Some Research on Tackling Obesity Pays People to Lose Weight. What Does It Get Wrong?
A study published this month showed that financial incentives to lose weight worked in tackling obesity among low-income populations. Another study, published in 2020, also looked at obesity and financial incentives among men. This followed yet another one in 2017 that looked at health insurers paying people to lose weight — and just like that, the list of publications go way back in time. It’s not just financial; a lot of research has been dedicated to looking at the most effective intervention strategies to make people feel incentivized to lose weight. Some draw on behavioral economics to find out the best ways to tackle the “obesity epidemic.” There’s a lot of lively debate on the subject, with one paper concluding: “With creative design, targeted use and evaluation, financial incentives for weight loss and healthy [behavior] may be a useful addition to the health policy toolkit.”
What they all have in common, however, are two significant limitations: they equate obesity with weight, and they look at the effects of financial incentives for individuals. In general, financial incentives are powerful motivators to do anything — but it doesn’t work as a health intervention. Any kind of incentive for weight loss isn’t just unhelpful from a structural point of view, it’s dehumanizing. Moreover, it stigmatizes obesity further as a condition characterized by greed, gluttony, and excess.
Take a look at the systemic reasons for obesity. According to the WHO, obesity is linked with inequality and poverty — with a report finding that obesity rates are higher in countries with higher inequality rates. Food insecurity is one of the main drivers: fast food industries in the global north often incentivize high-sugar processed foods in the global south, where they’re often more affordable than nutritious food. This is a problem that’s only worsening.
Moreover, obesity is more prevalent in marginalized communities, where environmental and systemic factors lead to high energy intake due to cost-effectiveness, and high stress. Obesity is an economic issue. Giving individuals money, however, doesn’t address their perpetual lack of access to nutritional food, healthier environments, and the stressors of systemic oppression. And weight loss through exercise, moreover, doesn’t negate the effects of unhealthy food. Obesity, then, is a symptom of surviving in a world marked by deprivation and neglect — it isn’t the disease.
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Further, epigenetics plays a role in determining somebody’s weight. Some populations are more prone to obesity by virtue of what their ancestors experienced: for a group with a history of surviving famines, a body adapted to food scarcity is more prone to obesity when living with food abundance.
Obesity is a systemic failure where individuals are demonized and caricatured — in popular culture, it’s come to symbolize a personal, moral failure. Contrary to popular wisdom, obesity isn’t a disease of the affluent. What financial incentives may get right, indirectly, is that it addresses the scarcity and lack of resources for healthcare at the heart of obesity. But as a public health measure, it works on the incorrect assumption that obesity is a function of physical weight. Moreover, paying people to lose weight still doesn’t address how the politics around obesity ensure that fat people — who are already vulnerable — are excluded from access to housing, employment, and healthcare, at higher rates, simply by virtue of their appearance being equated with bad health, poor motivation, and a moral failure.
“The deadliness of anti-fatness is in the fact that it’s predicated on desirability,” wrote Da’Shaun Harrison, in Belly of the Beast. And this shows what the problem has been, all along: weight being so intertwined with beauty means that it’s seen as grotesque when it’s in excess — and therefore unhealthy. It’s framed as a personal responsibility and, therefore, a moral one. The medical community is complicit in shifting the blame for fatness onto people who are fat — and for treating fatness itself as a disease in the first place.
“For decades, the medical community has ignored mountains of evidence to wage a cruel and futile war on fat people, poisoning public perception and ruining millions of lives,” wrote Michael Hobbes for The HuffPost. “There’s a lot we can do right now to improve fat people’s lives — to shift our focus for the first time from weight to health and from shame to support.”
Many healthcare practitioners have begun to advocate for changing the definition of obesity: rather than measuring it in terms of body mass index (BMI), medical professionals argue that internal biomarkers of health should define it instead. This is what recent Canadian guidelines say as well: “The dominant cultural narrative regarding obesity fuels assumptions about personal irresponsibility and lack of willpower and casts blame and shame upon people living with obesity,” adding that the definition for obesity should instead shift to “a prevalent, complex, progressive, and relapsing chronic disease, characterized by abnormal or excessive body fat that impairs health.”
This means that a person who may look thin on the outside but has high cholesterol, blood glucose, or other lipid markers is more accurately considered obese, rather than a person with healthy markers but a larger body. In other words, studies on financially incentivizing weight loss don’t get to the heart of the health concern they claim to solve — they focus on the construct of good health that criminalizes certain body types alone.
Wonderful piece! Paying people to lose weight doesn’t deal with the real problems. Not having incentive is never the problem. We could start by not demonizing fat people. People come in all shapes and sizes.