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Three Parts

Genuine Progress Index for Atlantic Canada Indice de progrès véritable - Atlantique T he Cost of Obesit y and what Dieticians Can Do About It Ronald Colman Ph.D Dieticians of Canada National Conference Halifax, 9 June, 2006. Three Parts.

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Three Parts

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  1. Genuine Progress Index for Atlantic CanadaIndice de progrès véritable - AtlantiqueThe Cost of Obesity and what Dieticians Can Do About ItRonald Colman Ph.D Dieticians of Canada National ConferenceHalifax, 9 June, 2006

  2. Three Parts 1) The larger context - measuring progress more accurately 2) Estimating the cost of chronic disease and its preventable portion (=purpose) 3) Estimating the cost of specific risk factors (in this case obesity) & cost-effectiveness of preventive interventions including those of nutritionists

  3. 1) The larger context 1) Measuring progress - what’s wrong with the way we do it now, and why doesn’t obesity get the attention it deserves 2) Doing it better - Population health as a key indicator of progress 3) Why economic valuation? (eg NS – DHP)

  4. What kind of world are we leaving our children?

  5. More possessions, longer lives, but disturbing signs: Higher stress rates, obesity, childhood asthma Insecurity - safety, livelihood Greater inequality Decline of volunteerism Natural resource depletion, species loss Global warming

  6. A key reason for confusion: • Our core measures of progress send misleading signals to policy makers and public: • ‘More’ equals ‘better’ (vs. health as balance – e.g. nutrition) • But does ‘healthy’ economy = healthy society? What might grow economy and signal decline in wellbeing?

  7. Sending wrong messages • Resource depletion as economic gain • Crime, sickness, pollution, war, natural disasters, car accidents, make economy grow — because money is being spent • GDP can grow as poverty, inequality increase • And if questionable activities are counted as contributions to wellbeing, what genuine contributions are ignored in GDP statistics?

  8. RFK (1968): GDP “counts everything except that which makes life worthwhile” • E.g. We count lawyers, advertising executives, brokers, but ignore unpaid work that contributes directly to community health (volunteers, work in home) • Free time has no value. More work hours, stress make economy grow (e.g. Statcan. study on work hours, health, weight gain)

  9. Why We Need New Indicators - Policy reasons: • Vital social, environmental assets ignored. • Preventive initiatives to conserve and use resources sustainably, to reduce poverty, sickness, obesity, and greenhouse gas emissions, are blunted and inadequately funded • E.g. Good nutrition not urgent policy or election issue though obesity kills far more than terrorism

  10. Indicators are Powerful What we measure: • reflects what we value as a society (e.g. “shopping is patriotic”) ; • determines what makes it onto the policy agenda (e.g. volunteerism); • influences behaviour (e.g. students)

  11. Good indicators can: • foster common vision and purpose; • identify strengths and weaknesses; • change public behaviour; • hold leaders accountable at election time (e.g. teen smoking, obesity) • initiate actions to promote wellbeing

  12. GPI Atlantic founded to address need for better indicators • Non-profit, fully independent research group founded April, 1997 • Located Halifax. www.gpiatlantic.org • Sole mandate is to create good, usable index of wellbeing and progress • Provincial/state + community pilots

  13. Measuring WellbeingIn the GPI: • Health, free time, unpaid work (voluntary and household), and education have value • Sickness, crime, disasters, pollution = costs • Natural resources = capital assets • Reductions in sickness, GHGs, crime, poverty, ecological footprint are progress • Growing equity signals progress

  14. Therefore, context for obesity cost estimates: 1) Need for better indicators, which include value of natural, social, human capital - Population health as core indicator of national, social progress 2) Economic valuation as strategy, language, based on physical indicators (e.g. voluntary work, crime, obesity). In an ideal world, economic valuation unnecessary - all policy decisions include health, social, envt. impacts

  15. Counting costs as costs, not gains to the economy. Eg: • The less people trust the water coming from their taps and the more they buy bottled water, the more the economy will grow • Free, clean tap water has no value in our conventional measures of progress based on GDP and related economic growth statistics • GPI: $33 million spent by households on filters, bottled water = cost (“defensive expenditure”), while water sources - rivers, lakes, wetlands valued

  16. 2) Chronic disease as cost;Prevention as investment • Medical expenditures conventionally counted as economic gain; here = cost • Indirect costs, particularly, are huge • What proportion of costs preventable? (= purpose of costing exercise) • Disease prevention (esp. dealing with root causes) is cost-effective

  17. Costs of chronic disease: • Four types of chronic disease account for about 3/4 of all deaths (cf 1900) Cardiovascular - 36%; Cancer - 30% COPD - 5%; Diabetes - 3%+ • Chronic diseases account for 60% medical costs; 3/4 of productivity losses due to disability and premature death; 70% total burden of illness = 13% GDP

  18. E.g.: Cost of Chronic Illness in Nova Scotia 1998 (2001$ million)

  19. These are under-estimates • Exclude diseases: Digestive, cirrhosis of liver, congenital, perinatal/LBW, blood, skin, genitourinary (chronic renal failure), etc. • “Principal diagnosis”: e.g. injury/fall vs osteoporosis; diabetes under-reported (complications: blindness, kidney failure, amputations, cardiovascular disease, infections)

  20. What portion is preventable? Excess risk factors account for: • 40% chronic disease incidence • 50% chronic disease premature mortality • Small number of risk factors account for 25% medical care costs • 38% total burden of disease (includes direct and indirect costs)

  21. A few risk factors cause many types of chronic disease • Tobacco - heart disease, cancers, respiratory disease • Obesity - hypertension, diabetes 2, heart disease, stroke, some cancers • Physical inactivity - heart disease, stroke, hypertension, colon and breast cancer, diabetes 2, osteoporosis • Diet/fat - heart disease, cancer, stroke, diabetes

  22. Design cost-effective prevention strategyknowing costs of key risk factors (e.g. Nova Scotia(2001 $ millions)

  23. Socio-economic Determinants of Health • Education, income, employment, stress, social networks are key health determinants. These too are modifiable • Lifestyle interventions effective for higher income/education groups, not lower - can widen inequity, health gap =The need for nutritionists, health care practitioners to be political……

  24. Health Costs of Poverty • Most reliable predictor of poor health, premature death, disability: 4x more likely report fair or poor health = costly • e.g. Increased hospitalization (Canada): Men 15-39 = +46%; 40-64 = +57% Women 15-39 = +62%; 40-64 = +92%

  25. Health Cost of Inequality • British Medical Journal: “What matters in determining mortality and health is less the overall wealth of the society and more how evenly wealth is distributed. The more equally wealth is distributed, the better the health of that society.” • e.g. Sweden, Japan vs USA; Gap widened

  26. E.g. Excess use of physicians • No high school diploma use 49% more physician services than those with BA • Lower income groups use 43% more than higher income; lower middle = 33% more • In NS: excess physician use due to educational inequality = $42.2 M./yr; excess use due to income inequality = $27.5 M./yr = small % total health costs

  27. Heart Health Costs of Poverty • Low income groups have higher risk of smoking, obesity, physical inactivity, cardiovascular risk = costly • Canada could avoid 6,400 deaths, $4 billion/year if all Canadians were as heart healthy as higher income groups

  28. Health costs of child poverty • 31 indicators - as family income falls, children have more health problems, (NLSCY, NPHS, Statistics Canada) • Child poverty -> higher rates of respiratory illness, obesity, high blood lead, iron deficiency, FAS, LBW, SIDS, delayed vocabulary development, injury+….

  29. Therefore, identify and target highest risk groups • Single mothers & their children • Homeless: longer hospital stay cf low income • Unemployed, Blacks and other minorities, native Americans, migrants, disabled.... = Clustered disadvantages (poverty, illiteracy, unemployment, ill-health): “Social exclusion”

  30. E.g. Health of single mothers • Worse health status than married (NPHS); higher rates chronic illness, disability days, activity restrictions • 3x health care practitioner use for mental, emotional reasons = costly • Longer-term single mothers have particularly bad health (Statcan)

  31. BUT... Doesn’t a successful preventive strategy just defer costs to older ages? • NS 65+: 2001 = 14%; 2036 = 28% • e.g. Philip Morris’ Czech Republic study • + Prevention hard to sell: 1) Successful prevention = nothing happens; 2) Costs won’t be diverted from health care Answer these objections

  32. Aging - Delay vs Cure Saves $ • US: 5-year delay in onset cardiovascular disease could save US $100 billion / yr; hip fracture 5-yr delay save $7.3 billion • Physically active - lower lifetime illness • Nutritional intervention - reduce hospital use 25%-45% among elderly • Ethics, methods of PM study • Accepting death

  33. Prevention saves: “... A strategic aging research effort would benefit the nation’s economy and boost productivity.... The United States will save billions of dollars by keeping older people out of hospitals, out of operating rooms and out of nursing homes.... Long life can be healthy and productive to the end.” American Federations for Aging Research

  34. “Compression of Morbidity” • Fries: “The amount of disability can decrease as morbidity is compressed into the shorter span between the increasing age at onset of disability and the fixed occurrence of death.” (= about 85: analysis of 1900s data) • “Successful aging” can preserve independence into old age

  35. Disease Prevention is Cost-Effective Investment • E.g. Workplace = 2:1 • WIC = 3:1 (mostly avoided LBW) • “Smoke-Free for Life” = 15:1 • Pre-natal counselling = 10:1

  36. Cost-effectiveness of nutritional counselling • Brief physician, nutrition, diet counselling – highly effective and cost-effective • See Cost of Chronic Disease for cost-effectiveness of nutrition interventions A chronic disease prevention strategy is responsibility of all sectors

  37. 3) Cost of Obesity 1) How we currently count obesity costs 2) Costs of obesity - health impacts 3) Global epidemic; U.S. trends 4) Economic costs: Methodology and cost estimates (direct and indirect) 5) Causes and solutions: cost-effective interventions

  38. Is obesity a “cost”, or is it good for the economy? • Americans spend more than $100 billion a year on fast food = 44% of all food service sales • Fast food, candy, sugared cereals = 1/2 of $30 billion annual food industry advertising in U.S. (Kelloggs spends $40 million /year to promote Frosted Flakes alone)

  39. Overeating contributes to economy many times over • Excess foods grown, processed, advertised, transported, warehoused, sold • Diet drug and weight loss industries then add $35 billion to US economy • Liposuction = leading form of cosmetic surgery in US = 400,000 operations / year = up 62% in 2 years = a growth industry

  40. Obesity-related illness • Costs U.S. $118 billion / year (Colditz) - now exceeds smoking; but doctor, drug, hospital costs make economy grow • More than 50% diabetes 2 due to obesity • Type 2 diabetes grown 5-fold globally since 1985 from 30 to 150 million (17 million in US). WHO predicts 300 million by 2025

  41. In the words of the pharmaceutical industry: “The type 2 diabetes market will double to $17.2 billion in 2011, reflecting sustained, robust annual growth of 7% from 2001 through 2011” • Consumption of oral diabetic drugs will grow five-fold from 2001 to 2011

  42. Eli Lilly - $119 bill. firm • Announced construction of world’s largest factories devoted to single drug (insulin) = $1/2 bill. plants in Virg. and PR (11% of PR population has diabetes) • Lilly global insulin sales up 16% in 2001 Humalog (Virg, PR) up 79%; Actos up 61% from 2000 (2001 sales = $901 mill) • James Kappel (Lilly): “You’ve got to be in diabetes.”

  43. Counting it wrong – why the context matters • So long as we count growth in fast food and diabetes industries as good news for the economy, the health policy agenda is unlikely to shift • So long as we use economic growth statistics as the primary measure of social wellbeing, we won’t give population health and prevention (including good nutrition) the attention they deserve

  44. Counting it right: Obesity as serious cost • Obese (BMI >30) = 50-100% increased risk of death (all causes) cf healthy weight • Overweight = higher premature death rate even if no smoking, otherwise healthy (American Cancer Society - 1 million subjects) • Second-leading preventable cause of death in US (Joann Manson - Harvard)

  45. Health Impacts • BMI >30 = 4x diabetes; 3.3x high blood pressure; 56% more likely have heart disease; 2.6 times urinary incontinence; 50% less likely rate health positively (Statcan) • Association with some cancers, gallbladder disease, stroke, asthma, arthritis, thyroid problems, back problems, sleep disorders, impaired immunity, depression, etc.

  46. A “Global Epidemic” (WHO) • Obesity increased 400% in the western world in the last 50 years. • Underfed and Overfed: The Global Epidemic of Malnutrition: “ for the first time in human history the number of overweight people in the world now equals the number of underfed people, with 1.1 billion each.” March, 2000, Worldwatch Institute, Washington D.C.

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