Manitoba Report Shows That BMI Is Neither A Good Measure Of Health Nor Of Healthcare Costs
Earlier this week, the Manitoba Centre for Health Policy (MCHP) released a report on Adult Obesity in Manitoba: Prevalence, Associations, and Outcomes. The document (and especially the summary) makes an interesting read as it describes the rather complex nature of the epidemic and its impact on Manitobans. While the analysis of about 35,000 Manitoba adults over the age of 18 who took part in one of three surveys between 1989 and 2008, documents the high prevalence of obesity and the fact that many health conditions are indeed more common in people with higher BMI’s, it also shows that these findings do not readily translate into higher healthcare costs till about a BMI of 33. Thus, as the report summarizes: “The Obese group almost always used more healthcare services than the other groups. However, the differences were small and often did not come into play until the very highest BMIs….people in the Obese group visited doctors more often than others. However, they only visited about 15% more overall. As well, the rise in visits only occurred from a BMI of 35 for men and 32 for women. Likewise, costs of prescription drugs went up quite slowly until very high BMIs were reached. Hospitalizations were higher for those in the Obese group, but only for BMIs at or above 33. Home care use did not differ much either.” This finding is actually not that surprising or unexpected. Regular readers will by now be quite familiar with the Edmonton Obesity Staging System (EOSS), which was developed exactly because BMI is such an inadequate measure of risk or health. Thus, I am confident that applying EOSS to this analysis would produce substantially different results than simply looking at BMI. Thus, for e.g. our recently published analyses show that about 50% of people in the overweight category actually rank as EOSS 2/3. These individuals would considerably amplify the costs of people within the BMI 25-30 range – probably to the same level as EOSS 2/3 in the Obesity categories, while the obese EOSS 0/1 folks (of which there are about 20% in the BMI 30-35 class) would have costs very much like those of the EOSS 0/1 overweight people. Such overlap in EOSS stages across BMI levels would readily mask any relationship between BMI and healthcare costs till rather extreme levels of BMI, where very few people will remain with EOSS 0/1 and the costs… Read More »
Treating Obesity In People With Prediabetes Could Save Billions
Today, as I attend the 47th European Association for the Study of Diabetes (EASD) Annual Meeting here in Lisbon, I cannot help but discuss an article by Kenneth E. Thorpe and Zhou Yang, Emory University, Atlanta, Georgia, published in the latest issue of Health Affairs. Based on their analysis of the significant impact of even modest sustained weight reduction on the incidence of type 2 diabetes, these authors suggest that enrolling overweight and obese pre-diabetic US adults aged 60–64 into a proven, community-based weight loss program nationwide could save Medicare $1.8–$2.3 billion over the following ten years. Estimated savings would be even higher ($3.0–$3.7 billion) if equally overweight people at risk for cardiovascular disease were also enrolled. Thus, lifetime Medicare savings could range from approximately $7 billion to $15 billion, depending on how broadly program eligibility was defined and actual levels of program participation, for a single “wave” of eligible people. A key assumption in their proposal, is that a fully funded sixteen-twenty week community program (perhaps delivered by the YMCA), would deliver about 4% weight loss and replicate the almost 50-70% reduction in progression to diabetes seen in some diabetes prevention studies. Using our Edmonton Obesity Staging System definitions – this program would target Stage 1 patients (pre-diabetes) or Stage 2 patients (with hypertension or dyslipidemia). There is no doubt that community based ‘lifestyle’ interventions are the only plausible way in which any program can be delivered to millions of eligible individuals. There is also little doubt that in randomised controlled trials, considerable benefits have been demonstrated. The question remains, however, whether enough eligible participants will in fact participate and persist with these ‘lifestyle’ changes without continuing and ongoing support (which is generally what the clinical trials have delivered). The notion that an intervention of limited duration (even twenty weeks) will lead to sustainable effects, may be a bit over optimistic, even if 10 year follow-up data from some diabetes preventions studies suggest long-term benefits even after the end of the trials. It is also worth discussing whether or not success is actually dependent on losing weight (not a behaviour) rather than simply increasing physical activity and eating better (which are behaviours). Whether or not there is indeed a realistic chance that millions of people can be enrolled in community based interventions programs will remain to be seen, but it is certain that, if feasible, savings would indeed be… Read More »
Moving Forward With The Edmonton Obesity Staging System
Over the last several days I have been examining various aspects and implications of our recent publications showing that the Edmonton Obesity Staging System (EOSS) does a far better job of predicting mortality than does BMI (in fact BMI does almost nothing in this regard). Not only does EOSS make intuitive sense to clinicians and most patients (especially the ones who are at EOSS 0) it is also a better way to individualize patient management strategies. But, despite these two publications in three independent samples that included over 20,000 participants, many important questions remain to be addressed: it is not clear whether all comorbidities should receive the same weight for defining the EOSS stage – for e.g. should chest pain due to reflux disease count the same as chest pain due to ischemic heart disease (probably not)? What is the natural history of EOSS stage progression? Or in other words, how long does it take for patients to move from Stage 0 to Stage 1 or from Stage 2 to Stage 3? Are there really patients, who never progress? Are there predictors of progression? If yes, can this progression be delayed or prevented? What does it take to reverse Stages and does reversing the obesity Stage improve prognosis (it probably does)? How do cost-effectiveness and risk-benefit ratios of obesity treatment for patients look at different EOSS stages? I am guessing that both increase at higher stages, but is this really the case? Can we develop a simplified version of EOSS (EOSS-lite?) that only counts certain comorbidities or only acknowledges certain dimensions of quality of life? Is EOSS a concept that health professionals, decision makers, and funders are ready to adopt and will it improve practice and outcomes? These are all questions that future research will need to address, some of this work is already underway, but I’d be happy to hear from potential collaborators or people wanting to do some of this research on their own. If nothing else, I at least hope that the EOSS discussion has opened a whole new way of thinking about clinical assessment and definition of obesity and will find its way into clinical care pathways and management guidelines. From everything I hear, this is already beginning to happen. AMS Edmonton, Alberta Padwal RS, Pajewski NM, Allison DB, & Sharma AM (2011). Using the Edmonton obesity staging system to predict mortality in a population-representative cohort… Read More »
Is Preventing Childhood Obesity Affordable?
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… Read More »
Are Tax Incentives Cost-Effective to Promote Physical Activity?
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… Read More »
Watch Dr. Sharma in the News!
Listen to Dr. Sharma!
