commentary

(Public Service Review: European Union)

April 21, 2011

Worth Its Weight in Gold?

by Roland Sturm

As researchers and financiers seek to capitalise on obesity innovation, RAND Europe Senior Economist Roland Sturm considers the consequences of not tackling the root cause

Obesity has been in European headlines for several years, attracting substantial resources into research and development. This could be a positive development because obesity is among the biggest public health issues in Europe. But a rapid flow of resources into very narrow areas, together with highly visible and exaggerated media exposure, has led to an outcome that more resembles California's Gold Rush than a route toward effective health policy.

Some of the 'next big things' in obesity research include lap-banding and brown fat, which, hopefully, will also provide benefits to patients. Yet despite the attention these topics receive in the media, the most promising solutions are likely to lie in public health innovations that prevent obesity in the first place. Unfortunately, prevention does not seem as exciting as profit-driven interventions or treatments, and that is a problem that requires more scrutiny.

As a serious public health issue, obesity deserves the attention it gets. Weight gain has been universal across all countries and demographic subgroups. In Europe, obesity has more than tripled over the past two decades; clinically severe obesity is growing at an even faster rate. Today, one in five Europeans is obese. There are some differences in obesity prevalence across Europe, but this is somewhat secondary to the overall trend. Last January, the UK was proclaimed the 'fattest EU country' based on data to be published in the New England Journal of Medicine later this year.

The typical definition of obesity is a body mass index (BMI) of over 30, which corresponds to a male of average height being 35lb overweight. Severely obese individuals — those who are 100 or 200lb or more overweight — have considerably more serious health problems. A male of average height and 100lb overweight has a BMI of 40. Using 1986 as a baseline, obesity (BMI over 30) increased by 200% (ie. tripled) by 2005; and clinically severe obesity (BMI over 40) increased by 500%.

Clinically severe obesity was once considered a rare pathological condition unrelated to behavioural changes in the general population. Data now shows that clinically severe obesity is an integral part of the population weight distribution. As the whole population shifts toward higher weight, the dangerously extreme categories grow the fastest.

On an individual level, moderate obesity (a BMI between 30-35), increases personal healthcare costs an average 20-30% compared to costs incurred by those of a normal weight. Clinically severe obesity — a BMI over 40 — more than doubles healthcare costs. Obesity far exceeds the costs of smoking, problem drinking, or other health behaviours. In terms of healthcare use and chronic health conditions, obesity is comparable to ageing 20 years, with the health of a 30 year old resembling that of a 50 year old. As a result, obesity has become the most prevalent cause of avoidable morbidity and excess healthcare costs in many industrialised countries. It is not yet, however, the main cause of premature deaths, a distinction in most European countries still held by smoking.

The reason smoking tops the charts for death is that the 'signature' disease of smoking is lung cancer, a relatively quick killer at any age. In contrast, the chronic conditions associated with obesity tend to lead to long-term ill health and require costly medical care for many years. Obesity disproportionately increases the financial burden on national healthcare systems as well as on other social services. In the US, obesity and its attendant disorders — particularly diabetes, arthritis and back problems — are already visible in rising national disability rates, even among 30-39 year olds. Within a few years, this is likely to be true in Europe as well.

These epidemiologic data suggest that a purely medical approach to treating morbid obesity in order to reduce its prevalence in the population will be futile. In contrast, a public health approach that focuses on preventing weight gain across the entire population is more likely to contain morbid obesity, even without explicitly targeting it. Prevention does not make headlines, or attract venture capital, because few profits can be made in prevention. Innovation in prevention, therefore, depends on public funding and a healthy dose of foresight. Obesity is preventable, but finding the balance between prevention and treatment is a difficult policy decision.

You may think the Gold Rush analogy a silly one, but the stampede of researchers and financiers in the wake of the 2009 'brown fat' findings feels comparable to the aftermath of the 1848 discovery of gold nuggets in California's American River. Brown adipose tissue is a type of fat that burns energy for heat instead of storing it and was believed to disappear among humans after birth. But new research found active brown fat in adults, suggesting a possible mechanism to burn excess calories. Energesis Pharmaceuticals is only one of several companies founded to mine brown fat. And while governmental agencies are not always the fastest responders, the EU quickly managed to fund several brown fat projects under its 7th Framework Programme. There are redeeming qualities to this approach: commercial backers are taking real risks, although few are likely to come out on top and public funding of basic research often improves society's knowledge.

Another 'fat mining' operation is even less risky and offers lucrative returns for medical establishments and investors: bariatric surgery for weight loss. At the moment, bariatric surgery remains the only effective treatment for severe obesity. It often cures diabetes too, although the actual mechanism remains unclear. Compared to many other medical procedures, bariatric surgery is even relatively cost-effective. But is this the best approach for society?

In the US, the number of bariatric surgical procedures for weight loss increased from 13,000 in 1998 to about 220,000 in 2009, according to the American Society for Bariatric Surgery. The procedures have become less invasive and safer over time. Somewhat disturbing is the aggressive advertising that contributes to the dramatic growth of this new industry and leads to predictable complications. For example, billboards that blanket Los Angeles suggest that this major surgery could be performed during a lunch break. Nevertheless, the explosive increase of this procedure has failed to make a dent in the prevalence of morbid obesity, which has increased at twice the rate of moderate obesity even as surgery rates rapidly increased in the US. There is no directly comparable data for Europe as a whole or for individual countries during the same time period. The NHS Information Centre released a report in 2010 that showed a doubling of bariatric procedures within two years in England. While advertising here does not quite reach the garishness of Los Angeles billboards, it is easy to find UK websites offering 'amazing deals' on lap-band surgery packages, done locally or as travel packages to Ireland or Italy.

And the new surgical procedure is not for adults only. A few years ago, performing such a drastic operation on children was almost unimaginable, but doctors at many children's hospitals now do it. These doctors worry that if they don't perform the procedure, adult surgery programmes will scoop up their young patients.

Wagging the 'personal responsibility' finger does not reduce either social or medical costs of obesity. Recommending healthy diets and regular exercise are rarely a successful strategy for very overweight children or adults. Their metabolism is altered. At 300lb or more, even a short walk becomes difficult because of joint pain and other problems. Whether or not society treats severe obesity, countries must deal with its associated health problems for a long time.

The niggling debate about who pays for bariatric surgery obscures a more fundamental problem. Treating an obese individual, whether morbid or moderate, is palliative and temporary and does not affect the roots of obesity. Every year, there will be new cases in need of treatment, which is good for surgical centres — bad for society. While markets react to new profit opportunities, it does not deliver the social gains promised by the invisible hand when those opportunities themselves are consequences of market failures and sooner or later, the heavy hand of government is felt. In tobacco, reducing smoking rates through very non-market oriented regulations was far more effective at improving health than trying to cure individual cases of lung cancer.

Obesity rates among children — not the epitome of well-informed rational consumers — have been increasing particularly quickly. Can this trend be reversed? Exhorting individuals to exercise, eat healthily, stop smoking, or drink responsibly doesn't work well by itself because environmental changes work against good advice. Such changes include car-friendly and bike and pedestrian-hostile urban developments, desk jobs, the attraction of television, and cheap calorie-dense foods. All these tip the balance between caloric intake and physical activity in a negative direction. Arguably, environmental interventions will be needed to counter the obesity epidemic. However, such preventive policies appear to be less attractive than pumping money into brown fat research, expanding bariatric surgery programmes, and spending ever-increasing sums on the health consequences of obesity.

This commentary appeared in Public Service Review: European Union on June 9, 2011