Monday, May 7, 2012

Who says being fat is bad?

Would you have guessed that, one fine day, health insurers will regret the demise of big tobacco and its contribution to health care costs? Would you have guessed that, when that day arrives, health insurers would also learn to love other frowned-upon-vices of their policy holders, such as getting fat and lazy? Your answer is probably "no, I wouldn't have guessed that in my dreams.". 
And also very probably this answer is based on what you typically read in the media, such as this piece of news titled "Obesity Adds More to Health Care Costs Than Smoking, Study Suggests." released on April 3, 2012, on The article text wraps the title message into a substantially larger amount of unsubstantial words, before it concludes what you would probably subscribe to blindfolded: the  " [1] provides new insights into the long-term costs of obesity and smoking, showing that both risk factors lead to persistently higher health costs throughout a seven-year follow-up period.". Dah, what else is news?
Well, for one, that the Joe Camels and the lardbuckets, with all their vices, cost their health insurers actually LESS money than Mr. and Mrs Healthy. For one simple reason: the "vice guys" die earlier.
But let's hold that thought for a moment and let's look at the figures. In a Dutch study performed by Pieter van Baal and colleagues, the authors compared the annual and lifetime health care costs of three cohorts, namely the obese, the smokers, and the healthy living people [2]. As the basis of their calculations they used the Dutch National Institute's of Public Health and the Environment (RIVM) chronic disease model, which, the authors assure us, has been widely used and validated in disease and cost projection analyses.
To make their results more comparable internationally, they ran their analyses with altogether 7 different scenarios, to account for different health care systems and for different mortality risk estimates. The latter had been drawn from observations in the U.S. published by Flegal and colleagues [3] who had found declining mortality risks in the obese cohorts. I mention this because I don't want you to suspect that the Dutch authors had based their calculations on an unrealistically high keeling-over rate for the obese. Now, fast forward to the astonishing results.
In all 7 models, as well as in the unadjusted base case scenario, the financially most attractive "villains" to health insurers are the smokers. The most expensive are always the goody-two-shoes healthy-living people. Somewhere in-between are the fat ones. In the model which assumed a yearly 1% increase in health care costs, the lifetime costs for an obese person amounted to € 399,000, compared to which the smoker comes at a 14% discount of € 341,000, but the healthy living person with a 17% premium at € 468,000.
How can that be? The answer is not where you and I would have looked first: The diseases which directly associate with smoking and obesity (heart disease, cancer, diabetes, pulmonary diseases, musculoskeletal disorders). They account only for 20% of total disease costs. The remaining 80% are for ailments and conditions, which come with age. But when that age doesn't come, because you die earlier, then those costs don't come either. And Joe Camel and Ronald McDonald are rather effective in cutting years out of your life, and thereby costs out of your health insurers balance sheet. For 7 and 5 years respectively, to be precise.   
So, where are the premium discounts for the obese and the smoking policy holders? Why are the healthy living people permanently miffed about not getting premium discounts, when they actually cost more? I have to admit, I belong to the latter, too. But recently, after having listened to one of my talks at a conference, a friend of mine, the CEO of a German health insurer, took me aside and told me, that my indignation about the healthy people having to share the cost burden of their willfully negligent peers, was unfounded.
As much as I wanted to disbelieve, I also knew that these insurance guys do one thing very well: calculating risk and premiums. So I had to give him the benefit of the doubt. Which is why I began to check. And by checking, I came to know about quite a number of studies confirming my friend's argument. One of those studies was van Baal's, which I chose to quote from because he is actually working for the Dutch National Institute of Public Health and the Environment. Not that I'm biased in favor of the Dutch. I'm biased in favor of anyone who articulates a viewpoint which is in stark contrast to what I would expect merely on the basis of his association. I mean, here you have someone telling you to NOT confuse health with health care cost savings, when his employer is actually trying to make everyone with a cigarette or a burger in his mouth feel guilty about sending health care costs sky high.  
So what now? Shall we promote the vices and lower our health care costs in a decade-long smoking and feeding frenzy? Well, it's your choice, but I'm not convinced that we have got the reasoning or the arguments right just yet. We need to do a little more detective work to solve this case.
Now, you know how the French, at least in their novels, dish out that piece of advice to the detective: Cherchez la femme (look for the woman)? Maybe it works in the French universe. In mine, I have always found this one to work better: "Cherchez l'argent" (look for the money).
Which will lead us to another few surprising discoveries in the next post. And, of course, a couple more reasons to believe that there are quite some powerful players around who yearn for the good old times when Marlboro Man and Ronald McDonald delivered us from the risk of a costly long life.

PS: To meaningfully pass the time until the next post, watch this video on the calorie cartel

Moriarty, J., Branda, M., Olsen, K., Shah, N., Borah, B., Wagie, A., Egginton, J., & Naessens, J. (2012). The Effects of Incremental Costs of Smoking and Obesity on Health Care Costs Among Adults Journal of Occupational and Environmental Medicine, 54 (3), 286-291 DOI: 10.1097/JOM.0b013e318246f1f4
van Baal PH, Polder JJ, de Wit GA, Hoogenveen RT, Feenstra TL, Boshuizen HC, Engelfriet PM, & Brouwer WB (2008). Lifetime medical costs of obesity: prevention no cure for increasing health expenditure. PLoS medicine, 5 (2) PMID: 18254654
Flegal, K. (2005). Excess Deaths Associated With Underweight, Overweight, and Obesity JAMA: The Journal of the American Medical Association, 293 (15), 1861-1867 DOI: 10.1001/jama.293.15.1861 Print Friendly and PDFPrintPrint Friendly and PDFPDF


  1. To make their results more comparable internationally, they ran their analyses with altogether 7 different scenarios, to account for different health care systems and for different mortality risk estimates.
    i like it , , ,

  2. A smile and a hug for you my friend! We are not designed to go and go. We are designed to serve others and wait upon the Lord. Blessings to you in this time of rest and trying new things!

  3. Hi Doctor,

    This point of view is indeed provocative, but I can't help but think not every factor has been considered. Focusing on the health care expenses of people gives you a certain view on the problem, but I think the view should be global to tell the whole picture.

    For instance, you say that a healthy person costs about 100,000€ more to governments in health care ; however, there's a number of factors that could be taken into account but that don't seem to be acknowledged here. If you're healthy and you die later, the government has to pay you a pension (additional cost for the government), but you'll spend more money in your life (additional revenue thanks to sales tax and taxes on the company selling you goods - basically anything that taxes the circulation of money), you'll be able to save more (in some countries the money saved is loaned to the government, which gives them a lower interest rate than on the market - additional money for the gvt then) and your inheritance will be larger (wealthier kids, that'll spend more money and that might be less likely to be bankrupt (they have money to pay for your health care costs, your funeral, etc), which is good for the government) ; besides smoking generates pollution that kills trees (huge government cost - trees make people statistically happier, healthier, reduces air conditioning use, etc) and obesity creates an overconsumption of food and resources, which I guess is good for sales taxes but bad for resource usage (the obese countries will have to either cover their whole country in crops or import their food, in both cases it's bad for them).

    Anyway, as provocative as it is, I think this point of view only tells one part of the story, and I'm not sure it's in the end good for governments to have people dying of obesity or smoking ! What do you think?



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