Monday, March 16, 2009

New Monograph Shows that Obesity is Equal to or Greater than Smoking in Terms of Health Care Costs to Employers; Will "Fat-Free" Workplaces Be Next?

The American Council on Science and Health (ACSH) has just released a new monograph which reviews the health effects and health care costs associated with obesity. Entitled "Obesity and its Health Effects," the monograph provides a comprehensive review of trends in obesity and overweight, the health effects (organized by chapters devoted to various body systems), and the health care costs.

The report concludes that obesity is the second most important public health problem in the United States, second only to cigarette smoking. But importantly, from the perspective of employer-related health care costs, obesity might even exceed smoking as a problem.

The report reaches a number of important conclusions relevant to the employer-related health costs of obesity. For one, while the overall mortality attributable to obesity is somewhat lower than that due to smoking, the years of life expectancy lost due to obesity are similar. This means that while obesity ultimately kills fewer people, those who die due to obesity generally die at a younger age.

The monograph points out that unlike cigarette smoking, obesity can have significant health effects even at a very early age. For example, it is estimated that about 40,000 adolescents in the U.S. have type 2 diabetes, mostly occurring in individuals who are obese. Obesity in childhood and adolescence also causes hypertension, high cholesterol, early signs of liver disease, gall stones, sleep apnea, and possibly asthma.

Thus, while employee smoking is mainly a concern as employees reach middle-age and beyond, obesity is a concern no matter what the age of the employee.

Second, the report notes that obesity may have a greater effect on morbidity than mortality. Thus, it is associated not only with lost productivity due to death, but also with expensive ongoing losses in productivity and treatment of people who remain alive. According to the monograph: "Obesity is associated with increased rates of a variety of diseases that can cause ongoing health impairment and require long-term treatment, such as diabetes, asthma, and osteoarthritis. The costs of treating these diseases are substantial. Obesity is also associated with increases in cardiovascular disease risk factors, including hypertension and abnormal levels of blood lipids. An individual's likelihood of dying of cardiovascular disease can be reduced if these risk factors are identified and treated, but diagnosis and treatment involve substantial costs for physician visits, diagnostic tests, and medicines.

Overall, the monograph concludes that: "Because of the health conditions associated with obesity, the health care costs of obesity may be in the same range as those of cigarette smoking, even though obesity is responsible for fewer deaths."

According to the monograph, the direct health care costs associated with obesity in the United States, are about $75 billion, while those attributable to smoking are about $75.5 billion per year. The direct health care costs attributable to obesity account for 9% of all health care costs in the U.S., of which about half are paid by Medicare and Medicaid. When indirect costs, such as lost productivity, are factored in, total health care costs associated with obesity are about $117 billion annually.

Finally, while smoking rates are generally decreasing in the U.S., the rates of both obesity and overweight are increasing steadily. Thus, obesity is likely to be an increasing source of higher health care costs for employers long into the future.

The Rest of the Story

An important policy implication of the findings in this monograph is that the precise reasoning being used by anti-smoking advocates to support smoker-free workplace policies also justifies policies by which obese or overweight individuals would not be considered for employment. The exact argument being used by anti-smoking practitioners to advocate for these smoker-free employment policies should, in fact, also be used to keep obese and overweight people out of the workplace, if they are to be consistent in their application of policy.

The findings in this monograph disallow as a justification for the singling out of smokers for non-employment the argument that smoking is the only behavior which produces such enormous costs for employers. Obesity is every bit as much of a problem from the standpoint of employee health care costs. If keeping smokers out of the workplace is justified on the basis of the health care costs they impose, then keeping obese and overweight people out of the workplace is also justified on the same grounds.

One also cannot argue that smoking behavior can easily be changed, while one's weight cannot. If anything, in my clinical experience, people are much more easily able to lose weight than they are to be able to quit smoking. While a sizable proportion of my patients were able to lose substantial amounts of weight, very few of my patients successfully quit smoking. Besides, we can't have it both ways. We can't on the one hand argue that smoking is an addiction and take the cigarette companies to court on the grounds that smokers do not make a free decision about smoking and then on the other hand argue that anyone who wants to quit smoking can easily do so.

To be clear, I think that a policy of throwing out the job applications of obese individuals would be discriminatory, unjustified, and disgusting. But employers who are throwing out the job applications of smokers are doing exactly the same thing and on exactly the same grounds.

Refusing to hire smokers is not only discriminatory, it is also unjustified and disgusting.

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