THE IMPACT OF LIFE STYLE ON HEALTH AND HEALTH CARE COSTS

1
THE IMPACT OF LIFE STYLE ON HEALTH AND HEALTH
CARE COSTS

• WILLIAM J. KLISH M.D.
• Professor Emeritus of Pediatrics
• Baylor College of Medicine
• Houston, Texas

2

• THE LIFESTLYE THAT WE ADOPT
• NOT ONLY DECIDES OUR DESTINY
• BUT AFFECTS THE HEALTH AND WELFARE
• OF OUR ENTIRE NATION.

3
DISEASES INITIATED BY LIFE STYLE

• Many serious diseases are either caused or made
  worse by the way we live, including
• Many types of cancer
• Cardiovascular disease
• Lung disease
• Liver disease
• Allergy
• AIDS and other STDs
• Obesity
• This lecture will focus on obesity

4
THE OBESITY EPIDEMIC

• The Most Serious Public Health Problem Today

5
GOALS AND OBJECTIVES

1. Discuss the present obesity epidemic
2. Describe health issues associated with obesity
   that have become major public health problems
3. Define how these issues impact health care costs.

6
Global Burden of Disease World Health
Organization Statistics

• Percent of death due to
• population heart
  disease cancer tobacco use
  overweight
• World 7 billion 31
  13 20
  34
• Ethiopia 83 million 15
  4 2
  7
• India 1.2 billion 24
  6 14
  11
• Russia 143 million 61
  13 41
  60
• U K 62 million 34
  27 17
  64
• U S 310 million 34
  23 16
  71
• 
  
  
• 
  
  Percent of all deaths
• 
  

7
BODY MASS INDEX

• Body Weight in Kg (Height in Meters)²
• or
• Body Weight in Pounds (Height in Inches) x 703
• Adult Standards
• Normal 18 25
• Overweight 25-30
• Obese gt30

8
(No Transcript)
9
(No Transcript)
10
OBESITY TRENDS

• Estimates are that by 2030, 39 states will have
  an obesity rate of over 50.
• All states will be above 44
• Wisconsin will be at 56

Trust For Americas Health, Robert Wood Johnson
Foundation. 2012
11
Obesity in Adulthood is Related to Obesity in
Childhood
Whitaker et al. NEJM 1997337869-873
12
(No Transcript)
13
Prevalence of Obesity in Children and Adolescents

• Overweight or obese (BMI 85 percentile)
• 26.7 percent of preschool children (2 to
  5 years)
• 32.6 percent of school-aged children (6
  to 11 years)
• 33.6 percent of adolescents (12 to 19
  years)
• Obese (BMI 95 percentile)
• 12.1 percent of preschool children
• 18.0 percent of school-aged children
• 18.4 percent of adolescents
•  Severe obesity (defined as a BMI 97 percentile)
• 9.7 percent of preschool children
• 13.0 percent of school-aged children
• 13.0 percent of adolescents

14

• Obesity (BMI) gt 95th percentile for age, based
  on Centers for Disease Control and Prevention
  (CDC) 2000 growth charts.

15
Prevalence of Obesity - Texas Children 1999-2002
Region Number BMI gt85th BMI gt 95th
Houston 5,266 36.2 19.2
Fort Worth 1,065 29.9 15.0
Hart 308 39.4 20.7
Rio Grand Valley 4,375 40.1 22.1
El Paso County 899 32.0 18.0
Texas Mexico Border 3,025 53.8 37.6
Total (age 6-18) 14,938 38.6 22.1
TX WIC (age 1-5) 128,004 28.6
16
Health Care Costs of Obesity

• USA 240 billion dollars in 2008 and could
  increase to 1 trillion dollars by 2030 (Wang et
  al. Obesity (Silver Spring). 2008 Oct
  16(10)2323-30)
• Medical costs will grow at a rate of 48-66
  billion per year (Trust For Americas Health,
  Robert Wood Johnson Foundation. 2012)
• Western Europe 10.4 billion euros in 2008
  (Muller-Reimenschneider et al. Eur J Epidemiol
  200823(8)499-509.)
• China 21.11 billion Yuan (2.74 billion) in
  2003 (Zhao W et al. Obes Rev. 2008 Mar9 Suppl
  162-7)
• Does NOT include decreased productivity, lost
  work days, obesity treatment etc.
• Medical costs are also underestimated because
  diagnosis of obesity is frequently not coded.

17
Health Care Costs of Obesity

• Obesity (BMIgt30) adds about 2,800 to a persons
  annual medical bills ¹
• Those with a BMIgt40 pay 5,530 more for health
  care than a normal weight person ²

1. National Bureau of Economic Research, 2010 2.
Mayo Clinic Employee Health Study, 2012
18
OBESITY
The Cause of The Problem
19
MOLECULAR GENETICS OF OBESITY

• The first obesity gene was mapped in the mouse in
  1994 (Ob or Leptin gene)
• Now the number of candidate obesity genes
  identified is greater than 200
• We all probably have at least one obesity gene

20
EXPLANATION FOR INCREASING RATE OF OBESITY

• Obesity genes offer survival advantage so they
  were favorably selected
• They increase the amount of available calories
  stored as fat when food was lacking
• When food is plentiful (and physical activity
  limited), these genes express themselves as
  obesity

21
Therefore the Cause of the Present Obesity
Epidemic is Obvious

• OUR LIFESTYLE CHANGED
• We Decreased Physical Activity
• The Availability of Calorie Dense Foods Increased
• We Lack Concern About the Consequences of Obesity

22

• OBESITY IS NOT A COSMETIC ISSUE!
• OBESITY IS A DISEASE!

23
Health Problems Associated with Obesity

• Psychological
• Lack of self esteem
• Depression
• Pulmonary
• Sleep apnea
• Respiratory insufficiency
• Pickwickian syndrome
• Skeletal
• Slipped femoral capital epiphysis
• Varus or Valgus deformities of knees (Blounts
  Disease)
• Osteoarthritis
• Foot pain

• Liver
• Steatohepatitis
• Biliary Disease, Gall Stones
• Metabolic
• Diabetes
• Hyperlipidemia
• Cardiovascular
• Hypertension
• Atherosclerosis
• CNS
• Pseudotumor cerebri
• Cancer
• Breast, etc.

24
Type II
Diabetesadult onset
25
DIABETES

• According to
• the International Diabetes Federation,
• in 2011,
• one person is dying from diabetes
• every seven seconds.

26
Prevalence of Type 2 Diabetes in Children
Cincinnati, Ohio
27
Co-Morbidities of ObesityGlucose Intolerance

• Current projections by the CDC include
  scenarios in which up to one third of the
  children born today will develop type 2 diabetes
  mellitus during their lifetime, a percentage that
  rises to 50 for Hispanics and Blacks.

Narayan, K.M., et al., JAMA 2003.
28
Prevalence of Type II Diabetes Houston
Metropolitan area (pop. 5.5 million) 21 or
1,155,000 are children 5-17 years of age
0

• 19.2 or 221,760 Houston children are obese
  (BMIgt95th)
• 25 of obese children have evidence of impaired
  glucose tolerance (Sinha et al, NEJM 2002
  346)
• Then 4.8 or 55,440 Houston children either have
  or are developing type II diabetes
• 
  (Estimated from U.S. 2006 census)

29
Health Care Costs of Diabetes

• Estimated world wide cost in 2011 is 465 billion
• Estimated cost in 2007 for the USA is 174
  billion
• 1 in 10 health care dollars is attributed to
  diabetes
• Yearly cost per individual diagnosis is 6,649
• Lost productivity is 26.9 billion
• Does not include social costs such as unpaid
  caretakers etc.

Am. Diabetes Assoc. Diabetes Care, 2008
Mar31(3)596-615 International Diabetes
Federation, Sept. 2011
30
Co-Morbidities of ObesityNAFLD (Non-alcoholic
Fatty Liver Disease)

• A spectrum of disease
• Fatty infiltration of the liver (up to
  40 of obese children by ultrasound)
  
  
  
  
  (Styne, Pediatr
  Clin North Am, 2000)
• Hepatic inflammation (15 of obese
  and 40-50 of super obese children have elevated
  ALTs) (Dietz, Pediatrics,
  1998)
• Fibrosis and cirrhosis
• If inflammation present it is called
  Steatohepatitis or "NASH" (nonalcoholic
  steatohepatitis)
• Weight loss is the only treatment
• Estimated 25 of US adults have this disease
• Krasnoff et al Hepatology 474 2008

http//www.uic.edu/com/dom/hepatology/fatty.liver.
disease.html
31
Co-Morbidities of ObesityNAFLD

• 20 of adult patients with this disorder
  eventually develop cirrhosis, and can progress to
  liver failure which can only be treated with
  liver transplant
• 
  
• 
  
  (Roberts, Curr
  Gastroenterol Rep, 2003)

32
NASH Accounts for 10.3 of all Liver
Transplantation at the Cleveland Clinic in 2006
33.1
12.8
10.3
www.clevelandclinic.org
33
Co-Morbidities of Obesity Steatohepatitis

• We studied 332 obese children (BMIgt95thtile)
• Aminotransferases were elevated
  (gt1.5 times normal) in 52
  children (15.7)
• ALT elevated in 100, AST in 49 GGT in 80
• 40 of these children had liver biopsy
• Mean age 10.9 2.4 years (range 6-16y)

Ruben Quiros, et al
34
Co-Morbidities of ObesitySteatohepatitis

• HEPATIC FIBROSIS
• Of the 40 children who were biopsied
• 35 children (87.5) demonstrated some degree of
  fibrosis
• 26 children (65) had stage II fibrosis or
  greater
• 2 children (5) had early cirrhosis

Ruben Quiros, et al
35
Prevalence of Obesity-Associated
Steatohepatitis Houston Metropolitan area
(pop. 5.5 million)21 or 1,155,000 are children
5-17 years of age
0

• 221,760 or 19.2 are obese (BMI gt95th)
• 33,264 or 15 will have elevated transaminases
• 21,621 or 65 will have significant (gtstage 2)
  fibrosis or cirrhosis in their liver bx.
• At least 4,324 or 20 will develop hepatic
  failure and be candidates for liver
  transplantation as young adults
• 
  (Estimated from U.S. 2006 census)

36
Average cost of a liver transplant today is over
150,000
37
Co-Morbidities of Obesity Cardiac Risk Factors

• Hypertension
• Hyperlipidemia
• Sleep apnea
• Insulin resistance
• 50 of overweight adolescents have one risk
  factor for developing cardiovascular disease
• 20 have two factors

38
Adjusted Hazard Ratio
Risk of fatal CHD event in adults
relative to rise of 1 BMI z score in children
FATAL EVENT
age
girls
boys
7 YR 1.07 (0.99 - 1.15) 1.10 (1.06 1.15)
8 YR 1.08 (1.01 1.17) 1.14 (1.09 1.19)
9 YR 1.10 (1.02 1.19) 1.16 (1.11 1.21)
10 YR 1.12 (1.04 1.20) 1.18 (1.13 1.23)
11 YR 1.18 (1.10 1.27) 1.22 (1.17 1.27)
12 YR 1.20 (1.11 1.29) 1.23 (1.18 1.28)
13 YR 1.23 (1.15 1.32) 1.24 (1.19 1.29)
Baker JL et al. NEJM 35723 Dec 6.2007
39
Hypertension CDC
Health Statistics

• Prevalence of Hypertension in the US
• 30 of all adults
• 58 of obese adults
• Prevalence of Hypertension in Children
• 1.5-2.5 of all children (HISD screening 2.2)
• 15-21 of obese children

40
Future economic burden of current adolescent
obesity related to coronary heart disease

• 254 billion
• 
  
  
• 
  
  Lightwood et al. Am J Public
  Health. Oct 15, 2009

41
Co-Morbidities of ObesitySleep Disorders

• Up to 37 of obese children have an abnormal
  polysomnogram when studied. (Wing, Arch Dis
  Child, 2003)
• True sleep apnea occurs in 7 of obese children.
  (Dietz, Pediatrics, 1998)

42
Health care costs of associated with sleep apnea

• Up to 300 per day per patient
• 
  
  
  Banno et al, Sleep. 2009 Feb
  132(2)247-52

43
Co-Morbidities of ObesityPsychosocial
Complications

• Higher risk for poor self-esteem, withdrawal from
  social interactions, anxiety and depression.
  (Deckelbaum, Obes Res, 2001)
• More likely to remain unmarried, have lower
  incomes and to live in poverty
  
  (Gortmaker, N Engl J Med, 1993)
• Less likely to be accepted into college
  (Must, Int J Obes
  Relat Metab Disord, 1999
• Cannot be quantified in a monetary sense
• These perhaps are the most significant "costs"
  this disorder inflicts on society

44
(No Transcript)
45
OBESITY

• Why should you care?
• Whose fault is it?
• Individuals?
• Food Industry?
• Society?

46

• There are solutions to this problem but you need
  to ask to get the rest of the story

47

• Thank You
• Any Questions?