Overweight but won’t exercise. Who should pay?

A new study says that the overweight live longer. Economists say that may be true, but the overweight have higher health costs.


A higher body mass index — a standard measure for determining whether people are overweight or obese — is associated with a number of chronic illnesses, including diabetes, heart disease and hypertension. These chronic illnesses are expensive to treat. If, as it now turns out, overweight people are living longer in addition to racking up more chronic illnesses, that means Medicare is on the hook for paying for more expensive people for more years….

In other words, your spare tire might help you live longer, but it is also accelerating the country’s debt problems.

[Prof. Goldman] gave as an example a doctor he knows who has an obese patient taking expensive drugs for various health problems related to being overweight. The doctor told Professor Goldman: “The best thing I could do for this patient would be to take him for a walk. But I don’t get paid for that.”

Across the pond, Savitri Hensman writing at Ekklesia, points to a proposal in the UK to cut benefits for people who don’t exercise:

As the NHS Choices website explains, GPs can help people to lose weight in various ways, including “exercise on prescription” and other physical activity opportunities. In addition “Many GP surgeries across the country prescribe exercise as a treatment for a range of conditions, including depression”. People with a family history of heart disease, at risk of osteoporosis, with diabetes, high blood pressure, arthritis or who have had a stroke are among those who can benefit.

A Dose of Localism recommends punishing those on such schemes who do not turn up to exercise sessions: “Relocalisation of council tax benefit and housing benefit combined with new technologies provide an opportunity for councils to embed financial incentives for behaviours that promote public health. The increasing use of smart cards for access to leisure facilities, for instance, provides councils with a significant amount of data on usage patterns. Where an exercise package is prescribed to a resident, housing and council tax benefit payments could be varied to reward or incentivise residents.”

Is it wrong to require those on Medicare to pay for their healthcare if there is a cheaper and superior alternative, i.e. exercise? If we can ban supersized sodas or kids meals with toys (as some cities do) why not mandate exercise by taxing your Medicare benefits if exercise is prescribed and you don’t do it?

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Category : The Lead

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  1. Paige Baker

    I am seriously disappointed in The Lead for posting this. There are serious reasons to dispute the accuracy of BMI for evaluating health, or much of anything, really. There is also a large amount of data disputing the connection between being overweight and being in poor health—in fact, data from the National Institutes of Health show exactly the opposite! Being overweight is correlated with living longer and “the popular belief that fatness is associated with heart disease among these patients has not been shown in any study.” (See link to Obesity Paradox #1 below for the source of the quote.)

    Articles such as these fail to take into account that:

    1. There is a wide range of “normal” weights in any given population.

    2. People are overweight for many different reasons—not all of them because they overeat or “refuse to exercise.”

    3. The biggest health concern many fat people face is the judgment of healthcare professionals. I personally know of cases where a patient was told that her problems were weight-related and she would get better if she just lost some pounds—when, in fact, she had cancer.

    Study after study shows the difficulty of losing weight permanently—and there is a mountain of evidence that “No one has ever gotten healthier, in any way, by being constantly treated like garbage” (to borrow from feminist blogger Melissa McEwan). Shaming people for being fat and engaging in punitive measures against them isn’t going to address the issue of normal variation in size across populations or solve the problems of food insecurity, nutritional deserts, potentially harmful additives or chemicals like high fructose corn syrup and BPA that are linked to weight gain, and other things that underlie the increases in obesity.

    We need to stop with the junk science from entities that stand to make serious money from our fixation on weight—and which completely misrepresents the essentially nonexistent link between obesity and poor health.

    If you don’t believe me that the links are not there, you’ll have to take it up with researchers from preeminent institutions like Case Western Reserve University, Cedars Sinai Medical Center, UCLA Medical Center, and those from the renowned Framingham Study:

    Obesity Paradox #1

    Obesity Paradox #2

    Obesity Paradox #3

    Obesity Paradox #4

  2. Ann Fontaine

    There are many proven conditions that are self caused and we do not question caring for them or suggest raising their rates. I think this is another bigoted piece about people whose weight does not meet the fashion magazine standard.

  3. tgflux


    Should we replace a “Shaming Obesity” problem w/ a “Shaming Those Want to Discuss Obesity” problem?

    IMHO, I think we need a conversation.

    JC Fisher

  4. Ann Fontaine

    Who gets to define “problem” — and why do we need to discuss other peoples’ weight? It is not shaming to point out that most of the “obesity is bad” literature is proving to be wrong. Sort of like another “condition” that we are only now understanding. Those who have that “condition” do not like to be “talked about”.

  5. Gary Paul Gilbert

    Public health policy should be about education rather than stigmatizing people. There is a whole food industry which does its best to encourage people to eat more and more often. Exercise is only one variable. If food cost more, most people would consume less, but then agribusiness would make less money. Can’t have that, can we?

    If cities were designed more for public transit and strolling, it would be easier to burn calories. But the automotive industry would be very unhappy.

    Food, health, and exercise should be about pleasure rather than prescriptions. It should be fun to exercise.

    Gary Paul Gilbert

  6. Gary Paul Gilbert

    Another issue is social position. Those with more education and money are able to eat better food and live in nicer places where it is easy to exercise. Better to judge those less fortunate than to look at the many variables which contribute to health problems.

    The poor need help and not more stigmatization. In inner-city neighborhoods it is harder to buy fresh fruits and vegetables but relatively easy to get fast food and snack foods.

    Gary Paul Gilbert

  7. Paige Baker

    JCF–did you read any of the links I provided? The point is that obesity is not the “problem” that it has been painted to be. We hear over and over and over that fat people are unhealthy, per se, and that they are a drain on the healthcare system.

    The evidence does not support those claims.

    Rather than shaming fat people and discussing punitive measures against them, THAT’s the thing we need to be having a conversation about. We have been convinced that the world is flat. Why is that? And who has benefited from convincing us to completely ignore all the scientific evidence to the contrary?

    I’ll be happy to have a conversation about the fact that our obsession with weight has nothing to do with health. It may have to do with aesthetics, or a multi-billion dollar diet industry, or with our Puritan desire to declare other people as “less than” and to control them through shame and social policy–but not with health.

  8. What about other risky behaviors?


    Drinking to excess

    Diabetics eating too many sugary foods

    Motorcycle riders

    Owners of guns

    I could go on. How will the behaviors be monitored? Another large bureaucracy to monitor risky behavior?

    Gary’s right. Education, not stygmatization is the answer. As has been mentioned, poor people all too often have fewer choices about food and exercise than those who are better off. And better public transit would get more of us out of our cars.

    Does anyone think that seriously obese people who find it difficult to get around and difficult to lose weight are happy with their condition?

    June Butler

  9. Gary Paul Gilbert

    Marion Nestle, Professor of Nutrition at NYU, on her blog Food Politics, says that in the real world being overweight increases the incidence of disease in some individuals. It is definitely a factor. In health as in nutrition one has to know many different factors.


    Her general advice remains to eat less and move more. She is critical of both the food and diet industries.

    We have a food industry which persuades Americans that it is a good idea to snack throughout the day and a diet industry which further helps to make people obsess about food. I was once pleasantly surprised to find a nutrition web sponsored by the French government which stressed “le plaisir de la table” ‘the pleasure of the table.’ In Europe people spend more time at table having conversations. There are many variables to health.

    Gary Paul Gilbert

    Gary Paul Gilbert

  10. tgflux

    JCF–did you read any of the links I provided? The point is that obesity is not the “problem” that it has been painted to be.

    If you would kindly re-read my post, I never said obesity was a problem, Paige. [FWIW, as someone who does muscle-building exercise, I have never trusted the BMI. Muscle weighs more than fat!]

    …but I do think we need a conversation about health, and how what (quality/quantity) we eat/how we don’t exercise (enough, inc myself) contributes to ill health.

    JC Fisher

  11. Savi Hensman

    As those who have read the articles cited – or my follow-up piece on http://www.ekklesia.co.uk/node/17751 – will have gathered, though I am in favour of promoting exercise, I am certainly not arguing for the proposal.

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