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RAND Review
Swollen Waistlines, Swollen Costs
Obesity Worsens Disabilities and Weighs on Health Budgets
By Roland Sturm and Darius Lakdawalla
Roland Sturm and Darius Lakdawalla are economists at RAND.
Obesity has become an epidemic in the United States since the 1980s. Severe obesity has spread the fastest. The epidemic has cut across all demographic groups irrespective of age, race, income, education, or geography. Meanwhile, everyone is paying for the epidemic.
Obesity is endangering the nation’s health care system in at least three ways:
- Obesity is linked to higher health care costs than is smoking or drinking.
- Obesity and its attendant disorders—particularly diabetes, arthritis, and back problems—appear to be associated with rising disability levels nationwide.
- The added health care costs for obesity-related conditions among those who will be age 50–69 in the year 2020 could account for as much as 1 in 5 health care dollars.
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Officially, obesity has only very recently become a public health priority; smoking and drinking have received far more attention. As part of its Healthy People 2010 initiative, the U.S. Public Health Service is now seeking to reduce the proportion of children, teenagers, and adults who are overweight or obese. A related goal of Healthy People 2010 is to increase physical activity among Americans. And in March 2004, the U.S. government launched an advertising campaign to promote exercise and healthier eating.
Nonetheless, the trends in obesity have been going in the wrong direction for 20 years without any sign of letting up. It is not clear that simply declaring weight control a higher national priority and producing an advertising campaign will lead to weight loss and improved health. Lasting behavioral change is rarely achieved only by exhorting individuals to exercise more, to eat healthier, to stop smoking, or to drink responsibly.
Many factors contribute to the obesity epidemic, and targeting some of them could be beneficial. Some of the recent environmental changes that have tipped the scales in favor of higher caloric intake and away from physical activity include inexpensive food that is high in calories, urban developments that are friendly to cars but hostile to walking and biking, and desk jobs.
Even though Americans are exercising more than ever in their leisure time, the occasional gym visits do not compensate for the decline in utilitarian physical activity (like walking kids to school, walking to the corner store, or walking to work). Most likely, it will be necessary for policymakers to weigh the many factors contributing to the obesity epidemic and to select the environmental interventions that show the greatest promise.
America Breaks the Scale
Obesity is defined as weight that is dangerously excessive because of its high proportion of body fat relative to lean body mass. A good screener for obesity is the Body Mass Index (BMI). BMI is a person’s weight in kilograms divided by height in meters squared. Because the BMI does not distinguish body fat from bone and muscle mass, the index can misclassify some people, such as those with large bones or muscles.
The standard BMI categories are as follows: underweight (BMI less than 18.5), normal (18.5 to 24.9), overweight (25 to 29.9), and obese (30 or more). The table illustrates how the BMI is used when expressed in pounds. For example, a man or woman who is 5 feet 6 inches tall is within the normal weight range at 115 to 154 pounds, overweight at 155 to 185 pounds, and obese at 186 pounds or more.
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Most Americans are either overweight or obese. More than one in five U.S. adults are classified as obese based on self-reported weight, which usually underestimates weight. About one in three U.S. adults are classified as obese based on objectively measured weight. Figures 1 and 2 show how obesity (based on self-reported height and weight) has spread from coast to coast since 1990.
The fastest growing group of obese Americans are "severely" obese—those with either a BMI of 35 to 40 (defined as class II obesity by the World Health Organization) or a BMI of 40 or more (class III obesity). The average man with a BMI over 40 weighs 300 pounds at a height of 5 feet 10 inches, while the average woman with a BMI over 40 weighs 250 pounds at a height of 5 feet 4 inches.
Between 1986 and 2000, the proportion of moderately obese individuals (those with a BMI of 30–35) merely doubled in the United States. In contrast, the proportion of individuals with a BMI of 40 or greater quadrupled from 1 in 200 adults to 1 in 50 adults (see Figure 3).
Costlier Than Smoking or Drinking
Obesity is linked to very high rates of chronic illnesses— higher than living in poverty and much higher than smoking or drinking. Figure 4 compares theincrease in chronic conditions related to obesity. The conditions of concern here are asthma, diabetes, heart disease, high cholesterol, hypertension, osteoarthritis, and some forms of cancer.
When compared with 100 normal-weight individuals of the same age and sex having similar backgrounds, 100 obese people would be expected to suffer 67 additional chronic conditions among them. In comparison, the increase associated with smoking is only about 25 additional conditions per 100 smokers (compared with 100 similar nonsmokers) and 12 additional conditions for problem drinkers.
Aging 20 years, from 30 to 50, is the only health risk comparable to obesity. Severely obese individuals, at least those who are aged 50–69, are more than twice as likely as are their normal-weight peers to be in only "fair" or "poor" health and suffer about twice as many chronic medical conditions.
Consequently, obese individuals incur higher health care costs than current smokers or problem drinkers. The obese spend 36 percent more on health care services and 77 percent more on medications than do their normal-weight counterparts. Current smokers spend only 21 percent and 28 percent more, respectively, than do nonsmokers; and problem drinkers spend yet smaller additional amounts on health care (see Figure 5).
The rapid growth in the proportion of Americans with clinically severe obesity has enormous implications for the nation’s health care system. With many more chronic medical conditions, the severely obese incur much higher costs for health care than do their normalweight counterparts. Whereas moderate obesity (a BMI of 30–35) is associated with 20–30 percent higher health care costs than those for normal-weight Americans between ages 50 and 69, a BMI over 35 is associated with a 60 to nearly 70 percent increase. And a BMI of at least 40 more than doubles health care expenditures.
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