Obesity Among Poor Americans : Is Public Assistance the Problem ? , by Patricia

Critics of welfare typically claim that public assistance leads to unintended consequences such as reduced work incentives, decreased marriage, and out-of-wedlock births. Patricia Smith argues that obesity has now earned a place on this list as well and aims to examine the extent to which the existing literature can offer empirical support for the claim that public assistance causes obesity. But to what degree is obesity actually being deployed as leverage against welfare in the United States, and to what degree has public assistance per se really been cast as a new and noteworthy culprit in the so-called ‘‘obesity epidemic’’? Smith opens the introduction with the fact that Douglas Besharov of the American Enterprise Institute has argued, in testimony before a congressional committee, that the Food Stamp and National School Lunch programs contribute to obesity (p. 1). Beyond this point, however, the book does not offer much background on the current place or circulation of such arguments in policy or public health domains nor the extent to which they have achieved traction in debates over public assistance in particular. While it may very well be true that obesity is now propped up as an unintended consequence of welfare, more space could have been devoted to situating this claim and the sociopolitical controversy it inspires, mostly because it serves as the central motivation for the book. Nevertheless, the causal question itself remains quite interesting, at least to this reader, and Smith does a wonderful job of engaging the empirical literature at hand. The volume of work that directly or indirectly relates to the basic question of whether public assistance causes obesity is large, so the project is ambitious and the author is to be commended for reviewing and organizing the literature from multiple disciplines (e.g., economics, epidemiology, nutrition, psychology, etc.) in a careful, consistent, and highly thoughtful manner. Smith employs a conceptual framework with four models or hypotheses, each of which would lead to the empirical observation of an association between public assistance and obesity: (1) public assistance causes obesity, (2) obesity causes public assistance, (3) poverty causes both public assistance and obesity, and (4) some ‘‘factor X’’ causes both public assistance and obesity. Each of these models is accorded a chapter in the book, and the author systematically summarizes and evaluates the existing evidence in support of each model. Moreover, subpathways are delineated within these models, which are also quite helpful in parsing out prior work. For Model One, Smith concludes that programs such as the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) and school food programs do not contribute to childhood obesity. For adults, Smith finds some evidence that participation in the food stamp program (FSP) is associated with a small-to-modest weight gain in women, likely through increased purchasing power and the monthly payment cycle, which can affect patterns of intake. Conclusions, however, remain tentative. For Model Two, there is sufficient evidence that obesity can function as a barrier to factors such as education, occupational attainment, earnings, and marital prospects among women, but no one has tested directly whether BMI affects the probability of being on public assistance. For Model Three, poverty leads to public assistance by definition. As for the influence of poverty on obesity, Smith focuses on how poverty influences food intake and physical activity. Potential mediators with varying degrees of empirical support include educational attainment, access to healthy foods, opportunities for physical activity, mental health, food insecurity, stress, and time preference. Lastly, Smith considers five possible ‘‘X factors’’ in Model Four: disabilities, mental illness, physical and sexual abuse, low intelligence, and high time preference. Only physical and sexual abuse garner empirical support as causes of both public assistance and obesity. 204 Reviews