Economic Graham

costs of obesity13

A Colditz Approximately

in

1980.

Obesity

insulin-dependent cardiovascular and colon

diabetes

approach

mellitus

costs

in

conditions.

to cost

1986

costs

discounted at 4%. Overall, $1 1.3 billion for NIDDM, ease,

$2.4

ofcosts

due

7.8%.

of the

costs

against

KEY

of 3 1.0%

38.5%

among

for

the

these

ceo-

medical

mortality

costs

of illness

disorders

of treatment

the

WORDS

costs,

costs

to musculoskeletal

raise

severe

health

1986. this

obesity

status

and

economic

direct

costs,

into

Moreover,

overweight

and obesity

risk factor for many disease (CVD) and

exacerbate

many

of

making

types:

prey-

were obese (overweight) adults were severely

Thus,

a major

portion

risk ofdisability,

of being

of

is more

(7) and is more common Americans than among

obese

costs ofillness

to a maximum

obesity

of the

disease,

adult

and pre-

overweight.

play an important

(9). Cost-of-illness

prevalence-based

and

studies

role in health can

be divided

incidence-based

analyses.

stage

ofdisease.

Prevalence-based

estimates

are particularly

well suited to estimating the magnitude of disease costs on an annual basis as well as assessing the economic burden attributable to acute or transient conditions. This approach does not, however, quantify the long-term consequences ofcurrent behaviors and chronic underlying conditions, such as smoking and being obese. For these purposes an incidence-based approach would

indirect

chronic diabetes.

chronic

by virtue

27.8

to a max-

prevalence-based approach identifies the costs incurred during a given year by persons with a particular illness, regardless

Introduction (overweight) is a major such as cardiovascular

Overall,

of these

overweight).

decision two

million

as BMI

increases

The

be

prevalence

Obesity diseases,

65-74.

is at increased

death

ofthe costs,

12.4

The economic

l992;55:503S-7S.

Obesity,

and

(severely

policy

quality

y of age and

whites

1980,

mature

was

must

45-54

aged

criteria,

US population

estimate

for men

women

(see Fig I) (8). 34 million adults

obese

Addition

for women,

nonHispanic in

defined

kg/rn2

than among men blacks and Mexican

By these

were dis-

(overweight),

27.3

alent among women among nonHispanic

were

of obesity

in

could

for

improved

Am J Clin Nuir

life.

irnurn

and

economic

and

hypertension,

the costs attributable to obesity $22.2 billion for cardiovascular

of the

or 5.5%

The

weighed

to obesity

ofobesity

for men

cholecystectorny, Using a prevaestimated

to morbidity

The prevalence kg/rn2

gall

estimate

billion,

to

for

and

$39.3

we

were of non-

bladder disease, $1.5 billion for hy$ I .9 billion for breast and colon cancer. Thus

billion

pertension, a conservative

risk

(NIDDM),

of illness,

due

adults

increased

disease and breast cancer.

attributable

Indirect

US

million with

disease, gallbladder and postmenopausal

lence-based nomic

34

is associated

be more

appropriate.

To complete

such

an analysis

reliable estimates ofthe incidence ofdisease sity at each age and for each gender. Although

dis-

would

require

attributable to obesuch an approach

eases (eg, hypertension, dyslipoproteinernia, osteoarthritis, and other musculoskeletal problems) (1). The prevalence of obesity in the United States is higher than that in Canada and the United

would provide an estimate of the lifetime costs of obesity, focused the current analysis on the annual economic impact obesity, using estimates ofthe prevalence and the proportion

Kingdom women

disease

index

(2). Data from representative samples ofUS men and 18-34 y of age show little variation in mean body mass

(BMI)

The

over a 20-y period

US population

from

is unlikely

1960 through

1980 (3, 4). in the near term. In

to get leaner

addition, women,

black women are on average more obese than a difference that is not explained by differences

ucation

or income

the

cost

of these

perspective

(3). The

health

conditions

of health

are

consequences therefore

of obesity important

the

value

sicians’

and

to obesity.

costs represent the monetary premature death as foregone in terms of direct and indirect

measured

white in ed-

from

attributable

Economic illness and

of resources services,

we of of

nursing

(personal home

health care,

burden on society of alternatives and are costs. Direct costs are care,

other

hospital professional

care,

phy-

services,

and drugs) that could be allocated to other uses in the absence of disease. Indirect costs are the value of lost output because of cessation or reduction of productivity caused by morbidity and

the

policy.

In 1980, ±

65.4

the mean weight of US males 18-74 y old was 78.1 1 3.5 kg (1 ± SD), and for US women of the same age it was ±

14.7

kg (5).

The

National

Center

defines overweight as BMI 85th percentile aged 20-29 y. Severe overweight is defined percentile (6). The 20-30-y-old population ence because these young adults in body weight with aging are

for

Health

Statistics

I From the Channing Laboratory, Brigham and Women’s Hospital and Harvard Medical School; and the Department of Epidemiology, Harvard School of Public Health, Boston. 2 Supported by research grant DK 36798 from the National Institutes of Health. 3 Address reprint requests to GA Colditz, Channing Laboratory, 180 Longwood Avenue, Boston, MA 02 1 15-5899.

ofmen and women as a BMI > 95th is used as the refer-

are relatively lean, and increases almost entirely due to fat accu-

mulation. Am J C/in Nuir

1992:55:5035-75.

Printed

in USA.

© 1992 American

Society

for Clinical

Nutrition

503S

Downloaded from https://academic.oup.com/ajcn/article-abstract/55/2/503S/4715327 by guest on 19 November 2018

ABSTRACT obese

COLDITZ

504S Prevalence

of

Overweight

Mencon

_

A,ner,con

Puerto

Picsnt

Rcon

bined

Non-Hieponic

Non-Hiapo&c

white

block

Cubort

11

increases

and

per

capita

care

expenditures

ductivity

from

1980

through

health

care

expenditures.

The

costs)

majority

of

amounted

incident

among men and women of cases were diagnosed > 28.3 kg/rn2 (18), and

Mole

FIG

cases

of

persons

Nutrition

Examination

and Nutrition ence 8.)

to

ofthe

percentage

amounts

Economic

costs

percentage of overweight Hispanic and nony of age. Data from the Hispanic Health and

20-74

Survey,

1982-84,

Examination

Survey,

and

the Second

1976-80.

National

(Reproduced

Health

from

refer-

The incidence tinuously with cystectomies

Morbidity

costs

able to work because value for persons too tasks. lost

Mortality

are wages

lost

of illness and sick to perform

costs

are

the

by people

diabetes

mellitus

(1 1), gall bladder

disease

present

value

( 13) (among

both

postmenopausal costs

men

for that

portion

(14,

and

chronic

with data relating analyses is estimation

tion of disease among studies use cutoff points

Center lars.

for Health Indirect

costs

due

breast

cancer

study

rate of 4%.

Economic

costs

used

to estimate

the

1986

are

in detail

those

due

related diabetic diabetic

of gall

to routine

to morbidity ketoacidosis, neuropathy;

that

CVD

overall,

57%

(0.6 1 X 0.94

are attributable

and

The

to obesity.

This

disease

Health

Study

population

BMI 29 kg/rn2 199 1 ).An estimated

were

(M Stampfer, 90% of these

perpercases

to obesity, and hence, 30% of the estimated associated with gall bladder disease are attribThis

is attrib-

figure

risk

of CVD

of CVD

adjustment

amounts

to $2.4

for

rises

billion.

with

(9) by 73%

BMI.

hypertension) This

trend

is most

evident

( I I) (see Fig 3). The costs by first inflating the direct costs reported

were estimated

1980

(excluding

for cigarette

measured by the Index (CPI) and

One lirnipropor-

are based

costs

ofCVD

the

in 1986 dol-

mortality

bladder

Nurses’ whose

to obesity.

after

ofsevere obewe focused in general and

All costs are expressed

costs care and

increases

levels

with

(see FIG 2) (10). of NIDDM elsewhere

smoking

to reflect

the

increase

medical component the increase in the

in medical

expenses

of the Consumer US population.

Price Indirect

costs were increased by a factor of 4 1% for men and 59% for women to reflect the increase in wages from I 980 to I 986. Because direct costs of hypertension account for 1 3.6% of total

CVD ofcosts could

personal

health

care

expenditure,

($7.6 billion) from be analyzed separately.

CVD

were attributed

from

the

1986

to NIDDM,

estimates.

we subtracted

the direct Because The

this portion

costs ofCVD so that this a portion of the costs of

these costs were also subtracted indirect

costs

of mortality

from

on

for

United

These

uncomplicated from

diabetic coma, and those that

by inflating

rising BMI; there is The procedures we

in the (16).

mortality

orders. To estimate costs we began 1980 US health care expenditure to 1986

y of age with BMI 94% of NIDDM

of clinically symptomatic gallstones rises conincreasing BMI. Approximately 33% of chole-

were attributable $8 billion costs utable

Many of the epidemiologic those defined by the National

an excess prevalence ofother disease with NIDDM, including circulatory,

mates

30-64 women,

of NIDDM

The incidence of NIDDM no evidence of a threshold set out

diagnosed

to $ 1 1.3 billion.

in the

Economic

we estimate

conditions

to morbidity

a discount

un-

cancer (among

colon

to severe obesity. of the attributable

the obese. other than

Statistics.

and

(12),

utable to obesity. Because ofthe relatively low overall prevalence sity (ie, only 36.5% of the total obese population), this economic analysis on the costs of obesity then concluded tation in these

are

In Rochester, MN, 59% and women with BMI Health Study, 61% of

earnings

hypertension

15). In this

of these

are

of non-insulin-de-

cholecystectomy

and women),

women)

of future

risk

(NIDDM)(l0), and

who

disability and an imputed their usual housekeeping

by people who die prematurely. Obesity is associated with increased

pendent

Thus

ofNIDDM

formed on women sonal communication, mortality.

obesity.

costs

pro-

billion.

NIDDM

who are obese. among men in the Nurses’

of health

Female

1 . Age-adjusted

Hispanic

attributable 0.57)

costs

and foregone

with

States

costs

in

include

NIDDM;

those

complications

such

diabetic retinopathy, arise as a consequence conditions among visual, renal, and

as and of

persons skin dis-

published estimates of the (1 7). We adjusted these esti-

them

in proportion

to the com-

22

22-22.9

23-23.9

24-24.9

25-26.9

-#{247}-45-49

..

27-28.9

50-54

FIG 2. Incidence of NIDDM according US women 30-64 y ofage. (Adapted from

29-30.9

--

31-32.9

33.34.9

35.

55-62

to BMI

reference

in a population

10.

of

Downloaded from https://academic.oup.com/ajcn/article-abstract/55/2/503S/4715327 by guest on 19 November 2018

=

US population

to $8.2

cases were diagnosed among women 29 kg/rn2 (10). Among these obese was

in the Direct

for $ 1 1 .6 billion,

accounted

(indirect

1986

ECONOMIC

COSTS

OF

505S

OBESITY

BMI

FIG 3. Relative risk of nonfatal myocardial infarction and fatal coronary heart disease (combined). according to categories of BMI in a cohort ofUS women who were 30-55 y ofage in 1976 and were followed for 8 y. (Adapted from reference 1 1.)

CVD
40% of the costs of obesity are attributable for severe

general

of surgery,

profiles

Yates

obesity.

Further,

the costs

of treatment

the indirect costs ofpremature death as a complication and the reduced costs of care due to improved risk

ofsurgery,

factor

to severe

obesity must be added to those outlined above for the obese population. These costs include the direct costs

and

better

reported

(26)

control

of NIDDM.

the average

charges

forjejunoileal

bypass

and gastric

bypass, which, inflated to 1986, are $10 8 13 for opand follow-up. This estimate was based on a survey rerate of only 17.6%, which limited its reliability. To esthe costs of surgery, we must add the indirect costs as-

eration sponse tirnate sociated

with

rate that

premature

premature

death

occurs

If the

profiles

widely

(30),

and

reported

improved

above,

for severe obesity and will be minor. Other improved

glucose

tolerance

the additional indirect benefits

psychological

are seen

suggest

Adventist among

Thus,

may and

to persist

relation

between

causes

ofdeath

other

been

omitted

from

have the

proportion

Phillips

may

of disease

and

and

men

100-109,

risk women

of colon (25)

observed

comparing

those

although

this

study suggests a major proportion may be attributable to obesity.

may

several (uterus

among

men

for women

may

small.

of 1 .45

from

Prospective with

an attrib-

follow-up

support

no association

Snowden of 3.3,

to risk

be too

(23). Data

for the costs

and

related

our estimate

a relative men

men

our estimate

tribution

among

cancer

is based

of25

women

may

as(25).

be conser-

an adjusted with

493

a stronger

relative

relative

on small

of colon cancer However, we note

weight numbers. among that we

female reproductive cancers and ovary), hence the female

that con-

be reasonable.

We have not included an estimate of the costs of obesity attributable to musculoskeletal disorders. If we assume that the relation of all muskuloskeletal disorders to obesity is similar to that observed for osteoarthritis (36), then 50% of the costs of these disorders may be attributable to obesity. This amounts to some

$17

billion.

Inclusion

of this

contribution

brings

the total

of obesity to 7.8% of the US total costs of illness. We conclude that obesity represents a major avoidable contribution to the costs ofillness in the United States. One approach costs

to containing States could ing weight

the rapidly rising be the implementation gain

in middle

I thank Christine assistance

in preparing

L Pappas,

and Anne

health care costs in the United ofprograms aimed at avoidlater

B

life.

Wolf, and JoAnn

Manson

for their

this material.

among

for obesity

direct

costs

due

and

patients

after

associated

weight

of $39.3 3.

to surgery mortality include the

quality

1.

2.

the associated

costs due to premature not considered here

status

obese

and

References

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4.

that

loss (32). 5.

Conclusions We provide quences

appears

lifetime

decreased need for medication (31). In contrast to the total cost estimates billion

effect inverse

strongly

of ‘-30%

have not considered are related to obesity

at a

in the literature but that may be -0. 1% earnings for a 34-y-old man are estimated at $785 488 and those for a 34-y-old woman at $592 426, even a mortality rate as low as 0. 1% (28) adds substantially to the cost oftreatment. Against this cost we must balance the reduction in cost due to improved cardiac function (29), improved lipid (27).

varies

mortality;

cancer

is more

Hawaii

among

This men

Costs

(35).

prevalence

obesity

> 125 to those

in 1986.

and

proportion

vative. risk

represents

fracture

This strong

than among women. Accordingly, be too large and that for men

Thus

attributable

the

among the obese population attributable to obesity were inferred from prospective studies. This may lead to some imprecision in our estimates. In addition, with respect to colon cancer, it is

sociation

to obesity

ofhip

estimates. of the

Seventh-day

Total

(34).

despite

diabetes,

current Estimates

utable

billion.

weight

groups,

and

than the

relative

age

a conservative

ofobesity.

We have

on musculoskeletal lower incidence

disorders than colon

cancer.

mortality

Further,

estimate of the economic consenot considered the impact of obesity (33) or on several cancers that have cancer and postmenopausal breast data

indicate

that

total

mortality

in-

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OBESITY