This Article Abstract Submit a response to this article Services E-mail this article to a friend Alert me to new issues of the journal

P E R S P E C T I V E
F U T U R E  E L D E R L Y 

26 September 2005  
  

Health Care Costs In Old Age Are 
Related To Overweight And 
Obesity Earlier In Life

A strategy of encouraging prevention at young ages
holds promise for reducing the toll of obesity among
tomorrow’s elderly Americans.

By Martha L. Daviglus

ABSTRACT:

Obesity is responsible for at least $90 billion in direct U.S. health care costs annually. A high proportion of people who were overweight or obese at younger ages survives past age sixty-five to experience adverse consequences. The determinants of obesity are complex and multifactorial, with genetic, biological, behavioral, social, and environmental contributors. The effects of adverse weight in older age have negative implications for healthy aging and lead to greater societal expenditures. Given the high costs and ineffectiveness of existing programs to treat obesity, perhaps the only solution to the obesity epidemic is primary prevention of weight gain beginning in youth.

Overweight and obesity (defined as body mass index [BMI] 25.0–29.9 and greater than 30.0, respectively)—recognized as major risk factors for coronary heart disease (CHD)—are associated with higher risk of hypertension, dyslipidemia, diabetes, certain cancers, other disorders, higher long-term mortality from cardiovascular diseases (CVD) and all causes, and impairments in current and future physical functioning and quality of life.¹ Despite declines in the prevalence of other major CVD risk factors—hypertension, hypercholesterolemia, and cigarette smoking—during the past few decades, the prevalence of overweight and obesity has increased markedly across all age, sex, socioeconomic, and ethnic groups in the United States, and the deleterious consequences of obesity such as non-insulin-dependent diabetes mellitus are now being manifest at earlier ages.²

At the same time, the U.S. population is aging rapidly. It has been estimated that the proportion of Americans age sixty-five and older will increase from 12 percent currently to 20 percent by 2050.³ This has important implications for expenditures by Medicare—the single largest U.S. source of health care spending. Moreover, a high proportion of people who were overweight or obese at younger ages survive to experience adverse consequences, such as morbidity, disability, and higher health care costs, in older age. Obesity is responsible for at least $90 billion in direct health care costs annually in the United States.⁴ The alarming combination of escalating obesity and the increasing population of older people is thus of concern to health care professionals, policymakers, and the public.

Darius Lakdawalla and colleagues use a microsimulation to estimate lifetime costs, life expectancy, disease, and disability for seventy-year-olds based on BMI.⁵ Consistent with existing literature, they report that obese people experience higher morbidity, incur greater Medicare expenditures, and enjoy fewer disability-free life years than their nonobese peers. Importantly, they report that although life expectancy at age seventy is approximately the same for obese people as for those of normal weight (about fourteen years), obese people will incur almost $40,000 in additional lifetime health care costs. This implies that for those who are obese, a substantial proportion of their remaining life is spent with disease and disability. However, the analysis by Lakdawalla and colleagues does not describe the long-term effects of obesity at younger ages on health outcomes in older age, which if included would likely be even higher.

Implications for future Medicare spending. Numerous reports have found significant relationships of BMI to health care costs, although the majority of these have been based on statistical stimulations of long-term costs, cross-sectional studies, or prospective studies involving less than a decade of follow-up. These studies, with relatively short-term follow-up, only partially reflect the full burden of medical expenditures associated with overweight and obesity at younger ages. However, a 2004 report from the Chicago Heart Association (CHA) study on health spending by Medicare over a nineteen-year period demonstrated that for both men and women, irrespective of changes in weight that might have occurred over the years, overweight/obesity in young adulthood and middle age is significantly and positively associated with higher CVD-related and total Medicare health care charges, average annual and cumulative, in older age.⁶ Adjustment for major CVD risk factors that are potentially in the causal pathways between BMI and subsequent disease only slightly attenuated the association, which points toward an independent effect of BMI on health care costs. These findings have important implications for future Medicare spending, given the continued and alarming increase in prevalence of overweight/obesity in the United States during recent decades. Data from the National Health and Nutrition Examination Survey (NHANES), 1999–2000, show that the age-adjusted prevalence of overweight (BMI 25.0 and higher) and obesity (BMI 30.0 and higher) increased to 65 percent and 31 percent, respectively, from 56 percent and 23 percent during 1988–94 (NHANES III).⁷ These results suggest that despite declines in other risk-factor levels, future Medicare spending will continue to rise if current trends of excess weight remain unchanged.

Difficulties in prevention and control. The determinants of obesity are complex and multifactorial, with genetic, biological, behavioral, social, and environmental contributors. Genetic and biological factors that predispose certain individuals and populations to weight gain have not yet been fully elucidated. However, it is certain that levels of susceptibility may be intensified by adverse environmental factors—all too common in modern society—that promote physical inactivity and overconsumption of calorie-dense foods. Numerous clinical trials have demonstrated that dietary therapy and physical activity can both result in weight loss.⁸ However, prevention and control of overweight and obesity is fraught with difficulties stemming from adverse environmental influences and insufficient, expensive, and ineffective treatment options. Weight control is a commonly reported behavior: Consumers spend approximately $33 billion each year on weight reduction products and treatments.⁹ In a 1998 national telephone survey, 29 percent of men and 44 percent of women reported trying to lose weight. However, most people were not following the recommended combination of reduced caloric intake and increased physical activity, which might explain the ineffectiveness of their weight-loss attempts. Moreover, although people who are advised by their physicians to lose weight are more likely to attempt to do so, fewer than half of obese adults report receiving such advice from their physician.¹⁰ Unfortunately, despite the demonstrated wide-ranging adverse consequences of obesity, neither excess weight nor the sedentary lifestyles that cause it have yet received the level of attention by health care professionals and policymakers that was directed at cigarette smoking (which has comparable deleterious public health consequences).

Given the cumulative impact of prolonged exposure to adverse weight levels, and the high costs and ineffectiveness of existing programs to treat obesity, perhaps the only solution to the obesity epidemic and its consequences is primary prevention of weight gain from young ages. Some researchers have debated the cost-effectiveness of primary preventive efforts such as those aimed at lowering heart disease, arguing that the strategies required to achieve populationwide risk factor modification at early ages would be costly, and also casting doubts on the efficacy of such interventions. However, they have generally included the costs of drug treatment for risk-factor modification, ignoring those who simply advocate the adoption of healthy lifestyle habits starting early in life to prevent development of such risk factors.¹¹ Some have contended that the current trend of increasing life expectancy may lead to growing numbers of frail, institutionalized older people, with poor quality of life and high health care costs.¹² Yet as recently demonstrated in a large prospective study after decades of follow-up, for the small percentage of people (less than 10 percent of 39,573 participants in the CHA study) with favorable baseline levels of all major CVD risk factors (including favorable baseline BMI levels) compared with all others, longevity is greater by years and end-of-life health care costs are much lower.¹³

Future direction. With current trends of increasing overweight and obesity affecting all age groups, urgent preventive measures are required, not only to lessen the individual and societal burden of disease and disability associated with excess weight, but also to contain future health care costs incurred by the aging population. For the young and middle-aged, whose lives may still be relatively uncomplicated by adverse levels of BMI and BMI-related risk factors, and for future generations, there is the need to maintain a healthy weight by pursuing a healthy lifestyle—adopting healthy eating patterns and remaining or becoming physically active. Unfortunately, by middle age, lifestyle patterns leading to excess weight have often been established for decades. Although success in sustaining weight loss among overweight or obese adults has been limited, even modest weight reduction has been shown to be beneficial. Hence, for those already overweight or obese, there is also the need for intensive and innovative multifaceted media and community-based educational programs emphasizing the possibility of successful weight loss and weight maintenance through exercise and moderation of diet, or at the least, prevention of further weight gain. As documented by Lakdawalla and colleagues, the effects of adverse weight at age seventy have negative implications for healthy aging (a disease- and disability-free old age) and lead to greater societal spending, which underscores the need for preventive measures starting early in life. The decades-long national efforts against tobacco use that have resulted in a dramatic decrease in adult smoking behavior could serve as models.

NOTES

1. T.B. Harris et al., “Carrying the Burden of Cardiovascular Risk in Old Age: Associations of Weight and Weight Change with Prevalent Cardiovascular Disease, Risk Factors, and Health Status in the Cardiovascular Health Study,” American Journal of Clinical Nutrition 66, no. 4 (1997): 837–844; K.F. Ferraro et al., “Body Mass Index and Disability in Adulthood: A Twenty-Year Panel Study,” American Journal of Public Health 92, no. 5 (2002): 834–840; and M.L. Daviglus et al., “Body Mass Index in Middle Age and Health-related Quality of Life in Older Age: The Chicago Heart Association Detection Project in Industry Study,” Archives of Internal Medicine 163, no. 20 (2003): 2448–2455.
2. K.M. Flegal et al., “Overweight and Obesity in the United States: Prevalence and Trends, 1960–1994,” International Journal of Obesity and Related Metabolic Disorders 22, no. 1 (1998): 39–47; K.M. Flegal et al., “Prevalence and Trends in Obesity among U.S. Adults, 1999–2000,” Journal of the American Medical Association 288, no. 14 (2002): 1723–1727; A.L. Rosenbloom et al., “Emerging Epidemic of Type 2 Diabetes in Youth,” Diabetes Care 22, no. 2 (1999): 345–354; and R. Sinha et al., “Prevalence of Impaired Glucose Tolerance among Children and Adolescents with Marked Obesity,” New England Journal of Medicine 346, no. 11 (2002): 802–810.
3. V.M. Fried et al., eds., Health, United States, 2003, with Chartbook on Trends in the Health of Americans, Pub. no. 2003-1232 (Hyattsville, Md.: National Center for Health Statistics, 2003); and D.K. Foot et al., “Demographics and Cardiology, 1950–2050,” Journal of the American College of Cardiology 35, no. 4 (2000): 1067–1081.
4. G.A. Colditz, “Economic Costs of Obesity and Inactivity,” Medicine and Science in Sports and Exercise 31, no. 11 Supp. (1999): S663–S667.
5. D.N. Lakdawalla, D.P. Goldman, and B. Shang, “The Health and Cost Consequences of Obesity among the Future Elderly,” Health Affairs, 26 September 2005, content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.r28.
6. M.L. Daviglus et al., “Relation of Body Mass Index in Young Adulthood and Middle Age to Medicare Expenditures in Older Age,” Journal of the American Medical Association 292, no. 22 (2004): 2743–2749.
7. Flegal et al., “Prevalence and Trends.”
8. National Institutes of Health, “Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report,” Obesity Research 6, Supp. 2 (1998): 51S–209S.
9. M.K. Serdula et al., “Prevalence of Attempting Weight Loss and Strategies for Controlling Weight,” Journal of the American Medical Association 282, no. 14 (1999): 1353–1358.
10. C.N. Sciamanna et al., “Who Reports Receiving Advice to Lose Weight? Results from a Multistate Survey,” Archives of Internal Medicine 160, no. 15 (2000): 2334–2339.
11. L.B. Russell, “Will Prevention Cut Medical Spending?” Internist 27, no. 9 (1986): 7–8, 10.
12. E.M. Crimmins, M.D. Hayward, and Y. Saito, “Changing Mortality and Morbidity Rates and the Health Status and Life Expectancy of the Older Population,” Demography 31, no. 1 (1994): 159–175; B.C. Spillman and J. Lubitz, “The Effect of Longevity on Spending for Acute and Long-Term Care,” New England Journal of Medicine 342, no. 19 (2000): 1409–1415; and L.M. Verbrugge, “Longer Life but Worsening Health? Trends in Health and Mortality of Middle-Aged and Older Persons,” Milbank Quarterly 62, no. 3 (1984): 475–519.
13. J. Stamler et al., “Low Risk-Factor Profile and Long-Term Cardiovascular and Noncardiovascular Mortality and Life Expectancy: Findings for Five Large Cohorts of Young Adult and Middle-Aged Men and Women,” Journal of the American Medical Association 282, no. 21 (1999): 2012–2018; M.L. Daviglus et al., “Favorable Cardiovascular Risk Profile in Young Women and Long-Term Risk of Cardiovascular and All-Cause Mortality,” Journal of the American Medical Association 292, no. 13 (2004): 1588–1592; and M.L. Daviglus et al., “Benefit of a Favorable Cardiovascular Risk-Factor Profile in Middle Age with Respect to Medicare Costs,” New England Journal of Medicine 339, no. 16 (1998): 1122–1129.


Martha Daviglus (daviglus{at}northwestern.edu) is an associate professor of preventive medicine and of medicine at the Feinberg School of Medicine, Northwestern University, in Chicago, Illinois.

Access the table of contents for this package

DOI: 10.1377/hlthaff.W5.R97
©2005 Project HOPE–The People-to-People Health Foundation, Inc.