intervention (Economos and Irish-Hauser, 2007). This is particularly important given that increased and effective engagement of stakeholders enhances the prospects of a successful implementation of interventions aimed at changing lifestyles (WHO, 2007; King and Gill, 2009).
The Impact of Interventions
Governments in OECD countries have intervened in a variety of ways to improve diets, increase physical activity and tackle obesity in recent years. The preventive interventions assessed in this analysis are drawn from the most commonly used approaches, including: health education and health promotion (mass media campaigns, school-based interventions, worksite interventions); regulation and fiscal measures (fiscal measures altering the prices of healthy and unhealthy foods, regulation of food advertising to children and mandatory nutrition labelling); and, counselling of individuals at risk in primary care. This chapter examines the characteristics, the costs and the relative success of each approach in improving health outcomes and social disparities in health, with a focus on five OECD countries: Canada, England, Italy, Japan and Mexico.
Perspectives on the Regulation of Food Advertising to Children
With the global increase of overweight and obesity, food marketing communications, particularly to children, have been in the public and political spotlight. Advertisers have been duty bound to review their marketing communications strategies to ensure that they are aligned with and promote – rather than undermine – healthy diets and balanced lifestyles.
Information, Incentives and Choice: A Viable Approach to Preventing Obesity
The basic biological causes and health effects of obesity have been common knowledge and a focus of public health concern since the mid-20th century. Still, little has been effective in slowing the upward trends of obesity in OECD populations. Adapting efficient solutions to this problem requires an understanding of the complex, interrelated factors that contribute to overweight and obesity, and the equally complex mix of tools that can remove or mitigate these causes. This chapter presents a discussion of critical factors in the design and implementation of effective prevention strategies, including considerations on how social norms form and evolve, as well as how individual approach and population approaches to chronic disease prevention can work together in the case of obesity. The chapter also discusses in further depth the meaning of a multi-stakeholder approach to prevention and the potential effects of government action on individual choice.
The Case for Self-Regulation in Food Advertising
Annex A. Supplementary Figures and Tables
Annex B. Author's and Contributors' Biographies
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