How Dare You —

Recently, I’ve been reading more studies on the economic costs of obesity, which include both medical costs and so-called “lost productivity” due to obesity. The purpose of these studies, aside from their attempts to quantify and compare the economic impact of the fatties, is to provide further incentive for government intervention.

As this study in Health Affairs on the economic impact of childhood obesity explains:

Our analysis provides data that can be used to estimate the economic benefits of interventions. Continued research is needed to develop successful initiatives to prevent and treat obesity; however, estimating the social costs allows us to determine whether investment in various interventions would be worth considering.

Of course, there is another underlying message to these reports, which get widely disseminated by the media. It’s a message sent directly to each and every fatty out there: how dare you.

How dare you cost the American taxpayer with your fatness!

How dare you become a burden on our medical system!

How dare you drive up the healthcare costs for the rest of us!

How dare you see the doctor more often!

How dare you spend more on medication!

How dare you laze about, stuffing your face with junk food!

How dare you!

In today’s anemic economy, the financial impact of obesity has become a powerful weapon in the anti-obesity arsenal. If the War on Fat is to be won, it will be won by turning each fatty into a commodity and treating your body as one of the contributing causes of the decline of the American healthcare system.

Passing the blame for healthcare inflation onto obesity (when healthcare costs are being driven by greater economic factors, as outlined so brilliantly in this Health Beat blog post) is just another attempt at scapegoating the fatties for major economic and social issues plaguing our country.

Rather than assign blame where it belongs, obesity cost estimates portray fatness as the number one drain on our economy. Rather than assess the full picture of healthcare issues, obesity researchers zero in on a group that is traditionally poorer, less educated and more disenfranchised: fat people.

If only the fatties would take care of themselves, we wouldn’t be have to be discussing the solvency of Medicare and Medicaid. As vesta pointed out last week, we are told that if we would just lose two pounds, we would save the country millions of dollars. You refuse to lose two pounds for the good of our country? How dare you!

So, it is important that we understand what these economic studies are counting. For example, this 1998 article in Obesity Research by Graham Colditz estimated the economic costs of obesity to be $117 billion per year. Yet the Center for Consumer Freedom claims Colditz et al. counted certain costs twice, which inflated the final estimate. (Point of caution: the CCF is a lobbying group for restaurant and food industries, so take their analysis with a grain of salt… also, if anyone is able to send me a PDF of that 1998 article, which is only available in print editions, I would be eternally grateful!).

So, when I began reading the Health Affairs study on the cost of childhood obesity, I expected some statistical shenanigans, but what I found was even more disturbing.

The authors claim that between 1999 and 2005 the costs associated with obesity hospitalizations increased from $125.9 to $237.6 million. On the surface, this is an astonishing number, but when you dig into it, you find some interesting things.

First and foremost, they defined obesity-associated hospitalizations as discharges for which obesity was listed as a primary or secondary diagnosis. Researchers determined the diagnosis from the diagnostic coding system hospitals use, and included “the eleven most frequent CCS* diagnoses** for which obesity was a secondary diagnosis.”

Translation: the researchers assumed that all ER patients who were diagnosed as obese, regardless of whether presenting health issue is actually related to or directly caused by obesity, is included in the “costs of obesity.” Second, we only looked at the most health issues for which obesity was co-diagnosed.

That second point might not seem like a big deal until you realize that this study provides absolutely no comparison. The authors only provided data on obesity-associated hospital visits, so we cannot compare the costs of obesity with the costs of, say, overweight, normal, or underweight BMI categories.

The closest thing the authors include is a comparison to the the changes in hospitalization frequency for each of the eleven diagnoses. But taken alone, this tells us little. Why?

As the study authors themselves warn:

The trends described are to be interpreted with caution because they could represent trends in diagnosis rather than an increase in patients in which obesity is causing other medical conditions.

This should be obvious enough from the data they provide on the number of hospitalizations we’re looking at:

We detected an increase in the number of hospitalizations of children and youth ages 2–19 for which obesity was listed as a diagnosis, from 21,743 in 1999 to 42,429 in 2005.

In six years, the number of hospitalizations doubled. Keep in mind that hospitalizations in the general population of children only rose from 7,291,032 to 7,558,812 between 2000 and 2006 (the six years for which pediatric discharge data is available from the same data source).

So, I ask you, what is more likely: twice as many fat children were hospitalized during those six years or twice as many fat children were diagnosed as obese during the six years when public awareness of childhood obesity increased significantly?

Case in point: the authors go out of their way to point out that obesity was “associated with significantly greater lengths-of-stay, charges, and costs” for seven of the eleven diagnoses. Meanwhile, diabetes remained relatively stable: “For diabetes, an increase in lengths-of-stay was detected, but no significant increase in charges or costs was found.”

Isn’t type 2 diabetes in childhood a “new epidemic”? Aren’t we facing a flood diabetic children that constitutes a “large economic burden”? Yet, in this study where all hospitalizations with a secondary diagnosis of obesity increased charges by $1,634 and costs by $727, the authors found that the charges for diabetes increased a modest $79, while the costs actually decreased by $98.

So if childhood diabetes isn’t driving the estimates of childhood obesity costs, then what is?

Brace yourself, because this is gonna piss you off.

Among hospitalizations for which obesity was listed as a secondary diagnosis, affective disorders were the most frequent primary diagnoses, followed by pregnancy-associated conditions, asthma, and diabetes. [rage-induced emphasis most certainly mine]

So, of the 114,559 obesity-associated hospitalizations included in this report, affective disorders comprise the largest chunk, 29,074 or around 25%. If you include the other two psychological illnesses on the list, other mental disorders and schizophrenia, that brings you to a total of 41,337 cases, or one-third of the cases included.

Affective disorders include major depressive disorder, atypical depression, melancholic depression, psychotic major depression, catatonic depression,postpartum depression, seasonal affective disorder, bipolar disorders, dysthymia, and substance-induced mood disorders. And, according to this study, among “other mental disorders,” the most common was depressive disorder.

The authors address the psychiatric connections to obesity with a brief comment:

Increases in other mental disorders complicated by obesity also merit further attention, especially because obesity has been documented to carry a strong social stigma.

Let’s set aside the obvious question of whether obesity causes depression or depression causes obesity, let alone well-documented side effects of anti-depressant induced weight gain in children.

As our courageous authors have done, let’s assume just for a minute that every instance of hospitalization due to depression was caused by obesity, and is therefore valid to include in their cost estimate. Even so, the conclusion they have subsequently drawn is incredibly disturbing.

The problem, as they see it, is that obesity carries a strong social stigma and that obesity itself causes one to bear the burden of that stigma, while society pays the price for securing the fat child’s mental health. Therefore, we may justify the millions we spend on preventing obesity in order to save these children from the torment of fat stigma.

In other words, shame on you, fat children, for allowing social stigma to damage your still-fragile emotional and psychological health.

Shame on you, fat children, for the millions of dollars society must pay to repair your brutalized egos.

Shame on you, fat children, for not simply losing weight and becoming physically and mentally healthy.

This is what the War on Obesity has come down to: waging psychological warfare on children and sending them the bill.

It was already hard enough to be a fat kid in America before the War on Fat began, as any adult survivor of a fat childhood can attest, but even more scrutiny has been placed on fat children with the predictable consequences of additional psychological trauma throughout society.

Any random idiot could have predicted that fat children would suffer even more symptoms of depression with the blazing white hot spotlight of the entire country focusing on them. What we couldn’t have predicted is that this discouraging trend would then be turned around and used against them to justify even more attention, which, in turn, will invite even greater stigma.

The bizarre, Kafka-esque logic that produced this paper leaves me completely and utterly speechless.

But I do have just one thing I want to say to the authors of this study, along with the countless media outlets that unfailingly broadcast this tripe to the masses, for using innocent, sick children to further their selfish agendas: how dare you.

*CCS stands for Clinical Classifications Software, which is a tool used to “cluster ICD-9 diagnoses into a management number of clinically meaningful categories.” ICD-9 stands for International Classification of Diseases, Ninth Revision.

**The eleven diagnoses include, in order of hospitalization frequency, affective disorders, pregnancy-related conditions, asthma, diabetes mellitus, appendicitis, other mental disorders, pneumonia, skin and subcutaneous infections, biliary tract disease, schizophrenia, and other bone diseases.