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Young Adult Obesity and Household Income: Effects of Unconditional Cash Transfers

Development Challenge

Obesity is poised to become the most significant non-communicable disease threat to public health and may slow or even reverse progress made reducing mortality in high-income countries.[1],[2] In the United States, there has been a drastic increase in the prevalence of childhood and adolescent obesity since the 1980s. According to the 2008 National Health and Nutrition Examination Survey, 11.9% of children aged 2–19 were at or above the ninety-seventh percentile of the Body Mass Index (BMI) for age growth charts, and 17% were at or above the ninety-fifth percentile.[3],[4] Being overweight in adolescence is a predictor of later-life obesity, diabetes and heart disease. Research has shown that there is a strong correlation between poverty and obesity, though little is understood about the relationship.  Given that the poverty rate in the United States stands at its highest since 1993, further research on this relationship is urgently needed. One hypothesis about the relationship between poverty and obesity suggests that as incomes increase, individuals consume greater quantities of food, and thus gain weight and increase the BMI. Beyond a certain income threshold however, diets increase in terms of quality and nutrition or health-related activities are pursued, resulting in a decrease in BMI. This study seeks to empirically describe this relationship by evaluating the impact of cash transfers on adolescent BMI.


This study examines the effects of cash transfers on young adults from tribal communities by measuring changes in BMI of young adults in the Eastern Cherokee tribe of North Carolina. The Indian Gaming Regulatory Act (IGRA) of 1988 enabled Native American tribes to build casinos and other potentially lucrative gaming ventures on their reservations in order to increase tribal incomes and help lift tribe members out of poverty. This evaluation contributes to the growing body of literature evaluating the effects of casino transfers on tribal members’ wellbeing, as well as determining the health effects of public policy interventions in childhood. 

Evaluation Strategy

The study utilized health data from the Great Smoky Mountains Study of Youth (GSMS), which is a panel survey of American Indian and non-American Indian adolescents from western North Carolina. The survey began in 1993 and the children were interviewed annually up to the age of 16, and then re-interviewed at ages 19 and 21. After the fourth year of the study, a casino was opened on the Eastern Cherokee reservation and began distributing a portion of its profits to all adult tribal members every six months. The average annual amount per person was approximately $4,000.

The research team studied the impacts of the cash transfer on BMI, height, weight, and obesity between children whose family received the cash transfers for four years, those who received the cash transfer for two years, and those who did not receive a cash transfer at all (nontribal members). In their analysis, the team also considered other factors that have potential to explain changes in a child’s obesity and BMI, such as the child’s birth weight (a proxy for individual health endowment), their mother’s education level and job status, distance between the child’s home and the casino, as well as the child’s own education at age 19.

Results and Policy Implications

The findings indicate that the cash transfers increased BMI among children from low income families, but not among their better off peers. Further investigation revealed that this is primarily due to weight gain among the youth from poorer backgrounds. Researchers showed that the weight gain among poorer children was not linked to many other potential factors such as birth weight, initial BMI (before the cash transfers), initial health conditions, or mothers’ job status.

The uneven impact of extra household income on children from different socioeconomic backgrounds has several implications for the design of welfare policies. First, policies that are intended to close the gap in socioeconomic status will have unintended medium-term effects on the BMI of young adults from impoverished families. Second, exposure to poverty during childhood cannot be fully tempered by increases in family income later in life. Finally, children’s body mass is likely to react to income transfers more quickly than other health outcomes, such as chronic conditions. Research on the long-term health effects of household income transfers should consider potential for differences in impact between children from varying socioeconomic backgrounds.



[1] Lancet. 2011. “Urgently Needed: A Framework Convention for Obesity Control.” 378 (9793): 741.

[2] Swinburn, Boyd A., Gary Sacks, Kevin Hall, Klim McPherson, Diane Finegold, Marjory Moodie, and Steven Gortmaker. 2011. “The Global Obesity Pandemic: Shaped by Global Drivers and Local Environments.” Lancet 378 (9793): 804–14.

[3] United States Department of Health and Human Services. Centers for Disease Control and Prevention. National Center for Health Statistics. “National Health and Nutrition Examination Survey (NHANES), 2007–2008.” ICPSR25505-v3. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2012-02-22. doi:10.3886/ICPSR25505.v3.

[4] Ogden, Cynthia L., Margaret D. Carroll, Lester R. Curtin, Molly M. Lamb, and Katherine M. Flegal. 2010. “Prevalence of High Body Mass Index in US Children and Adolescents, 2007–2008.” Journal of the American Medical Association 303 (3): 242–49.