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Women's Health in Context
Weighty Matters: Public Health Aspects of the Obesity
Epidemic Part II -- Economic Consequences of Obesity, the
"Obesity Economy," and the Roles of Nutrition, Exercise, and
Television
Martin Donohoe, MD, FACP
Medscape Ob/Gyn & Women's Health. 2008; ©2008 Medscape
Posted 01/04/2008
Introduction
This column, the second in a 5-part series focusing on the obesity epidemic, describes the
economic consequences of obesity, the "obesity economy," and the roles played by nutrition,
exercise, and television.
Economic Consequences of Obesity
In 2003, obesity-attributable national medical expenditures were $75 billion and ranged from $87
million in Wyoming to $7.7 billion in California.[1,2] Half of the healthcare costs associated with
obesity are currently covered by Medicare, which now classifies obesity as a disease. [1] Much of
the increased costs of healthcare associated with the obese are due to prescription drugs, but
complications from surgery are more common and hospital lengths of stay are longer for obese
than for normal-weight individuals.[3,4]
The Obesity Economy
Today there is a growing "obesity economy."[5] The plus-size apparel market is worth $17 billion
and accounts for 20% of women's clothing sales, up from 11% in 2001. Half of all US women
wear size 14 or larger clothing, whereas in 1985 the average size was 8.[5] Companies have
sprung up to cater to the morbidly obese, producing XXXL size, oversized autos, furniture,
coffins, and specialized medical equipment such as lifts, special chairs, and toilets.
Nutrition, fast food, supersizing, sweeteners, and soda. Major changes in the human diet
have contributed to the rise in overweight and obesity. These include the beginning of agriculture
more than 10,000 years ago and, more recently, changes in portion size, the spread of fast food
franchises since the mid-20th century, the use of artificial sweeteners and trans-fatty acids in
processed foods, and current high levels of consumption of sugar- and caffeine-containing sodas.
The contributions of agriculture to nutrition and society. The advent of agriculture,
considered a watershed in human societal evolution, brought the benefits of community and local
food production but also led to a class-based society with rulers, farmers, artisans, merchants,
and soldiers, each with distinct duties and positions in the group hierarchy. It may have hastened,
or even brought about, the advent of organized warfare. It also led to dramatic changes in diet
and exercise.
Our ancestors expended enormous calories in hunting and gathering. They ingested up to 7000
of the 75,000 different edible plant species on a predominantly vegetarian diet. The wild game
they ate, when it was available, was high in protein but very low in fat, unlike today's grain-fed
(and antibiotic- and hormone-treated) supermarket meat.[6] Today, humans eat a markedly
decreased variety of foodstuffs, and most of the planet relies on just a few crops (wheat, corn,
rice) for a large proportion of its calories.[7]
Fast foods and supersizing. In recent decades, portion sizes have grown, as has the size of
restaurant dinner plates.[8,9] Americans now spend about one half of their food budgets and
consume about one third of their calories outside the home.[10]
Fast food spending has increased 18-fold since 1970.[11] The US food industry produces 3800
calories per person per day, although average caloric need is only 2500 calories per person per
day. Fast foods (super-sized, protein-poor, carbohydrate- and fat-rich meals) now comprise 10%
of total caloric intake.[12] On any given day, 8% of Americans eat at McDonalds.[13] A typical
American eats 30 pounds of French fries per year.[14]
Serving size and the caloric content of typical packaged and fast foods have ballooned over the
last 50 years, as the following examples illustrate[15]:

In 1954, a Burger King hamburger weighed 2.8 oz. and contained 202 calories. The same regular
burger today weighs 4.3 oz. and contains 310 calories.

A serving of McDonalds fries was 2.4 oz. and contained 210 calories when the restaurant chain
began in 1955. Today, one serving is 7 oz. and contains 610 calories.

In 1916, the typical size of a bottle of Coca-Cola was 6.5 fluid oz. and contained 79 calories. Today
the typical bottle contains 16 fluid oz. and 194 calories.

Some mega-sized fast food burgers on the market today contain well over 1000 calories.
Fast food outlets tend to target poor inner city communities. Meals can be obtained inexpensively
and conveniently, which helps consumers working 2 jobs, raising children solo, or lacking
inadequate kitchen facilities. The fast food industry directly targets children, producing 20% of
Saturday morning television and offering, often in collusion with the motion picture industry, prizes
and inducements based on characters that appeal to youngsters.
Fast food restaurants tend to be clustered around schools.[16] Furthermore, some US hospitals
have regional and national fast food franchises located on the grounds of their main medical
centers, thus sending the wrong message to patients and their families about optimal nutrition. [17]
The consumption of fast and junk foods begins early in life. Each day, 3% and 10%, respectively,
of US infants and toddlers eat candy; 4% and 23%, respectively, consume sweetened soda
beverages.[18] Soft drinks, which account for 20% to 24% of calories for 2- to 19-year-olds, are
associated with tooth decay and decreased consumption of healthier alternatives, such as fruits
and vegetables.[19]
Americans of all ages are drinking more soda, and a majority of adults drink soda daily. Per
capita soda consumption has more than doubled since 1970, from 24 gallons per year to 53
gallons per year.[10] One well-known convenience store chain offers sizes such as "Big Gulp" and
"Super Big Gulp."[4]
Seventy percent of soft drinks consumed in the United States contain caffeine as an added
ingredient. Evidence suggests that the mood-altering and physical dependence-producing effects
of caffeine (a central nervous system stimulant) have contributed to high rates of consumption of
caffeinated soft drinks.[20] Soda's addictive properties put imbibers at risk of caffeine-withdrawal
symptoms such as headache.
The National School Lunch Program. The National School Lunch Program gives schools more
than $6 billion per year to offer low-cost meals to more than 27 million schoolchildren at 99,000
schools and childcare centers.[21] Begun in 1946, the program, administered by the US
Department of Agriculture, has the conflicting missions of providing healthy meals to children,
regardless of income, and subsidizing agribusiness, shoring up demand for beef and milk. [11] As
such, meals emphasize meat and dairy products at the expense of fruit and vegetables, contain
high levels of fat, and fail to meet the government's own inadequate nutritional standards, which
are out of date with current science and have not been updated since the 1970s.[1,21]
Eighty-one percent of schools serve lunches exceeding 30% fat content, less than 45% serve
cooked vegetables other than potatoes (usually French-fried), and less than 10% serve
legumes.[21] Overemphasis on milk products may increase long-term risk for breast cancer,
particularly if the milk comes from cattle treated with recombinant bovine growth hormone (also
know as recombinant bovine somatotropin).[22,23]
Such daily fare does not help to establish good nutritional habits in America's youth.
Unfortunately, dramatic changes in the National School Lunch Program are unlikely to occur
given the large amounts of political clout wielded (and campaign dollars donated) by the beef and
dairy industries, which have former lobbyists in key positions in the Department of Agriculture.[1,21]
Exercise and Television
The Institute of Medicine has urged Americans to exercise 1 hour per day, double the 1996
recommendation by the Surgeon General.[24] However, 70% of American adults are not active in
their leisure time; 40% are not active at all.[25] One third of children do not participate in the
minimum recommended level of moderate or vigorous physical activity, and the number taking
part in physical education courses has dropped significantly, in part due to school funding cuts.[1]
Neighborhoods with high levels of minorities and individuals of low socioeconomic status have a
paucity of facilities that enable and promote physical activity, such as parks and gymnasia. [26]
Perception of one's neighborhood as less safe is also associated with an increased risk of
overweight in children, likely due to fear of exercising outdoors. [27] Lack of exercise has effects
beyond obesity, as participating in daily physical education is associated with better school
attendance, more positive attitudes about school, and better academic performance. [1]
Instead of exercising, many youth spend their time watching television and using other electronic
media such as the Internet and video games. The average youth spends 67% more time
watching TV per year than he/she spends in the classroom.[28] Thirty-two percent of children aged
2-7 years have televisions in their rooms, as do 65% of children aged 8-18 years, which
diminishes parental control over viewing time and content.[29]
Increases in television viewing are associated with increased calorie intake among youth,
especially of calorie-dense low-nutrient foods of the type promoted on TV.[30] Businesses spend
an estimated $13 billion annually marketing food and drinks in the United States, much of it on
television advertising[31] American children are exposed to approximately 40,000 food
advertisements per year, 72% of which promote candy, cereal, and fast food.[32] Convenience/fast
foods and sweets comprise over 80% of foods advertised during children's programming.[33]
African-American-oriented television airs far more junk food ads targeted at kids than generaloriented networks.[34]
Neither the Federal Trade Commission nor the Federal Communications Commission has the
authority to limit such advertising, despite the fact that children are vulnerable to exploitive
advertising messages and unable to discern truth from fiction in ads. [35] The American Academy of
Pediatrics, which argues that children are cognitively and psychologically defenseless against
advertising, has called for severe restrictions on advertisements for junk food aimed at children. [36]
Intriguingly, overweight and obese characters on television represent less than half of their
percentages in the general population.[37] Such characters are less likely to be considered
attractive, to interact with romantic partners, or to display physical affection, no doubt
perpetuating stereotypes and contributing to the poor self-image many overweight individuals
face.[37] In the real world, the overweight and obese, especially women, suffer from various forms
of stigmatization. For instance, overweight and obese women get fewer promotions and face
more job discrimination, whereas heavyset men do not.[21]
Conclusion
Poor nutrition, lack of exercise, and excessive television viewing have all been associated with
obesity.
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Martin Donohoe, MD, FACP, Adjunct Lecturer, Community Health, Portland State University,
Portland, Oregon; Staff Physician, Department of Internal Medicine, Kaiser Sunnyside Medical
Center, Portland, Oregon
Martin Donohoe, MD, FACP, has disclosed no relevant financial relationships.