Yes, obesity is correlated with higher rates of cardiovascular disease, diabetes, and other ailments—but that doesn’t mean that everyone who’s fat is going to get sick. A 2008 study from the Archives of Internal Medicine found that a full one-third of all obese patients were “metabolically healthy” in terms of their blood pressure, cholesterol levels, and other measures. Meanwhile, one-fourth of the patients whose BMI was in the normal range showed abnormal metabolic signs. So a policy that varies its premiums as a function of body size is guaranteed to punish a bunch of people who are perfectly healthy and reward a bunch of people who are at risk.

The fundamental facts behind your statistics (e.g higher infant mortaility”) are that countries measure infant mortality differently. Life span, more a function of genetics and lifestyle than medical care. The US performs much better than you suggest. You need to do a little research so you can compare things properly.

I never said free market was the “balm”, though that is a highly ambiguous term. I happen to think health care insurance should be prohibited, or at least not be tax-deductible to employers, and everyone carry their own costs. That would be the most fair. Pay for what you use. I don’t want you, the government, or anyone else, telling me what I spend my income on. We, as a nation, spend a lot on health care because we chose to. Health insurance (though insurance is surely a misnomer) has just proven itself to be another corrupting influence, which is now getting in bed with the government in order to assure itself of one last period of profitability.

And yes, I think financial incentives, being immediate, are much more effective than health incentives. Too many health incentives (or disincentives) are delayed and diffuse. If people knew the immediate health impact of smoking, versus waiting for 30 years, no one would start.

I think we need to disabuse ourselves of the notion that spreading costs across the entire population will ever change costs. It might change your price, but not the cost. And it puts society’s nose under the tent even further; once the state thinks it pays for something, it thinks it has the right to dictate everything around it. Even when it pays for it with your own money.

Government reform threatens to destroy a very good medical care system and infrastructure and people’s freedom to contract for their own care, in order to socialize the cost. If it comes to pass, I think we’ll learn to regret that path.

Ingesting too much water can severeley stretch the small intestine just like too much beer, diet soda, orange juice or milk, noting that high calorie or high fat fluids just means more nutrients will be up taken by the bloodstream. Also, solid foods, particularly high glycemic index foods like breads, in a stretched intestine containing a lot of fluid will much more completely be converted into simple sugars that subsequently transferred more efficiently, too.

It is also possible many persons are born with small intestines that are large in relation to their intact (pre-obese) height and frame size. Just like some normal size people have large noses, feet, etc., why shouldn’t some people have abnormally small intestine size? A big sized small intestine could result in undesirably efficient transfer of nutrients due to greater intestine surface area, greater residence time of digesting foods, and better mixing of the contents.

It would be interesting to have nutritional researchers and biological engineers study if the following hypothesis are correct:
1. Excessive liquid intake positively correlates to obesity
2. Excessive high calorie containing liquid intake coorelates very strongly to obesity.
3. Small intestine dimensions ( lengths, diameters, and even more interestingly surface areas ) vary widely in pre-obese persons with the consequence that later in life those persons with larger surface areas are much more likely to become obese.
4. Excessive intake of high calorie fluids in persons with larger-than-average small intestine size in relation to pre-obese body size, where the same persons perform minimal abdominal exercise ( allowing greater intestinal stretching ), are highly certain to become obese.

Our goals should be to make health care choices more informed, more transparent, more competitive. Not less.

But what’s the alternative? As an AAAS member and general science geek I read the peer-reviewed literature regularly and, contrary to public perceptions, dietary and lifestyle choices have only a marginal effect on the risk of many specific diseases. Type II diabetes has a clear relationship to diet and exercise, but no one has been able to show conclusively that breast and prostate cancer do – small studies which suggested they might could not be replicated. Current evidence is that colon cancer risk can only be modified by about 30% with common lifestyle changes – earlier suggestions that dietary fiber might reduce colon cancer risk have not been borne out by later studies. Half of all heart disease happens to people with no specific serological risk factors. About 70% of hypertension is ideopathic. No one has shown any clear relationship between Alzheimers and diet or exercise although several current studies might alter that.

Bottom line: despite the pronouncements of some popular “health gurus”, diseases like Type II diabetes or emphysemia are the exception rather than the rule. Get on to NIH/PubMed and do some literature surveys (i.e., look at a few hundred research papers for any given disease and not just 1 or 2), and you’ll see that for most major disease the best science suggests that you can modulate risk by somewhere between 0 and a few 10’s of percent. So how would you apply that to insurance or health-care costs?

Part of the problem is that the general public has an abysmal grasp of science, and the press likes to grab dramatic stories. So if someone does a little study with 50 subjects that seems to show that a diet high in selenium reduces prostate cancer risk by 70% it makes the headlines. When larger studies with broader subject selection show no such result it doesn’t get reported because it’s not dramatic.

I follow prostate cancer because my father died of it. There was a study some years ago that showed that elderly Harvard alums who did regular physical exercise had about half the risk of prostate cancer of everyone else. Everybody got excited about this, but subsequent studies with broader demographics have failed to reproduce such dramatic findings although they seem to show some benefit to exercise. But even that’s being called into question because people who exercise are different in OTHER ways from people who don’t. Epidemiological research is extremely hard to do reliably.

The other flaw in your proposal is that it assumes that financial incentives are stronger than health incentives. In other words that someone is more likely to be motivated by having to pay a higher insurance premium, than by avoiding the fate of an early death from cancer after years of chemotherapy, surgery, and radiation!

And so far we’re only talking about disease here – a huge part of healthcare cost is caused by trauma – car accidents, work accidents, sports injuries, home accidents, violence, etc. ( having an abusive spouse is a “preexisting condition” in many states ). If you wanted to individualize insurance costs how would you account for all these variables?

I think we need to disabuse ourselves that capitalist, free-market behavior is the balm for health-care costs. For all of our regulations the US STILL has more competition and “free market” components than almost any other industrialized nation. So why do we pay 60% MORE than the “socialized” systems? (especially considering that we have shorter lifespans, higher infant mortality and less consumer satisfaction than many of those “socialized” systems?)

That’s certainly a factor and everyone should occasionally have a blood test to make sure their nutrients aren’t out of whack. My wife, who is active and a perfectly healthy weight, was shocked to discover recently that all of her vitamin and mineral levels were perfect except that her vitamin D was about 1/3 what it should be! Who woulda thunk it?

Years ago I was involved in research at UMass studying appetitive behavior in rats. We would give them a diet that deliberately omitted some specific nutrient. Not only would they eat more, but if given a choice they were usually able to choose the food that had the missing nutrient.

The first part might be the same with humans, although probably not the second part, else I would expect the average couch potato to suffer from cravings for salad

People should be however they want (or can manage) to be. But then they need to accept the consequences of that choice.

Healthy people should not have to subsidize the health insurance of unhealthy people, if the “unhealth” is due to controllable lifestyle choices. It doesn’t matter whether that is obesity, smoking, drinking, drug use, risky activities.

That is the basic flaw of national health insurance reform…it’s designed to make the individualized costs of health care even less transparent or apparent to the individual consumer. It’s all about spreading the pain, not realizing the consequences.

Our goals should be to make health care choices more informed, more transparent, more competitive. Not less.

But you’ve gone off on a different angle now, because if what you say is true, then fat people really ARE eating more calories, to satisfy those cravings.

What I and several other people here were discussing is different: the claim that some fat people make that they eat the same calories as their thin neighbors and maintain the same activity levels but gain weight anyway because of some metabolic problem. That’s what I’m skeptical about because the numbers don’t make sense. Calories are units of energy (1 cal = the amount of energy it takes to raise 1g of water 1 degree C, and a “food calorie” is a kcal = 1000 calories). And that energy has to be accounted for.

The only ways a fat person could gain weight with the same caloric intake and same activity level as a thin person are:

1. Have a much lower body temperature.
–or–
2. Be more efficient in that energy’s use – e.g., the fat person would have to be able to walk around the block consuming less energy that the thin person. Or if they both had a 2000 kcal diet the fat person would have to be able to do everything the thin one does on, say, 1700 kcal. If anything I’d expect the opposite since they have to lug around all that extra mass.

Someone might be tempted to point out that there could be BMR differences, but that doesn’t help because BMR is expressed in either kj/kg or total heat production / m^2 and since fat people have more m^2 and more kg, their total energy consumption at rest tends to still be higher than thin people, even if their ratios are lower. See, for example: http://www.fao.org/DOCREP/MEETING/004/M2845E/M2845E05.gif

A few years ago I was doing a photo shoot in Tuscany (see http://www.pnArt.com) on a hot day in August. The photographers and models were well-supplied with cases of bottled water. But I was sweating bullets and feeling worse and worse. Every time I drank some water it went right through me and within minutes I would pee great quantities of clear (not amber) urine. Meanwhile I was getting a splitting headache and feeling weaker and weaker. Luckily it dawned on me what was happening and I went down to the kitchen in Castle Bibbiano where we were shooting and mixed myself several glasses of water with as much salt as I could stand without vomiting. Within 20 minutes I was completely back to normal and finished the shoot with no problems.

Yes, that’s why I mentioned polysaccharides. If you eat an unsalted plain cracker or some potato and chew on it long enough without swallowing it will start to taste sweet because amylase is release in saliva so it starts to get broken down right on the spot.

I suspect that some persons genetics and the flora and fauna in their GI tracts cause them to be much more effcient at converting carbohydrates into sugars and to be much better at transporting high molecular weight lipids ( some of them fats ) into the bloodstream.

You seem to be positing that thin people have some kind of malabsorption syndrome so they’re not getting access to the calories they’re ingesting and, instead, it’s all coming out the other end. Or to put it another way, we’re all naturally fat but the thin people are suffering some sort of digestive disease. It’s an interesting thesis but I’ve never heard anyone else suggest it.

Many factors can affect these systems, e.g., type II diabetes (type I even more so, but insulin injections can compensate for a nonfunctioning pancreas); diverticulitis; a poorly functioning gall bladder (secretes bile into stomach to assist in digestion); a high-fat diet with too many inferior carbs and low fiber, undiagnosed food allergies, etc.

Too many liquids can interfere with the optimum functioning of the aforementioned systems, although it would take a lot of water, say, to cause a problem. That said, there have been cases of people becoming ill and even dying from excessive ingestion of water.

People who eat very rapidly often overeat before the brain gets the message that they are full causing the aforementioned systems to function improperly . Additionally, they bypass an important function of chewing small amounts and swallowing small amounts at a time. This is the first part of the digestive process. Also acids move farther up the upper GI tract with the habit of rapid eating which contribute to all kinds of problems, e.g., acid reflux, hiatal herniation, esophageal cancers, etc.

I suspect that some persons genetics and the flora and fauna in their GI tracts cause them to be much more effcient at converting carbohydrates into sugars and to be much better at transporting high molecular weight lipids ( some of them fats ) into the bloodstream.

I know of active people who eat nearly the same diet, one eating less in quantity than the other, but the one who eats less puts on weight puts on weight, while the other adds no weight. If there is a source of information that comprehensively and clearly explains such differences to the layperson, I have yet to read it but would appreciate learning the citations in the medical literature.

Perhaps we need some chemical engineers to study the problem of obesity as some of those engineers are experts in bioreactors and digestion of carbohydrates and fats. Nutritionists don’t seem to have produced the answer.

Where did you learn your physiology? The foods you eat are what they are. If the food is a mono-, di-, or polysaccharide then it HAS to be absorbed as a sugar – what else would it be? And lipids are lipids – what else would they be? The size of your intestine has nothing to do with it. If you’re a healthy person and you eat 100g of a polysaccharide (i.e., starch) it will be broken down by amylase enzymes and you will absorb 100g of sugar in the form of monosaccharides. Likewise with fats – the fat you eat will become fatty acids in the bloodstream. Where else would the fat go? If it comes out ‘the other end’ the symptom is a very loose stool or watery diarrhea. The only people who DON’T absorb sugars and fats from the intestines have malabsorption syndrome, and they are very sick and need hospitalization before long.

As I said earlier, metabolic disorders exist but they are serious illnesses requiring medical attention. It is not possible to eat the same calories as your thin neighbor AND maintain the same activity/temperature level and get fat, because that would violate the laws of thermodynamics – essentially doing the same amount of work (where work = expenditure of kinetic or thermal energy) on fewer calories. I say fewer because if you’re getting fat while your neighbor isn’t then you are left with a surplus to store.

Some persons who are severely overweight primarily get this way because of continually eating too much and/or eating the wrong foods, e.g. high fat foods, high calorie foods, high sugar foods.

Some other severely overweight persons do not overeat, but are genetically predisposed to be fat. This predisposition exists because of abnormal functioning of the endocrine system or an excessively large stomach and upper intestine ( the organs ), causing what is known as having a “bad metabolism”.

Most severely overweight persons, however, live with both of the above conditions! They eat too much or the wrong foods, and they also are metabolically predisposed to put on fat. This is the worst of all worlds.

Whatever the reason for one being fat, it is important to get professional help, early. Early in life, I think, physical changes occur in the size of our GI tract that progressively convert more of the food we intake into sugars that enter the bloodstream and also transfer more of the fats we ingest into the bloodstream. The consequences are not only weight gain, but the start of diabetes and circulatory disease.

If one sees signs of abnormal weight gain, things can often be done that help minimize the process. Important actions are to do physical exercises that keep the size of the gut ( the “belly” ) small by keeping the supporting muscles tight. In women, after pregnancy, it is particularly important to regain muscle tone in the abdomen that is thought to be aided by breast nursing your baby. Another action that can be important is not to ingest too much liquid of any kind, especially if your belly is soft and saggy; the heavy weight of the liquid can stretch the GI tract and make it larger. For guys, the caution about excess liquid also applies, and this refers to all kinds of liquids: sodas, beer, juices, and even water. Drinking more than a little alcoholic beverage is a large contributor for guys and for gals. Note that if your muscle tone is good and you perform regular aerobic exercise, drinking lots of healthy fluids should pose no problem.

The foregoing thoughts are the result of observations, not medical studies. Much still remains to be learned about all the causes of severe overweight. Even a lot of physicians I think are not well educated about the complexity of this disease, its prevention, and treatment.

Interestingly, obesity is becoming an issue in Africa too, sometimes in the same villages where malnutrition and being underweight are problems. Heard about it on the NPR a while back.

Over 1 billion hungry in the world is bad news, but there’s a lot of good news. More women are getting educated, and a lot of people are being lifted out of poverty in developing nations. Aid and charity only go so far– education and opportunity for people seem to be the way to go to really defeat poor circumstance.