Obesity $99.2 Billion Extraordinary Health Care Expenditures, More than 418,000 DeathsTraveling through 72 countries, and living in 27 of them (including Russia, Okinawa, Korea, and Ireland) provided key insights into how people other than Americans eat, why most people around the world are much healthier than us, and what we MUST do to eliminate our record high and easily explained obesity rate. The solution is MUCH simpler than any doctor, drug company, commercial, federal agency, nutritionist, or health care official will ever tell you, not because they don’t want you to know, but because THEY don’t know either. It’s 100% effective, EASIER than falling off a log, and works every time. The official obesity rate in the US is 31%, more than ten times higher than many other countries, including Japan and Korea whose diets I am intimately familiar with.  But this ignores another 35% who are not technically obese, but are still much heavier than they should be–something that just does not occur in most countries, and a problem which YOU can help me fight HERE. A friend and I discovered this by accident, and both lost more than 40 pounds without even realizing it, during a time that many of our friends gained that much, and more. Being an avid racquetball player, I’ve seen many athletes in many sports clubs exercise like crazy, sweat profusely, and still gain weight. One “A” player who used to beat me regularly, gained 40 pounds as I lost 40 pounds, making him easy prey. He never beats me now.  Another “A” racquetball player won the “A” league, rode the stair climber almost 4 hours per day, and STILL was 60 pounds overweight.  I have passed on this secret to everyone I meet, and most pay no attention, but THIS one paid strict attention and lost 60 pounds so fast that people had a hard time recognizing him.  Even at his relatively advanced age, he’s well on his way to becoming a world class racquetball player. I now weigh less than I did when I was 17 years old, except that I am much healthier now than I was at 17. At a recent college reunion, I was the only graduate from my alma mater, a military school, who can make this claim.  I take racquetball lessons from the first ranked racquetball player in the world, and by sheer luck, managed to beat an ex-pro who, by sheer luck himself, managed to beat my top ranked instructor.  Yes, exercise, and specifically cardiac exercise, is important, but the rest is easier than eating a big, fattening dinner.  You will NEVER have a hunger pang, NEVER miss your favorite meal, while spending much less for food–as much as fifty percent less.  There is one addition you need to make to your diet, but it is so inexpensive, and once you know how  to prepare it, so delicious, that you could literally live on that one staple for a long time.  But as I said, there’s no need to forego your favorite meal.Sure, this sounds too good to be  true. Latest State Data Show Rates of Obesity Remain High Obesity prevalence 30 percent or higher in 12 states Obesity has become a problem in every state, according to data analyzed by the Centers for Disease Control and Prevention. No state reported that less than 20 percent of adults were obese in 2010, which means that no state met the national Healthy People 2010 goal to lower obesity prevalence to 15 percent within the past decade, CDC researchers say. The data also show 30 percent or more of adults in 12 states were obese, compared to no states with that level of obesity in 2000, and nine states in 2009. The new data and updated national obesity trends map was released today online at http://www.cdc.gov/obesity/data/trends.html. The data come from the most recent Behavioral Risk Factor Surveillance System (BRFSS), a state-based phone survey that collects health information from approximately 400,000 adults aged 18 and over. “State obesity rates are still high,” said CDC Director Thomas Frieden, M.D., M.P.H. “Some of the leading causes of death are obesity-related – heart disease, stroke, type 2 diabetes and certain types of cancer. We must continue our efforts to reverse this epidemic.” The nine states in 2009 that reported an obesity rate of 30 percent or more are: Alabama, Arkansas, Kentucky, Louisiana, Mississippi, Missouri, Oklahoma, Tennessee, and West Virginia. In 2010, three more states reported an obesity rate of 30 percent or more: Michigan, South Carolina, and Texas. The BRFSS data highlight how obesity impacts some regions more than others. The South had the highest rate, at 29.4 percent, while the Midwest had an obesity rate of 28.7 percent, the Northeast had a rate of 24.9 percent; and the West had a rate of 24.1 percent. “It will take time and resources to win in the fight against obesity,” said Dr. William Dietz, director of CDC’s Division of Nutrition, Physical Activity and Obesity. “This epidemic is complex and we must continue to change the environments that make it hard to eat healthy, and make it hard for people to be active. By doing this, we not only help today’s adults, we also invest in our children and grandchildren, so they won’t have to endure this serious and costly health burden.” The BRFSS, a CDC-supported surveillance system, collects state-level public health data and provides a way for states to monitor progress toward national and state health goals. To assess obesity prevalence, phone survey respondents were asked to provide their height and weight, which was used to calculate their body mass index (BMI). An adult is considered obese if he or she has a BMI of 30 or above. For example, a 5-foot-4 woman who weighs 174 pounds or more, or a 5-foot-10 man who weighs 209 pounds or more both have a BMI of 30 or more so are considered obese. CDC supports a number of initiatives, including the two-year Communities Putting Prevention to Work program that helps states, territories, tribes and communities combat childhood and adult obesity through science-based nutrition, physical activity and obesity programs. The focus is creating changes that support healthy eating and active living where Americans live, work, learn and play. For more information on obesity prevalence, including an animated map, visit www.cdc.gov/obesity. Trends by State 1985–2010 During the past 20 years, there has been a dramatic increase in obesity in the United States and rates remain high. In 2010, no state had a prevalence of obesity less than 20%. Thirty-six states had a prevalence of 25% or more; 12 of these states (Alabama, Arkansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Oklahoma, South Carolina, Tennessee, Texas, and West Virginia) had a prevalence of 30% or more. The animated map below shows the United States obesity prevalence from 1985 through 2010. Percent of Obese (BMI > 30) in U.S. Adults Red States Vote Republican, Blue States Vote Democratic http://win.niddk.nih.gov/statistics/index.htm Over two-thirds of adults in the United States are overweight or obese, and over one-third are obese, according to data from the National Health and Nutrition Examination Survey (NHANES) 2003–2006 and 2007–2008. Risk Factors for Overweight and Obesity â– type 2 diabetes â– coronary heart disease â– high LDL (“bad”) cholesterol â– stroke â– hypertension â– nonalcoholic fatty liver disease â– gallbladder disease â– osteoarthritis (degeneration of cartilage and bone of joints) â– sleep apnea and other breathing problems â– some forms of cancer (breast, colorectal, endometrial, and kidney) â– complications of pregnancy â– menstrual irregularities Top ——————————————————————————– What are overweight and obesity? Overweight: Overweight specifically refers to an excessive amount of body weight that may come from muscles, bone, adipose (fat) tissue, and water. Obesity: Obesity specifically refers to an excessive amount of adipose tissue.[1] Top ——————————————————————————– Causes of Overweight and Obesity Essentially, overweight and obesity result from energy imbalance. The body needs a certain amount of energy (calories) from food to sustain basic life functions. Body weight is maintained when calories eaten equals the number of calories the body expends, or “burns.” When more calories are consumed than burned, energy balance is tipped toward weight gain, overweight, and obesity. Genetic, environmental, behavioral, and socioeconomic factors can all lead to overweight and obesity.[2] Top ——————————————————————————– Treating Overweight and Obesity Overweight and obesity are risk factors for diabetes, heart disease, high blood pressure, and other health problems. Since there is no single cause of all overweight and obesity, there is no single way to prevent or treat overweight and obesity that will help everyone. Treatment may include a combination of diet, exercise, behavior modification, and sometimes weight-loss drugs. In some cases of extreme obesity, bariatric surgery may be recommended.[2] Estimates on Overweight and Obesity The estimates on overweight and obesity in this fact sheet were taken from the Centers for Disease Control and Prevention (CDC). Data are based on the CDC’s National Health and Nutrition Examination Survey (NHANES) from 2003–2006 and 2007–2008. Some of the overweight- and obesity-related prevalence rates are presented as crude or unadjusted estimates, while others are age-adjusted estimates. Unadjusted prevalence estimates are used to present cross-sectional data for population groups at a given point or time period, without accounting for the effect of different age distributions among groups. For age-adjusted rates, statistical procedures are used to remove the effect of age differences when comparing two or more populations at one point in time, or one population at two or more points in time. Unadjusted estimates and age-adjusted estimates will yield slightly different values. Unless otherwise specified, the figures below represent age-adjusted estimates. Age-adjusted estimates are used in order to account for age variations among the groups being compared. For more details on the methods for deriving prevalence of overweight and obesity, visit www.cdc.gov/nchs/nhanes.htm.[3] Top ——————————————————————————– Overweight and Obesity Prevalence Estimates* Q: How many adults age 20 and older are overweight or obese (Body Mass Index, or BMI, > 25)? A: Over two-thirds of U.S. adults are overweight or obese.[4] All adults: 68 percent Women: 64.1 percent Men: 72.3 percent Q: How many adults age 20 and older are obese (BMI > 30)? A: Over one-third of U.S. adults are obese.[4] All adults: 33.8 percent Women: 35.5 percent Men: 32.2 percent Q: How many adults age 20 and older are extremely obese (BMI > 40)? A: A small percentage of U.S. adults are extremely obese.[4] All adults: 5.7 percent Q: How many adults age 20 and older are at a healthy weight (BMI > 18.5 to < 25)? A: Less than one-third of U.S. adults are at a healthy weight.[5] All adults: 31.6 percent Women: 36.5 percent Men: 26.6 percent Q: How has the prevalence of overweight and obesity in adults changed over the years? A: The prevalence has steadily increased among both genders, all ages, all racial/ethnic groups, all educational levels, and all smoking levels.[6] From 1960–2 to 2005–6, the prevalence of obesity increased from 13.4 to 35.1 percent in U.S. adults age 20 to 74.[7] Since 2004, while the prevalence of overweight is still high among men and women, there are no significant differences in prevalence rates documented from 2003 to 2004, 2005 to 2006, and 2007 to 2008.[4] In fact, among women, there has been no change in obesity prevalence between 1999 and 2008. Q: What is the prevalence of obesity among non-Hispanic Black, Hispanic, and non-Hispanic White racial and ethnic groups? A: Among women, the age-adjusted prevalence of obesity (BMI > 30) in racial and ethnic groups is higher among non-Hispanic Black and Hispanic women than among non-Hispanic White women. Among these three groups of men, the difference in prevalence is less significant. In this context, the term Hispanic includes Mexican Americans.[4] Non-Hispanic Black Women: 49.6 percent Hispanic Women: 43 percent Non-Hispanic White Women: 33 percent Non-Hispanic Black Men: 37.3 percent Hispanic Men: 34.3 percent Non-Hispanic White Men: 31.9 percent (Statistics are for populations age 20 and older.) Q: What are the percent distributions of obesity in other racial and ethnic groups?** A: Gender-specific data for Asian Americans, Native Americans, Alaska Natives, and Native Hawaiians or Other Pacific Islanders are not available. Following are percent distributions of obesity for men and women in these groups. Rates of obesity among Asian Americans are much lower in comparison to other racial and ethnic groups.[8] Asian Americans: 8.9 percent Native Americans and Alaska Natives: 32.4 percent Native Hawaiians or Other Pacific Islanders: 31 percent * The statistics presented in this section for adults and racial and ethnic groups are based on the following definitions unless otherwise specified: healthy weight = BMI > 18.5 to < 25; overweight = BMI > 25 to < 30; obesity = BMI > 30; and extreme obesity = BMI > 40. BMI is a number calculated from a person’s weight and height.[1] **Statistics are for populations age 18 and older. Figure. Overweight and Obesity, by Age: United States, 1971-2006. SOURCES: CDC/NCHS, Health, United States, 2008, Figure 7. Data from the National Health and Nutrition Examination Survey. Q: What is the prevalence of overweight and obesity in children and adolescents? A: Data from the NHANES survey (2003–2006) indicate that approximately 12.4 percent of children age 2 to 5 and 17 percent of children age 6 to 11 were overweight.*** About 17.6 percent of adolescents (age 12 to 19) were overweight in 2003–2006.[9] *** Overweight is defined by the sex- and age-specific 95th percentile cutoff points of the 2000 CDC growth charts. These revised growth charts include smoothed sex-specific BMI for-age-percentiles and are based on data from NHES II (1963 to 1965) and III (1966 to 1970), and NHANES I (1971 to 1974), II (1976 to 1980), and III (1988 to 1994). The CDC BMI growth charts specifically excluded NHANES III data for children older than 6 years.[10] Q: What is the mortality rate associated with obesity? A: Most studies show an increase in mortality rates associated with obesity. Individuals who are obese have a significantly increased risk of death from all causes, compared with healthy weight individuals (BMI 18.5 to 24.9). The increased risk varies by cause of death, and most of this increased risk is due to cardiovascular causes.[11] Obesity is associated with over 112,000 excess deaths due to cardiovascular disease, over 15,000 excess deaths due to cancer, and over 35,000 excess deaths due to non-cancer, non-cardiovascular disease causes per year in the U.S. population, relative to healthy-weight individuals.[11] Top ——————————————————————————– Economic Costs Related to Overweight and Obesity As the prevalence of overweight and obesity has increased in the United States, so have related health care costs. The statistics presented below represent the economic cost of obesity in the United States in 2006, updated to 2008 dollars.[12] Q: What is the cost of obesity? A: On average, people who are considered obese pay $1,429 (42 percent) more in health care costs than normal-weight individuals.[12] What is the cost of obesity by insurance status? A: For each obese beneficiary: â– Medicare pays $1,723 more than it pays for normal-weight beneficiaries. â– Medicaid pays $1,021 more than it pays for normal-weight beneficiaries. â– Private insurers pay $1,140 more than they pay for normal-weight beneficiaries.[12] What is the cost of obesity by the type of service provided? A: For each obese patient: â– Medicare pays $95 more for an inpatient service, $693 more for a non-inpatient service, and $608 more for prescription drugs in comparison with normal-weight patients. â– Medicaid pays $213 more for an inpatient service,$175 more for a non-inpatient service, and $230 more for prescription drugs in comparison with normal-weight patients. â– Private insurers pay $443 more for an inpatient service, $398 more for a non-inpatient service, and $284 more for prescription drugs in comparison with normal-weight patients.[12] Top ——————————————————————————– Other Statistics Related to Overweight and Obesity Q: How physically active is the U.S. population? A: Only 31 percent of U.S. adults report that they engage in regular leisure-time physical activity (defined as either three sessions per week of vigorous physical activity lasting 20 minutes or more, or five sessions per week of light-to-moderate physical activity lasting 30 minutes or more). About 40 percent of adults report no leisure-time physical activity.[5] About 35 percent of high school students report that they participate in at least 60 minutes of physical activity on 5 or more days of the week, and only 30 percent of students report that they attend physical education class daily. As children get older, participation in regular physical activity decreases dramatically.[13] In contrast to reported activity, when physical activity is measured by a device that detects movement, only about 3–5 percent of adults obtain 30 minutes of moderate or greater intensity physical activity on at least 5 days per week. Among youth, measured activity provides information on younger children than is available with reports and highlights the decline in activity from childhood to adolescence. For example, 42 percent of children age 6–11 obtain the recommended 60 minutes per day of physical activity, whereas only 8 percent of adolescents achieve this goal.[14] Q: What are the benefits of physical activity? A: Research suggests that physical activity may reduce the risk of many adverse health conditions, such as coronary heart disease, stroke, some cancers, type 2 diabetes, osteoporosis, and depression. In addition, physical activity can help reduce risk factors for conditions such as high blood pressure and blood cholesterol. Researchers believe that some physical activity is better than none, and additional health benefits can be gained by increasing the frequency, intensity, and duration of physical activity.[15] Top ——————————————————————————– References [1] Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults National Heart, Lung, and Blood Institute. September 1998. Available at www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.htm. [2] Strategic Plan for NIH Obesity Research. U.S. Department of Health and Human Services, National Institutes of Health. August 2004. NIH Publication No. 04–5493. [3] Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey 2003–2006. Available at: http://www.cdc.gov/nchs/nhanes.htm. [4] Flegal, KM, Carroll, MD, Ogden, CL, Curtin, LR. Prevalence and Trends in Obesity Among US Adults, 1999–2008. Journal of the American Medical Association. 2010; 235–241. [5] National Center for Health Statistics. Chartbook on Trends in the Health of Americans. Health, United States, 2008. Hyattsville, MD: Public Health Service. 2008. [6] Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. Journal of the American Medical Association. 2003; 289(1):76–79. [7] National Center for Health Statistics Health E-Stats. Prevalence of overweight, obesity and extreme obesity among adults: United States, trends 1976–80 through 2005–2006. 2008. [8] Pleis JR, Lucas JW. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2007. National Center for Health Statistics. Vital and Health Statistics 10(240). 2009. [9] Ogden C, Carroll M, Flegal K. High Body Mass Index for Age Among US Children and Adolescents, 2003–2006. Journal of the American Medical Association. 2008; 299(20):2401–2405. [10] Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 Centers for Disease Control and Prevention growth charts for the United States: Methods and development. National Center for Health Statistics. Vital Health Stat 11(246). 2002. [11] Flegal KM, Graubard BI, Williamson DF, et al. Cause-Specific Excess Deaths Associated With Underweight, Overweight, and Obesity. Journal of the American Medical Association. 2007; 298(17):2028–2037. [12] Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual Medical Spending Attributable To Obesity: Payer- And Service-Specific Estimates. Health Affairs. 2009; 28(5): w822–w831. [13] Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance—United States, 2007 Morbidity & Mortality Weekly Report 2008;57(No.SS-4). [14] Troiano RP, Berrigan D, Dodd KW, Mâsse LC, Tilert T, McDowell M. Physical activity in the United States measured by accelerometer. Medicine and Science in Sports and Exercise. 2008; Jan;40(1):181–8. [15] U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. October 2008. Available at http://www.health.gov/paguidelines. Top ——————————————————————————– Weight-control Information Network 1 WIN Way Bethesda, MD 20892–3665 Phone: (202) 828–1025 Toll-free number: 1–877–946–4627 Fax: (202) 828–1028 Email: WIN@info.niddk.nih.gov Internet: http://www.win.niddk.nih.gov The Weight-control Information Network (WIN) is a national information service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health (NIH), which is the Federal Government’s lead agency responsible for biomedical research on nutrition and obesity. Authorized by Congress (Public Law 103–43), WIN provides the general public, health professionals, the media, and Congress with up-to-date, science-based information on weight control, obesity, physical activity, and related nutritional issues. Publications produced by WIN are reviewed by both NIDDK scientists and outside experts. This fact sheet was also reviewed by Rick Troiano, Ph.D., National Cancer Institute; Cynthia Ogden, Ph.D., National Center for Health Statistics (NCHS), CDC; and Katherine Flegal, Ph.D., Senior Research Scientist, NCHS, CDC. This publication is not copyrighted. WIN encourages users of this fact sheet to duplicate and distribute as many copies as desired. This fact sheet is also available at http://www.win.niddk.nih.gov. NIH Publication Number 04–4158 Updated February 2010 http://www.wvdhhr.org/bph/oehp/obesity/mortality.htm Section One – Continued OBESITY AND MORTALITY According to the National Institutes of Health, obesity and overweight together are the second leading cause of preventable death in the United States, close behind tobacco use (3). An estimated 300,000 deaths per year are due to the obesity epidemic (57).The results of two extensive studies examining obesity-attributable deaths in the United States were published in 1999. Allison, Fontaine, and Manson et al., reporting in the Journal of the American Medical Society, used data from a number of prospective cohort studies, including the Alameda Community Health Study, the Framingham Heart Study, the Tecumseh Community Health Study, the American Cancer Society’s Cancer Prevention Study I, the National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study, and the Nurses’ Health Study, to estimate the number of deaths attributable to obesity in the United States on an annual basis (66). Their initial analyses, which examined deaths occurring among persons aged 18 and older in 1991, were adjusted only for age, sex, and smoking status. The weight categories used were overweight (BMI of 25-29.9), obese (BMI of 30-35), and severely obese (BMI >35).Using data on all eligible subjects from all six studies, Allison et al. estimated that 280,184 obesity-attributable deaths occurred in the U.S. annually. When risk ratios calculated for nonsmokers and never-smokers were applied to the entire population (assuming these ratios to produce the best estimate for all subjects, regardless of smoking status, i.e., that obesity would exert the same deleterious effects across all smoking categories), the mean estimate for deaths due to obesity was 324,940. Additional analyses were performed controlling for prevalent chronic disease at baseline using data from the CPS1 and NHS. After controlling for preexisting disease, the mean annual number of obesity-attributable deaths was estimated to be 374,239 (330,324 based on CPS1 data and 418,154 based on NHS data).Calle, Thun et al. selected their study subjects from over one million participants in the Cancer Prevention Study II, a prospective study of mortality among adults in the U.S. begun by the American Cancer Society in 1982 (67). Calle et al. examined deaths occurring between 1982 and 1996 among four cohorts: (1) current or former smokers with no history of disease3, (2) current or former smokers with a history of disease, (3) nonsmokers with no history of disease, and (4) nonsmokers with a history of disease. Weight categories were normal range (18.5-24.9), grade 1 overweight (25.0-29.9), grade 2 overweight (30.0-39.9), and grade 3 overweight (40.0+). All cause mortality, cardiovascular disease (CVD) mortality, and cancer mortality were examined.The lowest mortality rates from all causes were found among study subjects having a BMI of between 23.5-24.9 for men and 22.0-23.4 for women. The risk of mortality increased with increasing BMI at all ages and for all categories of death. The strongest association between obesity and death from all causes was found among study subjects who had never smoked and had no history of disease, with the highest rates among the heaviest men and women, i.e., those with a BMI of 40+. The relative risk (RR) was 2.68 among men and 1.89 among women, compared with the reference groups (a BMI of 23.5-24.9 among men and 22.0-23.4 among women). This association was stronger in whites than among blacks. Obesity was associated with higher mortality rates for both cardiovascular disease and cancer. BMI was most strongly associated with cardiovascular disease mortality among men (RR=2.90), but significantly increased risks of CVD death were found at all BMIs of greater than 25.0 in women and 26.5 in men. The findings showed an increase of 40% to 80% in risk of dying from cancer among both men and women in the highest weight categories. Calle et al.’s study supports the need for further research to ascertain the differences in the effect of obesity on mortality among the black population, especially among black women. Their data also support the use of a single recommended range of body weight throughout life.An earlier (1995) study by Manson, Willett, and Stamfer et al. examined data from the Nurses’ Health Study, looking at 4,726 deaths occurring from 1976 through 1992, 881 from cardiovascular disease, 2,586 from cancer, and 1,259 from other causes (68). A direct association was observed between BMI and mortality among women who had never smoked. Using a BMI of <19.0 as the reference group (relative risk [RR]=1.0), women with BMIs of 19.0-21.9 and 22.0-24.9 had a RR of 1.2; women with a BMI of 25.0-26.9 had a RR of 1.3; women with a BMI of 27.0-28.9 had a RR of 1.6; those with a BMI of 29.0-31.9 had a RR of 2.1; and those with a BMI of >32.0 had a RR of 2.2. Among never smokers, women with a BMI of >32 had a RR of 4.1 of dying from cardiovascular disease and a RR of 2.1 of dying from cancer. 3Cancer (excluding nonmelanoma skin cancer), heart disease, stroke, respiratory disease, current illness of any type, or a weight loss of at least 10 pounds in the preceding year.  Section One – Continued THE ECONOMIC COSTS OF OBESITY There have been numerous estimates of the economic costs of overweight and obesity. Among the most frequently cited are the direct and indirect health care costs calculated by Wolf and Colditz and published in Obesity Research in 1998 (69). The researchers based their estimates on weighted data from the 1988 and 1994 National Health Interview Surveys, inflating the results to reflect 1995 dollars. These estimates were those utilized by the National Institutes of Health at the time this report was undertaken. To estimate health care costs attributable to obesity, Wolf and Colditz used a prevalence-based approach including the obesity-related diseases of type 2 diabetes, coronary heart disease, hypertension, gallbladder disease, colon, breast, and endometrial cancers, and osteoarthritis. The total costs of each of these diseases to the economy were divided among direct medical costs (i.e., preventive, diagnostic, and treatment services such as personal health care, physician visits, hospital care, medications, nursing home care, and the like) and indirect health care costs (i.e., costs resulting from a reduction or cessation of productivity due to disease such as lost wages, lost future earnings, etc.). The total cost of overweight and obesity to the U.S. economy in 1995 dollars was $99.2 billion, approximately $51.6 billion in direct costs and $47.6 billion in indirect costs. By disease, the authors estimated the following breakdowns: Type 2 diabetes: $63.1 billion direct cost: $32.4 billion indirect cost: $30.7 billion coronary heart disease: $7.0 billion (direct cost) colon cancer: $2.8 billion direct cost: $1 billion indirect cost: $1.8 billion post-menopausal breast cancer: $2.3 billion direct cost: $840 million indirect cost: $1.5 billion endometrial cancer: $790 million direct cost: $286 million indirect cost: $504 million hypertension: $3.2 billion (direct cost) osteoarthritis: $17.2 billion direct cost: $4.3 billion indirect cost: $12.9 billion Using 1994 NHIS data, Wolf and Colditz estimated that nationally 39.3 million workdays were lost annually to obesity-related causes; in addition, obesity was responsible for 239.0 million restricted-activity days, 89.5 million bed-days, and 62.7 million physician visits. Compared with the 1988 NHIS data, the number of restricted-activity days increased 36%, bed-days increased 28%, lost work days increased 50%, and physician visits increased by 88%. While Wolf and Colditz estimated that the $51.6 billion in direct medical costs attributable to obesity represented 5.7% of total health care expenditures in 1995, researchers from Columbia University have recently refuted their statistics, estimating direct health care costs at approximately $39 billion, or 4.3% of total annual U.S. health care expenditures (70). They point out that the higher mortality rates of obese persons decrease direct medical costs; because of this, however, the indirect costs of obesity may be larger than originally estimated due to lost productivity. Two related studies have been conducted using data from Kaiser Permanente, a large health maintenance organization operating in nine states and the District of Columbia at the time of this report. In a 1993 analysis by Quesenberry et al. of cost and service utilization of 17,118 members of Kaiser Permanente, Northern California Region, significant associations were found between having a BMI of 30 or greater and higher inpatient and outpatient costs, increased physician visits, medication costs, laboratory services, and number of inpatient days (71). Total excess costs to the health plan among obese participants amounted to $220 million, or about 6% of the total outlay for all plan members. A 1998 retrospective cohort study by Thompson et al. examined future health care costs among 1,286 members of Kaiser Permanente Northwest who, when surveyed in 1990, were 35 to 64 years old, had a BMI of 20 or greater, did not smoke cigarettes, and did not have a history of cancer, AIDS, stroke, or coronary heart disease (72). Health care costs were then tallied for these subjects over the nine-year period from 1990-98 and compared by 1990 BMI category (20-24.9, 25-29.9, and 30+). The researchers found that cumulative total health care costs over the time period increased with BMI. Total costs for subjects having BMIs of 20-24.9 were $15,583, compared with $18,484 and $21,711 for subjects with BMIs of 25-29.9 and 30+, respectively. Higher cumulative costs were found among obese plan members for pharmacy services, outpatient services, and inpatient care. Health economist Roland Sturm of the Rand Corporation compared the effects of obesity with those of smoking, heavy drinking, and poverty on chronic health conditions and health care expenditures. His results, published in the April 2002 issue of Health Affairs, showed obesity to be the most serious health problem both in terms of chronic illness and health spending (73). Sturm’s findings were based on data obtained from approximately 10,000 respondents to Healthcare for Communities, a national household telephone survey conducted in 1998. Obese persons, those having a BMI of 30 or greater, reported an increase in chronic conditions (diabetes, hypertension, asthma, heart disease, and/or cancer) of 67% compared with normal-weight persons with similar social demographics. Normal-weight smokers reported 25% more chronic conditions, while normal-weight heavy drinkers reported 12% more chronic conditions. Living in poverty came closer to the effect created by obesity, resulting in an increase of chronic conditions of 58%. Only aging from 30 to 50 resulted in a comparable number of chronic conditions being reported. Health care expenditures included health services such as inpatient hospital care and physician visits and medications, both prescription and over-the-counter drugs. Obese respondents reported spending approximately 36% more on health services and 77% more on medications than normal-weight individuals. In contrast, smokers spent 21% more on services and 28% more on medications. Only aging resulted in higher expenditures on medications than did being obese. The economic burden imposed by obesity on U.S. businesses was assessed by David Thompson of Policy Analysis, Inc., in terms of increased health insurance costs, disability insurance, sick leave, and higher life insurance premiums (74). In a 1998 article in the American Journal of Health Promotion, Thompson estimated the annual total cost of obesity to the American business economy to be $12.7 billion. The largest share of this amount was $7.7 billion in increased health insurance premiums, with $2.4 billion in paid sick leave, $1.8 billion in higher life insurance premiums, and $0.8 billion in disability insurance. Wang and Dietz analyzed data from the National Hospital Discharge Survey from 1979-99 to estimate the increasing economic burden of obesity in youths aged six through 17 (75). Principal diagnoses of diabetes, obesity, sleep apnea, and gallbladder disease were examined, as well as other diseases for which obesity was listed as a secondary diagnosis. The percentage of discharges with obesity-related diagnoses increased in every category from 1979-81 to 1997-99. Discharges with diabetes as the principal diagnosis nearly doubled, obesity and gallbladder diseases tripled, and sleep apnea diagnoses increased fivefold over the 20-year period. The associated hospital costs more than tripled, from $35 million in 1979-81 to $127 million in 1997-99. The significant increase in the number of morbidly obese patients has put additional strains on the health care system, many of which have not yet been studied. Injuries among physical therapists, nurses, and other hospital staffers are on the rise, as well as hospital expenditures for special beds, lifts, scales, operating tables, wheelchairs, and other equipment that will accommodate very heavy patients (76). Some diagnostic facilities are not able to serve the morbidly obese, resulting in a lack of preventive and imaging services available to a portion of the bariatric population. The rapid rise in the numbers of morbidly obese patients has caught many sectors of the health care system unable to provide appropriate and sufficient services. ]]>