Calling for a cease-fire

Most “costs of obesity” figures — elaborate fabrications of computer models — have had so many flaws* as to not be taken seriously. But few have calculated the medical costs attributed to “obesity” over an entire lifetime ... and compared them to “healthy” people with government-recommended BMIs.

Public health professionals from the Netherlands just did. They found that the ultimate lifetime medical costs are highest for healthy, nonsmoking, “normal-weight” people.

In the long run, obese people cost the healthcare system less than nonobese, and smokers cost still less...

They found that while annual healthcare costs are highest for the obese earlier in life (prior to age 56) and highest for smokers at older age, the overall costs are highest for those “healthy” people who are trim and don’t smoke. The greatest differences in healthcare costs, they wrote, are not those caused by smoking- or obesity-related diseases, but by unrelated diseases that occur with aging and living longer. They conclude that medical costs will not be saved by “preventing obesity.”

The Netherlands study, just published in Public Library of Science Medicine, was motivated by public health programs that are focused on prevention of illness, under the belief such interventions will reduce healthcare costs. This basic promise of better health equaling lower costs, they wrote, isn’t new. But it is debatable. Prevention may actually induce more healthcare costs in the long run than they save in the short run, they said, when we work from assumptions, claim effectiveness for prevention programs based on risk factor reductions, and don’t consider cost increases related to increases in disease in the life years gained.

Over recent years, many estimates have been made of healthcare costs attributable to obesity. These authors found them flawed, such as not taking into account the additional costs of diseases that come with aging with longer lifespans. What set this study apart from others to date was its multiple efforts to analyze the robustness of their findings with respect to the most up-to-date information and future changes in disease epidemiology and healthcare costs, the different definitions of healthcare costs, and a series of analyses estimating lifetime costs in different scenarios:

· 1. An annual decrease of 1% in the incidence and mortality rates for all diseases, in accordance with the decrease used in the Global Burden of Disease projections of global mortality and burden of disease.

· 2. An annual decrease in all relative risks of the obese and smoking cohort to reflect disease prevention efforts in smokers and obese, per previous reports.

· 3. An annual increase of 1% in health-care costs for all diseases per person.

· 4. Using a broader definition of healthcare costs to include long-term and residential care.

· 5. Using a narrower definition of healthcare costs by excluding all expenditure on nursing and residential care.

· 6. Using mortality risk estimates for persons with 330≤BMI<35, as published by Flegal et al. for the obese cohort.

· 7. Using mortality risk estimates for persons with a BMI≥35, as published by Flegal et al.

Their findings held with all scenarios. In essence, healthcare interventions may prevent deaths from that targeted disease, but people will die of something different that may be less lethal but more expensive. This study, they concluded, “demonstrates that sound estimates of medical costs in life-years gained should be taken into account in cost-effectiveness analysis of prevention.”

Given practically every government in the world has made obesity and smoking prevention a major focus, this study isn’t likely to be popular. An editorial in this same issue by Kim McPherson, who helped create the UK Foresight Project, said this study’s cost estimates don’t mean government health interventions are unwarranted just because they have no benefits. The lower “quality of life” associated with fat people and smokers may justify public health programs. Echoing the authors, she said, prevention may “importantly, contribute to the health of nations.” Readers will remember the Foresight Tackling Obesities: Future Choices Project report, filled with 42 pages of policy proposals for an Orwellian future under the State.

While this new study can provide a much needed balance to the “costs to society” being assessed on fat people and anyone else not perceived as following a “healthy lifestyle,” hopefully, it will also serve as a call to end all such cost estimates. They are used, along with distortions of science, to point blame and lodge wars against those seen as costing too much or “using more than their fair share” of resources ... under the guise of health promotion and the common good. But, in reality, there are only two truisms:

1. Shit happens and no one gets out alive.

2. No one really knows how to change #1.

© 2008 Sandy Szwarc

* How bad are they? If you’ve examined the various “costs of obesity” reports purportedly showing skyrocketing healthcare costs attributed to obesity, you’ve caught them doing things like: failing to account for age (!) or socioeconomic status; tallying any condition that’s ever been “associated” with obesity, and even others that aren’t (like dental services and eye glasses); double counting of the same conditions (the same health risk factor used as the “cause” for as many as 4 different diseases); redefining obesity to overstate risks associated with it; piling on productivity and lost work hour estimates; not reporting that fat people actually cost less than thinner people; not factoring for weight loss pills and interventions imposed on fat people; including the iatrogenic consequences of obesity “treatments”; and failing to reveal that skyrocketing costs aren’t rising in numbers of cases, but rising costs per treatment — 70% of costs due to more expensive drugs and technological interventions.

** Their estimates for lifetime healthcare costs used the National Institute for Public Health and the Environment chronic disease model (RIVM-CDM) for disease and mortality data; and Costs of Illness data from the Netherlands and the Systems of Health Accounts for international cost comparisons.