Recently, I blogged about our observation that even in a publicly funded health care system, lower income patients are less likely to receive bariatric surgery than folks with higher income.
A new study by Thomas von Lengerke and colleagues from the University of Hannover, Germany, published in Psychosomatic Medicine, looks at the impact of socioeconomic status (SES) on direct medical costs for severe obesity in Germany (which has a mixed private and public insurance based health care system).
The researchers compared the costs of severe obesity among German adults in a subsample (N=947) of the KORA-Survey S4 1999/2001 (a cross-sectional health survey in the Augsburg region, Germany; age group: 25-74 years). Data included visits to physicians, inpatient days in hospital, and received and purchased medication. Body mass index was measured and SES was determined via reports of education, income, and occupational status from computer-assisted personal interviews.
In contrast to what the researchers expected (given the propensity for lower-SES patients to be heavier and have more medical problems), the excess costs of severe obesity were substantially (almost three-fold) higher in respondents with high SES (plus euro 2,966 vs. plus euro 1,012).
The differences were even greater after adjustment for the Physical Functional Comorbidity Index (PFCI), with severe obesity’s excess costs being euro 2,406 in the high SES-Index group versus only euro 539 in the lower status group.
This study confirms our findings (using the example of bariatric surgery) that despite similar or greater obesity burden, lower SES patients are less likely to incur direct health costs related to severe obesity.
Several factors may explain these findings:
1) Poorer patients may be less likely to recognize severe obesity as a medical condition that requires medical and/or surgical treatment.
2) Health services may be less accessible to lower SES patients for monetary reasons such as transportation to doctor/clinics, parking, taking time off work, etc.
3) Lower SES patients may be more prone to weight-bias and discrimination thereby making them less likely to seek out and insist on receiving the same level of health care as better-off patients.
Whatever the reasons, it appears that social inequality in access to obesity treatments and equitable allocation of health care resources across the SES continuum is an issue that is not just limited to Canada.
I’d love to hear what my readers think are the likely causes of this disparity and any suggestions that may help address this important issue.
von Lengerke T, John J, Mielck A, & KORA Study Group (2010). Excess direct medical costs of severe obesity by socioeconomic status in German adults. Psycho-social medicine, 7 PMID: 20421952
No doubt, the obesity epidemic is costing employers billions!
No doubt, sedentary jobs, unhealthy cafeteria food, and high job-related stress are all important contributors to the obesity epidemic.
So what would make more sense than to try to address obesity in the workplace?
To meet this need, the CDC yesterday launched a new website LEAN Works, which provides employers with extensive step-by-step recommendations, resources, and other features to address obesity in their employees.
Some of the features include:
– An obesity cost-calculator
– Information and resources to help employers set up and assess interventions to combat obesity.
– Information on how employers can estimate return on investment
While I have no doubt that the intentions are admirable and that the information provided is based on the best available evidence, the focus (as you may already guess) is sadly only on improving eating and activity behaviours.
Thus, I did not see much talk about depression and weight gain, emotional eating, dealing with past abuse, addressing food addiction, managing pain, coping with obesogenic medications, improving body image and self-esteem, managing peer pressure, or seeking competent medical advise on obesity medications and surgery (if I have missed any of this, please feel free to point this out).
What I did see was the usual recommendation to improve cafeteria diet, exercise prescriptions and opportunities, as well as the ubiquitous “weight-loss” competitions. Regular readers will appreciate my previous concern with all of the above, especially the nonsensical “competitions”, about which I have blogged before.
Regular readers will also perhaps recall my previous concerns on how targeting obesity with well-meant but simplistic “eat less – move more” messages can potentially do more harm than good, by simply reinforcing the “obese people are lazy gluttons” stereotype. I have previously blogged about the potential of workplace wellness programs to promote bias and discrimination.
Given the accumulating evidence that weight-bias and discrimination actually prevents people from adopting healthy lifestyles and may simply make the problem worse, I wonder what impact this program will have on people, who actually suffer from this condition?
Remember, overeating and undermoving are symptoms and not the root causes of obesity. Addressing the root causes of obesity requires truly identifying and understanding the actual determinants of overeating and undermoving: stressors, food insecurity, peer pressure, mental health, abuse, medications, self-esteem, long commutes, urban sprawl, absentee parents, and countless other factors that I can think of, which truly underly the causes of the obesity epidemic.
Australia and Canada are both large, highly industrialized and urbanized countries with rather high standards of living and relatively small populations (20 Million in Australia; 33 Million in Canada).
Interestingly, so are their rates of obesity: around 16-18% in adults, around 8-10% in kids.
So what is obesity costing these countries? I do not have the latest figures for Canada, but a report released this week by Access Economics, Australia’s premier economic consulting firm, estimates the total costs of obesity in Australia for 2008 at a staggering $58.2 Billion.
Assuming that the financial burden of obesity in Australia is probably not that different from the cost of obesity in Canada – simply based on the population size, this would translate to around $95 Billion in Canada.
Obviously, there may be some important differences in the health system and other relevant factors between Australia and Canada, so I am wiling to give or take a few Billion here or there.
No matter what, this number is staggeringly different from any estimate of obesity costs that I have heard for Canada. The most common number bounced around is about $3.5 Billion, which comes from an estimate of direct and indirect health care costs of obesity in Canada published in 1997.
While everyone appreciates that that number, given today’s obesity rates is a ridiculously low estimate, the numbers for Canada extrapolated from the Australian data for 2008 are more than 20-fold higher. This is both due to the growth in obesity in the last decade, but also due to the different and expanded methodology used by the Australian economists.
So what numbers did Access Economics come up with for obesity costs in Australia?
– The financial cost of obesity in 2008 was estimated as $8.283 billion. Of this, productivity costs were estimated as $3.6 billion (44%), health system costs were $2.0 billion (24%) and carer costs were $1.9 billion (23%).
– DWL from transfers (taxation revenue forgone, welfare and other government payments) were $727 million (9%) and other indirect costs were $76 million (1%).
– The net cost of lost wellbeing (the dollar value of the burden of disease, netting out financial costs borne by individuals) was valued at a further $49.9 billion, bringing the total cost of obesity in 2008 to $58.2 billion.
– Of the financial costs, 29.4% are borne by individuals, 19.2% by family and friends, 34.3% by Federal Government ($2.8 billion per annum), 5.1% by State Governments, less than 0.1% by employers and 11.8% by the rest of society. However, if the cost of lost wellbeing is included, the individual’s share rises markedly to 90.0% of the total.
I am no financial genius, but $95 Billion sounds like an awful lot of money. Unless the Access Economics fellows are totally off the mark or Canada is substantially more different from Australia than I suspect, this obesity problem is way more expensive than most Canadians (including the Government?) suspect.
As I have blogged before – the real cost of obesity is not in health care – it is in the loss of wellbeing and productivity of our current and future workforce.
The following quote is taken from a recent article in the ECONOMIST on the discontent of Americans with the economic state of their country:
Petrol prices, despite their recent retreat, hurt nearly everyone. Adam Julch, an enormous former college football star who is now a manager at a trucking firm in Omaha, Nebraska, complains that he had to trade in his pickup truck for a little Honda Civic. “I’m 350 pounds,” he says, “I feel like I’m in a clown car.”
Two aspects of this quote deserve comment:
1) Yes, larger people need larger cars to move them around – more larger people could mean more larger cars. This is not unlike the idea that it may not be the huge portion sizes in restaurants that lead to obesity but rather it is obesity that leads to larger portions sizes in restaurants (yes, large people need more calories and generally have bigger appetites than thin people) – so restaurants have to serve up portions large enough to feed even their hungriest customers.
2) The fact that this was a former athlete, as are many of my biggest patients, emphasizes that even being a highly successful competitive athlete does not protect you from severe obesity later in life.
Now there is food for thought. Feel free to comment.
Hat Tip to Michael Dwyer for bringing this quote to my attention
Given the strong relationship between excess weight and emotional, physical and economic health, it may be reasonable to pose the question whether obesity is a risk factor for early disability?
This question was just addressed by Martin Neovius and colleagues from the Karolinska Institute, Stockholm, Sweden, who examined the association between obesity status in young adulthood and disability pension in Sweden (International Journal of Obesity).
The aim of this study was to investigate risk of future disability pension according to body mass index (BMI) in young adulthood. BMI was measured at military conscription (1969-1994) in 1,191,027 young male recruits. Date and cause of disability pension, death and emigration dates were collected from national registers (1971-2006).
During 28.4 million person-years, 60,024 subjects were granted disability pension. The hazard ratios (HRs) for overweight (1.36), moderate (1.87) and morbid obesity (3.04) were significantly elevated compared to normal weight individuals.
Excess disability was associated with problems related to circulatory, musculoskeletal, tumor, nervous system, and psychiatric disorders.
Based on these data, the authors suggest that productivity losses associated with adverse BMI in young adulthood appear to be large (a rather stark understatement, if I ever heard one).
Remember, this was a study on people whose BMI’s were high as far back as 1969. Given our present obesity epidemic in children and young adults, I wonder what disabilty rates will look like 20 years from now.
I don’t want to be the fella spreading doom and gloom all over, but it sure makes me wonder whether, despite all the talk, we are really doing all we can to prevent and treat obesity.