Health and Economic Consequences of Obesity and Overweight in Pakistan

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1 Health and Economic Consequences of Obesity and Overweight in Pakistan Maryam Naeem Satti MS Health Economics Thesis Supervisors: Dr Durre Nayab Dr Mahmood Khalid 6 th March, 2015 PIDE

2 Introduction Overweight weight above than what is considered healthy Obesity condition of excessive fat accumulation in the body Global health problem affecting both developed and developing nations Poses serious health and financial burden Influenced by many factors - hereditary tendencies, environmental, behavioural factors, ageing, pregnancies

3 Global Situation of Excess weight Ng, M., et al. (2014)

4 Situation of Excess Weight in Pakistan Males Females 13 Afghanistan Bhutan Pakistan India Bangladesh Nepal Ng, M., et al. (2014)

5 Objectives The prevalence of overweight and obesity in Pakistan along with its major determinants The possible health consequences of overweight and obesity in adult population Relative Risks of selected obesity co-morbidities for overweight and obese individuals The cost of illness attributable to overweight and obesity in adults

6 Hypotheses Obesity and overweight is highly prevalent in Pakistani adults and differentials exist among different population groups Overweight and obesity have negative implication on the health of adult population The relative risks of selected chronic diseases are high for overweight and more precisely obese individuals A sizeable proportion of total illness cost is attributable to overweight and obesity

7 Rational of the Study Double burden of nutrition impose pressure on health care sector of the country Determinants identify groups most at risk Identifies burden of the risk factor on the individuals Priority setting in health sector given limited resources Base for future interventions, policy and research studies Cost of obesity has remained an unattended area regarding obesity research in Pakistan

8 Framework Proximate Determinants Socio-Economic & Cultural Background Immediate Factors Food Intake Physical Activity/ Life Style Determinants Overweight & Obesity Risk of Chronic Diseases Health Consequences Economic Cost Direct Cost Medical expenses Indirect Cost Productivity loss Economic Consequences

9 Data Pakistan Panel Household Survey, 2010 (Conducted by PIDE) Nutrition data available for all ages and gender Data available for Social and Economic aspects Detailed food consumption is available Detailed Health module is available Data requirement for costing is available

10 Methodology Measure of Prevalence of Obesity: Body Mass Index (BMI): Weight in kilograms divided by the square of the height in metres (kg/m 2 ). Unit of Analysis Adults (aged 18+) Classification BMI Range Underweight < 18.5 Healthy weight Overweight: >=25 Pre obese Obese >=30 Obesity Class I Obesity Class II Obesity Class III >=40 WHO

11 Differentials in Obesity and Overweight Dependent Variable: BMI Independent Variables: Age Gender Province Region Education Wealth status Marital Status Familial obesity Eating-out HH food consumption pattern Physical Activity & Lifestyle variable Working status Type of work Availability of Transport facility Availability of Entertainment Availability of Labour Saving Domestic Techniques

12 Health Consequences of Obesity and Overweight Dependent Variables: Prevalence of illness Type of disease Intensity of disease Episodes of illness Duration of illness Days of Hospitalization Independent Variable: BMI

13 Cost of Illness Attributable to Overweight and Obesity I Cost of illness methodology How much role a risk factor play in causing a particular disease and ultimately places an impact on society or a part of society Risk Factor Overweight and Obesity Illness (Obesity co-morbidities) Diabetes, Heart diseases Prevalence Vs. Incidence approach Measures the costs of an illness in one period, usually a year, regardless of the date of onset

14 Cost of Illness Attributable to Overweight and Obesity II Time Frame One year i.e Perspective Individual Patient Other perspectives include societal, Health care system, third party payers, businesses, government Cost Opportunity cost The value of the forgone opportunity to use in a different way those resources that are used or lost due to illness

15 Cost of Illness Attributable to Overweight and Obesity III Cost Components Direct cost Direct medical cost - Consultation fee, medicines, laboratory tests and hospitalization Indirect medical cost Transportation Indirect cost Productivity loss due to mortality Productivity loss due to morbidity Perceived impaired days due to illness self-reported

16 Cost of Illness Attributable to Overweight and Obesity IV Human Capital Approach (Copper & Rice, 1976; Hodgson & Meiners, 1982; Segel, 2006) To value Days lost due to illness Potential productivity loss not actual Measures lost production in terms of lost wages Individuals Employed Actual wages Unemployed If unemployed due to disease use opportunity cost and if unemployed due to other reason then zero wage Housewives Opportunity cost Vs. Replacement cost Students National mean wages Elderly/Not working neither willing to work Replacement cost for informal care

17 Steps Involved in Estimating Cost of Obesity I Estimating prevalence of overweight and obesity Estimating Relative risks for selected comorbidities Relative risk - prevalence of a particular illness in overweight and obese versus nonoverweight and non-obese 1 No difference < 1 less risk in the exposed group > 1 more risk in the exposed group

18 Steps Involved in Estimating Cost of Obesity II Calculating Population Attributable Fractions (PAFs) - How much the proportion of illness is attributable to overweight and obesity P(RR 1) [P RR 1 + 1] Calculate Direct and indirect cost Multiply PAFs with cost to yield the cost of illness attributable to overweight and obesity.

19 Sensitivity Analysis Deterministic sensitivity analysis How sensitive the outcome is to the different parameters used in the analysis One-way sensitivity analysis: Alter one parameter Relative risk is varied arbitrarily by ± 5, 10, 15 and 20 percent and change in cost is observed

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21 Prevalence of Overweight and Obesity In Adults Overweight 21% Obese 9% Underweight 13% Normal weight 57%

22 Excess Weight by Age Percentage of adults having excess weight by age

23 Overweight and Obesity by Gender Percentage of overweight and obese adults by gender Males Females Overweight Obese

24 Overweight and Obesity by Age and Gender Percentage of Overweight and Obese by Age and Gender Age Male Female Overweight Obese Overweight Obese

25 Overweight and Obesity by Province Prevalence (%) of overweight and obesity by province Punjab Sindh KPK Balochistan Overweight Obese

26 Overweight and Obesity by Region Prevalence (%) of overweight and obesity by region Urban Overweight Rural Obese

27 Overweight and Obesity by Poverty Percentage of overweight and obese adults by poverty status Non-poor Overweight Poor Obese

28 Overweight and Obesity by Education Percentage of overweight and obese adults by education No education Primary Secondary Higher Overweight Obese

29 Overweight and Obesity by Marital Status Percentage of overweight and obese adults by marital status Never married Currently married Sep/Widow/divorced Overweight Obese

30 Overweight and Obesity by Familial Obesity Percentage of Overweight and Obese Adults by Number of Overweight Persons in the Family other than the Respondent No Overweight One or Two Three or More Overweight Obese

31 Overweight and Obesity by Work Status Work Status Percentage of Overweight and Obese by Work Status BMI Underweight Normal weight Overweight Obese Total Housewives Students Others not in labour force Unemployed Non-manual workers Manual workers Total

32 Overweight and Obesity by Occupation Percentage of Overweight and Obese by Occupation BMI Occupation Under Normal Overweight Obese Total weight weight Legislators, senior officials & managers Professionals Technicians & associate professionals Clerks Service and sales workers Skilled agriculture & fishery workers 100 Crafts & related trades workers 100 Plant & machine operators Elementary occupations Armed forces

33 Overweight and Obesity by Transport Facility Prevalence (%) of overweight and obesity by availability of transport facility (car or motorcycle) Not Available Available Overweight Obese

34 Overweight and Obesity by Entertainment Facility Prevalence (%) of overweight and obesity by availability of entertainment facility (television, computer and internet) Not Available Available Overweight Obese

35 Overweight and Obesity by Labour Saving Domestic Techniques Prevalence (%) of overweight and obesity by availability of labour saving devices (refrigerator, microwave oven, cooking range or washing machine) Not Available Avaliable Overweight Obese

36 Overweight and Obesity by Eating-Out Meals Outside Percentage of Overweight and Obese by Eating out BMI Underweight Normal weight Overweight Obese Total Total No Yes Urban No Yes Rural No Yes

37 Overweight and Obesity by Food Consumption Food Items/ Consumption Percentage having Excess Weight by Food Consumption Below Median Consumption Above Median Consumption Grains Pulses Oil Sugar Dairy Products Eggs Meat Vegetables and Fruits Soft Drinks

38 Regression Results Result of Binary Logistic Regression Dependent Variable: Body Mass Index (0 = BMI<25, 1 = BMI=>25) Independent variables Coefficient (B) Significance Odd ratios Age * Gender Male (Ref) Female * Province Punjab (Ref) Sindh * KPK * Balochistan Region Urban (Ref) Rural * Poverty Non-poor (Ref) Poor

39 Marital Status Never married (Ref) Currently married * Formerly Married * Education * Work Status Housewives (Ref) Students * Other not in labour force * Unemployed Non-manual workers Manual workers Car Availability No (Ref) Yes * Motorcycle Availability No (Ref) Yes

40 Entertainment Availability No (Ref) Yes Labour Saving Techniques Availability No (Ref) Yes * Eating-Out Consumption of Grains Consumption of Pulses Consumption of Oil * Consumption of Dairy Products Consumption of Meat Consumption of Eggs * Consumption of Soft Drinks Consumption of Sugar Consumption of Vegetables and Fruits * Familial Obesity *

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42 Illness by Overweight and Obesity Percentage of adults suffered from a disease by nutritional status Underweight Normal weight Overweight Obese

43 Type of Disease by BMI Illness Type Percentage Having Specific Illnesses by BMI BMI Underweight Normal weight Overweight Obese Total Heart diseases Diabetes Reproductive problems Respiratory problems/tb Hepatitis/Jaundice Intestinal/Renal/Kidney problems Others Total

44 Disease Intensity by BMI I Mean Days Estimates of Disease Intensity by Nutritional Status BMI Episodes of illness Duration of illness Days hospitalized Underweight Normal weight Overweight Obese Total

45 Disease Intensity by BMI II Mean Days Estimates of Disease Intensity (Obesity Comorbidities only) by Nutritional Status BMI Episodes of illness Duration of illness Days hospitalized Underweight Normal weight Overweight Obese Total

46 Health Care Expenditure by BMI BMI Mean Health Care Expenditure on Illness by BMI Expenditure on Consultation Expenditure on Medicines Expenditure on hospitalization/lab tests Total expenditure underweight normal weight overweight obese Total

47 Regression Results Result of Binary Logistic Regression Dependent Variable: Obesity comorbidity (0 = No, 1 = Yes) Independent variables Coefficient (B) Significance Odd ratios Age * Gender Male (Ref) Female Province Punjab (Ref) Sindh * KPK * Balochistan * Region Urban (Ref) Rural * Poverty Non-poor (Ref) Poor * Marital Status Never married (Ref) Currently married * Formerly Married *

48 Education Work Status Housewives (Ref) Students Other not in labour force Unemployed Non-manual workers Manual workers Nutritional Status Normal/Low weight (Ref) Overweight * Obesity * Familial Chronic illness * Consumption of Grains Consumption of Pulses Consumption of Oil Consumption of Dairy Products Consumption of Meat Consumption of Eggs Consumption of Soft Drinks Consumption of Sugar Consumption of Vegetables and Fruits

49 Relative Risks Relative Risks of Selected Obesity Co-morbidities for Overweight and Obese Adults Diseases Overweight Obesity Heart Disease Diabetes Any of Two

50 Population Attributable Fractions 100% 100% 100% % 20% 12 22% Heart Disease Diabetes Any disease Overweight Obesity

51 Total Direct Cost of Overweight and Obesity 16,450,154 11,365,690 5,084,464 2,231, , ,355 1,269, ,903 1,460,258 1,584,893 2,106,450 3,691,343 Heart Disease Diabetes Any Disease Cost attributable to overweight Cost attributable to obesity Cost of illness

52 Average Direct Cost of Overweight and Obesity Heart Disease Diabetes Any Disease Cost attributable to overweight Cost attributable to obesity Cost of illness

53 Total Indirect Cost of Overweight and Obesity 77,292,220 44,726,048 32,566,172 8,779,723 3,783,824 3,992,613 4,995,900 5,360,392 9,353,005 7,776,436 10,356,291 18,132,728 Heart Disease Diabetes Any Disease Cost attributable to overweight Cost attributable to obesity Cost of illness

54 Average Indirect Cost of Overweight and Obesity Heart Disease Diabetes Any Disease Cost attributable to overweight Cost attributable to obesity Cost of Illness

55 Scaled-up Cost I Scaling-up of Annual Cost Attributable to Overweight and Obesity to the Whole Population (in Rupees) Direct cost of heart disease due to excess weight 44,545,438,925 Indirect cost of heart disease due to excess weight 175,294,366,558 Direct cost of diabetes due to excess weight 28,335,813,985 Indirect cost of diabetes due to excess weight 181,491,911,049 Direct cost for both diseases due to excess weight 72,881,252,911 Indirect cost for both diseases due to excess weight 356,786,277,607 Total cost for both diseases due to excess weight 429,667,530,518

56 Share of Scaled-up Cost in National Figures Share of Scaled-up Cost Attributable to Overweight and Obesity in National Expenditures (in Percentages) Share of direct cost of both diseases due to excess weight in national health expenditure Share of direct cost of both diseases due to excess weight in private out of pocket expenditure 16.20% 26.80% Share of direct cost of both diseases due to excess weight in GDP 0.40% Share of indirect cost of both diseases due to excess weight in GDP 1.95% Share of total cost of both diseases due to excess weight in GDP 2.35%

57 Sensitivity Analysis Results Result of Sensitivity Analysis Parameter and Cost - 20 percent Original + 20 percent RR overweight RR obesity Average direct cost overweight Average indirect cost overweight Average direct cost obesity Average indirect cost obesity Direct scaled-up cost 43,393,456,829 72,881,252,911 99,454,043,487 Indirect scaled-up cost Share of direct cost in Health Expenditure 217,007,452, ,786,277, ,544,892, % 16.30% 22.20%

58 Conclusions Prevalence of excess weight is highly prevalent among the adults of Pakistan Physical activity came out to be the significant determinant of excess weight Along with certain social factors, familial obesity is also a significant factor draws attention to the family Excess weight came out to be a major risk factor for heart disease and diabetes A sizeable proportion of illness and its cost incurred by the individuals is attributed to overweight and obesity

59 Policy Recommendations Determinants most vulnerable group should be targeted for interventions Target families instead of individuals Advocacy about adoption of active lifestyle Health professionals should advocate their patients To lower the burden of obesity from individuals: Control and Prevention Cost sharing schemes

60 References Musaiger, A.O. (2004). Overweight and obesity in the Eastern Mediterranean Region: can we control it? Eastern Mediterranean Health Journal, 10(6), Himes, C.L. (2000). Obesity, Disease, and Functional Limitation in Later Life. Demography, 37(1), Sander, B., & Bergemann, R. (2003). Economic Burden of Obesity and Its Complications in Germany. The European Journal of Health Economics, 4(4), Bhattacharya, J., & Sood, N. (2011). Who Pays for Obesity? The Journal of Economic Perspectives, 25(1), Hakeem, R., Thomas, J., & Badruddin, S.H. (2002). Food Habits and Nutrient Density of Diets of Pakistani Children Living in Different Urban and Rural Settings. Journal of Health, Population and Nutrition, 20(3), Lean, M.E.J. (2005), Prognosis In Obesity: We All Need To Move A Little More, Eat A Little Less. British Medical Journal, 330(7504), Lorant, V., & Tonglet, R. (2000). Obesity: Trend in Inequality. Journal of Epidemiology and Community Health, 54(8), Logue, J., Thompson, L., Romanes, F., Wilson, D.C., Thompson, J., & Sattar, N. (2010). GUIDELINES: Management of obesity: summary of SIGN guideline. British Medical Journal, 340(7744), Müller-Riemenschneider, F., Reinhold, T., Berghöfer, A., & Willich, S.N. (2008). Health-Economic Burden of Obesity in Europe. European Journal of Epidemiology, 23(8),

61 Questions? Comments?