Diet, obesity and health economics I nsights from the Netherlands Tommy LS Visscher
I mpact of obesity MORBI DI TY ZIEKTE MORTALI TY O Cardiovascular diseases B E S Type 2 diabetes mellitus I T Y Musculoskeletal disorders DI SABI LI TI ES Visscher TLS, Seidell JC. Annu Rev Publ Health 2001 ; 22: 355-75
I mportant measures • Prevalence rates • Relative risks • Population Attributable Fraction
Obesity prevalence around 2000 • USA: 28-33% Flegal et al JAMA 2002 • England: 17-22% Health survey for England 1998. • Finland: 20-21% Lahti-Koski et al Int J Obes 2001 • Germany: 19-21% Bergmann et al. Gesundheidswesen 1999 • Netherlands: 10% Visscher et al IJO 2002/2004
Obesity in the Netherlands
Obesity in the Netherlands
Obesity in the Netherlands
Obesity in the Netherlands
Obesity in the Netherlands
Obesity in the Netherlands
Obesity in the Netherlands
Obesity in the Netherlands age 37-43 jaar 10 9 8 Men % 7 Women 6 5 4 1976-80 1987-91 1993-97 Visscher, Seidell, Kromhout Int J Obes 2002;26:1218-24
Obesity in the Netherlands 15 % cbs-women cbs-men 10 5 0 1 3 5 7 9 1 3 5 7 9 8 8 8 8 8 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 1 1 1 1 1 1 1 1 1 1 jaar Statistics Netherlands
Obesity and educational level period: 1993/97, age: 20-59 years 20 men women 15 % 10 5 0 low middle high Visscher, Seidell, Kromhout Int J Obes 2002
Obesity and age period: 1993-1997 20 men 15 w omen % 10 5 0 20-29 30-39 40-49 50-59 Age (years) Visscher, Seidell, Kromhout Int J Obes 2002
Overweight and obesity in Dutch girls % 16 14 12 10 8 1980 6 1997 4 2 0 6 12 18 Age Fredriks et al Arch Dis Child 2000, Hirasing NtvG 2001
Obesity and age 35 men 30 prevalence of obesity (%) women 25 20 15 10 5 0 16-24 25-34 35-44 45-54 55-64 65-74 >75 Age (years) Health Survey for England 1997 Figure from: Seidell & Visscher. Eur J Clin Nutr 2000
Weight gain Energy-intake Behavioural Energy-balance Body weight determinants Energy expenditure
Food intake (The Netherlands 1988-1998) • Saturated fat + (favourable) • Tans-fatty acids + • Fish + • Fruits - (unfavourable) - • Vegetables VCP / Van Kreijl 2004 RIVM
Sugared softdrinks boys (13-18) 500 450 400 350 300 fruit juice g per day 250 soft-drinks 200 150 100 50 0 1987/ 88 1992 1997/ 98 Source: VoedselConsumptiePeiling
Relative risks US women from the Nurses’ Health Study Figure from Visscher et al Annu Rev Publ Health 2001
Relative risks • Higher for morbidity than for mortality Visscher Annu Rev Publ Health 2001, Visscher Arch Int Med 2004 • Decrease with ageing Stevens NEJM 1999, Visscher Arch Int Med 2004
Population attributable fraction • Prevalence rate • Relative risks
Population attributable fraction - BMI ≥ 30 Men Women • Diabetes 26.3 52.9 • Hypertension 12.0 23.5 • CHD 4.1 17.4 • Stroke 5.5 2.8 Dutch Health Council
Costs – obesity – The Netherlands Men Women • Calculated from PAF 0.8% 1.3 Source: Dutch Health Council and www.kostenvanziekten.nl; Calculated for Lipgene
Costs underestimated • Not all consequences • Not age-specific: – prevalence rate – Relative risks – absolute risk
Costs – obesity – The Netherlands - 1989 Million Euro’s BMI ≥ 25 BMI ≥ 30 General practitioners 46 12 Medical specialists 37 14 Hospital admissions 225 81 Medication 250 67 Total attributable to obesity: 558 174 4% 1% % Direct health care costs Seidell IJO 1995
Costs – obesity – The Netherlands Million Euro’s Overweight (BMI ≥ 25 ) 558 Obesity (BMI ≥ 30) 174 Seidell IJO 1995 Overweight (BMI ≥ 25 ) 505 Polder 1999 RIVM Diabetes II 430 Hypertension 433 Stroke 1029 MI 929 www.kostenvanziekten.nl
Costs of obesity Direct • USA: 6% Wolf AM, Colditz GA. Obes Res 1998 • Europe: 1-5% • Netherlands: 1% Seidell JC. Int J Obes;1995 Indirect • Loss of productivity : 10% Narbro K, et al. Int J Obes 1996
Obesity and work disabilty Relative risk 2.5 2 1.5 1 women 0.5 men 0 <22.5 22.5-24.9 25.0-27.4 27.5-29.9 30.0-32.4 >32.5 body mass index (kg/m 2 ) Rissanen, BMJ 1990
I mpact of obesity MORBI DI TY ZIEKTE MORTALI TY O Cardiovascular diseases B E S Type 2 diabetes mellitus I T Y Musculoskeletal disorders DI SABI LI TI ES Visscher TLS, Seidell JC. Annu Rev Publ Health 2001 ; 22: 355-75
Is health promotion cost-effective?
Outcome measures Life-years lost • Healthy life-years • Quality of Life • DALY’s - QUALY’s • Compression of morbidity
Health promotion cost-effective? Vita, NEJM 1998 – Less lifetime disability – Less disability at any given age Prevention: less lifetime disability Lubitz, NEJM 2003 – Health promotion improves health and longevity of the elderly without increasing health expenditures
Health promotion cost-effective? Vita, NEJM 1998 – Less lifetime disability – Less disability at any given age Prevention: less lifetime disability Lubitz, NEJM 2003 – Health promotion improves health and longevity of the elderly without increasing health expenditures Barendregt, NEJM 1997 – Smoking cessation: increased direct health care costs
Deaths attributable to obesity (USA) • 112,000 (Year 2000) Flegal JAMA 2005 • 414,000 (Year 2000) Mokdad JAMA 2004/2005 • 280,000 (Year 1991) Allison JAMA 1991 Confidence interval around 112,000: 54,000 – 170,000 Mark JAMA 2005
Costs: mortality versus morbidity Direct health care costs 25% reduced when obesity- mortality relation is taken into account Allison: AJPH 1999
Lost life-years BMI ≥ 30 at age 40 years: • 6-7 years Peeters Ann Int Med 2002 • BMI >33 from age 40 years: 2-3 years Fontaine JAMA 2003 • BMI ≥ 30 at age 40 years: 0.8 years Van Kreijl 2004 RIVM • BMI >30, age 37-43 years, 25 years: 0.2 years Visscher ECO 2005 Athens
Obesity / nutrition • BMI ≥ 30 at age 40 years: 0.8 years Van Kreijl 2004 RIVM • Unhealthy food pattern at age 40: 1.2 years Van Kreijl 2004 RIVM • BMI ≥ 30: 215,000 DALY’s per year Van Kreijl 2004 RIVM • Unhealthy food pattern: 245,000 DALY’s per year Van Kreijl 2004 RIVM
Unhealthy life-years BASELINE MORBIDTY MORTALITY HEALTHY UNHEALTHY
Relative risks US women from the Nurses’ Health Study Figure from Visscher et al Annu Rev Publ Health 2001
Unhealthy life-years 10% weight loss in those aged 35-64 years: – 1.2-2.9 fewer life-years with hypertension – 0.5-1.7 fewer life-years with diabetes II Oster AJPH 1999
Unhealthy life-years: empirical approach • Mortality • Work disability • Coronary Heart Disease • Chronic medication BASELINE MORBIDTY MORTALITY 0 HEALTHY UNHEALTHY 15
Unhealty life-years Social Insurance Instution’s Mobile Clinic Study (Helsinki) An adult obese Finn during 15 years: • Half a year longer Work disability • Half a year longer Coronary heart disease • One and a half year longer Chronic medication Visscher TLS et al Arch Int Med 2004
I mpact of obesity MORBI DI TY ZIEKTE mortality O Cardiovascular diseases B E S Type 2 diabetes mellitus I T Y Musculoskeletal disorders DI SABI LI TI ES Visscher TLS, Seidell JC. Annu Rev Publ Health 2001 ; 22: 355-75
Cost-effective? • Prevention more efficient than treatment Russell IJO 1995 • Which age-category? Seidell 2005 Boyd Orr
Which age-category? Children? • Relative risks high Stevens NEJM 1999, Visscher Arch Int Med 2004 • Behaviour and habits are learnt at young age (?) • If successful, long term effect
Which age-category? Adults? • Sharpest increase in incidence of obesity in adulthood • Absolute risk and PAF increase with age • Intervention at young and older adults affect more age-categories
Cost-effective? • Prevention more efficient than treatment Russell IJO 1995 • Which age-category? Seidell 2005 Boyd Orr • Effective? Evidence needed Swinburn Obesity Reviews 2005
Conclusions • Obesity prevalence is increasing in the Netherlands • PAF calculations are hard: - prevalence estimations, - relative risks, - subgroups • Cost calculations are hard: - Morbidity, - mortality
Conclusions • Direct costs moderate overweight higher than costs obesity • Direct costs comparable to hypertension, diabetes II • Direct costs in the Netherlands 4% (BMI ≥ 25) / 1% (BMI ≥ 30) • Indirect costs: 10%
Conclusions • Obesity more strongly related to morbidity and disability t han to mortality • Obesity related to UNHEALTHY life-years
Conclusions • Obesity more strongly related to morbidity and disability t han to mortality • Obesity related to UNHEALTHY life-years • Further increase obesity will clearly lead to increased costs • Weight gain prevention is essential in reducing health care costs
Thank you for your attention! Tommy.Visscher @ falw.vu.nl
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