Three Parts

Genuine Progress Index for Atlantic CanadaIndice de progrès véritable - Atlantique

Estimating the Cost of Preventable Illness

Genuine Progress InstituteHalifax, NS, 7 July, 2011

Three Parts

1) The larger context - measuring progress more accurately

2) Estimating the cost of chronic disease and its preventable portion (=purpose)

3) Estimating the cost of specific risk factors (in this case obesity) & cost-effectiveness of preventive interventions

1) The larger context

1) Measuring progress - what’s wrong with the way we do it now: Wednesday!

2) Doing it better - Population health as a key indicator

3) Why economic valuation? - Strategy; always derived from physical indicators

What kind of Nova Scotia are we leaving our

children?

Therefore, context for obesity cost estimates:

1) Need for better indicators, which include value of natural, social, human capital - Population health as core indicator of national, social progress

2) Economic valuation as strategy, language, based on physical indicators (e.g. voluntary work, crime, forests). In an ideal world, economic valuation unnecessary - all policy decisions include health, social, envt. impacts

2) Chronic disease as cost;

Prevention as investment

• Medical expenditures conventionally counted as economic gain; here = cost

• Indirect costs, particularly, are huge

• What proportion of costs preventable? (= purpose of costing exercise)

• Disease prevention (esp. dealing with root causes) is cost-effective

Costs of chronic disease:

• In west: four types of chronic disease account for about 3/4 of all deaths (cf 1900) Cardiovascular - 36%; Cancer - 30% COPD - 5%; Diabetes - 3%+

• Chronic diseases account for 60% medical costs; 3/4 of productivity losses due to disability and premature death; 70% total burden of illness = 13% GDP

E.g.: Cost of Chronic Illness in

Nova Scotia 1998 (2001$ million)

Hosp. Doctor Drugs OtherTotalDirect

Premat.Death

Dis-ability

TOTAL

Circulatory 161.6 26.6 63.6 137.8 389.6 326.8 244.4 960.8

Cancer 71.4 11.8 7.5 49.6 140.3 427.2 14.5 582.1

Respiratory 21.6 3.2 16.6 22.7 64.1 43.4 78.1 185.5

Musculoskeletal 55.9 20.3 22.0 53.8 152.0 3.5 307.2 462.8

Endocrine 18.5 7.2 29.3 30.1 85.0 43.8 27.0 155.8

Nervous system 55.3 27.9 19.2 56.0 158.5 30.0 158.6 347.0

Mental 104.2 17.7 39.2 88.2 249.2 16.0 72.3 337.5

TOTAL: 488.4 114.8 197.5 438.1 1,238.8 890.8 901.9 3,031.5

These are under-estimates

• Exclude diseases: Digestive, cirrhosis of liver, congenital, perinatal/LBW, blood, skin, genitourinary (chronic renal failure), etc.

• “Principal diagnosis”: e.g. injury/fall vs osteoporosis; diabetes under-reported (complications: blindness, kidney failure, amputations, cardiovascular disease, infections)

What portion is preventable? Excess risk

factors account for:• 40% chronic disease incidence

• 50% chronic disease premature mortality

• Small number of risk factors account for 25% medical care costs

• 38% total burden of disease (includes direct and indirect costs)

A few risk factors cause many types of chronic

disease• Tobacco - heart disease, cancers, respiratory

disease

• Obesity - hypertension, diabetes 2, heart disease, stroke, some cancers

• Physical inactivity - heart disease, stroke, hypertension, colon and breast cancer, diabetes 2, osteoporosis

• Diet/fat - heart disease, cancer, stroke, diabetes

• Alcoholism – first step = epidemiology: PAFs

Design cost-effective prevention strategy knowing costs of key risk factors (e.g. Nova

Scotia (2001 $ millions)

Deaths Direct Indirect Total

Tobacco 1,700 $188 $300 $488

Obesity 1,000 $120 $140 $260

PhysicalInactivity 700 $107 $247 $354

Socio-economic Determinants of Health• Education, income, employment,

stress, social networks are key health determinants. These too are modifiable

• Lifestyle interventions effective for higher income/education groups, not lower - can widen inequity, health gap

Health Costs of Poverty

• Most reliable predictor of poor health, premature death, disability: 4x more likely report fair or poor health = costly

• e.g. Increased hospitalization (Canada): Men 15-39 = +46%; 40-64 = +57% Women 15-39 = +62%; 40-64 = +92%

Health Cost of Inequality

• British Medical Journal: “What matters in determining mortality and health is less the overall wealth of the society and more how evenly wealth is distributed. The more equally wealth is distributed, the better the health of that society.”

• e.g. Sweden, Japan vs USA; Gap widened

E.g. Excess use of physicians

• No high school diploma use 49% more physician services than those with BA

• Lower income groups use 43% more than higher income; lower middle = 33% more

• In NS: excess physician use due to educational inequality = $42.2 M./yr; excess use due to income inequality = $27.5 M./yr = small % total health costs

Heart Health Costs of Poverty

• Low income groups have higher risk of smoking, obesity, physical inactivity, cardiovascular risk = costly

• Canada could avoid 6,400 deaths, $4 billion/year if all Canadians were as heart healthy as higher income groups

Health costs of child poverty• 31 indicators - as family income falls,

children have more health problems, (NLSCY, NPHS, Statistics Canada)

• Child poverty -> higher rates of respiratory illness, obesity, high blood lead, iron deficiency, FAS, LBW, SIDS, delayed vocabulary development, injury+….

BUT... Doesn’t a successful preventive

strategy just defer costs to older ages?

• NS 65+: 2001 = 14%; 2036 = 28%

• e.g. Philip Morris’ Czech Republic study

• + Prevention hard to sell: 1) Successful prevention = nothing happens; 2) Costs won’t be diverted from health care

Answer these objections

Aging - Delay vs Cure Saves $

• 5-year delay in onset cardiovascular disease could save US $100 billion / yr; hip fracture 5-yr delay save $7.3 billion

• Physically active - lower lifetime illness

• Nutritional intervention - reduce hospital use 25%-45% among elderly

• Ethics, methods of PM study

• Accepting death – Bhutan example

Prevention saves:

“... A strategic aging research effort would benefit the nation’s economy and boost productivity.... The United States will save billions of dollars by keeping older people out of hospitals, out of operating rooms and out of nursing homes.... Long life can be healthy and productive to the end.” American Federations for Aging Research

“Compression of Morbidity”

• Fries: “The amount of disability can decrease as morbidity is compressed into the shorter span between the increasing age at onset of disability and the fixed occurrence of death.” (= about 85: analysis of 1900s data)

• “Successful aging” can preserve independence into old age

Disease Prevention is Cost-Effective

Investment• E.g. Workplace = 2:1

• WIC = 3:1 (mostly avoided LBW)

• “Smoke-Free for Life” = 15:1

• Pre-natal counselling = 10:1

A chronic disease prevention strategy is responsibility of all sectors

3) Cost of Obesity

1) How we currently count obesity costs

2) Costs of obesity - health impacts

3) Global epidemic; U.S. trends

4) Economic costs: Methodology and cost estimates (direct and indirect)

5) Causes and solutions: cost-effective interventions

Is obesity a “cost”, or is it good for the

economy?• Americans spend more than $100

billion a year on fast food = 44% of all food service sales

• Fast food, candy, sugared cereals = 1/2 of $30 billion annual food industry advertising in U.S. (Kelloggs spends $40 million /year to promote Frosted Flakes alone)

Overeating contributes to economy many times

over• Excess foods grown, processed,

advertised, transported, warehoused, sold

• Diet drug and weight loss industries then add $35 billion to US economy

• Liposuction = leading form of cosmetic surgery in US = 400,000 operations / year = up 62% in 2 years = a growth industry

Obesity-related illness

• Costs U.S. $118 billion / year (Colditz) - now exceeds smoking; but doctor, drug, hospital costs make economy grow

• More than 50% diabetes 2 due to obesity

• Type 2 diabetes grown 5-fold globally since 1985 from 30 to 150 million (17 million in US). WHO predicts 300 million by 2025

In the words of the pharmaceutical

industry:“The type 2 diabetes market will

double to $17.2 billion in 2011, reflecting sustained, robust annual growth of 7% from 2001 through 2011”

• Consumption of oral diabetic drugs will grow five-fold from 2001 to 2011

Eli Lilly - $119 bill. firm

• Announced construction of world’s largest factories devoted to single drug (insulin) = $1/2 bill. plants in Virg. and PR (11% of PR population has diabetes)

• Lilly global insulin sales up 16% in 2001 Humalog (Virg, PR) up 79%; Actos up 61% from 2000 (2001 sales = $901 mill)

• James Kappel (Lilly): “You’ve got to be in diabetes.”

Counting it wrong

• So long as we count growth in fast food and diabetes industries as good news for the economy, the health policy agenda is unlikely to shift

• So long as we use economic growth statistics as the primary measure of social wellbeing, we won’t give population health and prevention the attention they deserve

Counting it right: Obesity as serious cost

• Obese (BMI >30) = 50-100% increased risk of death (all causes) cf healthy weight

• Overweight = higher premature death rate even if no smoking, otherwise healthy (American Cancer Society - 1 million subjects)

• Second-leading preventable cause of death in US (Joann Manson - Harvard)

Health Impacts

• BMI >30 = 4x diabetes; 3.3x high blood pressure; 56% more likely have heart disease; 2.6 times urinary incontinence; 50% less likely rate health positively (Statcan)

• Association with some cancers, gallbladder disease, stroke, asthma, arthritis, thyroid problems, back problems, sleep disorders, impaired immunity, depression, etc.

A “Global Epidemic” (WHO)

• Obesity increased 400% in the western world in the last 50 years.

• Underfed and Overfed: The Global Epidemic of Malnutrition: “ for the first time in human history the number of overweight people in the world now equals the number of underfed people, with 1.1 billion each.” March, 2000, Worldwatch Institute, Washington D.C.

Unequal distribution not food scarcity is the

problem• 80% of world’s hungry children live in

countries with food surpluses; 36% Brazilians, 41% Colombians overweight

• 50%+ US, UK, Germans overweight; 50%+ Bangladesh, India children underweight

• U.S. - 20% children overweight or obese (50% increase since 1980); Nearly 1/5 U.S. children “food insecure” (USDA)

Underfed and Overfed

• The hungry and the overweight share high levels of sickness and disability, shortened life expectancies, and lower levels of productivity -- all of which impede a country's development

• Among the overweight, "obesity often masks nutrient starvation," as calorie-rich junk foods squeeze healthy items from the diet. In Europe and North America, fat and sugar now account for more than half of total caloric intake

–

Low-income, poorly educated, elderly = higher rates overweight,

obesityPercent of Canadians who believe that low-fat foods are expensive, 1994-95

40

37

34

32

40

25

27

29

31

33

35

37

39

41

lowest low-middle middle upper middle highest

Pe

rce

nt

Overweight- by Education and Age (20-64), Canada, 1997

(%)

30 29

22

15

24

29

3639

36

0

5

10

15

20

25

30

35

40

45

Pe

rce

nt

Obesity Trends* Among U.S. Adults, 1985Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. AdultsBRFSS, 1985

Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. BRFSS – Behavioural Risk Factor Surveillance System - CDC


Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.






















(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

1995

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1995, 2005

(*BMI 30, or about 30 lbs overweight for 5’4” person)

2005

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Methodology - Estimating the Cost of

Obesity• Step 1: Assess relative risk (RR) for known

co-morbidities (epidemiological literature)

• Step 2: Calculate the population attributable fraction (PAF) due to obesity of each co-morbidity according to (1) the RR and (2) the probability (P) of a person being obese in a particular jurisdiction (i.e. rate of obesity)Formula: PAF = P(RR-1)/[P(RR-1)+1]

Estimating Cost of Obesity

• Step 3: Use PAF as percentage of official cost estimates for each disease to assess direct medical costs (hospital, doctor, drug, research, other) attributable to obesity

• Step 4: Assess indirect costs (productivity losses) due to premature death and disability (short-term and long-term). Various methods include human capital, inclusion of unpaid work, etc.

Step 1: RR for 10 known co-morbidities (Birmingham et al. (CMAJ): BMI = >27 compared to

BMI = 20-24.9

Hypertension 2.51 Hyperlipidemia 1.41

Type 2diabetes

4.37 Pulmonary embolism 2.39

Coronaryartery disease

1.72 Colorectal cancer 1.16

Gallbladderdisease

1.85 Postmenopausalbreast cancer

1.31

Stroke 1.14 Endometrial cancer 2.19

Limiting to 10 will underestimate costs

• Estimate will NOT include other illnesses associated with diabetes; e.g. osteoarthritis, musculoskeletal disorders, gout, asthma, back problems, thyroid problems, hormonal disorders, sleep apnea, infertility, pseudo tumour cerebri, impaired immune function

Exercise on cost of obesity: GP Institute: 11 July, 2011

• RR for type 2 diabetes = 4.37

• RR for hypertension = 2.51

• RR for coronary artery disease = 1.72

• And P for NB= 41% = >27

CALCULATE PAFs for these illnesses in NB

Step 2: Calculate PAF for particular jurisdiction. E.g. NB:

P= 41% = >27

Hypertension 38.2 Hyperlipidemia 14.4

Type 2 diabetes 58.0 Pulmonaryembolism

36.3

Coronaryartery disease

22.8 Colorectal cancer 6.2

Gallbladderdisease

25.8 Postmenopausalbreast cancer

11.3

Stroke 5.4 Endometrialcancer

32.8

Step 3: Direct cost estimates e.g. NB = pop.

3/4 million: • Direct costs 10 diseases: $C54.8 million/yr

• Add musculoskeletal at PAF of 15% = $15m

• Other obesity-related illnesses = $2 million TOTAL = $72 million = 5.6% health budget

• When account for other underestimates = (capital expenditures; RR of BMI = 25-27; 10% under-reporting), total cost estimate = $96 million/yr = 7.5% health budget

Step 4: Indirect costs• Based on Health Canada’s Economic

Burden of Illness ratios, add $90-$110 million in productivity losses due to premature death and disability

• Total cost to NB = ~ $200 million/yr = 1.4% of province’s GDP

• Note: Cost estimates do NOT include diet and weight loss programs, etc.

Estimates for U.S.• Colditz (Harvard) = $US 118 billion/yr

direct + indirect costs (> smoking)

• 1995 lost wages due to obesity = $47.6b.

• 39.3 million work days lost annually;

• 62.7 million physician visits

• 239 million restricted activity days

• 89.5 million bed days

European studies: e.g.

• Netherlands: Obese individuals 40% more likely visit doctors; 2.5 times more likely take drugs for CVD = direct costs

• Sweden: Obesity accounts for 7% of lost productivity due to sick leave, disability. Obese workers = 2x more likely to take long-term sick leave = indirect costs

Solutions must address causes of obesity

epidemic• Poor diet

• Physical inactivity

• Poverty, illiteracy

• Employment patterns

• Other underlying social causes

1) Obesity is only one consequence of poor

diet• Nutrient-poor, high-fat, high-sugar diets,

with low fibre and chemical additives contribute to cancers of breast, colon, mouth, stomach, pancreas, prostate

• 30% of cancers worldwide could be prevented by switching to healthy diets

• USA: fat + sugar = 50%+ average caloric intake; complex carbohydrates just 1/3

Dangers are out of sight

• Fats, oils, sugars, salt added to processed and prepared foods

• 1909: 2/3 discretionary sugar added in household. Today, more than 3/4 of sugar consumed is added to processed and prepared food, out of sight of consumer

• Whole grains largely replaced by refined grains (lack vitamins, minerals). Only 2% wheat flour in U.S.= unrefined

Fast food• Single fast-food meal may exceed daily fat,

sugar, cholesterol, and sodium RDAs

• Marketing: “Supersize” meal for 79c = 42 fl.oz. Coke (vs 16) + free refills; more than double weight of french fries = increases calories of nutrient poor, fat-rich meal from 680 to more than 1,340

• 1/5 “vegetables” consumed in U.S. = french fries and potato chips

Ignorance re processed food

• Surveys show food labels widely misunderstood, misinterpreted, esp. ingredient lists, nutritional panels, validity of food claims on labels

• $30 billion annual food advertising dwarfs nutritional education budgets. Consumers get their knowledge from industry.

2) Physical activity

• U.S. Surgeon-General: Physical activity promotes fat loss; weight loss (dose-response a/c frequency, duration of session and program)

• Sedentary = 44% higher rate of obesity than physically active; 5x risk of heart disease; 60% higher depression (see GPI report on cost of physical inactivity)

Television Viewing, Average Hours per Week;

1999

24.5

20.7

22.1

22.9

24.7

20.5 20.320.8

19.6

20.7

21.6

15

17

19

21

23

25

27

Canada Nfld PEI NS NB Que Ont Man Sask Alta BC

Ho

urs

TV linked to child obesity

• American Academy of Pediatrics: “Increased television use is documented to be a significant factor leading to obesity.”

• Study in JAMA: Children lost weight if they watched less television

• Add computer games. Childhood obesity rate has doubled in 20 years

3) Social Causes - E.g. Dual-earner families as a % of all Canadian

families

0

10

20

30

40

50

60

70

1951 1961 1971 1981 1995

Year

Perc

cen

tag

e o

f A

ll F

am

ilies

Dual Earner Families

Single Earner Families

No Earner

LF participation rate of mothers with infants, 0-2,

1961-1995

62.360.3

56.3

44.4

31.7

25

20

25

30

35

40

45

50

55

60

65

1961 1976 1981 1986 1992 1995

Pe

rce

nta

ge

Total Daily Paid+Unpaid Work, (averaged over 7-day

week)7.7

6.8

7.2

7.3

6.6

6.8

7

7.2

7.4

7.6

7.8

1992 1998

Ho

urs

pe

r D

ay

female male

A Day in the Life of a Working Mother - Total Daily Work Time: 11 hrs

12 mEducation

12mins

Primary Child Care

36mins

Shopping54mins

Domestic Work2hrs, 24mins

Paid Work7hrs, 12mins

Stress, health, and weight

• Women w. high levels of job strain 1.8 times more likely experience unhealthy weight gain vs low job strain. Reduced work hours = 1/2 odds of weight gain cf standard hours

• Longer hours = 40% more likely decrease physical activity; 2.2 times more likely experience major depression; higher levels smoking (stress-related) and drinking

(Statistics Canada)

Eating out has increased sharply,

but...• Harvard study - 16,000 children- the

more families eat at home together, the more fruits & vegetables are eaten, less fried food + higher intake of important nutrients (calcium, fiber, folate, iron, vitamins B & E

• Healthy diets persist into adulthood

The good news: Identifying problem suggests solutions

• Remember: Purpose of costing exercise is to identify cost-effective interventions to improve population health

• Concept of investment crucial - the language of business

• Investing in human, social, natural capital can be cost-effective, yield long-term return on investment

1) Promote Healthy Diets and Nutritional Literacy

– Teachers can be trained to explain nutritional labels in class

– Singapore “Trim and Fit” program cut school children’s obesity 33%-50%

– Doctors, nurses given more explicit diet and nutritional training, yet only 23% U.S. medical schools require separate nutrition course

Practising what we preach• Schools, universities, hospitals,

work-places can act alone to improve food quality, nutritional content (vs contract with fast food companies)

• Berkeley schools - vegetable gardens to teach, supply school cafeteria. 1999 - organic lunches

Case studies and models

• U.S. grade 3-5 “Child and Adolescent Trial for Cardiovascular Health” found lower fat, higher physical activity well into adolescence - Behavioural changes at young age have lasting effects

• Finland - nutrition media campaign, strict food labelling (e.g. “heavily salted”), education - helped cut heart disease deaths 65% 1970-95

And in the future....?• Restrictions on advertising (cf tobacco)

• Tax on foods inversely proportion to nutrient value per calorie (Kelly Brownell, Yale). Fatty, sugary, high-calorie, low nutrition = highest taxes, ; fruits, vegetables, whole grains exempt

• Tax revenues to nutritional education just as portion of cigarette, gambling revenues fund anti-smoking, counselling

= Step towards “full-cost accounting”

• Taxation makes toxic substances and social liabilities pay full costs = “user pay” since taxpayers absorb health costs. What is true cost of supersized french fries?

• Also helps reduce poverty, inequity (low-fat, healthy food more affordable)

2) Physical activity: can begin anywhere. Eg

schools• Tower Road school pact not to watch TV

for full week, keep journal. Gradual increase in physical activity

• Glace Bay High: anti-smoking pact, calculate savings to health care system, invest in town swimming pool

• Cost-effectiveness of school gym programs

3) Addressing broader social determinants of

health• E.g. Netherlands: shortest work hours of

any industrial county (1,370 cf 1,732 Can)

• No discrimination against part-timers = equal hourly pay, pro-rated benefits, career advancement; higher productivity

• Belgian civil service; Danes = 11 hours more free time / week; France - 35 hours

=Major shift from illness treatment paradigm to health

promotion• From high-tech medical interventions...to

population health strategy

• Determinants of health include income, literacy, employment status, the physical environment, and healthy lifestyles.

• Containing spiraling health care costs through reducing demand on system = improved population health as cost-effective

Obstacles

• Heavier weights more “normal” - desire for weight change declined (NB = 65% 1985 to 45% 1997 while overweight 2x)

• Materialism - consumption addiction

• Measures of progress send contrary message. Counting it right is a good place to start - can shift policy agenda, change behaviour

Creating a healthier world for our children

Genuine Progress Index for Atlantic CanadaIndice de progrès véritable - Atlantique

www.gpiatlantic.org

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