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Impact of Obesity Interventions on Managed Care

Obesity: Definition, Comorbidities, Causes, and Burden

Caroline M. Apovian, MD, FACP, FACN
Abstract
Body mass index of 30 kg/m2 or higher is used to identify individuals with obesity. In the last 3 decades, the worldwide prevalence of obesity has increased 27.5% for adults and 47.1% for children. Obesity is the result of complex relationships between genetic, socioeconomic, and cultural influences. Consumption patterns, urban development, and lifestyle habits influence the prevalence of obesity. The condition may be the result of disease or pharmacologic treatment. It may also be a risk factor for the development of comorbid conditions. Persons who are obese have less school attendance, reduced earning potential, and higher healthcare costs that may result in an economic burden on society. A review of the prevalence and economic consequences of obesity is provided. Potential causes and comorbidities associated with obesity are also discussed.

Am J Manag Care. 2016;22:S176-S185
Definition and Incidence of Obesity

Body mass index (BMI), which is weight in kilograms divided by height in meters squared, is used to iden-tify obesity. For adults, a BMI of 25.0 to 29.9 kg/m2 is defined as overweight and a BMI of 30 kg/m2 or higher is defined as obese.1 BMI is not used for children and adolescents age 2 to 18 years; instead, it is recommended that a percentile scale based on the child’s sex and age be used.2 In this population, overweight is defined as a BMI in the 85th to 94th percentile, and obesity is a BMI at or above the 95th percentile.

For every 5-unit increase in BMI above 25 kg/m2, overall mortality increases by 29%, vascular mortality by 41%, and diabetes-related mortality by 210%.3 Measures of central adiposity, such as increased waist circumfer-ence, predict cardiometabolic risk, which cannot be directly determined by elevated BMI.4 The Edmonton obesity staging system ranks excess adiposity on a 5-point ordinal scale and incorporates the person’s obesity-related comorbidities and functional status. The system is intended to complement current measures and has been found to be a strong, independent predictor of increasing mortality; however, it is still unclear how to best incorporate the system into clinical practice.5

Worldwide, the prevalence rate for being overweight or obese between 1980 and 2013 increased 27.5% for adults and 47.1% for children, for a total of 2.1 billion individuals considered overweight or obese.6 These increases were seen in both developed and developing countries. However, the prevalence of overweight and obesity is higher in developed countries than in developing coun-tries at all ages (data from 2013). In developed countries, more men were considered overweight or obese than women; the opposite was seen in developing countries. (Figure6). In the United States, obesity rates are 12.4% for boys younger than 20 years, 31.7% for men 20 years or older, 13.4% for girls younger than 20 years, and 33.9% for women 20 years or older. Prevalence rates increased between 1992 and 2002, but have since leveled off.6

Economic Consequences of Obesity

Direct Healthcare Costs

Obesity is associated with increases in annual health-care costs of 36% and medication costs of 77% com-pared with being of average weight.7 Data from the Medical Expenditure Panel Surveys (MEPS), a large national survey of civilian, noninstitutionalized indi-viduals (N = 21,877), reported 2006 costs across all payers (eg, Medicare, Medicaid, and private insurers). Results showed that patients who were obese had annual medical spending that was on average $1429 (42%) higher than patients who were of normal weight, and obesity was attributed to about $40 billion in increased medical spending. For Medicare patients, the main contribu-tors to healthcare costs were non-inpatient services and medications, which were attributed to the introduction of prescription drug coverage at that time. The costs for Medicare patients who were obese were $600 higher per year than for patients who were of normal weight.8

Longterm Economic Consequences of Obesity on the Individual

Obesity is associated with longterm negative economic consequences. Children with obesity were absent from school significantly more (12.2 ± 11.7 days) than children who were considered to be of normal weight (10.1 ± 10.5 days).9 Obesity was associated with 1.9 more days absent after controlling for age, gender, race/ethnicity, and school. A higher BMI in the late-teen years was associated with a lower level of accumulated education, and data from the National Longitudinal Survey of Youth found that a 1-unit increase in BMI is directly associated with 1.83% lower hourly wages.10 In addition, children who are obese or overweight are at increased risk for being the target of aggressive behavior from their peers. A study looking at the relationship between bullying and BMI found that adolescents who were overweight or obese were more often the victims of rumors/ lies, name-calling, teasing, physical abuse, and isolation.11

If obesity could be addressed early in life, it could have a substantial impact on healthcare costs. It is estimated that if the number of individuals ages 16 and 17 who are overweight or obese could be reduced by 1%, then the number of adults with obesity in the future could be reduced by 52,812; this would result in a decrease in life-time medical costs of $586 million.12 Obesity appears to influence school attendance, level of education, earning ability, and social interactions. overweight or obese were more often the victims of rumors/ lies, name-calling, teasing, physical abuse, and isolation.11

If obesity could be addressed early in life, it could have a substantial impact on healthcare costs. It is estimated that if the number of individuals ages 16 and 17 who are overweight or obese could be reduced by 1%, then the number of adults with obesity in the future could be reduced by 52,812; this would result in a decrease in life-time medical costs of $586 million.12 Obesity appears to influence school attendance, level of education, earning ability, and social interactions.

Factors Associated With the Development of Obesity

The exact cause of obesity is unknown; however, there appears to be a complex relationship among biologic, psychosocial, and behavioral factors, which include genetic makeup, socioeconomic status, and cultural influences.13 Obesity has been linked to microorganisms, epigenetics, increasing maternal age, greater fecundity, lack of sleep, endocrine disruptors, pharmaceutical iatrogenesis, and intrauterine and intergenerational effects.14 Comorbid conditions and their treatments may also be a factor  in developing obesity. A list of causes of obesity can be found in the Table.15 The pathophysiology of obesity is well understood; however, treatment and prevention have focused on the psychological and social components of the disease. To date, the best noninvasive interventions have been in dietary management and behavioral change. The best outcomes are associated with bariatric surgery. Drug therapy has limited effectiveness, particularly in children. Genetic testing is applicable for a small group of these patients. Researchers are still in the process of integrating basic science data with clinical research and learning how to apply the results to patient care.16

Food Choices and Influence on Weight

Food choices, which are influenced by the home, child care, school, workplace, and community environments, directly affect the type and amount of caloric intake. Over the last 100 years, because of technological advances in food processing, the types of foods consumed have changed. Foods with decreased fiber and increased fat, simple sugar, salt, and increased calories are more readily available, and they are typically cheaper than healthier alternatives. Consumption of these ultra-processed foods has led to a 205-calorie increase in an individual’s average daily caloric intake since the 1960s.17

A school-based study conducted by the CDC reported that two-thirds of high school students drank some type of sugar-sweetened beverage (eg, soda, Hawaiian punch, lemonade, Kool-Aid, other sweetened fruit drinks, iced tea) at least once a day, and about 22% drank them at least 3 times a day. Male and non-Hispanic black students ate at a fast food restaurant at least 1 day a week, watched television more than 2 hours a day, and had a greater chance of consuming sugar-sweetened beverages at least 3 times a day than other groups studied. Students less likely to consume those drinks were non-Hispanic or those who were physically active at least 60 minutes a day for at least 5 days a week.18 One soda a day, depend-ing on the size (8 oz to 20 oz), could provide 270 to 690 calories a day. Consumption of sugar-sweetened beverages is associated with an increase in the risk of obesity; the risk increases 1.6 times (95% CI, 1.14-2.24; P = .02) for each additional serving of sugar-sweetened drink consumed daily.19 Consumption of energy-dense foods is positively associated with an increase in waist circumference and BMI.20,21 A 6-year, longitudinal study demonstrated that women who consumed a diet made up of higher energy-dense foods, consisting of more servings from grain, meats, and fat groups, had an increase in BMI of 2.5 units, whereas women who consumed lower energy-dense diets, containing more servings of vegetables and fruit, had an increase in BMI of 0.9 units.21
 
Relationship of Socioeconomic Factors and Obesity

Racial or cultural makeup of the living environment likely influences a person’s weight. In another report, racial segregation in metropolitan areas was not associated with obesity among men; however, segregation did appear to affect obesity rates among some women. For black women, living in a highly segregated area was associated with a 1.29 times higher obesity prevalence (95% CI, 1.00-1.65), and a medium-segregated area was associated with a 1.35 times higher obesity prevalence (95% CI, 1.07-1.70). Conversely, for Mexican-American women, living in a highly segregated area was associated with significantly lower obesity prevalence (prevalence ratio, 0.54; 95% CI, 0.33-0.90).22

It is recommended that adults engage in at least 150 minutes of moderate-intensity physical activity a week.23 However, a reduction or lack of physical activity is attributed to neighborhood planning that discourages active transportation, such as walking or biking. Other factors contributing to lack of physical activity are decreased availability of physical education classes and a general philosophy in the work and school environment that physical activity is not a priority.24

A person’s urban environment impacts the amount and type of physical activity. One study examined proximity of physical activity facilities to the residential locations of the 20,745 adolescents who participated in wave I of the National Longitudinal Study of Adolescent Health.25 Higher socioeconomic areas had a greater number of physi-cal activity facilities, which, in turn, were associated with increased relative odds of adolescents participating in at least 5 sessions of physical activity a week and decreased rates of adolescents being overweight. Increased physical activity is important in management of excess weight; clinical guidelines recommend that all obesity management programs consist of a reduced-calorie diet, increased physical activity, and behavior modification.1,15

Genetics and Obesity

Numerous polymorphic gene products may also be a cause of obesity. Li and colleagues reported that 12 obesity-susceptible loci have been identified. Investigators examined the association between those loci and BMI, waist circumference, weight, and height, as well as the predictive value for obesity risk. Variants had a cumulative effect on obesity measures, with each additional allele associated with an increase in weight of 444 g and increased risk of obesity of 10.8%. However, the alleles combined had limited predictive value for obesity risk.26

 
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