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
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
Global Situation of Excess weight Ng, M., et al. (2014)
Situation of Excess Weight in Pakistan 49 43 38 38 33 28 Males 20 21 15 19 13 Females 13 Afghanistan Bhutan Pakistan India Bangladesh Nepal Ng, M., et al. (2014)
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
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
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
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
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
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 18.5-24.9 Overweight: >=25 Pre obese 25-29.9 Obese >=30 Obesity Class I 30-34.9 Obesity Class II 35-39.9 Obesity Class III >=40 WHO
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
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
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
Cost of Illness Attributable to Overweight and Obesity II Time Frame One year i.e. 2010 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
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
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
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
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.
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
Prevalence of Overweight and Obesity In Adults Overweight 21% Obese 9% Underweight 13% Normal weight 57%
Excess Weight by Age Percentage of adults having excess weight by age 40 40 37 28 28 17 18-24 25-34 35-44 45-54 55-64 65+
Overweight and Obesity by Gender Percentage of overweight and obese adults by gender 20 22 6 11 Males Females Overweight Obese
Overweight and Obesity by Age and Gender Percentage of Overweight and Obese by Age and Gender Age Male Female Overweight Obese Overweight Obese 18-24 13.5 3.3 22.5 3.8 25-34 16.6 5.2 27.2 8.6 35-44 25.8 7.5 26.5 16.6 45-54 27.0 7.2 26.0 17.5 55-64 23.7 8.2 21.3 14.4 65+ 18.3 7.2 13.7 9.0
Overweight and Obesity by Province Prevalence (%) of overweight and obesity by province 45 40 35 30 25 20 15 10 5 0 Punjab Sindh KPK Balochistan Overweight Obese
Overweight and Obesity by Region Prevalence (%) of overweight and obesity by region 22 21 12 8 Urban Overweight Rural Obese
Overweight and Obesity by Poverty Percentage of overweight and obese adults by poverty status 22 17 10 5 Non-poor Overweight Poor Obese
Overweight and Obesity by Education Percentage of overweight and obese adults by education 21 19 23 25 9 8 10 9 No education Primary Secondary Higher Overweight Obese
Overweight and Obesity by Marital Status Percentage of overweight and obese adults by marital status 15 23 19 10 11 4 Never married Currently married Sep/Widow/divorced Overweight Obese
Overweight and Obesity by Familial Obesity Percentage of Overweight and Obese Adults by Number of Overweight Persons in the Family other than the Respondent 37 26 15 11 18 5 No Overweight One or Two Three or More Overweight Obese
Overweight and Obesity by Work Status Work Status Percentage of Overweight and Obese by Work Status BMI Underweight Normal weight Overweight Obese Total Housewives 12.0 50.4 24.8 12.8 100 Students 21.5 60.2 12.8 5.5 100 Others not in labour force 15.2 62.0 17.5 5.2 Unemployed 17.4 58.9 15.8 7.9 100 Non-manual workers 4.5 50.4 32.2 12.9 Manual workers 13.8 61.6 18.6 5.9 100 Total 13.3 56.9 21.1 8.7 100 100 100
Overweight and Obesity by Occupation Percentage of Overweight and Obese by Occupation BMI Occupation Under Normal Overweight Obese Total weight weight Legislators, senior officials & 11.1 55.6 22.2 11.1 100 managers Professionals 7.1 50.3 29.0 13.5 100 Technicians & associate professionals 0.7 55.3 32.6 11.3 Clerks 6.1 41.5 39.0 13.4 100 Service and sales workers 12.5 63.9 17.2 6.4 100 Skilled agriculture & fishery 11.7 64.7 18.0 5.6 workers 100 Crafts & related trades 23.3 52.9 15.4 8.3 workers 100 Plant & machine operators 6.0 57.8 28.9 7.3 100 Elementary occupations 14.9 60.8 19.0 5.2 100 Armed forces 3.0 51.5 30.3 15.2 100 100
Overweight and Obesity by Transport Facility Prevalence (%) of overweight and obesity by availability of transport facility (car or motorcycle) 20 24 8 11 Not Available Available Overweight Obese
Overweight and Obesity by Entertainment Facility Prevalence (%) of overweight and obesity by availability of entertainment facility (television, computer and internet) 25 17 6 11 Not Available Available Overweight Obese
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) 27 15 14 6 Not Available Avaliable Overweight Obese
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 13.5 56.5 21.3 8.6 100 Yes 13.8 54.6 21.1 10.4 100 Urban No 12.1 54.2 22.1 11.6 100 Yes 6.3 49.8 23.7 20.3 100 Rural No 14.1 57.4 21.1 7.4 100 Yes 15.1 55.5 20.7 8.7 100
Overweight and Obesity by Food Consumption Food Items/ Consumption Percentage having Excess Weight by Food Consumption Below Median Consumption Above Median Consumption Grains 29.8 29.9 Pulses 30.0 29.7 Oil 26.3 33.5 Sugar 31.4 28.4 Dairy Products 25.0 34.7 Eggs 25.8 34.6 Meat 26.6 33.1 Vegetables and Fruits 24.7 35.2 Soft Drinks 27.9 33.5
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 0.015 0.00 1.015* Gender Male (Ref) Female 0.264 0.00 1.302* Province Punjab (Ref) Sindh -0.464 0.00 0.629* KPK 0.774 0.00 2.169* Balochistan -0.042 0.65 0.959 Region Urban (Ref) Rural -0.246 0.00 0.782* Poverty Non-poor (Ref) Poor -0.023 0.76 0.977
Marital Status Never married (Ref) Currently married 0.75 0.00 2.117* Formerly Married 0.33 0.02 1.391* Education 0.037 0.00 1.037* Work Status Housewives (Ref) Students -1.056 0.00 0.348* Other not in labour force -0.401 0.00 0.67* Unemployed -0.272 0.11 0.762 Non-manual workers -0.041 0.77 0.96 Manual workers -0.125 0.11 0.882 Car Availability No (Ref) Yes -0.232 0.02 0.793* Motorcycle Availability No (Ref) Yes 0.037 0.52 1.038
Entertainment Availability No (Ref) Yes 0.000 1.00 1.000 Labour Saving Techniques Availability No (Ref) Yes 0.264 0.00 1.302* Eating-Out -0.002 0.77 0.998 Consumption of Grains -0.008 0.36 0.992 Consumption of Pulses -0.014 0.94 0.987 Consumption of Oil 0.482 0.00 1.619* Consumption of Dairy Products 0.007 0.51 1.007 Consumption of Meat -0.115 0.23 0.891 Consumption of Eggs 0.065 0.01 1.067* Consumption of Soft Drinks 0.092 0.11 1.096 Consumption of Sugar -0.025 0.73 0.975 Consumption of Vegetables and Fruits 0.093 0.01 1.097* Familial Obesity 0.381 0.00 1.463*
Illness by Overweight and Obesity Percentage of adults suffered from a disease by nutritional status 47 39 34 37 Underweight Normal weight Overweight Obese
Type of Disease by BMI Illness Type Percentage Having Specific Illnesses by BMI BMI Underweight Normal weight Overweight Obese Total Heart diseases 10.4 12.0 18.7 24.2 14.6 Diabetes 2.1 3.6 6.3 8.5 4.5 Reproductive problems 6.4 6.0 8.5 6.3 6.6 Respiratory problems/tb 12.0 5.4 3.6 4.9 5.9 Hepatitis/Jaundice 6.2 4.9 6.2 4.7 5.3 Intestinal/Renal/Kidney problems 8.1 6.8 6.4 6.5 6.8 Others 54.7 61.4 50.2 45.0 56.2 Total 100 100 100 100 100
Disease Intensity by BMI I Mean Days Estimates of Disease Intensity by Nutritional Status BMI Episodes of illness Duration of illness Days hospitalized Underweight 1.8 374 8 Normal weight 1.8 346 12 Overweight 1.8 414 10 Obese 1.6 527 11 Total 1.8 385 11
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 2.0 646 5 Normal weight 1.8 645 8 Overweight 1.7 697 7 Obese 1.4 743 18 Total 1.7 678 8
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 1133 6547 1125 8804 normal weight 1186 6702 967 8854 overweight 1438 8780 1392 11610 obese 2189 8226 1655 12069 Total 1345 7298 1157 9800
Regression Results Result of Binary Logistic Regression Dependent Variable: Obesity comorbidity (0 = No, 1 = Yes) Independent variables Coefficient (B) Significance Odd ratios Age 0.036 0.00 1.036* Gender Male (Ref) Female 0.154 0.33 1.167 Province Punjab (Ref) Sindh 0.222 0.05 1.249* KPK 0.761 0.00 2.141* Balochistan -0.590 0.00 0.554* Region Urban (Ref) Rural -0.539 0.00 0.583* Poverty Non-poor (Ref) Poor -0.337 0.02 0.714* Marital Status Never married (Ref) Currently married 0.530 0.03 1.699* Formerly Married 0.527 0.06 1.694*
Education 0.024 0.12 1.024 Work Status Housewives (Ref) Students -0.508 0.38 0.601 Other not in labour force -0.380 0.08 0.684 Unemployed -0.351 0.33 0.704 Non-manual workers -0.030 0.92 0.970 Manual workers -0.263 0.08 0.769 Nutritional Status Normal/Low weight (Ref) Overweight 0.381 0.00 1.464* Obesity 0.593 0.00 1.810* Familial Chronic illness 0.475 0.00 1.607* Consumption of Grains -0.007 0.39 0.993 Consumption of Pulses -0.534 0.07 0.586 Consumption of Oil 0.061 0.80 1.063 Consumption of Dairy Products -0.007 0.70 0.993 Consumption of Meat 0.208 0.20 1.231 Consumption of Eggs 0.023 0.58 1.023 Consumption of Soft Drinks 0.099 0.25 1.104 Consumption of Sugar -0.047 0.72 0.954 Consumption of Vegetables and Fruits -0.047 0.47 0.954
Relative Risks Relative Risks of Selected Obesity Co-morbidities for Overweight and Obese Adults Diseases Overweight Obesity Heart Disease 1.60 2.06 Diabetes 1.93 2.61 Any of Two 1.67 2.18
Population Attributable Fractions 100% 100% 100% 9 11 29% 20% 12 22% 9 17 12 Heart Disease Diabetes Any disease Overweight Obesity
Total Direct Cost of Overweight and Obesity 16,450,154 11,365,690 5,084,464 2,231,085 961,537 623,355 1,269,548 836,903 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
Average Direct Cost of Overweight and Obesity 19481 13810 15175 8306 1168 1543 2711 2388 3207 5595 3557 4749 Heart Disease Diabetes Any Disease Cost attributable to overweight Cost attributable to obesity Cost of illness
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
Average Indirect Cost of Overweight and Obesity 124775 71303 54345 15297 35835 19895 46503 4598 6070 10668 26608 20538 Heart Disease Diabetes Any Disease Cost attributable to overweight Cost attributable to obesity Cost of Illness
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
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%
Sensitivity Analysis Results Result of Sensitivity Analysis Parameter and Cost - 20 percent Original + 20 percent RR overweight 1.34 1.67 2 RR obesity 1.75 2.18 2.62 Average direct cost overweight Average indirect cost overweight Average direct cost obesity Average indirect cost obesity 2779 4749 6481 15915 26608 35991 2420 3557 4614 13673 19895 25671 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 217,007,452,743 356,786,277,607 482,544,892,490 9.70% 16.30% 22.20%
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
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
References Musaiger, A.O. (2004). Overweight and obesity in the Eastern Mediterranean Region: can we control it? Eastern Mediterranean Health Journal, 10(6), 789-793. Himes, C.L. (2000). Obesity, Disease, and Functional Limitation in Later Life. Demography, 37(1), 73-82. Sander, B., & Bergemann, R. (2003). Economic Burden of Obesity and Its Complications in Germany. The European Journal of Health Economics, 4(4), 248-253. Bhattacharya, J., & Sood, N. (2011). Who Pays for Obesity? The Journal of Economic Perspectives, 25(1), 139-157. 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), 255-263. 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), 1339-1340. Lorant, V., & Tonglet, R. (2000). Obesity: Trend in Inequality. Journal of Epidemiology and Community Health, 54(8), 637-638. 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), 474-477. Müller-Riemenschneider, F., Reinhold, T., Berghöfer, A., & Willich, S.N. (2008). Health-Economic Burden of Obesity in Europe. European Journal of Epidemiology, 23(8), 499-509.
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