Societal costs

“Obesity outranks both smoking and drinking in its deleterious effects on health and health costs.” Excessive alcohol consumption and smoking have been recognized as considerable public health issues, particularly because these behaviors lead to chronic medical diseases that command considerable personal and societal resources to treat. In evaluating 1998 data from Healthcare for Communities, Sturm reported that obesity was associated with a 36% increase in inpatient and outpatient spending compared with a 21% increase in inpatient and outpatient spending for smokers and excessive drinkers. Although this is startling, it becomes more so when considering the greater number of obese people than smokers and excessive drinkers, the growing epidemic of obesity, and the many chronic conditions associated with obesity.

Several associated comorbidities have been linked to obesity: coronary artery disease, hypertension, type 2 diabetes mellitus, end-stage renal disease, cholecystitis, obstructive sleep apnea, breast cancer, endometrial cancer, renal cell cancer, colorectal cancer, low back pain, and arthritis. In aggregate, the direct costs for providing care for these obesity-related conditions in 1999 dollars were $331.4 billion and that portion attributed to obesity was $102.2 billion. As the number of obese people increases, so do the medical costs. In 2008 dollars, costs to treat obesity totaled approximately $147 billion.

Costs are commonly grouped into direct and indirect costs. Direct costs are defined as those costs associated with the diagnosis and treatment of diseases as well as treatment of the disease itself. Direct costs include costs, such as hospital and nursing home care, physician visits, and medications. Indirect costs are the value of lost output because of cessation or reduction of productivity caused by morbidity and mortality. Examples of indirect costs are lost wages caused by absenteeism or loss of future earnings caused by premature death. Wolf and Colditz estimated the direct costs of obesity in 1998 using data from the 1988 and 1944 National Health Interview Survey and concluded that the direct costs associated with obesity were $99.2 billion and approximately $51.64 billion of that was attributed to direct medical costs. The cost of lost productivity (indirect costs) associated with obesity was $3.9 billion and reflected 39.2 million days of lost work. Finkelstein and colleagues, using a different data set, estimated that obesity-attributable spending accounted for 9.1% of total US medical expenditures in 1998 for a total of $78.5 billion, which equals $92.6 in 2002 dollars.

The personal costs of obesity do not receive as much attention as the economic costs; however, personal costs of obesity are considerable. Discrimination against obese people is commonplace in society at large and in the health care arena. A perception of lower class citizenship, whether or not real, may have profound implications on the lives of the obese. Personal costs of obesity are not commonly quantified, but it has been shown that obese subjects earn less than their lean counterparts after corrections are made for intellectual ability and social background. Poor physical function may also limit earning potential. As patients are required to pay more for their health care, costs typically associated with direct costs may be attributed to personal costs, such as increased payments for insurance or higher costs for medicines.

Workplace costs

Several investigators have discussed the economic impact of obesity on the workplace. In 2000, private business expense for health services consumed 40% of pretax profits and 58% of after tax profits. Thompson and colleagues estimated the actual dollars spent by US businesses on health care for obese employees at $12.7 billion, including $2.6 billion for mild obesity (body mass index [BMI] 25–28.9) and $10.1 billion due to all others with a BMI greater than or equal to 29.

Direct costs to employers have been explored. Burton and colleagues evaluated the increased costs associated with BMI in a workplace of approximately 6500 employees. They reported the mean health care costs for employees with a BMI greater than or equal to 28 (approximate) were $6882 in comparison with $4496 for employees with BMI less than 28 (approximate). In another study by Finkelstein and colleagues, using the National Health Interview Survey and the Medical Expenditure Panel Survey (MEPS), the investigators found that overweight and obesity costs ranged from $175 per year for overweight male employees to $2485 for grade II obese (BMI 35.0–39.9) female employees. The investigators further estimated that the costs of obesity (excluding overweight) at a firm with 1000 employees would be $285,000 per year. In looking at total costs, obesity-attributable business expenditures on paid sick leave, life insurance, and disability insurance amounted to $2.4 billion, $1.8 billion, and $800 million, respectively, in 1994.

Indirect costs are also considerable for the workplace, particularly evident in employee absenteeism. Tucker and Friedman evaluated more than 10,000 employees who participated in an ongoing wellness screening program. The obese employees were 1.74 and 1.61 times more likely to experience high (7 or more absences due to illness within 6 months) and moderate (3–6 absences due to illness within 6 months) levels of absenteeism, respectively, than were lean individuals. Burton and colleagues found that employees with a BMI greater than or equal to 27.8 for men and BMI greater than or equal to 27.3 for women experienced twice as many sick days as lean employees. They were further able to document a direct correlation between increasing BMI and absenteeism. Using 1994 data, Wolf and Colditz estimated the cost of lost productivity attributed to employees with a BMI greater than 30 was $3.9 billion, which reflected 39.2 million days of lost work.

Despite the high cost of absenteeism to businesses, the true indirect costs must also include increased disability rates, higher employee injury rates, and presenteeism—all of which push indirect costs even higher. Presenteeism is defined as lower work output. Obese employees place a presenteeism burden on businesses due to several causes, such as physical inability to perform tasks efficiently or increased fatigue. Wolf and Colditz estimated restricted activity workdays at 181,540,000 for employees with a BMI greater than or equal to 25 compared with 239 million restricted activity workdays in employees with BMI greater than or equal to 30.

Workplace costs

Several investigators have discussed the economic impact of obesity on the workplace. In 2000, private business expense for health services consumed 40% of pretax profits and 58% of after tax profits. Thompson and colleagues estimated the actual dollars spent by US businesses on health care for obese employees at $12.7 billion, including $2.6 billion for mild obesity (body mass index [BMI] 25–28.9) and $10.1 billion due to all others with a BMI greater than or equal to 29.

Direct costs to employers have been explored. Burton and colleagues evaluated the increased costs associated with BMI in a workplace of approximately 6500 employees. They reported the mean health care costs for employees with a BMI greater than or equal to 28 (approximate) were $6882 in comparison with $4496 for employees with BMI less than 28 (approximate). In another study by Finkelstein and colleagues, using the National Health Interview Survey and the Medical Expenditure Panel Survey (MEPS), the investigators found that overweight and obesity costs ranged from $175 per year for overweight male employees to $2485 for grade II obese (BMI 35.0–39.9) female employees. The investigators further estimated that the costs of obesity (excluding overweight) at a firm with 1000 employees would be $285,000 per year. In looking at total costs, obesity-attributable business expenditures on paid sick leave, life insurance, and disability insurance amounted to $2.4 billion, $1.8 billion, and $800 million, respectively, in 1994.

Indirect costs are also considerable for the workplace, particularly evident in employee absenteeism. Tucker and Friedman evaluated more than 10,000 employees who participated in an ongoing wellness screening program. The obese employees were 1.74 and 1.61 times more likely to experience high (7 or more absences due to illness within 6 months) and moderate (3–6 absences due to illness within 6 months) levels of absenteeism, respectively, than were lean individuals. Burton and colleagues found that employees with a BMI greater than or equal to 27.8 for men and BMI greater than or equal to 27.3 for women experienced twice as many sick days as lean employees. They were further able to document a direct correlation between increasing BMI and absenteeism. Using 1994 data, Wolf and Colditz estimated the cost of lost productivity attributed to employees with a BMI greater than 30 was $3.9 billion, which reflected 39.2 million days of lost work.

Despite the high cost of absenteeism to businesses, the true indirect costs must also include increased disability rates, higher employee injury rates, and presenteeism—all of which push indirect costs even higher. Presenteeism is defined as lower work output. Obese employees place a presenteeism burden on businesses due to several causes, such as physical inability to perform tasks efficiently or increased fatigue. Wolf and Colditz estimated restricted activity workdays at 181,540,000 for employees with a BMI greater than or equal to 25 compared with 239 million restricted activity workdays in employees with BMI greater than or equal to 30.

Who pays?

Although the discussion of health care costs attributable to obesity is stimulating, the logical next question is, Who pays for health care for obese patients? Private insurance companies do not externally publish data on this subject or at least the authors were unable to secure such data. The senior author even asked a local medical director of a large insurance company and was told the data could not be made available. Estimates have been done to determine how much is paid and who pays for obesity-related health care issues. Using data from the Bureau of Labor Statistics, Thompson and colleagues estimated that of the $12.7 billion obesity-related costs to US businesses, $7.7 billion was paid out for health insurance expenditures. In 1998, national medical spending for obesity, excluding overweight, was $26.8 billion, using MEPS data, or $47.5 billion, using National Health Accounts (NHA) data. Despite the different methodologies, both the MEPS and NHA estimates revealed that the public sector was responsible for financing nearly half of medical spending for obesity-attributable diseases. In a recent follow-up study, Finkelstein and colleagues found that the increased prevalence of obesity was responsible for almost $40 billion of increased medical spending through 2006, including $7 billion in Medicare prescription drug costs. They estimated that the medical costs of obesity could have risen to $147 billion per year by 2008.