Financial costs of the U.S. obesity epidemic reach new heights

Sharon Begley, Reuters  Apr 30, 2012

NEW YORK – U.S. hospitals are ripping out wall-mounted toilets and replacing them with floor models to better support obese patients. The Federal Transit Administration wants buses to be tested for the impact of heavier riders on steering and braking. Cars are burning nearly a billion gallons of gasoline more a year than if passengers weighed what they did in 1960.

The nation’s rising rate of obesity has been well-chronicled. But businesses, governments and individuals are only now coming to grips with the costs of those extra pounds, many of which are even greater than believed only a few years ago: The additional medical spending due to obesity is double previous estimates and exceeds even those of smoking, a new study shows.

Many of those costs have dollar signs in front of them, such as the higher health insurance premiums everyone pays to cover those extra medical costs. Other changes, often cost-neutral, are coming to the built environment in the form of wider seats in public places from sports stadiums to bus stops.

The startling economic costs of obesity, often borne by the non-obese, could become the epidemic’s second-hand smoke. Only when scientists discovered that nonsmokers were developing lung cancer and other diseases from breathing smoke-filled air did policymakers get serious about fighting the habit, in particular by establishing nonsmoking zones. The costs that smoking added to Medicaid also spurred action. Now, as economists put a price tag on sky-high body mass indexes (BMIs), policymakers as well as the private sector are mobilizing to find solutions to the obesity epidemic.

“As committee chairmen, Cabinet secretaries, the head of Medicare and health officials see these really high costs, they are more interested in knowing, ‘what policy knob can I turn to stop this hemorrhage?’” said Michael O’Grady of the National Opinion Research Center, co-author of a new report for the Campaign to End Obesity, which brings together representatives from business, academia and the public health community to work with policymakers on the issue.

The U.S. health care reform law of 2010 allows employers to charge obese workers 30% to 50% more for health insurance if they decline to participate in a qualified wellness program. The law also includes carrots and celery sticks, so to speak, to persuade Medicare and Medicaid enrollees to see a primary care physician about losing weight, and funds community demonstration programs for weight loss.

Such measures do not sit well with all obese Americans. Advocacy groups formed to “end size discrimination” argue that it is possible to be healthy “at every size,” taking issue with the findings that obesity necessarily comes with added medical costs.

The reason for denominating the costs of obesity in dollars is not to stigmatize plus-size Americans even further. Rather, the goal is to allow public health officials as well as employers to break out their calculators and see whether programs to prevent or reverse obesity are worth it.

LOST PRODUCTIVITY

The percentage of Americans who are obese (with a BMI of 30 or higher) has tripled since 1960, to 34%, while the incidence of extreme or “morbid” obesity (BMI above 40) has risen sixfold, to 6%. The percentage of overweight Americans (BMI of 25 to 29.9) has held steady: It was 34% in 2008 and 32% in 1961. What seems to have happened is that for every healthy-weight person who “graduated” into overweight, an overweight person graduated into obesity.

Because obesity raises the risk of a host of medical conditions, from heart disease to chronic pain, the obese are absent from work more often than people of healthy weight. The most obese men take 5.9 more sick days a year; the most obese women, 9.4 days more. Obesity-related absenteeism costs employers as much as US$6.4-billion a year, health economists led by Eric Finkelstein of Duke University calculated.

Total annual cost of presenteeism due to obesity:

US$30-billion

Even when poor health doesn’t keep obese workers home, it can cut into productivity, as they grapple with pain or shortness of breath or other obstacles to working all-out. Such obesity-related “presenteeism,” said Finkelstein, is also expensive. The very obese lose one month of productive work per year, costing employers an average of US$3,792 per very obese male worker and US$3,037 per female. Total annual cost of presenteeism due to obesity: US$30-billion.

Decreased productivity can reduce wages, as employers penalize less productive workers. Obesity hits workers’ pocketbooks indirectly, too: Numerous studies have shown that the obese are less likely to be hired and promoted than their svelte peers are. Women in particular bear the brunt of that, earning about 11% less than women of healthy weight, health economist John Cawley of Cornell University found. At the average weekly U.S. wage of $669 in 2010, that’s a $76 weekly obesity tax.

MORE DOCTORS, MORE PILLS

The medical costs of obesity have long been the focus of health economists. A just-published analysis finds that it raises those costs more than thought.

Obese men rack up an additional US$1,152 a year in medical spending, especially for hospitalizations and prescription drugs, Cawley and Chad Meyerhoefer of Lehigh University reported in January in the Journal of Health Economics. Obese women account for an extra US$3,613 a year. Using data from 9,852 men (average BMI: 28) and 13,837 women (average BMI: 27) ages 20 to 64, among whom 28% were obese, the researchers found even higher costs among the uninsured: annual medical spending for an obese person was US$3,271 compared with US$512-for the non-obese.

Nationally, that comes to US$190-billion a year in additional medical spending as a result of obesity, calculated Cawley, or 20.6% of U.S. health care expenditures.

That is double recent estimates, reflecting more precise methodology. The new analysis corrected for people’s tendency to low-ball their weight, for instance, and compared obesity with non-obesity (healthy weight and overweight) rather than just to healthy weight. Because the merely overweight do not incur many additional medical costs, grouping the overweight with the obese underestimates the costs of obesity.

A hospital room in Birmingham, AL that has oversized chairs and strengthened mobile medical beds to accommodate the increasing size of overweight Americans.

     Marvin Gentry/Reuters

An oversized chair and an oversized hospital bed are pictured in the children's and women's maternity ward at the University of Alabama Hospital in Birmingham, Alabama.

Contrary to the media’s idealization of slimness, medical spending for men is about the same for BMIs of 26 to 35. For women, the uptick starts at a BMI of 25. In men more than women, high BMIs can reflect extra muscle as well as fat, so it is possible to be healthy even with an overweight BMI. “A man with a BMI of 28 might be very fit,” said Cawley. “Where healthcare costs really take off is in the morbidly obese.”

Those extra medical costs are partly born by the non-obese, in the form of higher taxes to support Medicaid and higher health insurance premiums. Obese women raise such “third party” expenditures US$3,220 a year each; obese men, US$967 a year, Cawley and Meyerhoefer found.

One recent surprise is the discovery that the costs of obesity exceed those of smoking. In a paper published in March, scientists at the Mayo Clinic toted up the exact medical costs of 30,529 Mayo employees, adult dependents, and retirees over several years.

“Smoking added about 20% a year to medical costs,” said Mayo’s James Naessens. “Obesity was similar, but morbid obesity increased those costs by 50% a year. There really is an economic justification for employers to offer programs to help the very obese lose weight.”

LIVING LARGE, BUT NOT DYING YOUNG

For years researchers suspected that the higher medical costs of obesity might be offset by the possibility that the obese would die young, and thus never rack up spending for nursing homes, Alzheimer’s care, and other pricey items.

“Growing obesity rates increase fuel consumption.”

That’s what happens to smokers. While they do incur higher medical costs than nonsmokers in any given year, their lifetime drain on public and private dollars is less because they die sooner. “Smokers die early enough that they save Social Security, private pensions, and Medicare” trillions of dollars, said Duke’s Finkelstein. “But mortality isn’t that much higher among the obese.”

Beta blockers for heart disease, diabetes drugs, and other treatments are keeping the obese alive longer, with the result that they incur astronomically high medical expenses in old age just like their slimmer peers.

Some costs of obesity reflect basic physics. It requires twice as much energy to move 250 pounds than 125 pounds. As a result, a vehicle burns more gasoline carrying heavier passengers than lighter ones.

“Growing obesity rates increase fuel consumption,” said engineer Sheldon Jacobson of the University of Illinois. How much? An additional 938 million gallons of gasoline each year due to overweight and obesity in the United States, or 0.8%, he calculated. That’s US$4-billion extra.

Not all the changes spurred by the prevalence of obesity come with a price tag. Train cars New Jersey Transit ordered from Bombardier have seats 2.2 inches wider than current cars, at 19.75 inches, said spokesman John Durso, giving everyone a more comfortable commute. (There will also be more seats per car because the new ones are double-deckers.)

The built environment generally is changing to accommodate larger Americans. New York’s commuter trains are considering new cars with seats able to hold 400 pounds. Blue Bird is widening the front doors on its school buses so wider kids can fit. And at both the new Yankee Stadium and Citi Field, home of the New York Mets, seats are wider than their predecessors by 1 to 2 inches.

The new performance testing proposed by transit officials for buses, assuming an average passenger weight of 175 instead of 150 pounds, arise from concerns that heavier passengers might pose a safety threat. If too much weight is behind the rear axle, a bus can lose steering. And every additional pound increases a moving vehicle’s momentum, requiring more force to stop and thereby putting greater demands on brakes. Manufacturers have told the FTA the proposal will require them to upgrade several components.

Hospitals, too, are adapting to larger patients. The University of Alabama at Birmingham’s hospital, the nation’s fourth largest, has widened doors, replaced wall-mounted toilets with floor models able to hold 250 pounds or more, and bought plus-size wheelchairs (twice the price of regulars) as well as mini-cranes to hoist obese patients out of bed.

The additional spending due to obesity doesn’t fall into a black hole, of course. It contributes to overall economic activity and thus to gross domestic product. But not all spending is created equal.

“Yes, a heart attack will generate economic activity, since the surgeon and hospital get paid, but not in a good way,” said Murray Ross, vice president of Kaiser Permanente’s Institute for Health Policy. “If we avoided that heart attack we could have put the money to better use, such as in education or investments in clean energy.”

The books on obesity remain open. The latest entry: An obese man is 64% less likely to be arrested for a crime than a healthy man. Researchers have yet to run the numbers on what that might save.

© Thomson Reuters 2012

Importance of Dental Care for Moms-to-be

Dental Issues In Pregnant Women Put Babies At Risk

By Colorado Public News and Cara DeGette

Enlarge image

Pamela McClain, Pres. of the American Academy of Periodontology, working on a patient. Studies have determined that poor dental hygiene & gum disease lead to many other health problems, including the potential for premature and low birthweight babies.

Dentists are warning pregnant women to take care of their teeth, for the sake of their babies.

Pregnant women with cavities and gum disease have an increased risk of having premature and low-birth weight babies. They also have a good chance of passing on their bacteria and bad habits to their children.

Over the past 10-15 years, numerous studies have determined that poor dental hygiene and gum disease lead to many other health problems, said Aurora periodontist Pamela McClain, who is president of the American Academy of Periodontology. Gum disease can lead to periodontal disease, or inflammation, infection and decay of the bone and tendons around the teeth. The studies have connected periodontal disease to increased risks for cardiovascular disease, Alzheimer’s disease and even pancreatic cancer, she said.

Research has also focused on women who are expecting.

“Many, many studies have shown that high levels of [the hormone] progesterone puts pregnant women at a higher risk and more susceptible to gum diseases,” McClain said. “Pregnant women who have periodontitis are two to four times more likely to have pre-term, low birthrate babies.”

“We all have bacteria in our mouths,” she said. However, some bacteria attach to teeth and become plaque, and if that plaque is not removed, it can lead to inflammation of the gums, or gingivitis.

Untreated, the bacteria ultimately start destroying the bones in your mouth – and that is not reversible, said McClain.

McClain said the percentage of women with poor oral hygiene giving birth to babies prematurely is relatively small. However, she notes that underweight and premature babies are far more likely to have mothers with periodontal disease. 

Women with dental problems also easily pass their germs onto their babies. Jeff Kahl, a Colorado Springs pediatric dentist, says the costs of treating children ages 0-3 years old with dental problems has skyrocketed in recent years. New mothers can easily transfer their own bacteria to their babies in a myriad of ways, including kissing them, sharing utensils – anything that enables the mother to transfer saliva to the baby.

“If we can screen pregnant women who are at the highest risk, and treat them, the probability they will transmit [bacteria] to their children is much lower,” Kahl said.

A bill being considered by the Colorado legislature this year would extend dental health care to women on Medicaid who are pregnant and have just given birth. The bill, sponsored by Sen. Jeanne Nicholson (D-Black Hawk), passed the Senate Health and Human Services committee in late March, with Democrats voting in favor and Republicans opposed.

“It’s going to be a tough road,” said Kahl, who supports the effort. “The Democrats think it's the greatest thing in the world. The Republicans we talk to think it’s great but say they have a problem with the price tag.”

The bill’s estimated cost is $3.5 million in the first year and $10.3 million next year according to legislative council staff. Bills for new programs that cost money often have a hard time in the legislature.

Kahl and McClain argue the investment would be saved over the long term by preventing future expensive dental treatments for children and their mothers. They also cite the huge savings on medical costs related to premature and low-weight babies. However, Kahl concedes that saving money by providing preventative treatments can be a tough sell.

“You’re talking about kids who aren’t even born yet,” he said.

Kahl recommends that pregnant women should make sure they are as healthy as possible, and advises would-be mothers on the following:

• As soon as possible after learning you are pregnant, get a dental check-up.
• Take care of any cavities you may have.
• Brush your teeth after eating.
• Floss your teeth daily.
• Consider using a prescription mouth rinse, with the medication Chlorhexidine, to minimize bacteria build-up in your mouth.

Enzymes in Saliva Help Offset Effects of Diabetes

Enzyme found to help regulate blood glucose

5 April 2012 -- Blood glucose levels following starch ingestion are influenced by genetically determined differences in salivary amylase, an enzyme that breaks down dietary starches, according to a new study in the Journal of Nutrition (April 4, 2012) by scientists from the Monell Center.

In the study, amylase activity was measured in saliva samples obtained from 48 healthy adults. Based on extremes of salivary amylase activity, two groups of seven were formed: high amylase (HA) and low amylase (LA).

Each subject drank a simplified corn starch solution and blood samples were obtained over a two-hour period afterwards. The samples were analyzed to determine blood glucose levels and insulin concentrations.

After ingesting the starch, individuals in the HA group had lower blood glucose levels relative to those in the LA group. This appears to be related to an early release of insulin by the HA individuals.

"Not all people are the same in their ability to handle starch," said senior author Paul Breslin, PhD, a sensory geneticist at Monell, in a press release. "People with higher levels of salivary amylase are able to maintain more stable blood glucose levels when consuming starch. This might ultimately lessen their risk for insulin resistance and non-insulin-dependent diabetes."

The findings are the first to demonstrate a significant metabolic role for salivary amylase in starch digestion, suggesting that this oral enzyme may contribute significantly to overall metabolic status.

Additional studies will confirm the current findings using more complex starchy foods, such as bread and pasta, the researchers noted.

Does Tooth Loss Influence Sleep Apnea?

Link suggested between onset of OSA and loss of teeth

5 April 2012 -- Previous studies have speculated that there may be an association between edentulism and worsening obstructive sleep apnea (OSA), but research presented at the recent American Association for Dental Research annual meeting did not find a link.

"We came across some papers stating that individuals who slept in their complete dentures had an improvement in their OSA," study author Jeff Tanner, DDS, an oral and maxillofacial surgery resident at the University of California Los Angeles (UCLA), told DrBicuspid.com. "Their assumption was that tooth loss/edentulism contributes at least in part to the worsening of OSA."

When people become edentulous, several physiological changes take place, Dr. Tanner noted. For example, the vertical dimension of occlusion reduces, the tongue grows larger because of the space that is no longer occupied by teeth, the position of the tongue changes, and the tongue rests in a different position.

Since no prior study has ever examined whether or not tooth loss per se was a predictor of OSA, the researchers decided to investigate this connection.  "When we became interested in this topic we found that there were several publications that had dealt with this issue, but not so directly," Dr. Tanner stated said during the session.

VA health system data

Dr. Tanner and his colleagues hypothesized that people with fewer teeth -- especially those who are edentulous -- have more serious OSA after controlling for age and body mass index (BMI), which are known predictors of OSA.

They conducted a retrospective chart review of patients from the greater Los Angeles U.S. Department of Veterans Affairs (VA) health system who were referred to the dental service for treatment of OSA. The researchers looked at the electronic medical records of 210 male veterans who had already undergone a sleep study at the VA hospital and were able to collect the age and BMI of these patients. The researches also used an apnea-hypopnea index to classify the severity of the patients' OSA.

They then used panoramic radiographs to quantify teeth using three different methods: total teeth lost, mandibular teeth lost, and posterior dental functional units lost.

Here are the key results:

• Of the 210 subjects, 25.5% had not lost any teeth, 36.6% lost one to five teeth, 20.8% lost six to 16 teeth, and 17.1% lost more than 16 teeth.
• 30% of the individuals had mild OSA, 36% moderate OSA, and 34% severe OSA.
• The bivariate association between the number of dentition present and severity of OSA showed no significance.
• In multivariate analysis, age and BMI were significant predictors of OSA severity, while total teeth loss was not significant

"The degree of tooth loss is not associated with OSA severity," the authors concluded. "Tooth loss does not worsen OSA. "

More research needed

OSA is difficult to understand because of the causative factors, Dr. Tanner said.

Age and obesity are proven predictors so the study controlled for those variables; however, the authors were still not able to prove that tooth loss predicted a worsening of OSA, he noted.

This line of research could be improved by obtaining a sleep study on the same individual prior to edentulism, after edentulism, and wearing complete dentures, Dr. Tanner added.

"Only by conducting this type of study will we be able to be certain to state whether or not tooth loss predicts OSA," he said. "If in the future it could be stated that edentulism worsens OSA, it would be a strong case for dentists to attempt to restore patients back to a dentate state with implants which maintain alveolar ridge height unlike dentures."

Given that OSA is an epidemic that is just now catching the public's attention, "This connection would be huge, as that type of treatment would be medically driven dentistry, possibly covered by medical insurance," he concluded.

reported by DrBicuspid.com

April is Oral Cancer Awareness Month

This month marks 13th year for raising oral cancer awareness

The Oral Cancer Foundation (OCF) is encouraging the dental community to get involved in Oral Cancer Awareness Month this April 2012 by offering free oral cancer screenings to the public in an effort to raise awareness of this disease across the U.S.

Oral cancer screening for side of tongue

OCF is asking dental and medical professionals nationwide to act as the first line of defense against oral cancer through the process of early discovery, and to raise public awareness of this cause by opening their doors for at least a half-day, during the month of April, to screen members of their community.

Oral cancer is one of the few cancers that are on the rise in the U.S. When found early, oral cancers have an 80% or better survival rate. Unfortunately, most oral cancers are found in late stages, when the five-year survival rate plummets to about 30%. Late-stage diagnosis can be greatly reduced through increased public awareness of these facts, and OCF believes that a national program of opportunistic screenings is the best means of creating that awareness.

In April 2012, OCF will again join forces with both professional societies and private sector companies who are stakeholders in this disease. The ADA, the American Academy of Oral and Maxillofacial Surgery, the Academy of General Dentistry, and the American Academy of Oral Medicine form the core of the professional society sponsorship.

OCF has also aligned with Henry Schein, LED Dental, and Bristol-Myers Squibb, who are asking their customers to be active in this April's endeavor. In addition, the 21 treatment facilities with head and neck departments that participated in 2011's effort are expected to participate again in 2012.

With the help of these partners in 2011, OCF was able to create more than 2,000 screening sites/events, according to the foundation. These events, combined with seven major walk/run awareness events coordinated by OCF, resulted in more than 50,000 individual screenings for oral cancer during April alone.

Cancer-causing Agent Identified in Smokeless Tobacco

Oral carcinogen shown to induce cancer for snuff/chew users

April 2, 2012 -- A chemical present in smokeless tobacco products is a strong oral carcinogen, according to research being presented this week at the American Association for Cancer Research's annual meeting in Chicago.

Although smokeless tobacco products have long been linked with certain cancers, including those of the oral cavity and esophagus, this is the first study to identify a specific chemical present in smokeless tobacco products that induces oral cancer in animals, according to Silvia Balbo, PhD, research associate at the Masonic Cancer Center of the University of Minnesota.

"(S)-N'-nitrosonornicotine, or (S)-NNN, is the only chemical in smokeless tobacco known to cause oral cancer," Balbo said in a press release.

Balbo and colleagues administered (S)-NNN and (R)-NNN to four groups of 24 rats. The rats were given either (S)-NNN alone, (R)-NNN alone, a combination of both, or tap water. The total dose was approximately equivalent to the amount of (S)-NNN to which a smokeless tobacco user would be exposed from chronic use of these products.

All rats assigned to (S)-NNN alone or the combination of the two began losing weight after one year of exposure and died by 17 months. Rats assigned to (R)-NNN or tap water were terminated at 20 months.

All rats assigned to (S)-NNN had esophageal tumors and demonstrated 100% incidence of oral tumors, including tumors of the tongue, buccal mucosa, soft palate, and pharynx. In contrast, researchers found oral tumors in only five of 24 rats given (R)-NNN and esophageal tumors in only three of 24 rats assigned to (R)-NNN.

Twelve rats given the combination of (S)-NNN and (R)-NNN had 153 esophageal tumors and 96 oral tumors.

Since the U.S. Food and Drug Administration regulates tobacco products, Balbo hopes the results of this study will inform regulatory decisions. Moving forward, she and her colleagues hope to identify other chemicals that may be carcinogens in smokeless tobacco and to understand what level of these chemicals is present in smokeless tobacco products.

CEREC Outshines The Competition

Chairside all-ceramic restorations shine in long-term study

A study of 1,335 all-ceramic restorations placed between 1987 and 2009 has found that they are both predictable and reliably successful, with a 93.5% probability of survival over a 10-year period (International Journal of Prosthodontics, January/February 2012, Vol. 25:1, pp. 70-78).

Only glass ceramic restorations placed between 1987 and 2009 were evaluated in the study, which was conducted by members of the clinical department of restorative and prosthetic dentistry at Medical University Innsbruck.

Cases involving bruxism, nonvital teeth, and specific cementation agents created significantly increased rates of failure. Yet even when failures occurred, patients overwhelmingly reported "excellent" satisfaction.

"The purpose of this clinical retrospective study was to evaluate the clinical quality, success rate, and estimated survival rate of silicate glass-ceramic restorations in both dental arches over a 20-year period," the authors wrote. They also examined patient- and restoration-specific variables to see which could predict a ceramic restoration failure.

Study methodology

A total of 302 patients (120 men and 182 women) participated in the study. They were examined at the university during regularly scheduled visits for maintenance. Patient-specific data about sex, age, tooth sensitivity, smoking, and bruxism were noted, as well as self-reported data regarding their level of satisfaction with their restorations: excellent, good, medium, or none. The restorations were categorized by region as well, into anterior, premolar, and molar regions.

All 1,335 silicate ceramic restorations had been placed at the university between November 1987 and December 2009. Of these restorations, 451 were observed over a 10-year period, 84 for 15 years, and 24 over 20 years.

Clinical examinations were carried out by two dentists between March and July of 2010. One dentist had placed most of the restorations, whereas the other had placed none of them. California Dental Association/Ryge criteria were used to rate each ceramic restoration as a success if it received an alpha or bravo grade, or as a failure if it received a charlie or delta grade.

Any restorations that had severe enough issues to necessitate replacement were deemed an absolute failure. If a finishing procedure or polishing could correct the issue, the restoration was labeled a relative failure.

Survival rates

Only 95 restorations were rated as failures, 79% of which were absolute. Most failures occurred in the anterior region, with 65, while 19 occurred in premolars and 11 occurred in molars.

Success rates remained strong over time. The estimated survival rate was 97.3% at five years, 96% at eight years, 94% at 10 years, 85.8% at 15 years, and 78.5% after 20 years. Nearly half of the failures occurred in the first eight years, the researchers noted.

While the entire study included 1,335 all-ceramic restorations, 69 failures took place prior to the 2010 examination, so 1,266 were considered. Of these, 26 were rated not acceptable and unsatisfactory when evaluated.

The most frequent reason for failure was fracture of the ceramic, according to the researchers, followed in order by cracks in the ceramic and secondary caries.

Interestingly, "comparing the type of restoration and all-ceramic material as a predictor for failure, no significant differences were found," they added.

Nonvital teeth and patients with bruxism displayed significantly higher failure rates (p < 0.0001 and p = 0.0045, respectively). The choice of luting agent also was relevant. Cementation using Variolink (Ivoclar Vivadent) showed significantly fewer failures than Optec cement (Pentron, p = 0.0217) and Dual cement (Ivoclar Vivadent, p = 0.0099), the researchers noted.

Patient satisfaction

Patient responses to questions about satisfaction were quite positive, with 96% rating it as "excellent" and 4% rating it as "good." Not a single respondent rated his or her satisfaction as "medium" or "none."

"All of the patients, even those who had ceramic failures, regarded the all-ceramic restorations as an ideal type of dental restoration and would bear the time and costs of the all-ceramic procedure again," the researchers wrote.

However, because of the higher occlusal forces present in molar teeth, "the dentist has to be especially careful of ceramic material selection depending on indication, the extent of the defect, and the patient," they added.