Understanding the Economics of Obesity

    • May 2, 2013

Health economist John Cawley, PhD, has an intellectual's curiosity about problems and a pragmatist's approach to solving them. Those qualities stood him in good stead at the University of Michigan, where in 1999–2001, he was a Scholar in the Robert Wood Johnson Foundation Scholars in Health Policy Research program.

The Scholars program provides new doctorates in economics, political science, and sociology with two-year fellowships to bring their disciplines into the field of health policy research. The program is based on the belief that engaging talented young people from these disciplines in debate about health policy will result in better health policy, and ultimately in better health. See Program Results Report for more information about Scholars in Health Policy Research.

An interest in obesity. Curiosity and pragmatism continue to drive Cawley's research, which focuses on obesity. A good example is The Oxford Handbook of the Social Science of Obesity, a project that Cawley conceived and edited and the Oxford University Press published in 2011. The Handbook is a "Rosetta stone" for the field of obesity, Cawley says—a single reference volume, with chapters by 85 authors, that explains how psychology, sociology, demography, epidemiology, economics, and other disciplines view the causes, prevention, and treatment of obesity.

It is a timely book for a field marked by innovation and learning. As Cawley notes, advances in anti-obesity drugs and surgeries are being made every year. New policies, spurred by the Affordable Care Act, will give employers incentives to enroll overweight workers in wellness programs and require restaurants to list the calorie count of menu items. "Obesity is a complex, interdisciplinary problem that involves genetics, environment, psychology, and economics. That makes for a lively field with a lot of...collaboration and debate," Cawley says.

Cawley earned a bachelor's degree in economics from Harvard University in 1993 and a PhD in economics from the University of Chicago in 1999. He has served since 2001 on the faculty of Cornell University's Department of Policy Analysis and Management. But it was the Scholars program, he says, that "gave me exposure to many of the top health economists and health services researchers in the country."

Cawley is replicating that experience as co-director of the Cornell Institute on Health Economics, Health Behaviors, and Disparities, which holds a weekly seminar for students, faculty, and visiting scholars that often focuses on obesity. "It's a great way to increase intellectual exchanges and to build ties between graduate students and faculty," Cawley says.

Working and obesity. Cawley is especially interested in the relationship between labor markets and obesity. One of his research projects looked at former welfare recipients who entered the labor market after welfare reform in 1996. Many were obese, and Cawley measured the correlation of obesity with problems they might face in transitioning from welfare to work—specifically, in getting or holding a job. In an analysis of racial differences in obesity discrimination, Cawley found that White females are the group for whom obesity is associated with the worst labor market outcomes.

Cawley's subsequent research indicates that obesity can trigger discrimination regardless of a person's race. In a 2011 commentary in the New York Times, he wrote that "some part of the obesity wage penalty"—the lower wages paid to obese women compared with non-obese counterparts—"is due to discrimination."

Cawley has also conducted research on how working mothers use their time with their children to understand why working mothers are more likely to have overweight children. He found that working mothers spend significantly less time grocery shopping, cooking, eating, and playing with their children.

"That was a great lesson on how to frame research on a controversial topic," Cawley observes. The researcher's role, he says, is to delve into such topics "where people have strong feelings and biases and emotions, and to focus attention on the data, calm things down, and show that you can answer these questions empirically."

Medical costs of obesity. Cawley's research has examined the medical care costs of obesity. He found that "the medical care costs of obesity are significantly higher than previously appreciated. That has implications for the cost effectiveness of different anti-obesity interventions, because the value of averting obesity is higher." He also has evaluated several major interventions, including HealthCorps, a school-based program developed by Mehmet Cengiz Oz, MD, a cardiothoracic surgeon in New York City, known on television as Dr. Oz, and (with funding from RWJF) the Alliance for a Healthier Generation's Healthy Schools Program.

His career moves on. Since finishing his term as a Scholar, Cawley has served on obesity panels or advisory committees for the Centers for Disease Control and Prevention, the Institute of Medicine, the Food and Drug Administration, and the Federal Communications Commission. In 2012 he joined the national advisory committee of the Scholars program.

As of 2013, Cawley is studying the consequences of rising obesity rates for the United States' armed forces, military academies, and public health service. He finds that obesity is disqualifying a lot of people from military service and is documenting how obesity has impacted the percentage of civilians who are eligible to enlist. He also helps employers, local governments, and insurance companies evaluate their efforts to reduce obesity.

"It's fun to figure out what works, share that information, and keep improving interventions to make them more effective and cost-effective so we're not wasting resources," Cawley says.

RWJF perspective. The Robert Wood Johnson Foundation Scholars in Health Policy Research program is designed to foster a new generation of creative thinkers in health policy research within the disciplines of economics, political science, and sociology. The fellowship program, established in 1991, annually selects a total of nine recent PhD graduates from among those three disciplines to spend two years studying at one of three participating sites (currently Harvard University, University of California, Berkeley/San Francisco, and University of Michigan).

Participants learn about health and health policy, gain exposure to the perspectives of the other two disciplines through seminars with peers, receive mentoring from prominent scholars, develop research ideas, and conduct research while receiving a stipend and benefits that free them from other professional obligations. "We're looking for people who aren't too far along in pursuing a specific research agenda. Our goal is to catch people early and tempt them into the field of health policy," says Lori Melichar, PhD, RWJF director for the program.

While in the Scholars program, participants have conducted research on issues and policies related to individual health, public health, social and economic determinants of health and health care, health care financing, and health care systems and institutions. After completing the program, alumni stay connected to their peers through a network facilitated by the Boston University Health Policy Institute, which serves as the national program office.

Scholars from the Health Policy Research Program have made significant contributions to their disciplines and to the field of health policy research. The program's 200-plus alumni, many of whom hold faculty appointments at universities and colleges, have authored hundreds of widely cited books and articles; held editorial posts at top scholarly journals; sat on scientific advisory panels; served as senior advisers to presidential, Congressional, federal agency, and national scientific councils; and received numerous professional awards for their research.

Although the original purpose of the program—to increase the number of economists, sociologists, and political scientists conducting health policy research—remains important, RWJF's focus has expanded to include "building the community" of health policy researchers and supporting them at institutions nationwide. "Now it's more about creating a critical mass so that we have a self-sustaining community [of researchers]," Melichar says.