The Effect of State Obesity Rates on Mortality in the United States

By Helen Schneider, Ph.D., The University of Texas at Austin

Introduction

Americans lead shorter and less healthy lives than people in other high-income countries. For

example, in 2020 U.S. life expectancy at birth of 78.7 years ranked 28th among other thirty seven

developed countries; these countries had average life expectancy of 80.7 years (United Health

Foundation 2020). Preliminary data from the Centers for Disease Control (CDC) released on

August 31st of 2022 show that life expectancy in the U.S. fell again in 2021 due to COVID and

rising opioid overdoses; Americans’ life expectancy last year fell 0.9 year on average to 76.1

years (Arias et al. 2022). While the COVID-19 pandemic increased mortality rates around the

world, mortality rates in the U.S. already showed an upward trend in years before the outbreak of

COVID-19. Pre-pandemic mortality data published by the CDC indicate that the trend started in

2015; most of this mortality increase is due to lower life expectancy for males, younger and

middle-aged individuals (particularly those between 24 and 44 years of age) (Murphy et al.

2019). Although multiple factors lead to increasing mortality rates, there is mounting empirical

evidence that poor lifestyle is one of the major contributors. Of the 10 top leading causes of

death, heart disease, cancers and diabetes are linked to a dramatic rise in obesity rates in the

United States.

In the United States obesity is a growing and costly problem. Hales et al. (2020) find that

the prevalence of obesity among adults aged 20 and over in 2017-2018 was 42.4%. While

between 2003–2004 and 2013–2014 there were no significant changes in childhood obesity

prevalence, adults showed an increasing trend (Ogden et al. 2015). These rising overweight and

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obesity rates are associated with serious health risks, including increased risks of cardiovascular

disease, high total cholesterol, high blood pressure, and high fasting insulin, an early indicator of

diabetes risk (Freedman et al. 2007; Guo et al. 2002). While obesity imposes significant internal

costs that include poor health status and higher private health care spending, it also imposes high

external costs on society in a form of higher public health spending and higher insurance

premiums that affect everyone. In monetary terms Finkelstein et al. (2009) estimate the annual

medical cost of obesity in the United States to be $147 billion in 2008 US dollars and the

medical cost for the average obese person is $1,429 higher than that of a person of normal

weight. Therefore, reducing obesity rates is an important mission for policy makers.

Literature Review

Existing empirical literature on the relationship between obesity rates and mortality

rates is limited and ambiguous. On one hand, Lung et al. (2018) find that overweight and obesity

are associated with premature mortality and adults with severe obesity experience the largest

years of life lost, relative to healthy weight. On the other hand, Diehr et al. (2008) find that for

older adults being underweight was associated with worse outcomes than being normal weight,

while being overweight or obese was “rarely associated with worse outcomes than being normal

weight and was sometimes associated with significantly better outcomes.” (p. 76) Similarly,

Walter et al. (2009) found that higher body mass index (BMI) did not reduce total life

expectancy but was instead associated with higher risks of disability. Authors hypothesize that

lack of the relationship between obesity and higher mortality may be attributed to medical care

improvements, specifically improvements in treating heart disease. (Walter et al. 2009)

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 This study contributes to the previous literature by estimating the effect of state-specific

obesity rates on mortality. We use state as our unit of analysis and collect data at the state level.

Empirical Model

Linear regression is used to estimate the relationship between state mortality rates and obesity

rates. In this paper we estimate the following regression model:

Mortality=α + β 1 Obesity + β 2 Income+ β 3 Uninsured+ β 4 Region+u

In the model above Mortality variable measures number of deaths per 100,000 population. Our

independent variable of interest is Obesity which measures proportion (%) of the population that

is obese.

Income variables include median income for each state and proportion of the population

that falls below the federal poverty line. Uninsured variable measures proportion of the total

state population without health insurance. Finally, we control for geographic region; West is

excluded.

Data
Mortality data was obtained from the Kaiser Family Foundation and is based on calculations of

mortality counts by the National Center for Health Statistics. The data was collected for 2020

and is available from Number of Deaths per 100,000 Population | KFF.

Obesity variable is based on 2020 publicly available state-level data. Data sources for

state obesity rates are based on the Behavioral Risk Factor Surveillance System (BRFSS), an

ongoing, state-based, random-digit-dialed telephone survey of non-institutionalized civilian

adults aged 18 years and older. Information about the BRFSS is available at

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http://www.cdc.gov/brfss/index.html. Independent variable defines obesity as percentage of

adults in a state who are obese. Obesity is measured using Body Mass Index (BMI) that

calculates a person’s weight in kilograms divided by the square of height in meters. Healthy

weight is defined as BMI between 18.5 and 25. An adult who has a BMI between 25 and 29.9 is

considered overweight. An adult who has a BMI of 30 or higher is considered obese. In this

study we use state obesity rates as reported by the CDC for 2020. (Adult Obesity Prevalence

Maps | Overweight & Obesity | CDC)

State characteristics include poverty rate (percent of the population at or below poverty),

annual median income, and proportion of the state population that is uninsured. Uninsurance

data measures percent of uninsured adults in each state; the data is based on the estimates by the

U.S. Census Bureau. All state characteristics were obtained for 2021 from the Kaiser Family

Foundation. State-level data can be found at: https://www.kff.org/statedata/

Table 1 below presents descriptive statistics.

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 Table 1. Descriptive Statistics

Variable Mean Minimum value Maximum value

(st. dev)
Mortality per 100,000 854.37 588 1138.7
(111.66)
% of adults who are 31.94 23.9 39.4
obese (4.04)
Median income 69,438.84 48,716 90,203
(11,272.45)
Poverty rate 12.63 7 19.6
(2.74)
% Uninsured 9.28 2.9 20.5
(3.58)
West 0.25 0 1
(0.44)
South (excluded) 0.33 0 1
(0.48)
Midwest 0.24 0 1
(0.43)
Northeast 0.18 0 1
(0.39)

Table 1 above shows a wide variance in mortality rates across states from 588 per 100,000 in

Hawaii to 1,138.7 in Mississippi with the average of 854.37 deaths per 100,000. Obesity

prevalence in the United States varied from the rate of 23.9% in Colorado to 39.8% in

Mississippi with the average of 31.94%.

Empirical Results
Regression results in Table 2 below show that obesity is an important determinant of state

mortality rates. Higher rates of obesity lead higher mortality. When obesity rate increases by

1%, mortality rates increase 10.26 deaths per 100,000 population (p-value<0.01).

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Table 2. Regression Results

. regress mortalityper1000002020 obesity2020 poverty2021kff medianannualincome2021 uninsured2021 south midwest northea

> st

Source SS df MS Number of obs = 51

F(7, 43) = 23.24
Model 493071.185 7 70438.7407 Prob > F = 0.0000
Residual 130339.823 43 3031.15867 R-squared = 0.7909
Adj R-squared = 0.7569
Total 623411.007 50 12468.2201 Root MSE = 55.056

mortalityper1000002020 Coef. Std. Err. t P>|t| [95% Conf. Interval]

obesity2020 10.26434 3.754932 2.73 0.009 2.691794 17.83688

poverty2021kff 22.96297 4.963257 4.63 0.000 12.95361 32.97233
medianannualincome2021 -.0002345 .0014933 -0.16 0.876 -.0032459 .002777
uninsured2021 1.300382 2.882093 0.45 0.654 -4.511913 7.112677
south 35.62955 28.08866 1.27 0.211 -21.01662 92.27573
midwest 51.38608 28.33223 1.81 0.077 -5.751307 108.5235
northeast 46.59851 26.64214 1.75 0.087 -7.130478 100.3275
_cons 208.5201 238.6241 0.87 0.387 -272.7112 689.7515

Other important determinants of mortality rates include poverty and regional variables.

Although state median income is not statistically significant, higher poverty rates lead to higher

mortality (p<0.01). The paper also finds that Midwestern (p<0.1) and northeastern states (p<0.1)

have higher mortality than Western states.

Alternative Specifications
Results presented in Table 2 can be sensitive to alternative definitions of unhealthy weight as

well as self-reported nature of the data. Thus, we re-ran the model using rates of overweight and

obesity as our independent variable of interest; this data was collected by the Kaiser Family

Foundation. We found that effect of being overweight or obese was again negative and

significant (p-value <0.01). This gives us confidence that empirical results are not sensitive to

alternative definitions of unhealthy weight or alternative sources of data.

Conclusions and Policy Implications

Empirical results show that obesity rates are important determinants of mortality rates. This

result is consistent with Lung et al. (2018) that found decreases in life expectancy for overweight

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men and women in a microsimulation model of obesity progression. Therefore, reducing BMI

should be considered an important target for public health officials and policy makers as a

potential means of reversing the upward trend in mortality rates. Such policy interventions may

include healthy food subsidies through supplemental nutrition assistance program (SNAP),

stricter physical education mandates in state public schools, and improvements in infrastructure

that encourage a more active lifestyle. Our empirical results also support the view that family

welfare policies for the households that fall below the poverty line threshold could result in a

good return in reduced mortality differentials.

Results of this study are not without limitations. First, BMI statistics were self-reported,

which may introduce error and bias our results. Second, our obesity data relies on BMI as an

indicator of unhealthy weight. However, waist circumference might be a better measure when

evaluating obesity-related health risks and mortality (Walter et al. 2009). Third, unhealthy

behaviors may be correlated and therefore this study overestimates the effect of obesity. Finally,

we did not take into account the impact that increased obesity rates have on quality of life, where

evidence has shown that there are significant impairments as a result of higher morbidity and

disability (Walter et al. 2009).

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