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How Dare You —

September 20, 2011
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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.

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22 Comments leave one →
  1. sweet Priscilla permalink
    September 20, 2011 1:34 pm

    I’m not as much pissed as horribly horribly sad…
    When is this witch huint going to end?

    • September 20, 2011 4:42 pm

      I don’t know, Priscilla, but I do know they’re doing more damage waging this war than there would be with a more sensible, health-based policy.

      Peace,
      Shannon

  2. vesta44 permalink
    September 20, 2011 3:58 pm

    I’d love to see a study done on the costs of alcoholism – I would wager that its costs far outweigh the so-called “costs of obesity”. Treatment, time missed from work, deaths caused by drunk drivers (and the lost wages/taxes unpaid of those lives), etc not to mention the costs to the health of the alcoholics themselves. But that’s a socially acceptable way to kill yourself and others, and the ravages of it don’t show up physically, if at all, for years (not that I’m saying being fat is killing yourself, it’s not – just that society sees it that way, unjust as it is).

    • September 20, 2011 4:44 pm

      I’m right there with you, vesta. If this were simply about our health, then we’d see the same amount of energy spent on alcohol consumption, which is just behind obesity in terms of mortality. Plus, alcoholism affects other people directly, as with the example you gave of drunk drivers. I didn’t even think of the lost productivity from victims of drunk drivers. Hell, we could come up with our own staggering report on alcoholism and these piddling obesity estimates would pale in comparison. It’s all about socially acceptable vice, of which drinking is Number One.

      Peace,
      Shannon

  3. Catgal permalink
    September 22, 2011 2:56 pm

    Wow. I never thought of the Alcoholism statistics. They have to be huge! What about prescription drug abusers? Smokers? Smokers are being legislated right out of a habit, for their own good of course. Look government, give out as much advice as you want and let people do what they want with it. You can not legislate me thin!

    • September 26, 2011 4:48 pm

      Or stress. Just watched a great documentary about stress this weekend, which will definitely be an upcoming post.

      And you know what? They would never use those statistics to drum up the kind of public health campaign against any of these health issues. A few PSAs and required “Drink Responsibly!” tags and we’re set. But for the fatties? Full frontal assault until we eradicate every last fat cell.

      The level of hypocrisy is astonishing.

      Peace,
      Shannon

  4. Fab@54 permalink
    September 23, 2011 8:47 am

    OK, My experience yesterday at the health clinic made me think of this post and comments.
    (I also need to vent a little)

    So I go to the clinic, yesterday. Am I sick? No. But I need my life-long BP and thyroid meds refilled, so of course I have to schlep to the clinic, pay them $25 (that I really can’t afford) just so they can check off a few boxes on a form and then renew my $150 worth of scripts for 3 months. (Joy). Ok, I know the deal, can’t fight city hall I guess….

    I’m handed a script for blood work to check thyroid, glucose levels, and a few other things I have no complaints about, but I really don’t look at it until I’m in my car.
    There on the bottom of the script is a list of diagnoses;

    [medical code] Hypertension (systemic)
    [medical code] Joint pain, localized in left knee / left shoulder
    [medical code] Osteoarthritis
    [medical code] Obesity
    [medical code] Hypothyroid

    Hypertension, (Blood pressure) and Hypothyroid are reasons to take blood work and check levels. So that’s logical. I was given a script for pain meds — after bitching for 20 minutes and stressing, over and over again, that I am “in pain –EVERY DAY”, so I understand why Osteoarthritis and Joint Pain is listed on this particular diagnosis/assessment.

    But Obesity? WHY is that listed?
    I have never been treated *specifically* for Obesity. I have never sought weight loss advice, diet programs, or nutritional information. I have never complained about my weight, or asked for diet pills or about WLS. I have never even MENTIONED my weight in conjunction with any other complaint I have presently, or in the past.
    So why is it automatically listed as a current diagnosis? Just because I am (obese)?

    Well, no wonder every single fat person who sees a physician for ANY REASON UNDER THE SUN is counted as a medical obesity patient and the statistics are skewed sky high for our ‘medical costs’.

    Meanwhile, I COULD be an alcoholic, or a drug dependent person, or any number of other things that doctor wouldn’t have a CLUE about — unless I exposed that about myself. And those things could REALLY be affecting my health and be considered a diagnosis; but noooo…. I was never asked about those things. But they can SEE I’m fat, so that’s enough of a “diagnosis” for them! I’m really pissed about this.

    • September 26, 2011 5:08 pm

      This is exactly the problem. And are they stressing the same diagnostic standards for those in all weight categories? Let’s say that a thin person with your exact same list of complaints came in. Would they document that this person was “normal” weight? Would they dig down to find out the source of that ‘person’s hypertension? Stress, maybe? Underweight is consistently side-by-side with obesity in terms of correlation and mortality. Would an underweight person with hypertension have that underlying causes assumed?

      It almost seems like obesity is its own diagnosis. If your weight and height give you a BMI, then they are encouraged to chart it, while the other weights don’t include a similar diagnosis. And the reason is because obesity itself has been turned into a disease. And the paranoid part of me can’t help but wonder if they have been pushing for a diagnosis of obesity for reasons like this: long-term statistical tracking.

      But if they aren’t also tracking the other weight classes with equal vigilance, then there’s no point, really, aside from the shock value of having a ton of correlated diagnoses they can point to in reports like this and say, “SEE! OBESITY AND XXX ARE ON THE RISE!”

      Maybe I’m just cynical, though.

      Peace,
      Shannon

    • BBDee permalink
      June 12, 2012 9:19 pm

      Hi Fab, sorry I’m repeating myself here but i soooooooooo know what you’re talking about and also need to vent more about an outrage I endured from a doctor today. He recommended BARIATRIC SURGERY as treatment for a COLD!!! My raw, red throat was not caused by me being sick, but because “it’s really crowded in there because of all that fat around your neck!” I am so urinated off I have no idea how i’ll get to sleep tonight.

  5. September 23, 2011 11:11 am

    And even if, for a second, all of the statistical voodoo was absolute 100% correct…it shouldn’t matter how much the fatties cost us in healthcare BECAUSE THEY ARE PEOPLE. Same as alcoholics or other substance abusers, people with mental illnesses, people with Autism, or terminal illnesses.

    It brings to mind Dave Eggers’ op-ed piece in the NYT about teachers and how Americans (don’t) value education. He said that people are wringing their hands about cost when really we should shut up and just do it. We found a way (financially) to get to the moon back during the Space Race; we can find a way to treat all of our fellow human beings with dignity and respect and do our best to give them the best quality of life possible.

    • Fab@54 permalink
      September 24, 2011 8:40 am

      Amen sistah.

    • September 26, 2011 5:35 pm

      Exactly. I often give an example of a client I worked with a while back. He was drinking and driving on his 21st birthday and had a horrible accident and had a traumatic brain injury. The economic costs to keep him alive, let alone to help him become mobile (with the aid of an electric wheelchair) and communicative (with the aid of a computer speaking device). This was 20 years ago, and he has needed constant medical supervision that entire time. But if you want to be cold and ruthless about it, you could say he did it to himself. He got drunk and wrecked his car, so why should we pay for him?

      The fact is, people make poor choices, but you don’t leave them in a ditch to die because it costs too much. Same with fat people… even if every fatty is a gluttonous sloth, you don’t just abandon them to poor health. But most fatties aren’t gluttonous sloths. Most are doing the best they can with the resources they have. But our government, and our society, treats all fat people like gluttonous sloths, and any diseases the gluttonous sloths get were totally preventable.

      Except, even if that were true, the costs of treating disease do not explain the cost of healthcare in the United States. I had skimmed this post before, but I finally read it all the way through and I highly recommend it. But here’s the best takeaway, from one of their sources:

      Obesity isn’t that expensive, either. It’s not driving our costs.

      Before you start in on me about how obesity is linked to other things and such, you should know that the overall McKinsey & Company analysis showed that the prevalences of disease in the US could account for perhaps an extra $25 billion in health care spending. Let me make a new chart for you:

      Chart

      This is what is really driving healthcare costs: technology and profiteering.

      Of course, it’s easier to pass the buck onto fatties than to have a nuanced conversation about cost, but that’s another conversation for another day.

      Dignity and respect are our right, regardless of the cost.

      Thank you for commenting, Kokoba.

      Peace,
      Shannon

  6. vesta44 permalink
    September 23, 2011 11:28 am

    Yeah, Fab@54, I know the feeling all too well. I just had my thyroid removed last week, and my surgeon said it should have come out 4 years ago, when it was first diagnosed as enlarged (Dr W, who diagnosed it, said it was nothing to worry about, that I was just using it as an excuse to be fat). The reason it should have come out 4 years ago? Well, for starters, a surgery that normally takes 3 hours took 4 1/2 because my thyroid was so enlarged, it was almost wrapped around my wind pipe and esophagus. Nothing to worry about all right. And you know my surgery is going to be cited as one of the rising costs of obesity, simply because I’m a DEATHFATZ bitch who won’t cave and starve myself thin. And the thyroid medication that I’m going to have to take for the rest of my life is probably going to be another of those costs, for the same reason. I’ve had “OBESITY” stamped on my medical records as a diagnosis for more years than I care to count, because every doctor I’ve ever seen has been too lazy to look for real causes of my problems and would rather blame them on fat and prescribe the Nightmare On ELMM Street. I’m beginning to think that fat-phobia and laziness go hand-in-hand when it comes to the medical field.

    • Fab@54 permalink
      September 23, 2011 12:37 pm

      Vesta, thanks for sharing your experience as well. I’m tellin’ ya, the more I think about it, the more pissed off I get!

      And here’s another issue I have that’s all wrapped up in being “fat” in a doctor’s office;
      My blood pressure.
      I was diagnosed with BORDERLINE “high” bp several years ago.
      By borderline, I mean my average bp at any given time was around 120/ 85-90.
      Not perfect… but certainly not something to worry about.

      And I know what I’m talking about because I was a trained, certified EKG technician and certified phlebotomist. I know how to take and read vitals. But just like BMI ranges, the powers that be (pharmaceutical companies and their distributors- doctors) decided that they needed to LOWER the ranges for what was considered “high” and “borderline high” BP. Suddenly I find myself on pills for high blood pressure. But even with BP meds, I am still always checking out with “borderline high bp” at 120 / 90-100. Huh?

      I believe it all comes down to technicians and nurses EXPECTING me to have high bp when they see how fat I am. Let me explain further….
      Taking someone’s BP should never EVER hurt them, unless they have extremely high BP and you *need to* pump up the cuff over 200. You should NEVER pump that cuff up to 200 or beyond the first time you attempt to take a person’s BP. Never. IT HURTS. A LOT.

      All you need to do is pump up slowly, and deliberately, and WAIT between every few pumps to see when you can no longer hear the pulse. You don’t have to pump it up like a freakin’ maniac until you’re at 190-200 before you start listening! IT HURTS. I’d go home with bruises and lingering, aching pain in my (fat) upper arm every time.

      And that’s the other thing- VERY FAT UPPER ARMS make it difficult to get an accurate reading even with an extra large cuff. I have fat upper arms. Really fat upper arms!

      A few visits back, I got sick and tired of them hurting me trying to get a BP reading. I refused to have the nurse take it on my upper arm. I told her, “Go get a special wrist cuff, or take it on my forearm”. They started taking it on my lower arm. Guess what? Not only is it easier to hear the pulse and there’s no need to bring me to fucking tears — my BP has been in the “normal” range now for the last 2-3 visits. Imagine that. My next move? To wean myself off these stupid BP meds with – or without- my doctor’s approval, and see where my TRUE bp range is.

    • September 27, 2011 11:29 am

      Gee, a person with a thyroid problem is obese? Clearly obesity CAUSED the thyroid condition. CHARGE IT TO THE FATTIES!

      Peace,
      Shannon

  7. vesta44 permalink
    September 23, 2011 2:04 pm

    Fab@54, I’ve had the same damned problem with blood pressure readings too. I have a wrist blood pressure cuff at home, and when I check my blood pressure at home, it’s usually in the 112/65 to 124/76 range. Go to the doctor’s office, they use an extra large cuff, on my very fat upper arm (it measures 21″) and they pump it up to 200 because, well, I’m fat and therefore I’m supposed to have high blood pressure. I have fibromyalgia, which complicates things, makes it hurt like hell, pisses me off, and so of course, my blood pressure is high when they take it (usually about 128/80). My former Dr wanted to put me on BP meds and I told her to take a hike, that she was the reason my BP was high when I had to see her, and she could just deal with it.
    Now, when I was in the hospital, they used the regular blood pressure cuff, and took it on my lower arm. Guess what my blood pressure was? Every time it was in the range I quoted above – 112/65 to 124/76 and the nurses all told me that was very good. My surgeon was happy with it, and so was my endo. And the machine doesn’t pump the cuff up fast, it goes slowly, and only as far as it needs to. As far as I’m concerned. every doctor’s office should be using that machine to check blood pressure, and should be doing it on the forearm of fat people, instead of the upper arm. It would be more accurate and would get a lot of people off of unnecessary medication.

    • sweet Priscilla permalink
      September 23, 2011 5:15 pm

      What an eye opener! I used to wonder if I was the only one who dreaded getting her BP checked because they pumped it so hard I’d have a black and blue mark on my arm! I don’t have really big arms either, it was more like they couldn’t believe a fatty like me could have normal bp readings

    • September 27, 2011 11:32 am

      That is fascinating. I wonder if there are any studies on size, BP cuffs and location of the cuff… it doesn’t seem that difficult to test whether those kinds of variables have an effect on overall BP. Interesting.

      Peace,
      Shannon

  8. Fab@54 permalink
    September 23, 2011 5:59 pm

    Ha! I wonder if a doctor saw a patient sitting in a sports bar, enjoying a couple of beers, if they would then stamp this patient’s medical record “ALCOHOLIC” at the next visit, just because they SAW this person drink beer.
    That makes about as much sense as stamping fat people’s medical records with “OBESITY” — even if NONE of the patient’s complaints, illnesses or treatments had anything to do with being fat.

    • sweet Priscilla permalink
      September 23, 2011 6:11 pm

      I came back from living in Ecuador with a serious case of impatego, forgive my spelling, my friend who is nurse diagnosed me but couldn’t write a prescription so I had to go to a walk in clinic. The Doc looked at me and said “How long have you been diabetic?” So being overweight with a tropical infection meant I was just a fatty with wounds that don’t heal? I asked her to please writye me a prescription for an antibiotic and that was the last I saw of her

      • Fab@54 permalink
        September 25, 2011 11:45 am

        The medical profession has a lot to learn (and UN-learn) when it comes to accurately assessing what is – or is not – “obesity related” problems and diagnoses. And doctors and nurses really should check themselves on those instant eye-ball assumptions and narrow-mindedness.

  9. BBDee permalink
    June 12, 2012 9:14 pm

    Also the interesting fact that I have not YET been busted for Driving While Fat or fired from a job for coming in fat. (Not hired for a few, but that’s another story…

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