Dr. Sharma's Obesity Notes

This may seem like a stupid question - of course, many readers will probably agree, that we need to prevent and better manage childhood obesity, no matter what it costs.

But in the end, someone still has to pay the bills, and so knowing what it may cost, is not an unreasonable question to ask.

The problem, however, is that economic forecasts are highly dependent on all kinds of assumptions and the perspective of what costs count, depends on who is looking - a narrow ‘health-care’ cost perspective is very different from a broader societal perspective of lost income, reduced productivity, and the substantial emotional cost of obesity (much of which has little to do with obesity itself but rather results from the pain caused by the societal bias and discrimination that kids and adults with excess weight have to endure).

Nevertheless, even with a very narrow perspective through the lens of people who pay for health care, these kind of analyses can be enlightening.

Therefore, it is with interest that I read the paper by Sai Ma and Kevin Frick from the Johns Hopkins Bloomberg School of Public Health, published in the latest issue of Academic Pediatrics.

As the authors point out:

“To endorse interventions at the earliest ages, one needs to understand 3 critical details: 1) the persistence of childhood obesity into adulthood, 2) the degree to which interventions are likely to be adopted by the children and their families at different stages in children’s lives, and 3) the potential returns on investment.”

So this study attempts to project at what level of effectiveness and cost a population-based or targeted intervention for childhood obesity would yield a positive net economic benefit.

The analyses is based on data from the National Health and Nutrition Examination Survey, the persistence of obesity from childhood to adulthood from a literature review, and a cost estimate from the 2006 Medical Expenditures Panel Survey.

Simulations were conducted to estimate the break-even point for interventions that take place between ages 0 and 6 years, ages 7 and 12 years, and ages 13 to 18 years, with a range of effectiveness.

The simulations show that, from a pure medical cost perspective, spending approximately $1.4 to $1.7 billion at present value for each birth cohort will break even if 1 percentage point reduction in obesity among children is achieved.

If this 1 percentage point in obesity rates is achieved through population-based interventions, they would break even between $280 and $339 per child at present value.

In contrast, If this 1 percentage point reduction is achieved solely by targeting obese children, one could afford to spend up to $1648 to $2735 per obese child.

In addition, the authors note that:

“…although for population-based interventions, per capita breakeven point for every percentage point reduction is about the same in each age group, to reach 1 percentage point reduction requires a higher effectiveness level of the intervention in the younger age group. For example, for every 2 percentage point reduction in obesity, a 55% effectiveness level is needed among the 0- to 6-years age group, 20% effectiveness level is needed for those aged 7 to 12 years, and approximately 17% is needed for those aged 13 to 18 years. This implies that interventions need to be more effective for younger children than those targeting older children in order to achieve the same economic returns.

The high cost savings of targeted interventions and needed higher effectiveness of interventions for children aged 0 to 6 years implies that providing targeted approaches perhaps makes more economic sense than providing population-based interventions.”

In support to favouring targeted interventions for younger kids, the authors discuss that:

“Limited research has found engaging parents is one single important effective factor among early interventions, which again requires intensive and customized interventions. Additionally, empirical evidence suggests preventions targeting high-risk children, such as children with obese parents or from disadvantaged backgrounds, could achieve better results than those offering service to the whole population of children.

In contrast, a population-based approach could be more applicable for older adolescents because they have a much higher obesity rate (18%), and there are problems such as stigma and feasibility imbedded in targeted interventions.”

As the authors also discuss, these estimates need to be taken with a grain (or rather a teaspoon) of salt, as we do not really know what health problems will actually develop in today’s kids with overweight and obesity (they may well end up far healthier than we think). Also, we don’t really know how health care costs will increase in the future.

Perhaps, even more importantly, while the authors tell us how much one could ‘afford’ to spend on these measures, they also note that data showing that any such interventions would actually work are rather limited - indeed, I am not aware of any strategies that have actually shown sustainable population-level reductions in 1 percentage point in obesity prevalence.

So even if policy makers did make this money available for addressing childhood obesity, it is not readily apparent on what specific interventions (population-wide or targeted) this money would actually be best spent to achieve this result.

In my patients, I always worry about balancing the potential risk of doing nothing against the potential risk of doing the wrong thing.

At a population level such risk-benefit analyses are even more daunting. As with all complex problems, wrong policy decisions (no matter how well-intended), that result in ‘unintended consequences’ (e.g. increasing weight-bias, reinforcing obesity stereotypes, promoting unhealthy weight-obsessions or dieting behaviours, etc.), could potentially harm far more people than they help.

All cost discussions aside, perhaps improving the health of the population by making it easier for all kids and adults to eat healthier, increase their physical fitness, and feel good about themselves (no matter what their weight), may not only reap greater health benefits but also turn out to be far more affordable and feasible than focusing too narrowly on simply reducing obesity percentage points.

Let us save the obesity treatments for the folks, who really need them.

AMS
Toronto, Ontario

Ma S, & Frick KD (2011). A simulation of affordability and effectiveness of childhood obesity interventions. Academic pediatrics, 11 (4), 342-50 PMID: 21764018

Government can hope to affect the health of populations by using fiscal measures to give tax credits for positive behaviours and to slap punitive taxes on behaviours that are deemed harmful - typical examples would be a tax-write off for gym-memberships and higher sales tax on fast food or sugary pop.

While both measures (and similar types of incentives or disincentives) may appear popular (the former, because everyone loves tax cuts or tax returns and the latter because everyone likes to see the ‘bad guys’ punished), whether any such measure are actually effective or even affordable is less clear that people may think.

This topic, in the context of using tax incentives to promote physical activity, is now explored in a paper by Barbara von Tigerstrom from the University of Saskatchewan published in the latest issue of the American Journal of Public Health.

These incentives come in two flavours: tax credits and sales-tax exemptions - both measures have recently been introduced in various jurisdictions across Canada.

Tax credits for enrollment and participation in physical activity include the federal government’s Children’s Fitness Tax Credit (CFTC) and credits for the use of public transportation. Several provinces and territories have or are currently looking into introducing similar measures.

With regard to sale-tax rebates or exemptions, although not specifically aimed at promoting physical activity, Ontario and British Columbia have dabbled in reduced taxes for bicycles and childrens’ recreational clothing and footwear, while Other provinces, such as Saskatchewan and Manitoba, do not impose sales tax on a broader range of athletic and recreational programs.

While all of this sounds good at first glance, von Tigerstrom and colleagues discuss that these measures may not be as effective as people may think and may in fact be rather expensive for the ‘return on investment’.

After all, these programs result in a substantial ‘investment’ costing the governments:

“When a government creates tax credits or exemptions, it chooses to forgo tax revenue that would otherwise be collected. Such measures, referred to as ‘‘tax expenditures,’’ therefore represent investments of public funds that should be justified in the same way that direct spending is.

The cost of the measures recently introduced in Canada is substantial. For example, the CFTC is estimated to cost the federal government approximately $90 million to $115 million each year in forgone tax revenue.

The province of Saskatchewan, with a population of about1million people, budgets $11 million to $18 million annually for its Active Families Benefit, out of a total departmental budget (Tourism, Parks, Culture and Sport) of approximately $113 million to $138 million.”

Not surprisingly, such measures are generally enthusiastically supported by those who have the most to gain - the fitness and recreational industry, which has lobbied governments with optimistic estimates on how such investments can pay substantial dividends in health care savings and tax revenues from a more productive workforce.

Needless to say, all of the optimistic assumptions for such calculations (as outlined in this paper) require some ‘blue-sky’ assumptions and have virtually no data to demonstrate their actual impact (which of course, as is usual with most such interventions, everyone is careful not to actually measure).

In fact, most of the limited data available show or suggest that such tax-expenditures have minimal effects, if any.

As the authors note:

“It is easy to spot the flaws in this assessment, but it is much more difficult to make a sound and realistic prediction of the long-term impact of tax incentives on a complex, multifactorial behavior like physical activity. No data exist on the extent to which income tax incentives change health behaviors because the fitness tax credits are the first income tax initiatives to have this aim, and no studies have yet directly studied their impact on physical activity.”

“Furthermore, even if a tax credit does encourage more parents to enroll their children in eligible programs, it is not clear what impact this would have on the children’s overall levels of physical activity. Will a child continue to be active on days when he or she is not participating in the organized activity or after the program has ended? If not, the benefits will be very modest in proportion to the government’s investment. If participation in organized physical activity does occur, will it simply displace physical activity that would have taken place in the form of free play or casual sports or games?”

“A related concern is that a tax credit will not provide an equal benefit or incentive to all families and in particular may not have much effect on lower-income groups.”

In contrast to tax credits, sales tax exemptions or rebates may have advantages in that they provide an immediate incentive and would particularly make expenditures more affordable for lower-income families. However, it is not evident that the magnitude of such rebates (about 6-8% in most provinces) would in itself have enough of an impact on prices to make these services or products more affordable and provide a real incentive to change behaviours.

It is far more likely that:

“…most tax-based schemes will create windfall gains for families that are inclined toward physical activity and that could easily afford the costs of programs and equipment without any public support.”

Another concern is that:

“Tax expenditures aim to affect individual behaviors without addressing systemic factors that could be strong influences on those behaviors; for example, they give incentives to register in physical activity programs or to purchase equipment, but they do not necessarily affect the availability of such programs or of safe places to use the equipment.”

In summary:

“The estimated costs of the tax-based programs in Canada are substantial; therefore, it is important to consider whether those public funds are better spent on other strategies that could instead provide direct public funding to improve recreational facilities and active transportation networks or to enhance physical activity programs in schools.”

I guess in the end we will still be likely to see more policies that are populistic and ‘buy’ votes than fiscal policies that actually make sense.

AMS
Edmonton, Alberta

von Tigerstrom B, Larre T, & Sauder J (2011). Using the Tax System to Promote Physical Activity: Critical Analysis of Canadian Initiatives. American journal of public health PMID: 21680912

I have previously blogged about the fact that in talking about the obesity problem, we spend more time talking about ‘what’ people do than ‘why’ they do it.

I, for one, am convinced that addressing ‘what’ people do, without addressing ‘why’ people do so, is unlikely to change behaviour or provide any meaningful solutions.

This is perhaps best exemplified by the problem with fast food - which, is often enough, blamed for its putative role in this epidemic.

I have tried to put this idea into the following video (subscribers will have to head to my site to see it).

Appreciate all comments,

AMS,
Edmonton, Alberta

In any public discussion of obesity, the prime concern appears to be about health.

Interestingly, however, the same public does not seem to actually support treating obesity like any other health problem - at least not in a publicly funded healthcare system.

This, perhaps not all that surprisingly, is the result of a study by Lund and colleagues from the University of Copenhagen, Denmark, just published in OBESITY.

Thus, in this representative survey of the Danish public (N = 1,141), although the majority supported prevention measures and ’softer’ obesity treatments (read ‘diet and exercise’), more radical treatments like bariatric surgery only found limited support.

The best predictor of these attitudes to the treatment of obesity was the belief that individuals are personally responsible for their own obesity.

This is perhaps not surprising given that public health messaging as well as many ‘well-meaning’ health professionals continue to propagate the stereotype that obesity is largely a self-inflicted condition easily prevented or remedied by simply choosing to eat less and move more. The fact that this piece of ‘advise’ is largely ineffective and does little more than increase weight-bias and stigmatisation, still appears to fall in the category of ‘privileged information’.

What is particularly paradoxical about this situation is that every single health economic assessment to date supports the notion that obesity treatments (particularly bariatric surgery for people with severe obesity) are far more cost-effective than many of the other ‘health’ services routinely provided to patients.

Thus, you would imagine that anyone who pays taxes (or insurance premiums) for health care, would be far more enthusiastic about their taxes (or premiums) being spent on treating obesity rather than watching them disappear into the black hole of treating its many complications.

Apparently, this is not how most tax payers think - not in Denmark and probably not in Canada either.

Interestingly, based on my own conversations with patients, people with obesity pretty much think the same.

Thus, even people who suffer from obesity themselves (or have battled it all their life) are far more enthusiastic when it comes to raising money for breast cancer, heart disease, diabetes, or arthritis than for obesity itself.

Thus, for example, as I have blogged before, it is rather funny how, although obesity is one of the biggest drivers of post-menopausal breast cancer, virtually none of the money raised for breast cancer each year ever finds its way into obesity research (or better treatments).

In fact, it would be fair to assume that the same people, who will happily give generously to cancer research, will be appalled if any of their money found its way into researching better surgical treatments for obesity, a treatment that is known to reduce cancer mortality by 60%.

How can anyone ever expect the ‘public’ to support obesity treatments, when even people with obesity (and apparently their friends and family) themselves don’t seem to think this a worthwhile cause?

Where are the donors, the sponsors, the trusts, the foundations, the campaigns, the armies of volunteers when it comes to finding “the cure” for obesity?

Just wondering - that’s all.

AMS
Toronto, Ontario

Lund TB, Sandøe P, & Lassen J (2011). Attitudes to Publicly Funded Obesity Treatment and Prevention. Obesity (Silver Spring, Md.) PMID: 21512511

A recent report commissioned by Alberta Health Services estimates that in 2005, the total direct and indirect costs of illnesses attributable to obesity in Alberta were $1.27 billion.

This represents 28.0% of the total direct and indirect costs attributable to obesity for 22 specific health conditions and 5.6% of the total direct and indirect costs for all health conditions in Alberta.

Coronary heart disease ($307.1 million) had the highest direct and indirect costs attributable to overweight and obese BMI status; osteoarthritis ($167.7 million), type 2 diabetes ($161.5 million), hypertension ($125.5 million), and the 14 cancer sites ($117.5 million) had the highest obesity-attributable costs after coronary heart disease. Among the 14 cancer sites, colorectal cancer ($31.6 million), postmenopausal breast cancer ($14.5 million), and leukemia ($11.0 million) had the highest costs attributable to overweight and obesity in Alberta.

While the direct health care cost attributable to overweight and obesity was $630.1 million, or 49.5% of the total cost of overweight and obesity, the indirect cost was $643.8 million including $63.1 million in short-term disability costs, $209.6 million in long-term disability costs, and $371.1 million in premature mortality costs.

As the report notes, these costs are conservative as the analysis did not include the costs for:

• Private out-of-pocket costs such as those paid for private caregivers, illness-related aids, and home modifications not reimbursed by governmental agencies;
• Costs associated with reduced production during work hours (presenteeism) as a result of a health problem;
• The value of time lost from work
• The value of lost leisure time of family members or friends who care for the patient;
• Intangible costs that involve pain and suffering borne by patients and their families.

The report also did not assess the cost of obesity in youth under age 15 or in the Aboriginal population living on reserves.

Although the report did not analyses how much of these costs could be reduced or avoided by providing effective obesity treatments, it is very likely (based on other estimates) that the savings could be substantial.

As I have said before, no health care system can afford not to tackle obesity.

AMS
Edmonton, Alberta

The Summary of The Cost of Obesity in Alberta Report is available here