Contributing Factors

Overweight and Obesity: An Overview

Is there a quick answer to the question, "what contributes to overweight and obesity?" Overall there are a variety of factors that play a role in obesity. This makes it a complex health issue to address. This section will address how behavior, environment, and genetic factors may have an effect in causing people to be overweight and obese.

Overweight and obesity result from an energy imbalance. This involves eating too many calories and not getting enough physical activity. Body weight is the result of genes, metabolism, behavior, environment, culture, and socioeconomic status. Behavior and environment play a large role causing people to be overweight and obese. These are the greatest areas for prevention and treatment actions.

Adapted from U.S. Surgeon Generals Call to Action to Prevent and Decrease Overweight and Obesity, 2001

The Caloric Balance Equation

When it comes to maintaining a healthy weight for a lifetime, the bottom line is calories count! Weight management is all about balancebalancing the number of calories you consume with the number of calories your body uses or "burns off."

A calorie is defined as a unit of energy supplied by food. A calorie is a calorie regardless of its source. Whether youre eating carbohydrates, fats, sugars, or proteins, all of them contain calories. Caloric balance is like a scale. To remain in balance and maintain your body weight, the calories consumed (from foods) must be balanced by the calories used (in normal body functions, daily activities, and exercise).

If you are Maintaining your weight Gaining weight

Your caloric balance status is . "in balance." You are eating roughly the same number of calories that your body is using. Your weight will remain stable. "in caloric excess." You are eating more calories than your body is using. You will store these extra calories as fat and youll gain weight. "in caloric deficit." You are eating fewer calories than you are using. Your body is pulling from its fat storage cells for energy, so your weight is decreasing.

Losing weight

Genetics and the environment may increase the risk of personal weight gain. However, the choices a person makes in eating and physical activity also contributes to overweight and obesity. For more, see Healthy Weight Balancing Calories.

Environment
People may make decisions based on their environment or community. For example, a person may choose not to walk to the store or to work because of a lack of sidewalks. Communities, homes, and workplaces can all influence people's health decisions. Because of this influence, it is important to create environments in these locations that make it easier to engage in physical activity and to eat a healthy diet. The Surgeon Generals Call to Action to Prevent and Decrease Overweight and Obesity 2001 identified action steps for several locations that may help prevent and decrease obesity and overweight. The following table provides some examples of these steps. Location Steps to Help Prevent and Decrease Overweight and Obesity

Home

Reduce time spent watching television and in other sedentary behaviors Build physical activity into regular routines Ensure that the school breakfast and lunch programs meet nutrition standards Provide food options that are low in fat, calories, and added sugars Provide all children, from prekindergarten through grade 12, with quality daily physical education Create more opportunities for physical activity at work sites Promote healthier choices including at least 5 servings of fruits and vegetables a day, and reasonable portion sizes Encourage the food industry to provide reasonable food and beverage portion sizes Encourage food outlets to increase the availability of lowcalorie, nutritious food items Create opportunities for physical activity in communities

Schools

Work Communit y

Genetics

"Despite obesity having strong genetic determinants, the genetic composition of the population does not change rapidly. Therefore, the large increase in . . . [obesity] must reflect major changes in non-genetic factors." Hill, James O., and Trowbridge, Frederick L. Childhood obesity: future directions and research priorities. Pediatrics. 1998; Supplement: 571. How do genes affect obesity? Science shows that genetics plays a role in obesity. Genes can directly cause obesity in disorders such as Bardet-Biedl syndrome and Prader-Willi syndrome.

However genes do not always predict future health. Genes and behavior may both be needed for a person to be overweight. In some cases multiple genes may increase ones susceptibility for obesity and require outside factors; such as abundant food supply or little physical activity. For more information on the genetics and obesity visit Obesity and Genetics: A Public Health Perspective.

Other Factors
Diseases and Drugs Some illnesses may lead to obesity or weight gain. These may include Cushing's disease, and polycystic ovary syndrome. Drugs such as steroids and some antidepressants may also cause weight gain. A doctor is the best source to tell you whether illnesses, medications, or psychological factors are contributing to weight gain or making weight loss hard. Centre for disease control and prevention CDC

Health Consequences
Overweight and obese individuals are at increased risk for many diseases and health conditions, including the following:

Hypertension (high blood pressure) Osteoarthritis (a degeneration of cartilage and its underlying bone within a joint) Dyslipidemia (for example, high total cholesterol or high levels of triglycerides) Type 2 diabetes Coronary heart disease Stroke Gallbladder disease Sleep apnea and respiratory problems Some cancers (endometrial, breast, and colon)

Economic Consequences
Overweight and obesity and their associated health problems have a significant economic impact on the U.S. health care system (USDHHS, 2001). Medical costs associated with overweight and obesity may involve direct and indirect costs (Wolf and Colditz, 1998; Wolf, 1998). Direct medical costs may include preventive, diagnostic, and treatment services related to obesity. Indirect costs relate to morbidity and mortality costs. Morbidity costs are defined as the value of income lost from decreased productivity,

restricted activity, absenteeism, and bed days. Mortality costs are the value of future income lost by premature death.

National Estimated Cost of Obesity

According to a study of national costs attributed to both overweight (BMI 2529.9) and obesity (BMI greater than 30), medical expenses accounted for 9.1 percent of total U.S. medical expenditures in 1998 and may have reached as high as $78.5 billion ($92.6 billion in 2002 dollars) (Finkelstein, Fiebelkorn, and Wang, 2003). Approximately half of these costs were paid by Medicaid and Medicare. The primary data sets used to develop the spending estimates for this study included the 1998 Medical Expenditure Panel Survey (MEPS) and the 1996 and 1997 National Health Interview Surveys (NHIS). The data also included information about each persons health insurance status and sociodemographic characteristics. Table 1, Aggregate Medical Spending, in Billions of Dollars, Attributable to Overweight and Obesity, by Insurance Status and Data Source, 19961998 Overweight and Obesity Insurance Category Out-of-pocket Private Medicaid Medicare Total MEPS (1998) $7.1 $19.8 $3.7 $20.9 $51.5 NHA (1998) $12.8 $28.1 $14.1 $23.5 $78.5 Obesity MEPS (1998) $3.8 $9.5 $2.7 $10.8 $26.8 NHA (1998) $6.9 $16.1 $10.7 $13.8 $47.5

Note: Calculations based on data from the 1998 Medical Expenditure Panel Survey merged with the 1996 and 1997 National Health Interview Surveys, and health care expenditures data from National Health Accounts (NHA). MEPS estimates do not include spending for institutionalized populations, including nursing home residents. Source: Finkelstein, Fiebelkorn, and Wang, 2003 As shown in Table 1, in 1998 aggregate adult medical expenditures attributable to overweight and obesity is estimated to be $51.5 billion using MEPS data and $78.5 billion using 1998 National Health Accounts (NHA) data. For obesity alone, the estimated costs are $26.8 billion and $47.5 billion, respectively. The inclusion of nursing home expenditures in the NHA estimates causes most of the difference between the MEPS and NHA results.

State-Level Estimated Costs of Obesity

A more recent study focused on state-level estimates of total, Medicare and Medicaid obesity attributable medical expenditures (Finkelstein, Fiebelkorn, and Wang, 2004). Researchers used the 1998 MEPS linked to the 1996 and 1997 NHIS, and three years of data (19982000) from the Behavioral Risk Factor Surveillance System (BRFSS) to predict annual state-level estimates of medical expenditures attributable to obesity (BMI greater than 30). State-level estimates range from $87 million (Wyoming) to $7.7 billion (California). Obesity-attributable Medicare estimates range from $15 million (Wyoming) to $1.7 billion (California), and obesity-attributable Medicaid expenditures range from $23 million (Wyoming) to $3.5 billion (New York). The state differences in obesityattributable expenditures are partly driven by the differences in the size of each states population. These state-level estimates can assist state policy makers to determine how best to allocate public health resources and provide information concerning the economic impact of obesity in a state. However, these estimates should not be used to make comparisons across states, or between payers within states. In addition, these state-estimated data are limited to direct medical costs, as defined above, and not indirect costs (example: absenteeism and decreased productivity) attributed to obesity. Table 2 shows the estimated percentage of total, Medicare, and Medicaid adult medical expenses that are attributable to obesity. Table 2, Estimated Adult Obesity-Attributable Percentages and Expenditures, by State (BRFSS 19982000) Total Medicare Medicaid population (Millions population (Millions population (Millions (%) $) (%) $) (%) $) 6.3 6.7 4.0 6.0 5.5 5.1 4.3 $1320 $195 $752 $663 $7675 $874 $856 7.7 7.7 3.9 7.0 6.1 5.1 6.5 $341 $17 $154 $171 $1738 $139 $246 9.9 8.2 13.5* 11.5 10.0 8.7 11.0 $269 $29 $242 $180 $1713 $158 $419

State Alabama Alaska Arizona Arkansas California Colorado Connecticut

Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico

5.1 6.7 5.1 6.0 4.9 5.3 6.1 6.0 6.0 5.5 6.2 6.4 5.6 6.0 4.7 6.5 5.0 6.5 6.1 4.9 5.8 4.8 5.0 5.5 4.8

$207 $372 $3987 $2133 $290 $227 $3439 $1637 $783 $657 $1163 $1373 $357 $1533 $1822 $2931 $1307 $757 $1636 $175 $454 $337 $302 $2342 $324

9.8 6.5 6.1 7.1 4.8 5.6 7.8 7.2 7.5 6.4 7.5 7.4 5.7 7.7 5.6 7.8 6.6 8.1 7.1 6.2 7.0 5.0 5.4 7.1 4.6

$57 $64 $1290 $405 $30 $40 $805 $379 $165 $138 $270 $402 $66 $368 $446 $748 $227 $223 $413 $41 $94 $74 $46 $591 $51

13.8 12.5 11.6 10.1 11.2 12.0 12.3 15.7 9.4 10.2* 11.4 12.9 10.7 12.9 7.8 13.2 8.6 11.6 11.9 9.8 10.3 10.1* 8.6* 9.8 8.5

$66 $114 $900 $385 $90 $69 $1045 $522 $198 $143 $340 $525 $137 $391 $618 $882 $325 $221 $454 $48 $114 $56 $79 $630 $84

New York North Carolina North Dakota Oklahoma Ohio Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Total

5.5 6.0 6.1 6.0 6.1 5.7 6.2 7.4 5.2 6.2 5.3 6.4 6.1 5.2 5.3 5.7 5.4 6.4 5.8 4.9 5.7

$6080 $2138 $209 $854 $3304 $781 $4138

6.7 7.0 7.7 7.0 7.7 6.0 7.4 8.1

$1391 $448 $45 $227 $839 $145 $1187

9.5 11.5 11.7 9.9 10.3 8.8 11.6 10.1

$3539 $662 $55 $163 $914 $180 $1219

$305 $1060 $195 $1840 $5340 $393 $141 $1641 $1330 $588 $1486 $87 $75,051

6.5 7.7 5.9 7.6 6.8 5.8 6.9 6.7 6.0 7.3 7.7 5.9 6.8

$83 $242 $36 $433 $1209 $62 $29 $320 $236 $140 $306 $15 $17,701

7.7 10.6 9.9 10.5 11.8 9.0 8.6 13.1 9.9 11.4 9.1 8.5 10.6

$89 $285 $45 $488 $1177 $71 $40 $374 $365 $187 $320 $23 $21,329

*Estimates based on fewer than 20 observations. Source: Finkelstein, Fiebelkorn, and Wang, 2004.

References

(NHANES) National Health and Nutrition Examination Survey 19992000 Finkelstein, EA, Fiebelkorn, IC, Wang, G. National medical spending attributable to overweight and obesity: How much, and whos paying? Health Affairs 2003;W3;219 226. Finkelstein, EA, Fiebelkorn, IC, Wang, G. State-level estimates of annual medical expenditures attributable to obesity. Obesity Research 2004;12(1):1824. U.S. Department of Health and Human Services. The Surgeon General's call to action to prevent and decrease overweight and obesity. [Rockville, MD]: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General; [2001]. Available from: US GPO, Washington. Wolf AM, Colditz GA. Current estimates of the economic cost of obesity in the United States. Obesity Research.1998;6(2):97106. Wolf, A. What is the economic case for treating obesity? Obesity Research. 1998;6(suppl)2S7S.