Tuesday, January 22, 2013

European Notes: The Obesity Gap

I've now been in Europe for a little over a week, mostly in London, Zurich and Milan. As of yesterday afternoon, I had not seen a single person who was extremely overweight. In an hour or two walking around a U.S. city I would expect to see several such. 

Yesterday evening, while I was describing my observation to my host, someone entered the restaurant we were eating at whom I would describe as extremely overweight. But that's one out of (I'm guessing) more than a thousand people I have seen over that period.

The obvious explanation is that food is somewhat more expensive in Europe than in the U.S. and incomes somewhat lower, but while obvious I do not think it can be correct. In the U.S., obesity exists all the way through the income scale—I think a little more common at the lower end. I do not believe a poor person in the U.S. can more easily afford to eat a lot than an average person in London, Zurich or Milan.

My current guess is that the explanation is cultural. Perhaps the norms against being very overweight are stronger in Europe, or perhaps some other difference explains the pattern. Readers are welcome to suggest explanations or provide additional observations.

43 comments:

Gorgasal said...

I live in Germany but work a lot with US colleagues. I don't think norms against being overweight are more stringent in Europe.

My guess would be that fast food is a lot less common here - far fewer McD or similar outlets, and fewer people eat there often; you really only go there once in a while. (This observation may be heavily biased by my socioeconomic status.)

In addition, servings are far smaller than in the US; no supersizing here. You will usually not find a soft drink in a larger container than 0.5l, which is less than 17 oz.

jure said...

http://www.livescience.com/11825-global-obesitiy-united-states-ranking.html

Well US is not the most obese nation, but ranks pretty bad. I think that main factors involved in obesety are: 1.culture and level of stigma 2.genetic 3. availability of food (whick is main component of genetic) 4. not just level of input but also output (exercise)
Alaskan indians have much higher rates than caucasians. And texans have higher rates than californians.

For example many people are obese despite not living in industrialized world. Pacific islands, egyptians and some arabic nations. Also the mongols are far more obese than chinese or japanese. After all, they are small and stocky as well as polinesians. Back in the past here in Europe if someone was fat- it was a sign of nobility and wealth. Because many people who are on lower pay scale can still afford to be fat- being fat is seen as lacking self-control and not caring for sexual attractiveness. But being fat doesn't mean you just eat a lot. Everyone who does a lot of exercise also eat a lot. Maybe there is in US kind of low level of importance in culture to take exercise. Here in Slovenia practically everyone does some sport. Either mountain hiking, cycling, runing...

One reason for EU and US disparity might also be the prevalence of totalitarian colectivistic thinking in EU compared to US. EU today has many states that used to be socialistic (like mine) and there children very always taken to the state schools where physical education and education for ''advancement of body and mind'' (this really was the name of the programs for kids) were very important subjects. Being in great physical shape was seen as a duty to the nation and promotion of ''our strenghts''. Therefore this kind of thinking is still prevalent, cause the main duty of government is seen to be that it takes care for children to shape them in ''healthy comrades''. I often hear today from some older people when they are giving us ''lectures'' how we became too ''americanized'' and atomistic individuals compared to ''good old days''

EH said...

Having lived on both sides of the atlantic, I would also say the difference is a cultural one.

Europeans are a lot more conservative when it comes to their food choices. Perhaps because americans have a shorter history to build habits on, or because they are generally more willing to take a plunge; I don't know.

Europeans tend to leer at infinite refills of sugar water. Not that they wouldn't drink it if you put it in front of them, or because of a nuanced understanding of their bodies' limited ability to metabolize fructose; but because its 'american'.

One can muse about agricultural subsidies or other forces transcending the individual, but id say the general trouble with our eating habits is that we have gotten a lot better at making food cheaper and more tailored to our tastebuds (great things, in principle), but hardly any better at knowing what an optimal diet actually looks like.

Conservative logic (what was good for the grandfather, is good for the grandchild) can pay off in those situations.

Marco said...

One factor may also be that in the US some people literally do everything by car - and the infrastructure also allows them to do so. In places like London, Zurich and Milan it is simply not practical to run every errand by car. Anyhow, petrol is simply too expensive to do so. Hence people walk and bike more and commute by public transport. This involves at least some physical exercise, which may go a long way in avoiding the most extreme cases of obesity.

Robert Easton said...

Marco's suggestion can be tested by comparing Europe to cities like New York and Boston where car use is lower. Although from what I've seen, even in those, car driving is easier than London. I can't comment on the other cities. I think it's already known that obesity is lower in high density cities.

Regarding the "cultural" differences with fast food, note there is also a cost issue here. It's not simply the case that food is more expensive in Europe. Eating out is more expensive, but ingredients for eating at home are no more expensive I think. And eating out at fast food places (where labour costs make a higher share of the total cost) is doubly more expensive. So that's going to make people eat fast food a lot less, and eat at home a lot more.

Glen said...

I'm pretty confident that eventually we'll find something like a "fat virus" - a virus or bacteria or collection of them that *make* people fat who otherwise wouldn't be. Have you looked into Gary Taubes? He's pretty good at pointing out flaws in the traditional hypotheses about obesity, even if he so far lacks a convincing counter-narrative.

Toni said...

The taxes in US are lower than in Europe which makes eating out (vs. making food at home) relatively cheaper. For some reason, people eat unhealthier when they eat out? Most US food chains are either fast food or diners that have pretty unhealthy food choices compared to what people were perhaps making at home?

David Friedman said...

"In addition, servings are far smaller than in the US; no supersizing here."

The normal Italian dinner seems to consist of an appetizer, a first course (often pasta), a second course, and a desert. That adds up to a lot of calories.

Of course, it's possible to have only the pasta and nothing else, but I don't think that's the norm.

On the question of eating out ... . I wonder if home cooking is more common in Europe, either for cultural reasons or, perhaps, because fewer married women have full time jobs? I don't know what the data on that show.

Jan said...

It may be a case of multiple possible equilibria, with the US being in a "high" and Europe being in a "low" equilibrium. I think cigarette smoking has been to be "contagious" -- not literally, but in the sense that people smoke more and a more likely to start smoking if people around them smoke. There may be something similar going on for "being obese".

TheVidra said...

My hypotheses (having lived extensively in both continents):

1) Europe is much more urbanized than the US, which is heavier on suburbs and isolated rural households. Also, zoning laws in many non-urban US jurisdictions do not allow commercial areas to be in the same place as residential areas, increasing the distances needed to travel for everyday errands; in Europe separating the two areas geographically is impractical due to the high population density. Gasoline in the US is much cheaper as well. Therefore, due to the incentives created by the realities mentioned above (population density, zoning laws, gas prices), Europeans tend to walk more, whereas Americans rely more on cars. I think this lifestyle choice is the biggest determinant in the obesity factor. To support this hypothesis, please compare obesity rates in walkable US cities (NY, Washington DC, San Francisco) with those in non-walkable US cities (Atlanta, Little Rock, etc.) or with non-walkable suburban and rural areas.

2) To go along with #1, many Europeans live in old apartment buildings without elevators (as opposed to houses or skyscrapers where an elevator is a necessity), so they are forced to walk up the stairs every day, even if they are not otherwise active.

3) In the US, cold drinks are the norm (even in winter it is common to serve ice in one's water!), whereas I don't remember that being the case in any European country I've been in. I read somewhere that abnormally cold drinks (i.e. with ice) really hamper with digestion and metabolism and the gut flora, so this might also be a factor (but I cannot locate that article or remember the publication, and I am no nutritionist so I cannot vouch for the scientific merit of that claim).

4) More smokers (% of population) in Europe?

All in all, I still think it has to do with the population density and thus physical activity, rather than other factors I thought of.

Anonymous said...

DAVID - I have an alternative theory. I have made similair observations between two different countries, which have very similair diets and availability of food. You need to look at the women.

That's right, in one country there are what I consider to be a high proportion of beautiful women. In the other country, I dare say the proportion is far less.

In country 1 - An obese male with a good income has nearly as good a chance of getting a beautiful female, as a normal male.

In country 2 - There are far less beautiful women (i'm serious). As such the males are thin, non-smokers, persistant at exercising and eating right.

I realise the subjectivity of my assessments in regards beauty. I guess my question is - how many good looking ladies do you see in London?

Anonymous said...

If you're interested in obesity, you should check out Gary Taubes' work. He offers a different paradigm of weight gain than the standard energy balance paradigm.

Basically, it mostly comes down to the tremendous amount of high fructose corn syrup in the American diet, which raises insulin.

RKN said...

Population genetics and diet.

What else could it be?

Simon said...

I would second Anonymous suggesting looking at Gary Taubes' Why We Get Fat. Basically he very convincingly questions the notion that obesity is due to too much food and too little exercise. After all if it was that, wouldn't our weights be going up and down wildly as we ate a bit too much or a bit too little? (I'm summarising and it's worth reading the original)
Essentially obesity is due to to much carbs especially sugar. I would guess the obesity difference would correlate with sugar consumption. I'd imagine you could probably even see it with just looking consumption of coca cola. Obesity is very rare in Japan and I think the diet culturally here has very low sugar content.

TheVidra said...

Then how can Gary Taubes explain that people in Washington DC are generally fit, whereas people about 1.5 hours driving distance away are overwhelmingly obese? I presume both groups have the same diet, or similar intake of high fructose corn syrup and other refined sugars, given they all buy groceries from the same big chain stores. And the non-walkable parts of Washington DC (the ghetto, where the metro doesn't venture, and the streets are generally deserted) also have much higher rates of obesity than the more civilized, walkable parts of the city?

TheVidra said...

On the other hand, I think in the US the preference for sweetener is cane sugar, and refined corn products, whereas in Europe it tends to be beet sugar, or honey... this might validate this Taubes guy to some degree, but it still doesn't explain the differences I mentioned in my above comment regarding the extremely high differences in walkable vs non-walkable areas within the US.

David Friedman said...

An anonymous poster suggests a correlation between thin men and a shortage of attractive women. Even if true, that does not explain the absence of very overweight women in Europe—so far I have seen none.

And Milan provides striking evidence against his thesis. In several days, I saw only one very overweight man--and a very high number of women with the hour glass figure typical of a good looking eighteen year old.

David Friedman said...

On the claim—I'm not sure if Taubes makes it, not having read his work—that the problem is corn syrup, it occurs to me that there is a simple test. High fructose corn syrup is so common in the U.S. because of the high import tariff on sugar. So see if the difference between U.S. and European obesity rates only started when the tariff was imposed.

It's an attractive thesis, since it implies that U.S. obesity is a product of government interference in free trade.

Robbo said...

@TheVidra
There is a big class difference in obesity, middle and upper classes are much less likely to be obese. This would explain large differences within DC.

My view is that the American habit of sweetened drinks - soda, pop, etc. is a large part of the cause. These are much less prevalent in Europe.

Joey said...

David & Anonymous,

Taubes doesn't claim that corn syrup is the problem. He argues that obesity is a hormonal condition and foods that raise insulin levels are the cause. Since corn syrup has fructose, it causes a smaller insulin response than glucose would alone.

That's not to say that fructose is healthy; I've heard it considered a hepatotoxin.

David, being a libertarian, I'm surprised you haven't read Gary Taubes' books. It's full of information about how bad science and the establishment, with government help, make us less healthy. Highly recommended.

P.S. Taubes argues that low-carb diets are healthier as measured by other biomarkers (triglycerides, HDL) as well.

Anonymous said...

Surely many of the above reasons contribute. One other reason not yet mentioned relates to socioeconomics. The ability (and resources) to self-regulate is strongly correlated with educational attainment. Europeons and Asian populations are better educated (as a whole).

EH said...


It's an attractive thesis, since it implies that U.S. obesity is a product of government interference in free trade.


I do not think the price difference implied by these subsidies is nearly large enough to explain the large differences in consumption patterns and obesity. Moreover, it is not like Europe has much resembling a free market in food.

Also, I do not think the arguments about walking in the city hold water. Walking to and from the metro station does not make the difference between obesity and non-obesity. Infact, even serious exercise has very little influence on weight.

Tibor said...

Anonymous: Maybe you're right, but what do you base this on? I think the sheer amount of university graduates can barely say anything about education. If of course by education you mean actually learning something and not getting a rather meaningless piece of paper that says you have finished some kind of a course.

I think a lot what was mentioned here contributes a little bit to the difference, while it cannot be explained with a single decisive variable (or even a few major ones).

But there surely has to be a statistical analysis (or a couple of them) of this phenomenon available, and it could shed some light onto the subject.

Anonymous said...

David: It's not really hypothetical about the tariff, the rise of obesity coincides almost exactly with the introduction of HFCS:

http://en.wikipedia.org/wiki/High_fructose_corn_syrup#Historical

http://en.wikipedia.org/wiki/Obesity_in_the_United_States

The above article also mentions sugary drinks rose in the late 70s as well, which may just be the indirect cause.

Simon said...

Why We Get Fat is not so much a diet book but a book about how the science of diet has gone astray. It's a story of preconceived notions and politics distorting experimentation and its interpretation. There are parallels with economics and I'd recommend also Gary Taubes EconTalk conversation.

Milhouse said...

I was surprised to be told yesterday that Canadian soft drinks are also sweetened with HFCS, despite the price of sugar in Canada being at world levels (which is why the Life Savers factory moved there). Can anyone confirm that this is so, and if so offer an explanation?

746.43 said...

When I lived in Munich, I drank a lot of beer, walked up 5 flights to my apartment and had no car. It was sheer pleasure do walk around Schwabing anytime. I bought all food around the corner and carried it up to my flat. Trams and buses went everywhere and walked and ran to catch them. There were some overweight Bavarians, for sure, but most folks were fit and trim.

In Austin, Texas, it is no fun whatsoever to walk around my neighborhood. There are no sidewalks, the only folks I see are those walking dogs, I have to drive to get groceries and I unload them a few steps from the pantry and fridge.

If I did drive to where there are sidewalks, the costs to park are exorbitant. It is too dangerous to ride a bike on the only road to downtown that has no bike lane and a 40mph speed limit.

On the other hand, at my second home in Crested Butte, CO, I walk everywhere. There are sidewalks and free parking everywhere. There are no skyscrapers, no 5-story flats and Coloradans are the fittest folks in Amerika.

I think we need to start taxing our car culture if we hope to overcome the obesity problem. Folks without cars will demand local groceries, denser accommodations, buses, trams and sidewalks, all of which will help reduce the obesity problem.

David Friedman said...

"I think we need to start taxing our car culture if we hope to overcome the obesity problem."

I think the decision of how to live is one that individuals ought to be free to make for themselves, not one that the state should make for them in order to make them less likely to make a choice that imposes costs mostly on themselves.

Daveon said...

Less fast food, and it is generally speaking cheaper to buy food to make at home than to buy takeout food, and buying food in the supermarket to cook at home is also, generally speaking, cheaper than the US equivalent. Oh, and the preprepared British versions of 'TV Dinners' are better too.

Smaller portion sizes. No free refills on soft drinks. Take a look at those Italian meals, and actually have a guess at the calorie content. It's almost certainly lower than, say, having the bottomless pasta bowl at Olive Garden.

Oh,and people walk more.

People are lousy at making good decisions about their health. Not sure why this should shock anybody.

Daveon said...

I think the decision of how to live is one that individuals ought to be free to make for themselves, not one that the state should make for them in order to make them less likely to make a choice that imposes costs mostly on themselves.

I'm not sure that you can make an argument that the only costs on a society of obesity are on the individual.

Even if people are 'paying their way', medical services tied up on handling huge numbers of Type II Diabetes illness and associated lifestyle sicknesses will still be resources that can't be used for other things, at least not with a cost being imposed by too few doctors treating illnesses they shouldn't have to.

Then there's soft costs, furniture, buildings and facilities needing to handle mobility problems.

I think without too much trouble you could come up with a list of costs incurred by mass obesity that go wayyyyyyy beyond the impact on the obese person.

Joey said...

Daveon,

Even if people are 'paying their way', medical services tied up on handling huge numbers of Type II Diabetes illness and associated lifestyle sicknesses will still be resources that can't be used for other things

It's unclear to me that obese people use more lifetime medical resources than thin people. If you can prove that, I'd like to see the data. Obese people tend to have shorter lives and need less geriatric care.

I think without too much trouble you could come up with a list of costs incurred by mass obesity that go wayyyyyyy beyond the impact on the obese person.

If obese people pay their own way, then none of this is a problem. People will change their facilities if it is profitable, and more people will become doctors or doctors will work more hours if more people demand medical care.

Ian said...

One of the most significant reasons for rampant American obesity is American corn subsidies. In the United States, high fructose corn syrup is much cheaper than sugar, so we put it in everything. Notice that HFCS is far less prevalent in Europe than the US -- even in junk food.

As it turns out, HFCS is an especially bad substance for fat production -- it hits the system so fast that insulin can barely keep up, and a lot of the energy ends up stored as fat, rather than used. That has the additional factor of making us hungrier, since we're not getting a reasonable long-term even supply of calories.

Daveon said...

It's unclear to me that obese people use more lifetime medical resources than thin people. If you can prove that, I'd like to see the data. Obese people tend to have shorter lives and need less geriatric care.

I found a LOT in Google myself with the search string 'costs of obesity on us healthcare' - many studies being conducted working out how much that is.

With respect to your second point. You don't *just* become a cardiac surgeon because lots more obese people need coronary bypass surgery.

Plus, speaking from the experience of a close friend. The cost of doing a triple bypass on a 300lb+ plus sixty year old man, includes several extra hours in OR getting them onto the bypass machine to start with, and the costs of having a couple of orderlies scrub in for the close because the PA, nurses and surgeon aren't strong enough to close the rib cage without more people leaning on the sides... Then there's significantly more time spent in hospital in recovery.

That's ignoring the costs associated with obese poor people in the USA turning up as free-riders on the US healthcare system in the first place.

Milhouse said...

I found a LOT in Google myself with the search string 'costs of obesity on us healthcare' - many studies being conducted working out how much that is.

People can claim all sorts of things, but it doesn't make it true. I think it's pretty well established that smokers do not consume more health care than non-smokers, because they tend to die sooner, and yet I'm sure you'll find all sorts of claims otherwise.

Joey said...

That's ignoring the costs associated with obese poor people in the USA turning up as free-riders on the US healthcare system in the first place.

Let's table that one. We are talking about a hypothetical in which everybody is "paying their own way". No free riders.

I found a LOT in Google myself with the search string 'costs of obesity on us healthcare' - many studies being conducted working out how much that is.

Could be true, but when I searched it the sources gave no comparison to the total lifetime costs of thin people, which is a serious omission considering their argument.

With respect to your second point. You don't *just* become a cardiac surgeon because lots more obese people need coronary bypass surgery.

If people are paying their own way, if more people use medical care, the extra money will entice more doctors to expand their production, too. There doesn't have to be a 10 year (med school + residency) delay until that happens. Some doctors may choose to come out of retirement, others may work overtime, others may re-train to become cardiac surgeons.

Can you think of a better solution? If so, do you trust politics to implement it properly?

Unknown said...

Some additional hypotheses;
You are visiting cities when you go abroad, you should compared obesity results for like areas in the US, as others have noted the high obesity areas seem to be in the suburbs, which people rarely visit while on holiday or business.
The genetic mix in the US is different to Europe, perhaps tendency to obesity was a successful evolutionary tactic for people emigrating to the US in the early periods, there is definitely a genetic basis for obesity, I can see it in the two halves of my family, my dads family is lean and my mums is obese, me and my siblings take after one or the other.
The US being more car friendly means the cost of being obese is less (plus better medical care), people respond to incentives on the margin. Don't under estimate how more car friendly the US is compared to Europe or Japan. When I lived in Europe I often did my shopping without a car, because of the hassle and cost of parking. You have to be able to walk in that environment or face significantly higher costs to obtain the basics of living.
Another idea, less climate control in Europe, being obese in a non-AC environment is not pleasant. Also colder houses mean you burn more calories.
eating out frequency is significantly higher in the US, and restaurants put a lot of fat and sugar in their food because it's cheap and tasty.
More use of anti-depresemt medicine in then US, not only do these drugs cause you to naturally put on weight, they cause you be more accepting of your circumstances.
Cultural prejudice against obese people is higher in Europe.
And so on.....

Daveon said...

Joseph, actually I have to stop you now. As we're not dealing with a hypothetical. People in Europe are less obese, so the free rider problem is actually real.

I chose poorly in my words earlier. So let's consider reality where people are fatter and a 350lb male is turning up at ER without insurance suffering from an MI while having un-diagnosed Type II Diabetes and untreated hypertension because they have no primary care physician and that you and I are paying for.

The reality is, nobody who has any type of surgery, in either a single payer nor insurance model is actually 'paying their way' when they have any kind of specialist surgery because very very very few people can actually afford to pay for the treatment they need if they need anything more serious than a minor procedure or drugs.

I'm minded that in the US at the moment, the author Jay Lake, without the ACA would have hit his life time limit for insurance... just saying.

But responding to your point. Honestly, most doctors wouldn't come out of retirement regardless of what you offer them because there is a) a limit on how long you are prepared to stand in OR for 6 straight hours working on somebodies heart and b) they just don't need to, because they've made enough money that they don't need to keep working into their late 60s and 70s.

So, again, sorry for my choice of words. Let's focus on the world we live in?

Daveon said...

Can you think of a better solution? If so, do you trust politics to implement it properly?

As an aside, yes, I, generally, trust politics to implement things, and I think that taxation does affect behaviour and is therefore a way to manage things better.

I also think that Single Payer national healthcare is, on the whole, a better way to manage the downside than the US alternative that I've been living through for the last few years.

For the record I'm a Brit currently living in the US with good health insurance and finding that, on the whole, it's on par or inferior to what I had in London with the NHS.

Oh and with respect to another thread here, I REALLY miss London black cabs.

Joey said...

Daveon, you keep moving the target.

In the UK and in the US there exists a free rider problem. The US is fatter, but not by much. Lots of other relevant features differ between the two. I don't see what there is to learn by comparing the two systems.

I have been trying to address your 8:45 am comment in which you argued that there are too many externalities that even a free-market in healthcare can't internalize them all.

It just occurred to me that we might not be on the same wavelength. I am arguing that a free-market would solve all of these problems and you are arguing that we can patch the current system with more regulations or a single payer system.

So here's my response on your terms:
Single payer system might or might not be better than what we have now. It's not a very descriptive term. Anyway, with a truly single payer system, an individual will either have to give up freedoms like smoking, eating soda, and doing other medically expensive things, or they will be taxed/subsidized. The most efficient and fair tax would be one that imposes the total medical cost of smoking on the smoker. Same goes for skydiving, drinking, swimming, driving, etc.. To be even more fair, you'll have subsidies for healthy activities. In the end, and if you discover the optimal tax/subsidy combinations, you'll have a system that looks a hell of a lot like an outcome of laissez-faire capitalism but will have arrived there a lot less elegantly.

astrolabio said...

As an italian I think it's a cultural difference. We see american taste for foods very naive, with sugar, fats and glutammate everywere to make things very tasty. That's the mentality of an italian child, that would eat chips, coke, ice cream every hour of the day. An italian adult eat those things only once in a while and likes more structured flavours (I can't imagine an average american drinking an espresso without sugar). it makes even the four courses dinner (wich are only for special occasions, for informal dinners the norm is 2 out of four courses) less caloric and more glycemic index friendly than an average junk food dinner.

Anonymous said...

Good post on Taubes: http://squid314.livejournal.com/350821.html

Jeeves said...

Is Gary Taubes a scientist? A nutritionist? Robert Lustig's theory goes something like: the diet of the average person in the US has undergone a dramatic shift over the last 30-40 years, not only in increased sugar consumption but a decrease other foods (those that contain fiber and so rot more quickly on the shelf). Both of these things combine to make the body put on weight, even when it is consuming other foods.

Here is an even more subjective opinion: after living in Europe for about a year. Besides being less sedentary and generally eating less food and more healthy food, European people, especially those outside of the major cities, seem much less depressed.

Anonymous said...

Fat Americans were less usual before 1970. Poor people in America are more likely to be fat. I like this; I like a country where the poor are fat.
Wages in America have dropped since 1970= Americans are more likely to be poor. I don't like this.