According to the Weight-control Information Network (WIN) of the National Institute of Diabetes and Digestive and Kidney Diseases, the U.S. government's lead agency responsible for biomedical research on nutrition and obesity and part of the National Institutes of Health (NIH), the total cost of overweight and obesity was about $123 billion in 2001. Estimates of the total cost of overweight and obesity in the United States vary depending on how the conditions are defined, whether overweight and obesity are considered together or separately, and which costs and obesity-related conditions are included in the estimates and projections. For example, the WIN total cost is based on epidemiological studies that defined obesity and overweight as body mass index (BMI) equal to or greater than twenty-nine.
Economists Eric A. Finkelstein and Ian C. Fiebelkorn of RTI International, an independent, nonprofit research corporation, and Guijing Wang of the Centers for Disease Control and Prevention (CDC) examined costs attributable to persons who were overweight, which they defined as BMI between 25 and 29.9, and obese, which they defined as BMI of 30 or higher ("National Medical Spending Attributable to Overweight and Obesity: How Much, and Who's Paying?" Health Affairs, Web exclusive, May 14, 2003). Using data from a nationally representative sample of 9,867 adults aged nineteen and older, derived from the 1998 Medical Expenditure Panel Survey and linked to the 1996 and 1997 National Health Interview Surveys, they computed the fraction of medical spending associated with being overweight and obese. Because of including both overweight and obesity-related costs, they estimated annual medical spending due to overweight and obesity to be as much as $93 billion in 2002—9.1 percent of U.S. health expenditures.
The researchers also reported that among persons under age sixty-five, medical expenditures for persons who are overweight or obese are approximately 37 percent higher than those of normal weight and observed that about half of these costs are financed by the federal and state government public assistance programs Medicare and Medicaid. (The majority of Medicare enrollees are persons aged sixty-five and older. Medicaid is the entitlement program that uses federal and state funds for the provision of health-care insurance to persons less than sixty-five years of age who cannot afford to pay for private health insurance.) This study was the first to assess the effect of being overweight or obese on select payers, including individuals, private insurers, Medicare, and Medicaid.
The combined prevalence of overweight and obesity averaged 53.6 percent across all insurance categories, and was largest, 56.1 percent, among persons enrolled in Medicare. Because obesity is associated with chronic diseases such as cancer, heart disease, and diabetes, obesity-related expenditures for older adults (persons aged sixty-five and older) were significantly higher than among younger populations.
The researchers found that overall annual medical costs for an obese person were about 37.7 percent more, or $732 higher, than the costs for persons of normal weight. An obese Medicare recipient incurred medical expenses of $1,486 more a year than one of healthy weight, and an obese Medicaid recipient cost $864 more than a normal-weight Medicaid recipient. For persons with private health insurance the per capita increase among obese people was $423.
In an updated study, "State-Level Estimates of Annual Medical Expenditures Attributable to Obesity" (Obesity Research, vol. 12, January 2004), Finkelstein and Fiebelkorn estimated that in 2003 Medicare and Medicaid spent $75 billion treating obesity-related diseases. In this study the researchers calculated state-level estimates of total, Medicare, and Medicaid obesity-attributable medical expenditures. According to the CDC 1999–2000 National Health and Nutrition Examination Survey, which is based on measured heights and weights, among Medicare recipients, obesity prevalence ranges from 12 percent in Hawaii to 30 percent in Washington, D.C.
The percentage of annual medical expenditures in each state attributable to obesity ranged from 4 percent in Arizona to 6.7 percent in Alaska. Medicare expenditures connected to obesity ranged from 3.9 percent in Arizona to 9.8 percent in Delaware. For Medicaid recipients, the percentages were considerably higher because of the higher prevalence of obesity among Medicaid recipients—from 7.7 percent in Rhode Island (where 21 percent of Medicaid recipients were obese) to 15.7 percent in Indiana (where 44 percent of Medicaid recipients were obese).
State-level estimates ranged from totals of $87 million in Wyoming to $7.7 billion in California. Obesity-attributable Medicare estimates range from $15 million in Wyoming to $1.7 billion in California, and Medicaid estimates ranged from $23 million in Wyoming to $3.5 billion in New York. (It is important to remember that state-level spending is largely a function of population, so it is reasonable that the less populous Wyoming would spend fewer state and federal dollars than population-dense California and New York.)
The California Department of Health Services reported even higher costs than those estimated in the RTI/CDC report—nearly $25 billion in private and public medical services, lost productivity, and workers' compensation. The state health department attributed these costs to the 59 percent of adults in California who are obese or overweight. In the January 23, 2004, issue of the Los Angeles Times Susan Foerster, chief of cancer prevention and nutrition for the California Department of Health Services, explained that her department is examining the factors that may explain the relatively recent jump in obesity in the state. Foerster cited "car-dominated or unsafe neighborhoods and limited access to fresh fruits and vegetables" as possible sources of the state's surge in obesity, and stated that "It's not a matter of simply pushing away from the table or getting up off the couch—the increase in rates over time has been a function of changed lifestyles and changed environment" (Lisa Richardson, "Fat of the Land: Obesity Costs State, U.S. Billions, Studies Say," Los Angeles Times, January 23, 2004).
Health economist Eric Finkelstein observed that the amount of Medicare and Medicaid dollars spent on obesity-related illnesses was just slightly less than that spent to treat smoking-related illnesses. In a January 21, 2004,
FIGURE 7.1
Ambulatory care visits for diabetes among adults 18 years of age and over, by age, 1995–2000
news release from RTI International, U.S. Department of Health and Human Services Secretary Tommy G. Thompson responded to the results of the study, with the assertion that "This report further drives home the point that we must stem the tide of the obesity epidemic in this country. These findings are a dramatic illustration of the devastating economic impact obesity has on health-care delivery systems across the nation."
Medical Care and Health-Related Costs
In addition to 2001 estimates of total direct and indirect costs of overweight and obesity, the WIN study specified the obesity-related diseases that contributed to these costs. Heart disease related to overweight and obesity generated direct costs of $8.8 billion, 17 percent of the total direct cost of heart disease, independent of stroke. The study considered $98 billion, the total cost of Type 2 diabetes, as attributable to obesity. Figure 7.1 shows that the rate of visits to physicians' offices or hospital outpatient departments for diabetes increased for persons aged forty-five and older. Between 1995–1996 and 1999–2000, the number of physician visits per 1,000 population increased 35 percent among persons forty-five to fifty-four and rose by 43 percent among persons fifty-five to sixty-four years of age.
FIGURE 7.2
Hospital discharges for diabetes among adults 45 years of age and over, by age, 1990–2001
Another significant contribution to increasing diabetes-related costs was hospitalization. Between 1990–1991 and 2000–2001 the number of hospital discharges that involved diabetes increased among persons of all ages. Hospital discharges attributable to diabetes increased with advancing age—the rate among persons aged seventy-five and older was five times higher than the rate among persons aged forty-five to fifty-four years. (See Figure 7.2.)
In contrast, just 17 percent of the total cost of hypertension—$4.1 billion—was direct costs related to overweight and obesity. Of the $3.4 billion total cost of gallbladder disease, $3.2 billion was related to overweight and obesity, and of the $21.2 billion total cost of osteoarthritis, the direct cost linked to overweight and obesity was $5.3 billion.
Of the $2.9 billion total cost of breast cancer, $1.1 billion was considered direct cost related to overweight and obesity. For endometrial cancer the direct cost was $310 million of the $933 million total cost, and for colon cancer the direct cost was $1.3 billion of the $3.5 billion total cost.
The WIN researchers also calculated indirect costs of $58.8 billion in 2001, comparable to the economic toll of cigarette smoking. The indirect costs attributed to specific diseases included $15.9 billion for osteoarthritis, $187 million for gallbladder disease, $1.8 billion for breast cancer, $623 million for endometrial cancer, and $2.2 billion for colon cancer.
The cost of lost productivity related to obesity (BMI greater than 30) among Americans ages seventeen to sixty-four was $3.9 billion. This dollar figure translates into 39.3 million lost work days, 62.7 million physician office visits, 239 million days of restricted activity, and 89.5 million bed-days (days when persons remained in bed rather than performing their activities of daily living) related to obesity.
Another study conducted by health economist Roland Sturm and psychiatrist Kenneth Wells at the RAND Corporation, a nonprofit research organization that analyzes challenges facing the public and private sectors, compared effects of obesity, smoking, heavy alcohol consumption, and poverty on chronic health conditions and health expenditures ("The Effects of Obesity, Smoking, and Problem Drinking on Chronic Medical Problems and Health Care Costs," Health Affairs, vol. 21, no. 2, 2002). Sturm and Wells found that obese individuals spent more on both health-care services and medication than daily smokers and heavy drinkers. For example, obese individuals spent about 36 percent more than the general population on health-care services, compared with a 21 percent increase for daily smokers and a 14 percent increase for heavy drinkers. Further, obese persons spent 77 percent more on medications. The only variable with a greater effect on health-care expenditures was aging—and aging trumped obesity only on expenditures for medications. The investigators concluded that obesity generates significantly higher health-care expenditures and affects more individuals than smoking, heavy drinking, or poverty.
HOSPITAL COSTS OF CHILDHOOD AND ADOLESCENT OBESITY.
Researchers Guijing Wang and William H. Dietz of the CDC examined trends in obesity-linked diseases in youths and their related economic costs. In "Economic Burden of Obesity in Youths Aged 6 to 17 Years: 1979–1999" (Pediatrics, vol. 109, no. 5, May 2002), the researchers reported the results of an analysis and comparison of data from the 1979–1981 and 1997–1999 National Hospital Discharge Surveys conducted by the National Center for Health Statistics. When the researchers adjusted hospital costs to reflect 2001 dollars, they found that hospital costs linked to childhood obesity and three specific obesity-related illness—diabetes, sleep apnea, and gall-bladder disease—more than tripled since 1981, from $35 million to $127 million per year.
Days spent in the hospital for obesity-related disease more than doubled, from 152,000 during 1979–1981 to 310,000 days during 1997–1999. The average length of hospital stays increased by about a third, from 5.3 to seven days. The researchers observed that this increase in average length of stay occurred during a time when U.S. hospital stays overall were shortening, and asserted that longer lengths of stay for children with obesity-related medical problems underscored the severity of these problems.
The researchers concluded that the increase in the percentage of discharges with obesity-related diseases was most likely a reflection of the medical consequences of the obesity epidemic. They wrote, "Although the numbers of percentage are small, the increases are substantial, especially for obesity (197 percent increase), sleep apnea (436 percent), and gallbladder disease (228 percent). These data may suggest that the increasing prevalence of obesity in children and adolescents has led to increased hospital stays related to obesity-associated diseases. The increasing proportion of hospital discharges with obesity-associated diseases in the last twenty years may also reflect the impact of increasing severity of obesity."
Insurance Coverage for Obesity Treatment
Ironically, although the Medicare and Medicaid programs spend billions on obesity-related illnesses, neither entitlement program covers treatment for obesity itself. Medicaid does not cover obesity treatment, and under Medicare, hospital and physician services for obesity are excluded. Medicare justifies excluding coverage for obesity treatment by asserting that obesity is not a disease. However, Medicare does cover treatment when obesity results from a disease such as hypothyroidism or Cushing's disease and when weight loss is medically necessary to treat a disease such as diabetes, hypertension, or heart disease. It also provides coverage for surgical treatment of obesity when it is medically appropriate and the surgery is to correct an illness that caused the obesity or was aggravated by the obesity. Some health-care analysts, including the AOA, contend that it is difficult to reconcile this limited coverage of obesity in light of Medicare coverage for inpatient and outpatient alcohol detoxification and rehabilitation; chemical dependency treatment and drug rehabilitation; and services for sexual impotence.
In view of the high prevalence of obesity among the populations covered by Medicaid—the poor and minorities—and the significant Medicaid expenditures for obesity-related illnesses, many health-care industry observers believe it is short-sighted that twenty-nine states specifically exclude coverage of antiobesity products in state Medicaid programs. Just nine states—Alaska, California, Kentucky, Montana, North Carolina, Oregon, Rhode Island, Washington, and Wisconsin—cover antiobesity pharmaceuticals through Medicaid. Arizona covers antiobesity pharmaceuticals through a specific managed health-care plan.
According to the AOA, many health insurance plans do not provide reimbursement for weight-loss treatment. Further, few private insurance indemnity plans or managed-care organizations (health maintenance organizations and preferred provider organizations are examples of managed-care plans) appear to cover the costs of obesity treatment independent of whether the service is a medically supervised weight-loss program, surgery, or a prescription drug. The AOA cites the benefits provided by Wal-Mart (as described in the company's 1999 employee benefits booklet) as typical of employer insurance coverage for obesity. The Wal-Mart plan describes as "not payable for treatment or services charges from: medications and diet supplements which result from diet programs, appetite control, weight control, and treatment of obesity or morbid obesity, including gastric bypasses and stapling procedures even if the participant has other health conditions which might be helped by the reduction of weight." As of 2004 at least five states—Georgia, Hawaii, Maryland, Montana, and Virginia—were considering legislation that would require health insurance coverage for weight-loss programs.
The Pharmacy Benefit Management Institute, Inc. (PBMI), an independent organization that is not affiliated with any employee benefits program or pharmaceutical manufacturer, periodically surveys employers to determine the extent, cost, and coverage of their pharmacy benefits. The Institute analyzes survey data and trends in a national research report entitled Benefit Design Survey Report. The survey queries 375 companies that provide coverage to nearly twelve million beneficiaries. The PBMI study found that antiobesity drugs, including appetite suppressants, were excluded from coverage by more than 80 percent of employers.
SHOULD OVERWEIGHT PEOPLE PAY MORE FOR HEALTH INSURANCE COVERAGE?
Since overweight and obese people incur higher medical costs, should they be required to pay higher premiums for health insurance? During 2003 at least one Maryland legislator, Joan F. Stern, suggested this highly controversial move. In a July 11, 2003, interview with Steven Dennis, "Shape Up or Shell Out?" in The Gazette, Stern, who had lost 30 pounds at the time of her proposal, said that higher premiums for the overweight and discounts for persons of healthy weights would improve health, help pay for the cost of medical treatment for obesity, and would reduce health insurance costs. She explained that "You can be as fat as you want, but when you become a burden on the health care system, when you start going to the emergency room, when you start having to take insulin and these other drugs, the insurance premiums of everyone else go up and some people won't be able to afford it because of folks who abuse the system—and it really is abusing the system." Her plan would not penalize persons whose obesity was caused by a medical problem such as Cushing's disease and would prevent insurance companies from denying coverage to obese people.
In his article, reporter Dennis observed that after an earlier story about her proposal appeared in The Gazette, Stern softened her position because she feared that she would be viewed as attacking overweight people. She shifted her focus to insurance coverage for obesity treatments and insurance incentives tied to reducing obesity. In addition she advocated requiring daily physical education in schools, improving school nutrition standards, and revamping school menus.
While Stern may have reconsidered her position about higher health insurance premiums for obese people, George Washington University Law School professor John F. Banzhaf III is a staunch advocate of such a policy. He maintains that the current practice of charging all insurance subscribers the same rates unfairly forces normal-weight people to subsidize treatment for obesity. Banzhaf asserts that higher insurance premiums would give obese people another incentive to lose weight and observes that this policy would be consistent with others such as requiring smokers to pay more for life insurance, and drivers who have car accidents to pay higher automobile insurance rates.
Critics of higher premiums for overweight and obese people counter that since smokers and persons who consume alcohol excessively do not pay higher health insurance premiums under most plans, obese people should not be asked to pay higher premiums. Executive director of the AOA Morgan Downey believes that economic incentives would not be effective inducements for weight loss, and observes that the entire premise of insurance is to share risk across a population that varies in terms of health and illness. Other health-care industry observers contend that some health insurance companies already discriminate against obese people by denying them coverage or imposing higher deductibles (the fixed dollar amount subscribers must pay before their health benefits begin). Finally, opponents observe that overweight people might be forced to drop their health insurance coverage altogether should it become too expensive, and that more obese people might rely on publicly funded programs, ultimately shifting obesity-related medical costs to taxpayers.
Funding Obesity Research
During the last four decades, considerable progress has been made in identifying the causes of obesity and developing treatments. Despite the enhanced understanding of the origins of obesity, increasing numbers of Americans continue to become overweight and obese. The AOA, along with myriad medical professional organizations and advocacy groups, contends that public funding for obesity research is woefully inadequate in view of the size and scope of this public health problem. For example, in 2002 Dr. Michael Jensen, president of the North American Association for the Study of Obesity, testified before the House Appropriations Committee Subcommittee on Labor, Health and Human Services, Education and related
TABLE 7.1
National Institutes of Health disease funding table, special areas of interest, fiscal years, 2002–04
| Research/disease areas (dollars in millions) | Fiscal year 2002 actual | Fiscal year 2003 estimate | Fiscal year 2004 estimate |
| Aging research | $1,900.4 | $2,048.1 | $2,119.9 |
| AIDS (budget authority) | 2,499.5 | 2,759.9 | 2,869.9 |
| Minority AIDS | 516.7 | 566.4 | 585.9 |
| Pediatric AIDS | 294.3 | 316.8 | 328.6 |
| Vaccines AIDS | 329.4 | 413.6 | 456.3 |
| ALS | 34.9 | 37.6 | 38.4 |
| Alzheimer's disease | 594.7 | 640.5 | 663.8 |
| Anthrax research | 48.4 | 79.3 | 132.2 |
| Arthritis research | 350.9 | 375.0 | 387.7 |
| Asthma | 231.0 | 254.2 | 262.2 |
| Autism | 73.9 | 81.3 | 84.2 |
| Autoimmune disease | 556.6 | 602.3 | 626.3 |
| Behavioral and social science | 2,399.5 | 2,576.6 | 2,664.5 |
| Bioengineering | 825.9 | 907.6 | 938.6 |
| Bioterrorism1 | 291.1 | 1,745.8 | 1,625.1 |
| Brain disorders | 4,365.3 | 4,700.0 | 4,873.5 |
| Cancer research | 4,922.7 | 5,441.2 | 5,644.9 |
| Breast cancer | 640.4 | 698.0 | 720.2 |
| Lung cancer | 259.0 | 280.6 | 290.3 |
| Ovarian cancer | 109.4 | 118.2 | 122.0 |
| Prostate cancer | 345.3 | 387.5 | 399.9 |
| Cardiovascular research | 2,047.5 | 2,192.4 | 2,254.9 |
| Clinical research | 7,642.3 | 8,381.2 | 8,659.1 |
| Complementary and alternative medicine | 252.9 | 273.4 | 282.3 |
| Cystic fibrosis | 113.4 | 120.7 | 124.6 |
| Diabetes research2 | 790.3 | 860.5 | 946.0 |
| Diagnostic radiology | 593.0 | 658.5 | 679.7 |
| Emerging infectious diseases | 340.0 | 1,087.6 | 1,686.2 |
| Chronic fatigue syndrome | 7.2 | 7.5 | 7.7 |
| Fibromyalgia | 10.1 | 11.1 | 11.0 |
| Gene therapy | 379.7 | 409.8 | 422.7 |
| Hepatitis C | 94.9 | 104.1 | 108.3 |
| Hypertension | 330.4 | 354.5 | 362.1 |
| Infant mortality (low birth weight) | 496.6 | 542.6 | 564.3 |
| Kidney disease | 346.0 | 375.4 | 389.8 |
| Lupus | 82.5 | 89.9 | 92.3 |
| Mental health | 1,624.4 | 1,743.2 | 1,806.8 |
| Multiple sclerosis | 89.3 | 95.3 | 97.3 |
| Muscular dystrophy | 27.6 | 31.4 | 32.3 |
| Neurosciences research | 4,305.9 | 4,638.5 | 4,811.9 |
agencies, urging Congress to increase obesity research spending. In a press release dated May 2, 2002, Jensen called upon the NIH to double its budget allocation for obesity from 1 percent to 2 percent in an effort to reverse the epidemic.
Table 7.1 shows NIH funding for a variety of diseases and research areas for fiscal year 2002 and estimates for 2003 and 2004. Funding for obesity research increased by just $12 million from fiscal year 2003 to fiscal year 2004, and received funding comparable to allocations for stroke research, but less than research funding for arthritis, kidney disease, and schizophrenia, disorders that afflict far fewer Americans. In addition to insufficient NIH funding for obesity research, the AOA cites inequities in research grants awarded by the NIH—although more grants have been awarded to obesity research than in past years, obesity still receives a disproportionately small share of grant funding.
TABLE 7.1
National Institutes of Health disease funding table, special areas of interest, fiscal years, 2002–04
| Research/disease areas (dollars in millions) | Fiscal year 2002 actual | Fiscal year 2003 estimate | Fiscal year 2004 estimate |
| Nutrition | 922.0 | 987.0 | 1,021.5 |
| Obesity | 297.2 | 320.3 | 332.3 |
| Osteoporosis | 197.5 | 213.7 | 221.6 |
| Parkinson's disease | 210.7 | 233.2 | 242.3 |
| Pediatric research | 2,828.6 | 3,046.3 | 3,164.3 |
| Polycystic kidney disease | 25.4 | 27.5 | 28.5 |
| Prevention | 5,781.0 | 6,594.4 | 6,810.8 |
| Sexually transmitted diseases/herpes | 217.1 | 244.1 | 254.1 |
| Schizophrenia | 313.1 | 338.0 | 350.2 |
| Sickle cell disease | 83.2 | 89.1 | 91.6 |
| Sleep disorders | 175.0 | 188.2 | 194.2 |
| Small pox | 69.2 | 71.2 | 79.4 |
| Smoking and health | 501.6 | 542.8 | 561.7 |
| Spinal cord injury | 80.8 | 89.2 | 91.6 |
| Stroke | 288.0 | 312.7 | 321.2 |
| Sudden infant death syndrome | 64.7 | 69.7 | 72.6 |
| Topical microbicides | 55.8 | 71.0 | 76.3 |
| Transmissible spongiform encephalopathy (TSE) | 27.3 | 29.4 | 30.5 |
| Tuberculosis research | 95.7 | 105.3 | 109.1 |
| Vaccine development | 610.2 | 962.0 | 988.2 |
| West Nile virus | 18.3 | 27.9 | 40.2 |
| Women's health | 3,058.5 | 3,311.7 | 3,433.3 |
| 1Fiscal year (FY) 2002 includes $180 million appropriated to the PHS Emergency Supplemental Fund (P.L. 107-117) | |||
| 2Includes funds for Type 1 diabetes research in accordance with the Balanced Budget Act of 1997 (P.L. 105-33, FY1998 through FY2002) and P.L. 106-554 (FY2001–FY2003); $97 million in FY2002, $100 million in FY2003, and $150 million in FY 2004. | |||
| SOURCE: "NIH Disease Funding Table: Special Areas of Interest," National Institutes of Health (NIH), Bethesda, MD, March 19, 2003 [Online] http://www.nih.gov/news/fundingresearchareas.htm [accessed January 25, 2004] | |||
Weighing the Price Business Pays
Employers report that obese employees incur substantially higher health-care costs than normal-weight employees. In "Watching the Corporate Waistline" (Forbes online, August 4, 2003), Kasia Moreno reported that at Bank One an obese worker cost the company $6,822 per person in health-care costs over three years, while non-obese employees averaged health-care costs of $4,496. Although Bank One charges workers who smoke $28 per month more in health premiums than it does non-smokers, obese employees are not asked to contribute to offset their excess health-care costs. Bank One's medical director, Dr. Wayne Burton, asserted that the company does not wish to be viewed as "discriminating against obese workers, or to create the impression that it considers obesity a purely behavioral issue."
According to the Washington Business Group on Health, a consortium of large employers that researches and develops innovative solutions to health-service delivery challenges, U.S. companies pay out $12 billion per year for medical-care costs to treat obesity-related diseases, lower productivity, and absenteeism. This dollar figure is consistent with an earlier estimate of $12.7 billion reported by David Thompson and his colleagues in "Estimated Economic Costs of Obesity to U.S. Business" (American Journal of Health Promotion, vol. 13, no. 2, November–December 1998). The investigators attributed approximately $2.6 billion to mild obesity (BMI between 25 and 28.9) and $10.1 billion to moderate to severe obesity (BMI equal to or greater than 29). Health insurance expenditures were $7.7 billion of the total, representing 43 percent of all spending by U.S. business on coronary heart disease, hypertension, Type 2 diabetes, hypercholesterolemia, stroke, gallbladder disease, osteoarthritis of the knee, and endometrial cancer. Obesity-attributable business expenditures for paid sick leave, life insurance, and disability insurance amounted to $2.4 billion, $1.8 billion, and $800 million respectively.
Another study, "Obesity and Absenteeism: An Epidemiologic Study of 10,825 Employed Adults" (American Journal of Health Promotion, vol. 12, no. 3, January–February 1998), conducted by Larry Tucker and his colleagues in the Department of Physical Education, Brigham Young University in Provo, Utah, sought to determine the extent of the relationship between obesity and absenteeism due to illness. The investigators analyzed specific variables—age, gender, family income, length of workweek, obesity, and cigarette smoking—and data about absenteeism for 10,825 employed men and women. They found that obese employees were more than twice as likely to experience high-level absenteeism (seven or more absences due to illness during the past six months), and 1.49 times more likely to suffer from moderate absenteeism (three to six absences due to illness during the last six months) than their normal-weight counterparts.
A more recent study conducted by Dee Edington, director of the University of Michigan's Health Management Research Center, and his colleagues confirmed that overweight and obese people have medical bills up to $1,500 greater a year than those of people of healthy weight. The study "Excess Costs Associated with Excess Risks in a Consortium of Companies" (American Journal of Health Promotion, January–February 2003) looked at about 178,000 adults in General Motors' health-care plan, which includes workers, retirees, and their family members. Researchers compared medical costs incurred to body weight, using federal categories that classified subjects as ranging from underweight to greatly obese. Medical costs rose with increasing weight—the average cost for normal or healthy-weight subjects was $2,225. The lowest category of overweight was slightly higher, at $2,388, but costs rose sharply after that, reaching $3,753 for the most severely obese subjects.
OBESITY-RELATED DISABILITY.
In "Estimated Economic Costs of Obesity to U.S. Business," Thompson and his colleagues estimated that businesses spent approximately $800 million on obesity-attributable disability insurance during the late 1990s. Many industry observers believe that the price business pays for obesity-related disability is destined to rise as sharply as the prevalence of obesity has increased in the United States.
RAND researchers Darius N. Lakdawalla, Jayanta Bhattacharya, and Dana P. Goldman assert that obesity is a key cause of the more than 50 percent increase in disability rates over the last two decades, particularly among younger Americans. In "Are the Young Becoming More Disabled?" (Health Affairs, vol. 23, no. 1, 2004), Lakdawalla and his colleagues analyzed data from the National Health Interview Survey, an annual nationwide government survey of about 36,000 households. They identified disability trends among persons ages eighteen to sixty-nine between 1984 and 2000 and found significant growth in reported disability rates among those under fifty years but not among the elderly.
The investigators reported that "Obesity accounts for about half the increased disability among those ages eighteen to twenty-nine." For those thirty to thirty-nine years old, the number reporting disabilities increased from 118 per 10,000 people to 182 per 10,000 people from 1984 to 1996. Among persons forty to forty-nine years old, the number rose from 212 per 10,000 to 278 per 10,000 in the same period. Among persons aged fifty to fifty-nine, disability rose only among those who were obese. The number of disability cases resulting from musculoskeletal problems and diabetes grew more rapidly than those from other problems during the length of the study, and the proportion that was diabetes-related doubled. The RAND researchers cautioned that the increase in the disability rate could translate into higher health-care costs in the future. Since persons with disabilities generally use more medical services, should this trend persist, it could generate additional costs to the nation's already enormous health-care bill.
To address this issue, the National Business Group on Health established the Institute on the Costs and Health Effects of Obesity, which aims to:
- Serve as a source of information and resources for large employers about the health and cost consequences of obesity and related chronic conditions.
- Provide employer tool kits to jump-start efforts to offer employees healthy options and information.
- Propose innovative solutions that large employers can implement to control costs related to obesity. This will include identifying effective strategies to decrease the incidence of obesity and delay the onset or decrease the incidence of several chronic conditions among the U.S. workforce.
- Develop and disseminate clear messages emphasizing that obesity is preventable, as well as messages that communicate obesity as a health and well-being issue, rather than a cosmetic issue.
By 2005 the Institute on the Costs and Health Effects of Obesity intends to achieve its objectives by completing the following projects:
- Development and distribution of a communications tool kit for employers that will include practical information about the health effects of obesity as well as innovative weight-management program ideas and implementation-ready resources.
- Design and dissemination of a modeling tool employers may use to assess the cost of overweight and obesity in their workforce.
- Creation of a forum for large employers where they may collaborate to identify solutions and develop key messages for senior management, human resources personnel, and employees.
- Launch of a national weight-awareness initiative about the health consequences of obesity and exhort companies across the nation to participate.
- Development of a series of Issue Briefs that focus on topics related to obesity and its impact on large employers and the workforce. Topics will include bariatric (weight-loss) surgery, food at work, stress and weight, and return-on-investment evidence for weight management programs.
- Sponsorship of an April 2004 Summit to provide a venue where large employers may explore the health and cost challenges related to obesity as well as share effective solutions and strategies.
- Creation and maintenance of an online resource that large employers may access to explore the implications of recent research findings related to obesity and research innovative workplace weight-management initiatives. This resource will enable large employers to share the costs, benefits, and challenges of implementing work site interventions.
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