Health Affairs And Costs The Effects Of Obesity , Smoking , And Drinking On Medical Problems

This paper compares the effects of obesity, overweight, smoking, and problem drinking on health care use and health status based on national survey data. Obesity has roughly the same association with chronic health conditions as does twenty years’ aging; this greatly exceeds the associations of smoking or problem drinking. Utilization effects mirrors the health effects. Obesity is associated with a 36 percent increase in inpatient and outpatient spending and a 77 percent increase in medications, compared with a 21 percent increase in inpatient and outpatient spending and a 28 percent increase in medications for current smokers and smaller effects for problem drinkers. Nevertheless, the latter two groups have received more consistent attention in recent decades in clinical practice and public health policy. M a n y b e h a v i o r a l r i s k f a c t o r s , chief among them smoking, heavy drinking, and obesity, are known causes of chronic health conditions. Chronic health conditions, like cancer, diabetes, or heart disease, in turn are primary drivers of health care spending, disability, and death. This paper compares the associations of smoking, problem drinking, and obesity with health care use and chronic conditions. All three risk factors are prevalent, although only obesity has dramatically increased over the past twenty-five years. There is an extensive literature of the association of individual risk factors with selected clinical problems. Overall assessments are rare, however, and no direct comparisons of obesity and other risk factors have been reported. Obesity research is also a newcomer in health services and policy research, in contrast to a long tradition of influential work on tobacco and alcohol, starting © 2002 Project HOPE–The People-to-People Health Foundation, Inc. Roland Sturm is a senior economist at RAND. He directs the economic and policy research program in the UCLA/RAND Managed Care Center for Psychiatric Disorders and is the principal investigator of several projects that study the economic implications of the changing health care system. DATAWATCH 245 H E A L T H A F F A I R S ~ M a r c h / A p r i l 2 0 0 2 H E A L T H R I S K S & C O S T S on O cber 1, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom with the U.S. surgeon general’s reports on smoking from the 1960s. Overweight and obesity refer to increased amounts of body fat, commonly assessed by the body-mass index (BMI, calculated as weight in kilograms divided by height in meters squared). The standard categories are underweight (BMI less than 18.5), normal (18.5–24.9), overweight (25–29.9), and obese (30 or more). According to these criteria, about one in three Americans are overweight but not obese, and an additional one in five are obese. The primary drawback of the BMI is that it cannot distinguish fat mass from lean mass and therefore misclassifies some persons. Other methods occasionally used in epidemiologic studies are waist circumference, waist-to-hip ratio, and skin-fold thickness. A higher BMI, beginning in the upper range of the normal weight category, is associated with increased mortality and increased risk for coronary heart disease, osteoarthritis, diabetes mellitus, hypertension, and certain types of cancer. Even modest weight reductions can have substantial lifetime health benefits. In the United States there was only a minor increase in overweight (including obesity) rates between 1960 and 1980, but rates have increased dramatically since then. Moreover, this recent increase was concentrated in the obese category, which between 1991 and 2000 alone grew 60 percent. Other industrialized countries, in particular Britain and Germany, have experienced similar growth rates in obesity but started from lower levels. The debate continues about whether obesity should be considered a disease in its own right. Recognition of obesity as a disease or disability could lead to changes in tax treatment for weight maintenance programs, insurance coverage, and other legal rights. Advocacy groups such as the American Obesity Association strongly support this goal, which was pioneered successfully by mental health advocates and played an important role in mental health parity legislation. The disease paradigm also has been promoted, although less successfully, for alcohol and drug abuse. Others warn that applying the disease paradigm to obesity could be interpreted as selfserving advocacy without a sound scientific basis.