An Ear Full of Childhood Obesity
No doubt obesity is associated with a wide range of health problems affecting almost every organ system. But acute earache is perhaps not a health problem that immediately comes to mind when we consider the health risks of excess weight. According to a paper by Stefan Kuhle and colleagues from University of Alberta, School of Public Health, published in the latest issue of Pediatric Obesity, acute middle ear infections (otitis media) may be far more common in obese than in normal weight kids. This prospective cohort study, linked data from a population-based survey of Grade 5 students (aged 10-11 years) in the Canadian province of Nova Scotia in 2003 with Nova Scotia administrative health data via Health Card numbers. Relative to normal weight children, obese children had twice as many healthcare provider contacts for severe purative otitis media (ICD9: 382; ICD10: H65-66), incurred more costs per otitis media-related visit ($47 vs. $24) and were two-and-a-half times more likely to have repeated otitis media infections. There was a significant dose-risk effect with overweight kids fitting nicely between normal weight and obese kids in terms of increased risk. This risk was independent of a range of socioeconomic factors, history of breastfeeding, presence of an allergic disorder or chronic adenoid/tonsil disorders. Although, association does not prove causality, it is worth noting that this finding has considerable biological face value. Thus, the authors provide the following possible explanation for this relationship: “…obesity has been linked with low-grade systemic inflammation, which may produce a milieu that increases the risk of otitis media or lead to chronic otitis media. Alternatively, gastroesophageal reflux, which is seen more frequently in individuals with higher BMI may enter the middle ear through the Eustachian tube and cause otitis media. Finally, in obese individuals fatty tissue may accumulate around the Eustachian tube thereby compromising ventilation of the middle ear.” As the authors also point out, this finding may have considerable public health implications: “Acute otitis media is the second most common reason for visits to a family physician, accounting for 10– 15% of all childhood visits. Recurrent otitis media may result in long-term sequelae such as learning disability, impaired linguistic development or hearing disorder, or sleep apnoea because of the development of chronic adenoid/tonsil disorder.” But the cost implications are also worth noting: “We were able to show that the per capita physician costs for otitis media between 2001 and 2006 were… Read More »
What Do Patients Really Want?
As someone working in a public health care system, I am particularly interested in what exactly patients ‘value’ in health care. In other words, what is it that patients really want from health care? This, is the topic of a commentary by Allan Detsky from the University of Toronto, published in a recent issue of JAMA. According to his analysis (and experience), here are some of the things that patients value and want most: Most patients want a health care system that responds (quickly) when care is needed. Although patients generally understand the concept of preventive medicine, they are really far more interested in quickly receiving help that relieves illness and symptoms when they have the problem (or in other words, “while prevention is nice – what I really want is quick help when I am sick!”) Patients want hope and certainty (even if there is no hope and things are uncertain). They also prefer doing ‘something’ to doing nothing. When in doubt, many would prefer the extra test or two even if it is unlikely that the test will be useful – ‘just to be sure’. Many are also open to ‘trying’ something, even if the likelihood that the treatment will actually work is small. Patients want continuity, build relationships with their providers, and want their providers to communicate effectively with each other. Patients prefer treatments that require little effort (medications, surgery) to treatments that require a lot of effort (behavioural change). Not quite as high on the priority list are: Efficiency, whereby, patients define efficiency in terms of ‘their own time not being wasted’. This is different from how decision makers define efficiency, namely delivering the best value with the least resources. The latter is something patients don’t really worry about too much. Statistics, whereby, most patients don’t really care about the ‘average’ patient. Most care mainly about themselves. They are also not impressed by ‘statistical’ findings of what works and what doesn’t – “so what if the treatment doesn’t work for most people, as long as it works for me”. (also, I would add, “if it works for me, it should be covered!”). Conflicts of interest, whereby, most patients are less concerned about whether or not their doctors are making extra money, as long as the service they receive makes them feel better. Interestingly enough, according to Detsky, things that have the lowest priority for patients are… Read More »
Canadian Health Systems Miss The Boat On Obesity And Chronic Diseases
Last week the Conference Board of Canada released a not too flattering report on the status of chronic disease and obesity management in Canada. According to the press release that accompanied this Health Report Card, which Canada receives “A” grades on self-reported health status, mortality due to circulatory diseases (primarily heart disease and stroke), and premature mortality, it receives “B” grades on mortality due to mental disorders and mortality due to respiratory diseases (which include asthma, tuberculosis, bronchiolitis, emphysema, cystic fibrosis, influenza, and pneumonia). But, when it comes to the prevention management of three major chronic diseases, Canada’s performance is dismal compared to its 17 peers: – Mortality due to musculoskeletal diseases—“C” grade, 11th-place ranking – Mortality due to cancer—“C” grade, 13th-place ranking – Mortality due to diabetes—“C” grade, 15th-place ranking (out of 17?!?) It does not take a genius to recognize that all three of these conditions are tightly linked to obesity, which is why Gabriela Prada, the Conference Board’s Director, Health, Innovation, Policy and Evaluation is quoted as saying: “Canada is facing a growing burden from chronic diseases such as diabetes and cancer. This burden is expected to increase due to an aging population and rising rates of obesity”. Indeed, as the report points out: “Obesity has taken centre stage as a major risk factor for chronic diseases. Obesity is one of the most significant contributing factors to many chronic conditions, including heart disease, hypertension, and type 2 diabetes—type 2 diabetes accounts for 85 to 95 per cent of all diabetes cases in high-income countries. The share of overweight or obese Canadians continues to increase. According to calculations based on measured data, almost two-thirds of Canadians were considered to be either overweight or obese in 2008, and 24 per cent were considered to be obese. Particularly troubling is the growing share of children who are overweight. More than one in four Canadian children are considered overweight—a share that is higher than the OECD average.” So while decision makers in Canada’s health care system may well feel that other issues are perhaps more important (or have stronger lobbies), the future of Canada’s health care system very much depends on whether or not these decision makers will eventually recognize that without significant attention to chronic diseases and obesity Canadians’ health will be unlikely to become ‘world class’. Importantly, none of this is simply a matter of pouring more money into… Read More »
Impact of BMI on Health Status, Hospitalizations, Day Procedures, and Physician Costs
While in individuals BMI may not be the best measure of obesity (or health), in population studies, it does serve as a reliable indicator of the ‘burden’ of overweight and underweight. In a paper by Jean-Eric Tarride (McMaster University) that we just published in ClinicoEconomic and Outcomes Research, we examine data from all Ontarians who participated in the Canadian Community Health Survey (CCHS), cycle 1.1 and provided consent to data linkage were linked to three administrative databases. Obese adults, and to a lesser extent overweight adults (together about 50% of the population), were more likely to report physician-diagnosed comorbid conditions, to use medications, and to have a lower health-related quality of life. After adjustment for for personal income, smoking status, physical activity status, age and gender, the hospitalization and physician costs were respectively 40% and 22% higher among obese and overweight adults than among normal-weight adults. No statistical cost differences were observed between normal and underweight individuals or between normal and overweight individuals. On the other hand, health-related quality of life was significantly lower in both the underweight and obese adults when compared to normal-weight individuals. With regard to the excess costs associated with obesity, these were not equally distributed between the genders – surprisingly enough, overall obese men did not appear to incur higher medical costs in this analysis. In contrast, “women had significantly higher physician, day procedure and hospitalization costs than men once a cost has been incurred. In addition, women had a higher probability of being hospitalized or undergoing a day procedure than men.” Thus, we suggest that obesity programs targeted towards women may have greater potential for reducing costs associated with hospitalization, day procedures, and physicians. Similarly, increased costs were not equally distributed across age groups – the greatest cost difference were seen in the 40–59 year old age group. This finding suggests that obesity programs should perhaps focus their interventions on middle-aged obese individuals, which also suggests that the workplace may be the most practical environment for the implementation of such programs. In this paper, we also point out that, “…BMI does not truly reflect the burden of obesity-related health risks. Thus, as recently demonstrated in several large US population samples,26,27 the Edmonton Obesity Staging System (EOSS), which classified overweight and obese individuals on a 5-point ordinal scale based on the presence of medical, mental and/or functional comorbidities, strongly predicted mortality, whereas BMI did not. Importantly, in this… Read More »
Canadian Arthritis Report Targets Obesity
Yesterday, the Arthritis Alliance of Canada together with the Canadian Arthritis Network released The Impact of Arthritis in Canada: Today and Over the Next 30 Years, a 50-page report that provides a detailed look at the impact of arthritis in Canada and offers solutions on how to mitigate and manage the situation. According to this report, there are currently more than 4.4 million people living with osteoarthritis (OA) in Canada. In 30 years, more than 10 million or one in four Canadians is expected to have OA. Within a generation (in 30 years), there will be a new diagnosis of OA every 60 seconds. Currently OA drives about $10 billion in direct health care costs and about $17 billion in indirect costs (lost wages, lost taxes, etc.) – together with other forms of arthritis (especially rheumatoid arthritis) the total cost of arthritis amounts to an estimated $33 billion annually. These numbers will on only grow. Recognising that excess weight is one of the prime (modifiable) drivers of the OA epidemic, the report suggests that targeting obesity should be a priority (along with better access to joint replacements and adequate pain management) in reducing the burden of arthritis on Canadians. As the report points out: If a prevention program was available to reduce obesity rates by 50% in the Canadian population over the next 10 years: • 45,000 new cases of OA could be avoided over 10 years and over 200,000 cases of OA could be avoided over 30 years; • 25,000 workers could avoid OA over 10 years and over 136,000 cases of OA in the labour force could be avoided over 30 years; • $3.8 billion could be saved in cumulative direct health care costs over 10 years and $48.3 billion over 30 years (2010 dollars); and • $14.0 billion could be saved in cumulative productivity losses over 10 years and $163.7 billion saved over 30 years (2010 dollars). (Limitation: Costs attributable to obesity-reduction interventions were unavailable and, therefore, not considered in the model.) While this conclusion stresses the importance of obesity as a key driver of arthritis costs, this assumption of course is rather optimistic. To my knowledge, there is no known prevention strategy that comes even close to reducing obesity prevalence by 50% in 10 years. Indeed, for those at the highest risk of OA, namely, those who are already obese, ‘prevention’ strategies come too late – you would actually have to look… Read More »
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