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August 07, 2009


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I think the fact that your healthcare costs will reduce by a huge 42% is enough incentive for anyone to start losing weight. This extra cash could go towards so many other things such as debt management, saving for college or paying your mortgage!

Hold on here. Year for year that is true but non-obese people tend to live longer and thus have higher lifetime healthcare costs. Obese people are only more expensive if they life more than 70% longer than a non-obese person. For example if a non-obese person lives to 75 and an obese person 53 their costs are the same it's when the obese person lives past 53 their lifetime costs are more than the non-obese person. You also have to explore end of life issues such as which group will see the sharpest increase in healthcare expenses in the last few years of their life. It can often be non-obese person since they are more likely to survive a heart attack (for example) thus need continued treatment and medicine. So to say being non-obese costs less isn't necessarily true and can often be wrong. Simple and rudely put living obese and dying young is cheaper than being healthy and dying old.

Meoip --

So you're saying what? That we sould all eat a ton, get fat, and that will actually save us money? Or you're advocating that people being overweight is actually a savings to the US healthcare system? Not sure of your main point.

Personally, I'd rather have the longer, more fulfilling life generally associated with being the proper weight. It might cost me more in total, but it's also likely that I'll earn more (check the stats) as well as have a better life.

I think Meoip's comment was supposed to be tongue in cheek. At least I hope it was...

You'd think in these "tough economic times" (politicians' favorite buzz phrase) that America's waist line would be slimming. In the long run, obese people will bankrupt any type of healthcare plan the Government comes up with.

I believe overweight (not obese) people actually live longer than "normal" weight people.

And if your insurance is provided by your employer, there is a very good chance losing weight will actually cost you most money (the cost of athletic equipment, healthier foods, gym memberships without any real savings if insurance is paying the bulk of your medical bills). It's also worth mentioning that dieting is a major cause of health problems because keeping much more than 15 pounds off is virtually impossible and there is no health advantage at any BMI level for a loss of just 15 pounds. But gaining and losing weight over and over again is bad for your health. You are better off being overweight consistently than fluctuating between being overweight and normal weight (or just being overweight and less overweight).

While I won't go as far as say that we should all eat a ton, I will say that the focus on weight rather than activity is costly, and staying physically active is far more important than fitting into an arbitrary weight category.

While I understand your argument, you're neglecting the fact that the person who dies at 53 doesn't earn any income from 53 until retirement. I'd venture a guess and say that healthier people are more productive on average and therefore earn more, so as a percentage of total lifetime income, health costs are much less for healthy people than for obese people.

I feel your "surviving a heart attack" argument is invalid as non-obese people are MUCH less likely to have a heart attack in the first place. The same is true for surviving other maladies.

I've long been a proponent of encouraging people to get healthy to reduce costs (not only for them, but for me too!). I heard that in the UK, doctors and patients actually get incentives to lower blood pressure, cholesterol, weight, etc. to healthy levels.

What are everybody's thoughts on an incentive system for insurance? What about discouraging use of tobacco and alcohol, unhealthy foods, etc through taxes?

Good idea to lose weight, and the process might save one some money. However, the current media flutter about obesity and money is a fad. Why not choose an issue like, say, divorce? Last week there was a study reported in the news that people who are divorced have twenty percent more medical problems. So when will we see some msm stories about "staying married and saving health care costs." Or pick any of several other circumstances and do the same.

"It's also worth mentioning that dieting is a major cause of health problems because keeping much more than 15 pounds off is virtually impossible "

Nonsense. If you exercise and watch what you eat it is easy to lose weight and keep it off. Weight loss is nothing more than creating a consistent caloric deficit. Creating a consistent caloric deficit forces your body to use your energy reserves, namely fat. Do this long enough, and you will lose weight.

So the short answer to losing weight and keeping it off is:

Eat less, Exercise more.

I've dropped 55 pounds since 2004 and kept it off. I've dropped my body fat percentage from 18% to roughly 7%.
Can't be done...give me a break.

Mike --

I like that incentive idea.

DB --

People who are divorced also take a big net worth hit too...

Brian, congrats your in the roughly 5% of people that successfully keep that kind of weight off (and dropping your body fat into the sub 10% range implies you are probably quite the athlete as well). I hope you are able to keep all 55 lbs off. Your experience is not normal though and eat less, exercise more is basically useless when the first part is essentially telling you to ignore evolution and everything your body tells you and the 2nd part is only discouraged because exercising isn't actually that useful for losing weight (exercise increases your appetite and actually increases the number of calories your body wants to intake). Maintaining the kind of caloric deficit the rest of your life is not quite as simple as the short phrase "eat less" implies.

You are correct though, I should have said "virtually impossible for the vast majority of the population, especially the portion of the population that would benefit most from the weight loss."

Unfortunately genetics play a significant role in matters such as longevity and obesity and our genetics are beyond our control.

It is a fact that 90% of a person's total healthcare expenses occur in the last year of their life. In our society, end of life choices are discussed between the physician and the patient's loved ones and the physician is morally bound to acquiesce with the family's wishes. This is where healthcare insurers, the current universal healthcare proposals, the cost of some treatments, and the wishes of a terminal patient and their family collide.

What happens then when a person has either very limited or no healthcare insurance and very limited financial resources. In most areas, in a capitalist society like the USA, wealthy people deservedly have a more pleasant experience than poor people - that's one of the rewards of wealth no matter how the wealth was obtained.

I am a healthy 74 year old, my wife is a not quite as healthy 75 year old, we are very secure financially, so what do we do to stay as healthy as possible?

1) We eat very healthy and nutritious home cooked (and often home grown, organic) food, except for two meals in nearby restaurants every week (no fast food or sodas ever).

2) We have regular checkups and tests and both take medications to control cholesterol and blood pressure as well as vitamins and several nutritional supplements. Our healthcare clinic is state of the art, our doctors are great, and our coverage is as good as it gets.

3) We keep our weight under control, we could both stand to lose a few pounds but our weight has been constant for many years.

4) We have successfully worked hard to eliminate all forms of STRESS from our lives. A happy 53 year marriage and financial security helps a lot.

5) I am a strong hiker, mountain climber and trekker in earlier years, and take regular very strenuous hikes, my wife can no longer accompany me because of two artificial hips and a diminished lung capacity, kept under very good control with inhalers.

And stop smoking.
And stop reckless risky behaviors.
And stop drinking excessively.
And stop stress inducing life styles.

The study in question is about "obese" people and not "overweight" people. Those two classes are distinctly different. Obesity is the more severe category. Example of obesity vs overweight, if you're 5'9" and between 169-202 pounds then you're in the "overweight" category but if you're over 202 pounds then you are technically "obese". This is a generalization, and the real measure is based on actual % of body fat.

Genetics are definitely a part of it. Its harder for some people to keep weight off and they have more propensity for gaining weight. But genetics did NOT account for the drastic increase in obesity in the past 20 years. The rate of obesity has about doubled din that time and that is not genetics.

"What about discouraging use of tobacco and alcohol, unhealthy foods, etc through taxes?"

We already have such taxes on tobacco and alcohol. Those should discourage their use by making them more expensive.

Its harder to regulate "unhealthy" food since food isn't really inherently unhealthy. I mean sugar is not unhealthy in itself but if you eat too much and aren't active enough then you'll probably get gain weight. So how do you decide what is healthy vs unhealthy?

Of course a single cigarette a week or a beer once in a while isn't going to pose a health risk either... yet those are taxed and regulated as 'sins'.

Tobacco reduces health costs in the long term because the patients die sooner, and cigarettes are an appetite suppressent, so smokers tend to weigh less as well.

A single cigarette a week does increase your risk of lung cancer though. There really isn't much advantage in moderation when it comes to cigarettes.


Re: tobacco and alcohol. Like you stated, we already tax those items yet people still choose them to consume them. I should have stated, "even higher taxes." What say you to that? I personally can't decide. For tobacco, it seems more clear that no good comes from it, but's tough to say. What about the French Paradox with wine?

You are correct that it would be near impossible to regulate things like sugar, but what about prepared foods or ready-to-eat foods? Ex: fast food, potato chips, candy, soda, etc. All of these items are required to have nutrition facts, so that might be an avenue.

The other direction would be to subsidize things like fresh produce....

I'm not advocating one way or the other; I'm just trying to create a dialogue about what options we have. To do nothing is always an option too--let Darwin take care of it.

We have taken at least two foreign vacations ever since our kids left home and that was quite a while ago as our youngest is now 46. You cannot avoid doing some people watching when you are on vacation in foreign countries.

Whether Americans like to hear it or not our observations have been that out-of-control obesity is a fast growing American idiosyncracy. Elsewhere you see an occasional obese person but here you can't go anywhere without seeing loads of them in restaurants, supermarkets, & shopping malls. It isn't confined to one race or one gender either. The only race that avoids it to a very large extent are the Asians, and particularly the recent arrivals.

I believe that diet is the #1 contributor, lack of exercise is #2, lack of willpower is #3, and genetics is #4, but I am not a physician.

Now that we have excellent food labelling it's easy to control the amount of sugar, fat, and carbohydrates that you consume. Even some restaurants are now making this information available. It is partcularly saddening to also see a large number of children that are either obese or very close to it.

I noticed how the soft drink industry let out a huge squawk recently when a proposal was recently made to put a large tax on sodas. Does anyone really think that the soft drink industry gives a damn about the health of their primary consumers.

There are enough serious diseases that we don't know how to prevent but smoking, excessive drinking, obesity, drug use, and reckless behavior all end up costing society a lot of money in more ways than we know.

"So you're saying what? That we sould all eat a ton, get fat, and that will actually save us money? Or you're advocating that people being overweight is actually a savings to the US healthcare system? Not sure of your main point."
Actually what Meoip is saying is based on a study done if I am not mistaken in Netherlands (or Denmark). It was a real study, published in major medical journals which evaluated life time health care costs. It concluded that healthy people indeed live longer and cost more over the life time.

Now, the study didn't take lost productivity into consideration, only total health care costs. But the question is how much of these extra years of life gained fall into productive period and how much is not. Is it a difference between living till 53 vs 70 or is this a difference between living till 65 vs 80?

This is talking about costs to insurer/government rather than person. Obviously, you me and most of us want to live long lives and die in our sleep at the age of 100. But this is individual choice. However when you are talking about controlling behavior and essentially telling others what they should do, then you need to need to have justification of benefit for others not just person involved. You and the politicians use cost savings as such justification. However, there is no evidence at all that what you are saying will save money, in fact there is evidence to the contrary. Like for example the studies that show that healthy people cost more.

"We have regular checkups and tests and both take medications to control cholesterol and blood pressure as well as vitamins and several nutritional supplements. Our healthcare clinic is state of the art, our doctors are great, and our coverage is as good as it gets."

These are good things, but these things aren't cost-saving. In fact statins for example are quite expensive and so is screening. Now, your main argument would probably be "it's cheaper to take statins than to treat a heart attack". Yes - for one person. What about treating 70 people for 5 years with statins to prevent one heart attack? Is it still cheaper? What about 250 people? This is called Number Needed to Treat, and this is what most people like you don't understand. The reason I mentioned 70 and 250 is that because 70-250 is the actual number of people who had not yet had heart attack but who have risk factors like high blood pressure that have to be treated for 5 years with statins to prevent 1 heart attack in 1 person. NNT of 70 is for people with more risk factors, NNT of 250 with less risk factors. Still sounds cheap?

Actuall, I don't have time now, but I can show to you real studies that show that this is not only not cost saving but actually expensive.

What about checkups. Now, there was a study published in JAMA that showed that over 50% of annual checkups include not recommended tests (i.e. tests that haven't been shown to save lives; even tests that carry "against" recommendation from USPSTF). Do you know what "against" recommendation from USPSTF means. It means that "harms are likely to outweight the risks". You may not think that tests can possibly be harmful, but tests aren't perfect. Tests have false positives, false positives lead to more invasive tests and these have real risks. In some cases there is "overdiagnosis" - an early diagnosis of a condition that may never cause problems if remains undected. But when it is detected, it is treated - as it should be because nobody can say which case will progress and which will not, and the treatment has risks. This is why it is important to distinguish tests that are recommended, that have been shown to actually save lives from tests that are not recommended.

But we are not talking about whether screening or checkup is good or not. We are talking about costs and tests which have actually been shown to save lives. In many cases, in order for someone's live to be saved or, since we are talking about money, to save money by treating something earlier, you need to screen hundreds even thousands of people for 10 years. During the same period of time a large percentage of these people will have false postiives leading to more expensive (and riskier) tests. Only a small percentage of these false positives will be a real positive.

No need to do math. There have been studies done that show that this is not only not cost saving, but actually quite expensive. Now, since you or me may be this 1/500 (for example) whose life is saved, it's obviously important for us to have access to these tests. But don't pretend or claim that you are saving money. Because you are not.

This is an example of why politician shouldn't be making decisions that is realm of epidemiology. It's because politicians don't understand what NNT or NNS means, they confuse cost-effectiveness (defined in epidemiology as cost of quality-adjusted life year be under 50K) with actual cost savings. It'll be nice if these decisions are left to people who can read and interpret the studies.

Oh and why some life choices will increase your chance of long and healthy live, it's no guarantee. Don't think that because of your life style bad things aren't going to happen to you. My never-smoking mother from never-smoking (even strongly anti-smoking) family has lung cancer.... Yes, the risk is lower, but it's never zero.

"It means that "harms are likely to outweight the risks".

This should read "harms are likely to outweight the benefits". This is what happens when one types after 11pm. Getting enough sleep is really important for health too. We should encourage that.

Kitty --

I understood the issue when I asked that question. What I'm getting at is "what are you recommending we do about the issue?"

I still haven't heard an answer to that one.

FMF - you should do what you think is right for yourself individually and not worry about society. It is obviously to your individual advantage to eat right, to exercise and not to smoke.

In terms of screening or preventive drugs -- you can either follow recommendations or if you have time or desire learn about the benefits and risks and make a decision that is right for you. This is a decision between you and your doctor, it's a decision who has impact on your life so it's not something that society should interfere in, IMHO, especially since there are no savings for society there. If you are really interested, for example, to learn about what tests can or cannot do, I'd recommend book by H. Gilbert Welch "Should I be tested for cancer". I might've mentioned it before - there is nothing controversial about this book: it is a book by someone who is a doctor, a professor of medicine at Dartmourth, a well-known researcher; this book received good reviews from medical community too. He doesn't tell you what to do, only explains basic concepts, limitations of tests, possible benefits and risks. The information is applicable to all tests (for healthy people) not just cancer screening; some of it is applicable to drugs too. Don't read it if you want certainty, though, if you want certainty just follow the recommendations. One thing the book will show you is how complex these issues really are and how something that seems obvious is not always true.

But in terms of society - I don't know. One thing though - neither you nor I nor politicians are qualified to make these decisions. There have to be real studies, and the people who interpret them should be those who are qualified.

Kitty --

Ok, I think we're on the same page. :-)

So Kitty,
Are you saying that you don't care how many people around you smoke and elevate their risk for cancer (and over a large population, cause cancer) even if it directly affects your quality of life through diminished take-home earnings as a result of higher insurance premiums?

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