The modern environment constantly encourages people to eat more calories than they expend. In this article from RGA's ReFlections newsletter, RGA's Peter Hovard helps insurers understand the mortality and morbidity implications of the obesity crisis, as well as steps they can take to help fight it.
It is often said that the world today is obesogenic, i.e., an environment tending to cause obesity. Modern life is physically much easier than in past centuries – today, both work and transportation are much less physically demanding, and dwelling temperatures can be controlled easily. This means, compared to our ancestors, people don’t need to consume as many calories for their day-to-day needs, and their bodies don’t need to work as hard to regulate their temperature. Additionally, food is more energy-dense, easier to access, and marketed better than ever before.
Expending less energy than is consumed is leading to people across the globe gaining weight to clinically concerning levels. The larger question, however, is this: If successfully regulating one’s energy intake is a fundamental physiological need, why are people so affected by these environmental conditions that it is causing poor health, in the form of obesity and obesity-related disease?
Obesity is a major and growing concern, and risk, for the insurance industry. The causes are complex and have genetic, physiological, psychological, behavioral, socioeconomic, and industrial and commercial components.3
It is well established that dietary habits are a major factor in several serious non-communicable chronic diseases, such as hypertension, heart disease, type 2 diabetes, cancer, and mental illness.1, 4 As obesity is often associated with these diseases, it is a growing concern.
However, obesity is also considered preventable, and what and how people eat is a major factor.5
It is a biological necessity for humans to regulate how much they eat: ensuring enough calories are eaten to function, but not so many that ultimately their mortality and morbidity risk increases. Clearly, it’s a struggle in today’s world. What makes it so difficult, thereby making obesity so much more likely?
The main challenge faced now is that the physiological appetite controls that were useful for our ancestors ensured they were motivated to find and consume enough nutrition to survive in times of scarcity. Today, the challenge is very different, as high-calorie foods are abundant and easy for most to access.9 But the motivations to eat, endowed by evolution, have remained.
Feedback received by the brain via nerves that are activated as the stomach fills (originally tested by inflating balloons in people’s stomachs10), or via hormones that respond to the nutrition in the body,9 communicates whether the body is nutritionally depleted or replete. This feedback is interpreted as either hunger or satiety.
However, human physiology is highly protective of energy intake. Indeed, many who actively attempt to restrict their caloric intake in order to lose weight find they regain any weight lost because the restrictions generally trigger an increased motivation to eat.11
Humans eat, not just for homeostasis but also for pleasure, which is experienced because the brain’s opioid systems are activated by eating palatable foods.12 Relationships are also learned between the sights, smells, and tastes of various foods and the positive biological outcomes (more energy) of eating them, via dopamine reward systems. This means people learn to experience foods such as doughnuts and hamburgers as tasty precisely because they are high in calories, thereby energy fuel.9
More concerning, however, is how learned cues that predict availability of energy from particular foods, such as sights, smells, and tastes, can also activate dopamine systems, which triggers “wanting” (i.e., desires for particular foods).13 People today are surrounded by advertising from a myriad of outlets, that stimulates a desire to eat calorie-dense foods, often resulting in eating whether needed or not.
Ultimately, to achieve meaningful change in dietary behaviors, the wider environment must change as well.
Senses and thoughts about foods also play a role in appetite. If, for example, a food is expected to be filling because of previous learning, it will enhance feelings of fullness after eating it.14
One implication of this aspect of human psychobiology is that because typically beverages such as water contain few if any calories, drinking something does not signal to the body that it has consumed energy as strongly as does eating. People therefore do not experience as substantial a sense of fullness after downing a soft drink. Interestingly, soup is experienced as more filling if consumed with a spoon than as a beverage, because of the experiential signals eating with a spoon generate.15 Hence, high-calorie drinks are a particular concern, as the body does not experience them as having provided energy.
Various other quirks of human psychology can lead people into overeating, such as:
The factors described above are just some of the ways in which people struggle, physically and mentally, with the twin pressures of food abundance and modern marketing techniques. Ironically, many who consciously restrict their eating are also more susceptible to overeating.
What can insurers do to reduce dietary- and obesity-based risks?
Among traditional treatments, the most effective for severe obesity with associated complications has long been bariatric surgery, a procedure which reduces stomach size, increases post-ingestion fullness, and improves morbidity and mortality outcomes.21
More recently, new and effective pharmacological interventions have emerged. Semaglutide, under the brand names Wegovy and Ozempic, and tirzepatide, under the brand names Mounjaro and Zepbound, mimic the effects of the gut hormone GLP-1 alone, or the hormones GLP-1 and GIP, to suppress appetite. Both have been demonstrated as effective in clinical trials and are approved by many government bodies for weight loss and diabetes management.22
Surgical and pharmacological interventions are generally reserved for severe obesity cases, which may be less prevalent in the insured population. These drugs are typically prescribed alongside behavior change interventions such as diets and exercise programs. Older pharmacological treatments aimed at appetite suppression were generally unsuccessful, as patients were able to override the reduced appetite effects and regain weight, and many were associated with serious side effects such as increased risk of cardiovascular diseases and mental health conditions.23 Several treatments are currently banned in many jurisdictions: sibutramine, for example, a selective serotonin reuptake inhibitor (SSRI), was withdrawn by the U.S. FDA due to increased risk of cardiovascular diseases, and rimonabant, a cannabinoid receptor antagonist, was withdrawn due to increased risk of psychiatric issues such as anxiety, depression, and suicide.
Lifestyle change is still at the heart of intervention for obesity, for comorbidities such as diabetes, and for maintaining healthy diets and weights in the non-obese population. Surgical and pharmacological interventions are prescribed only if lifestyle changes have failed.
Dietary interventions can be successful for weight loss24 and diabetes.25 Programs such as WeightWatchers, which provide incentives and nutrition coaching, have been commercially successful. There is some evidence for success in weight loss maintenance,26 and many elements of these programs are provided digitally. Part of the success of these programs is the focus on promoting dietary adherence. Most diets fail, and research has found that dietary adherence is more predictive of weight loss than the type of weight-loss food plan followed.11
This may be an area where insurers can influence behavior.
With carefully considered incentives, communications, gamification, and – most importantly – scientifically validated behavior change techniques, insurers can help customers navigate the obesogenic environment.
This could mean promoting food plan adherence or the maintaining of healthy food habits. It’s also likely that those with healthy behaviors are more disposed to self-select a wellness program which has a risk-selection benefit for insurers.
To be successful, however, insurer-sponsored prevention and intervention programs must consider the science of dietary behavior. Given that those who restrict their energy intake often regain the weight lost (and sometimes more), successful interventions need to ensure that people’s nutritional requirements and preferences are met.11 Similarly, programs that encourage personalized goal-setting, self-monitoring techniques, and mutual support via social engagement may be more likely to be successful and engaging.27
The world is currently in an obesogenic age, with major morbidity and mortality risks that will worsen as the obesity crisis deepens. Insurers will benefit from understanding the behavioral dynamics at play in this environment.
Insurers can help mitigate the environment by covering and supporting treatments for severely obese patients, and by promoting positive dietary behavior via wellness programs that create engagement to help and support people to maintain healthy habits.
This may involve more than just providing dietary advice; it may also mean helping customers navigate environmental temptations, using behavioral science to develop successful and engaging approaches.
Ultimately, to achieve meaningful change in dietary behaviors, the wider environment must change as well. Governments are already introducing interventions such as taxation of sugar in beverages to incentivize producers to reformulate products with lower calorie contents as well as public health campaigns that promote healthier diets. But with a vested interest in morbidity and mortality, the insurance industry can also consider how to contribute meaningfully to battling the obesogenic environment.
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