What causes obesity? A major new study is upending common wisdom.
Why? A major study published this week in PNAS brings surprising clarity to that question. Using objective data about metabolic rates and energy expenditure among more than 4,000 men and women living in dozens of nations across a broad spectrum of socioeconomic conditions, the study quantified how many calories people from different cultures burn most days.
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For decades, common wisdom and public health messaging have assumed that people in highly developed nations, like the United States, are relatively sedentary and burn far fewer daily calories than people in less-industrialized countries, greatly increasing the risk for obesity.
But the new study says no. Instead, it finds that Americans, Europeans and people living in other developed nations expend about the same number of total calories most days as hunter-gatherers, herders, subsistence farmers, foragers and anyone else living in less-industrialized nations.
That unexpected finding almost certainly means inactivity is not the main cause of obesity in the U.S. and elsewhere, said Herman Pontzer, a professor of evolutionary anthropology and global health at Duke University in North Carolina and a senior author of the new study.
What is, then? The study offers provocative hints about the role of diet and some of the specific foods we eat, as well as about the limits of exercise, and the best ways, in the long run, to avoid and treat obesity.
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Is diet or inactivity causing obesity?
'There's still a lively debate in public health about the role of diet and activity' in the development of obesity, Pontzer said, especially in wealthy nations. Some experts believe we're exercising too little, others that we're eating too much, and still more that the two contribute almost equally.
Understanding the relative contributions of diet and physical activity is important, Pontzer noted, because we can't effectively help people with obesity unless we first tease out its origins. But few large-scale studies have carefully compared energy expenditure among populations prone to obesity against those more resistant to it, which would be a first step toward figuring out what drives weight gain.
So, for the new study, Pontzer and his 80-plus co-authors gathered existing data from labs around the world that use doubly labeled water in metabolism studies. Doubly labeled water contains isotopes that, when excreted in urine or other fluids, allow researchers to precisely determine someone's energy expenditure, metabolic rates and body-fat percentage. It's the gold standard in this kind of research.
They wound up with data for 4,213 men and women from 34 countries or cultural groups, running the socioeconomic gamut from tribes in Africa to executives in Norway. They calculated total daily energy expenditures for everyone, along with their basal energy expenditure, which is the number of calories our bodies burn during basic, biological operations, and physical activity energy expenditure, which is how many calories we use while moving around.
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A new theory of how our metabolisms work
After adjusting for body size (since people in wealthy nations tend to have larger bodies, and larger bodies burn more calories), they started comparing different groups. Anyone expecting a wide range of energy expenditures, with hunter-gatherers and farmer-herders at the high end and deskbound American office workers trailing well behind, would be wrong.
Across the board, the total daily energy expenditures of the 4,213 people were quite similar, no matter where they lived or how they spent their lives. Although the hunter-gatherers and other similar groups moved around far more throughout the day than a typical American, their overall daily calorie burns were nearly the same.
The findings, though counterintuitive, align with a new theory about our metabolisms, first proposed by Pontzer. Known as the constrained total energy expenditure model, it says that our brains and bodies closely monitor our total energy expenditure, keeping it within a narrow range. If we start consistently burning extra calories by, for instance, stalking prey on foot for days or training for a marathon, our brains slow down or shut off some tangential biological operations, often related to growth, and our overall daily calorie burn stays within a consistent band.
- - -
The role of ultra-processed foods
The upshot is that 'there is no effect of economic development on size-adjusted physical activity expenditure,' Pontzer says. In which case, the fundamental problem isn't that we're moving too little, meaning more exercise is unlikely to reduce obesity much.
What could, then? 'Our analyses suggest that increased energy intake has been roughly 10 times more important than declining total energy expenditure in driving the modern obesity crisis,' the study authors write.
In other words, we're eating too much. We may also be eating the wrong kinds of foods, the study also suggests. In a sub-analysis of the diets of some of the groups from both highly and less-developed nations, the scientists found a strong correlation between the percentage of daily diets that consists of 'ultra-processed foods' - which the study's authors define as 'industrial formulations of five or more ingredients' - and higher body-fat percentages.
We are, to be blunt, eating too much and probably eating too much of the wrong foods.
'This study confirms what I've been saying, which is that diet is the key culprit in our current [obesity] epidemic,' said Barry Popkin, a professor at the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill and an obesity expert.
'This is a well-done study,' he added.
Other experts agree. 'It's clear from this important new research and other studies that changes to our food, not our activity, are the dominant drivers of obesity,' said Dariush Mozaffarian, director of the Food is Medicine Institute at Tufts University in Boston.
The findings don't mean, though, that exercise is unimportant, Pontzer emphasized. 'We know that exercise is essential for health. This study doesn't change that,' he said.
But the study does suggest that 'to address obesity, public health efforts need to focus on diet,' he said, especially on ultra-processed foods, 'that seem to be really potent causes of obesity.'
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Boston Globe
31 minutes ago
- Boston Globe
Arbitration agreements shield assisted living homes from accountability, some experts say
Advertisement E.J. Lococo, a retired federal agent, said he thought it meant arbitration would apply if 'someone stole my mother's Depends or CD player. . . . I didn't know [that] if you were going to kill my mother, we were going to go to arbitration.' Yet, Lococo alleges, that is exactly what happened. His mother, 80, died in August 2021 from pressure ulcers that her family alleges went untreated for months while she was at the Atrium. Her son filed a wrongful death suit against Benchmark Senior Living LLC, which operates Atrium, on behalf of her estate last year. But in March, a judge granted the facility's motion to dismiss all claims against it, ruling the estate was legally required to resolve them through binding arbitration. Advertisement Facing steep filing fees and the costs of paying an arbitrator, Lococo's lawyer, Michael Grace, said he decided not to pursue arbitration against Benchmark. He is, however, going forward with claims against two outside companies that provided medical care to Judith Lococo while she lived at the Atrium, and were not included in the arbitration agreement. The case underscores the impact of arbitration agreements, which are legal and common in the assisted living industry, but severely restrict residents from holding facilities accountable when something goes wrong, according to elder care lawyers and advocates. 'Americans are more likely to be struck by lightning than win in forced arbitration,' according to a 2019 report by the American Association for Justice, a Washington, D.C.-based nonprofit organization for trial lawyers. Moreover, critics say, residents of assisted living facilities and their family members don't realize the implications of what they're signing. They also don't have to put themselves in that situation: they are not required to sign arbitration agreements as a condition of admission, these critics said, and should not do so. Unlike court proceedings, an arbitrator is privately paid, usually with both sides sharing the expense, which can cost plaintiffs thousands of dollars. Court rules don't apply, meaning plaintiffs may not call as many witnesses or obtain as much evidence as they believe they need to support their case. The arbitrator, usually just one person, is supposed to be neutral. But critics say the facilities too often have a preexisting relationship with an arbitrator who is likely to favor their side. And when arbitrators do rule in favor of plaintiffs, judgments tend to be much lower than those awarded by juries. Advertisement In Lococo's case, the arbitration agreement even included a clause that would require the family to pay Benchmark's legal fees if it filed a lawsuit. Benchmark declined to comment on Lococo's allegations, but said in a statement released by its lawyer that it 'places its highest priority on the care, safety and well-being of our residents.' The lawyer, Joseph M. Desmond, said in an email, 'We stand firmly behind the quality of care we provide and our attentive staff, whose skills consistently receive high marks for resident satisfaction.' He added that Benchmark's policy is 'to offer a voluntary arbitration agreement to individuals moving into our communities' and that arbitration 'is entirely optional and not a requirement for residency.' The Massachusetts Assisted Living Association, which advocates for the assisted living industry in the state, said arbitration has the advantage of resolving disputes more quickly and at a lower cost than through litigation. Arbitration agreements can be negotiated and amended before a resident moves into a home, a spokesperson said. 'Residents and families sometimes select an option for arbitration when they move in so that if they have concerns they can resolve them in a way that is both timely and less costly than litigation,' said Brian Doherty, the group's president. The devastating blaze that killed 10 residents of an assisted living facility in Fall River in July drew attention to the lack of transparency in the industry, which in Massachusetts is more loosely regulated than nursing homes. And, critics say, arbitration agreements contribute to that lack of transparency because the proceedings are not public and settlements are confidential. Those conditions can obscure from public view problems and dysfunction at a facility, details that would come to light in court proceedings. Advertisement Arbitration agreements, so far, at least, appear not to be a factor in the Fall River case. 'It has not come up in our case at this point,' said Robin Gouveia, who filed the first lawsuit on behalf of a Gabriel House resident. Arbitration agreements also include a clause requiring that residents agree not to sue the home or seek other court remedies. 'There's a constitutional right to have a jury and an arbitration clause takes it away with the swipe of a pen,' said David J. Hoey, an attorney who has represented families alleging abuse and neglect at nursing homes and assisted living centers for more than 30 years. 'I've arbitrated enough cases to know that they're unfair to the injured party.' In 2019, he filed a wrongful death suit on behalf of the estate of a client who was allegedly shoved to the ground by another resident at an assisted living home in Danvers, broke his hip, and later died of complications from the injury. A judge dismissed the suit against the operators, citing an arbitration agreement. The arbitrator ruled in favor of Hoey's client. But he said the judgment of $360,000, was much less than Hoey believed a jury would have awarded. The state attorney general's office is drafting new consumer protections for the assisted living industry, but a spokesperson would not say whether changes to arbitration clauses are under consideration. As attorney general in 2017, now-Governor Maura Healey signed on to a letter with counterparts from 16 states that criticized arbitration agreements and opposed a federal proposal to lift a ban on their use in nursing homes. Advertisement The federal government lifted its ban on arbitration clauses in nursing homes following a legal challenge. Instead, in 2019 it adopted new requirements, prohibiting nursing homes from denying admission to anyone who refused to agree to arbitration and allowing residents or their representatives 30 days to change their mind if they do sign one. Assisted living facilities, which are not regulated by the federal government, are not bound by the same arbitration requirements as nursing homes, but generally have adopted the same standards, according to Hoey. A Massachusetts commission formed this year to consider new regulations for the industry recommended a ban on them as a condition of admission in a draft proposal. Other states differ on how they regulate such clauses. Hoey said the agreements aren't foolproof and can be challenged in court on various grounds, including if they were signed by a person who didn't have legal authority to represent a resident or was under duress. Lococo's son said he tapped into his retirement savings to pay for his mother's care, including more than $13,000 a month to the Atrium at Cardinal Drive. Several months after she moved, COVID-19 swept the country, and the facility was placed in lockdown. Lococo said there were staffing shortages and he feared his mother wasn't getting the care they were paying for, which included assistance with bathing, toiletry, and medical treatment. She fell several times in late 2020, and developed bed sores, according to the lawsuit. Advertisement But, Lococo said, nobody at the facility ever told him his mother had developed a pressure ulcer around May 2021 that had allegedly gone untreated. He said he learned of it when the family moved her to another facility three months later and a nurse sent him graphic photos of her wound, showing exposed bone. 'I was enraged,' Lococo said. His mother died days later. 'These places that call themselves assisted living fly under the radar. . . How is this not regulated?' Lococo's attorney, Michael Grace, said family members generally don't think about something bad happening to their relatives after spending so much time and emotional energy finding an assisted living home for them. They waive their right to sue, he said, because they're thinking 'it looks like a good place and nothing is going to go wrong.' Shelley Murphy can be reached at
New York Post
31 minutes ago
- New York Post
This ‘dictator' of hormones has a major impact on sleep and metabolism — how to tell if your levels are out of whack
Stop the stresses! Cortisol is known as the body's primary stress hormone, but it has many essential functions. It naturally peaks in the morning to help you wake up and feel alert and then gradually decreases throughout the day to eventually prepare your body for sleep. Elevated cortisol over a long while can lead to increased appetite, weight gain, high blood pressure, muscle weakness, mood swings, a higher risk of diabetes, sleep troubles and skin problems. Cortisol, known as the 'stress hormone,' is produced and released by the adrenal glands. Creative Habits – That's why it's important to know your cortisol patterns. Enter Eli Health, a Montreal-based health tech startup that recently soft-launched an at-home instantaneous cortisol test. 'We started the company six years ago, initially out of a personal need,' Marina Pavlovic Rivas, cofounder and CEO of Eli Health, told The Post. 'We started with this hormone, given the wide-reaching impact it has on health.' Here's a look at how the test works — and how to improve cortisol levels. What does cortisol do? Cortisol is made and released by the adrenal glands in response to stress. Light exposure, diet and sleep also significantly influence cortisol levels. Cortisol can directly affect mood. It can lead to depression and anxiety if it's out of whack. Yura Yarema – The hormone dictates the body's fight-or-flight response, while helping to manage blood pressure and blood sugar levels and regulate immune function. 'It goes way beyond stress — it has an impact on all bodily functions,' Pavlovic Rivas said about cortisol. '[It's been] said that hormones are not a democracy, and that cortisol is the dictator,' she added. 'When cortisol is dysregulated, it has a trickle-down impact on all other hormones that also play a role in health.' How does the Eli Health test work? Eli Health recommends testing at least every two weeks to monitor your cortisol curve. 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A healthy diet, moderate-intensity exercise, consistently adequate sleep, mindfulness practices, time in nature and supportive relationships can contribute to healthy cortisol levels. A line appears in the window if saliva has been properly collected. Cortisol levels are calculated in the app within minutes. Courtesy of Eli Health 'We've seen this again and again in the user base,' Pavlovic Rivas said. 'For some people, for example, just being out in nature would be enough to have a very significant impact on cortisol.' Pavlovic Rivas said that users have also noted that their late-night high-intensity workouts may not be as helpful as they thought. 'At night they feel tired but wired, don't have a great night of sleep,' she said. 'By being able to see that their cortisol curve is dysregulated with higher levels in the evening, [they can] prioritize lower intensity exercise in the evening or do it earlier in the day.' Cortisol testing is slated to be fully available to the public at the end of September. Eli Health also plans to launch its testing system for the fertility hormone progesterone — which regulates the menstrual cycle and influences mood, sleep and energy — in the fall.
Vox
32 minutes ago
- Vox
How 'the Grim Reaper effect' stops our government from saving lives
is a senior correspondent and head writer for Vox's Future Perfect section and has worked at Vox since 2014. He is particularly interested in global health and pandemic prevention, anti-poverty efforts, economic policy and theory, and conflicts about the right way to do philanthropy. Last summer, the Congressional Budget Office released a report under the unassuming name 'Budgetary Effects of Policies That Would Increase Hepatitis C Treatment.' I read it because I am the type of person who is interested in the budgetary effects of policies that would increase hepatitis C treatment. Embedded in the report, though, was a point that will be important for just about anything the federal government tries to do to save the lives of Americans. Hep C is a nasty viral infection whose effects are, for a virus, unusually long-lasting. Untreated, it causes serious liver damage over the course of decades, leading to much higher rates of cirrhosis and liver cancer, all of which is very expensive to treat. But in the 2010s, a number of extremely effective antivirals, which randomized trials show cure upwards of 95 percent of chronic infections, came on the market. Like most new drugs, these antivirals are under patent and quite expensive; as of 2020, the cost of an eight-to-twelve week course of the drugs, usually enough to cure an infection, was between $11,500 and $17,000. Yet CBO concludes that the drugs are so effective, and the costs of treating patients with hep C who haven't been cured are so massive, that expanding treatment with these drugs reduces federal spending on hep C treatment and associated complications overall. Doubling the number of Medicaid patients getting the drugs would increase federal spending by $4 billion over 10 years. But over the same decade, the federal government would save $7 billion through reduced need for treatments like liver transplants and ongoing care for chronic cases. Put like that, this starts to sound like one of the rarest discoveries in federal budgeting: a free lunch. That means a policy that is good on its own merits (saving lives and preventing debilitating chronic disease) but also saves the government money. But the most interesting part of the report to me comes at the end. 'An increase in hepatitis C treatment could also affect the federal budget in other ways—for example, by leading to improved longevity and lower rates of disability,' the authors note. The latter point is pretty straightforward: If hepatitis C leads to disabilities that make people eligible for disability insurance and subsidized health coverage, then reduced hep C means lower spending on those programs. But (and this is me speculating, so blame me and not the CBO if I'm wrong) that effect is probably swamped by that of 'improved longevity.' Simply put: curing hep C means people live longer, which means they spend more years collecting Social Security, Medicare, and other benefits. That could mean that whatever cost savings the actual hep C treatment produces might be wiped out by the fact that the people whose lives are being saved will be cashing retirement checks for longer. I like to call it the Grim Reaper effect. The US runs a large budget deficit. It also provides far more generous benefits to seniors than to children or working-age adults. Per the Urban Institute's regular report on government spending for children, the ratio of per capita spending on senior citizens to per capita spending on children is over 5 to 1. Put together, the deficit and the elder-biased composition of federal spending implies something that is equally important and macabre: helping people live longer lives will, all else being equal, be bad for the federal budget. In an increasingly aging country, hep C is not the first place where the Grim Reaper effect has been felt, and it won't be the last. I don't have an easy fix for the situation, but it feels important to at least understand. Logan's Run economics One of the first and clearest cases of this longevity dilemma in budgeting came with cigarettes. The history of mass cigarette smoking in the US is surprisingly short. Per the CDC, American adults were only smoking 54 cigarettes annually per capita as of 1900. By 1963, that number had grown to 4,345. The development of automatic rolling machines, milder forms of tobacco, and mass marketing meant millions of working and middle-class Americans became pack-a-day smokers. But while the per capita average floated around 4,000 from the late '40s to the early '70s, it then began a precipitous decline. In 2022, the most recent year for which the Federal Trade Commission released data, Americans bought 173.5 billion cigarettes, or 667 per adult, less than a sixth of the peak, while fewer than 12 percent of American adults now smoke. Cigarettes are, of course, deadly, but they kill with a lag, usually after decades of regular smoking. That meant that in the late 1980s and 1990s, the US started to hit peak cigarette deaths, as adults who came of age during the smoking era started to get lung cancer and emphysema en masse, at numbers that less-addicted subsequent generations wouldn't match. The male death rate from lung cancer peaked in 1990, and the female death rate peaked in 1998. A flurry of economic research at the time tried to make sense of what this meant for the federal budget. Smoking harms your health. But it also shortens your lifespan. A useful 1998 Congressional Budget Office report noted that most research found that, over their lives, smokers spend more in health care costs (including more that goes on the federal tab) than non-smokers, even accounting for their shorter lifespans. But that picture changed once you added in pensions and other non-health spending. Economists John Shoven, Jeffrey Sundberg, and John Bunker in 1989 estimated that the average male smoker saved Social Security $20,000 (about $60,000 today) in benefits not paid. The figure for women, who live longer than men on average but earn less in wages and thus in Social Security, was about half that. 'It seems likely that the Federal budget currently benefits from smoking,' two Congressional Research Service researchers concluded in 1994, when the 'benefits' of early death to Social Security and Medicare were included. Malcolm Gladwell, in a thoughtful 1990 treatment of the problem in the Washington Post, was catchier: 'Not Smoking Could be Hazardous to Pension System.' Decades later, the CBO did a fuller analysis of the budgetary consequences of smoking in the aftermath of the large cigarette tax increase President Obama signed in early 2009 and proposals for further hikes. At first blush, the revenue raised from a cigarette tax should be easy to estimate: multiply annual cigarette sales by the amount of the tax. But obviously raising the price of the good will reduce the amount people buy; one major reason for cigarette taxes, after all, is to deter smoking. The CBO used a price elasticity of -0.3, meaning that a 10 percent increase in cigarette prices reduces the number sold by 3 percent. But the 2012 report was meant to go a step or two further, according to then-director Doug Elmendorf, who explained the backstory in a recent conversation with me. 'The effects of making people healthier are good for those people, obviously, but also perhaps good for the federal budget because the federal government pays for a lot of health care. If you're healthier, you don't need so much health care.' But at the same time, 'It was clear that if people were healthier, they would live longer, and that could have budgetary costs. It wasn't obvious offhand what the balance of those effects would be.' The 2012 CBO report tried to put all these effects together: the effect of lower smoking on reducing health-care spending (including government-funded spending) due to a healthier population, the effect on Social Security and other benefit spending from resulting longer lifespans, the effect of lower smoking rates on wages, and tax revenue from those wages. (The latter is often not included in formal CBO scores, as it tips closer to 'dynamic' scoring where the effect of legislation on the overall economy is included.) Over the first 10 years after a hike in the cigarette tax, they found that having a healthier population was more of a blessing than a curse, budget-wise. The health effects of a cigarette tax hike reduced federal health spending by over $900 million over a decade, even after accounting for people living longer and claiming more years of Medicare. By contrast, retirement programs only spent $183 million more because people lived longer. Swamping all that was a $2.9 billion increase in tax revenue from a healthier population capable of working and earning more. But that's just the 10-year effect. As the decades pass, the effect of longevity would grow and grow. First, Medicare costs would start to rise, as the cost of a longer-lived population began to swamp the cost savings of that population being healthier overall. (Even people who've been healthy for a long time can run up major health spending at the end of their now longer lives.) Social Security costs would keep rising, too. Fifty years in, these costs would overwhelm the benefits, and the cigarette tax's health effects would start costing the budget, on average. The point isn't 'cigarette taxes are good' or 'cigarette taxes are bad.' The point is that even a policy that saves lives isn't necessarily a slam dunk from the hard-eyed perspective of budget policy. Recent years provided a possibly even darker example. In 2022, the Medicare Trustees pushed back the date they expected the program's Hospital Insurance Trust Fund to be depleted by two years. They had several reasons, but a major one was that Covid-19 had killed hundreds of thousands of Medicare patients prematurely. Not only that, but 'Medicare beneficiaries whose deaths were identified as related to COVID had costs that were much higher than the average Medicare beneficiary prior to the onset of the pandemic.' Put another way: Covid killed off Medicare's sickest, and most expensive, enrollees. That meant the program was left with an overall healthier population, which by itself lowered medical costs by 2.9 percent in 2021. Similarly, a paper by a team of health economists earlier this year estimated that the 1.4 million excess deaths in the US due to Covid had the net effect of boosting the Social Security trust fund to the tune of $156 billion. That represented $219 billion in benefits that no longer needed to be sent, minus $44 billion in lower payroll tax revenues and $25 billion in new benefits to surviving family members. It all reminds one of Logan's Run, in which people are killed off upon hitting age 30 lest they take up too many of society's resources. That movie is a dystopia — but as a budget proposal, it'd score very well. It's good to save lives, actually The economists and agencies doing this math are, of course, only doing their jobs. We need to know what government programs will cost over the near- and long-run. These effects on health and life and death matter to those calculations. 'Members of Congress regularly thought that we were ghoulish for talking about how, if people live longer, there'll be higher benefits for Social Security,' Elmendorf recalls. 'But it's not ghoulish. Obviously, we want to live longer and members of Congress should try to help all Americans live longer. CBO's job — an analyst's job in general — is just to be honest about the likely effects.' But the fact that increased human longevity on its own worsens the budget picture should lead to some reflection. For one thing, it suggests that sometimes we should embrace policies simply because they're the right thing to do, even if they don't pay for themselves. Recall the hepatitis C treatments that prevent expensive long-term expenses for Medicaid, but might add on new costs by extending the benefits' lifespans. It's possible that, upon taking the latter into account, expanding access to hep C drugs costs the government money on net. It's a free lunch no longer. That's not a reason not to embrace the policy, though. Lots of things the government does cost money. The military doesn't pay for itself. K–12 schools don't pay for themselves. Smithsonian Museums don't pay for themselves. That doesn't mean those aren't important functions that it makes sense to put some of our tax dollars toward. Hep C treatment, I think, fits in that list, even if it's not literally free from a budget standpoint. Congress should also allow agencies like the CBO to do more to symmetrically account for the positive budgetary effects of longevity, along with the negatives. People who live longer, after all, often earn wages in those new years of life, wages that generate income and payroll tax revenues for the federal government. Moreover, people at the end of their careers are earning more money and hence paying more taxes than young people, meaning life extension helping people in their 50s and 60s might be especially good for tax revenue. The problem is that the CBO generally considers 'how many workers paying taxes are there' to be an economic effect and only considers it in special 'dynamic' scores of legislation, in which the economic consequences of them are taken into account. Dynamic scoring has been a topic of great controversy for decades, going back at least to the Bush II administration, but the rule Congress sets for CBO on when to use dynamic scoring results in CBO applying dynamic scoring very rarely in practice. A middle ground option, though, would be something called 'population change' scoring, in which CBO considers the direct effects of a change in the population (through longer lifespans, say, or immigration) on the level of employment and tax revenue, without doing a full, more complicated dynamic score. That would make its accounting of the effects of longer lives less biased: the budgetary benefits would be counted alongside the costs. We should also consider the aspects of our budget situation that make the longevity effect a reality. One is the US's long-standing, bipartisan choice to run massive budget deficits, even during relative boom times. One arithmetic consequence of that choice is that it makes the continued existence of every American a net loss for the country's books. That's not the main reason to avoid large deficits during booms, but it's a somewhat toxic byproduct all the same. The other aspect driving this effect is the choice to invest government resources very heavily in seniors relative to other age groups. This is due in large measure to the US choice to provide universal health care for seniors but not other age groups, and due to our lack of investment in very young children and working-age adults compared to other rich nations. There is no law of nature saying the US has to weigh its priorities that way. As long as we do, the numbers will imply that it's better for the budget for people to die before they get old.
