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Energy balance
Source: Centers for Disease Control And Prevention (CDC).
THE ENERGY BALANCE
INTAKECalories from foods
OUTPUTCalories used during
physical activity
• Hypertension (high blood pressure)
• Osteoarthritis
• Dyslipidemia
• Type 2 diabetes
• Coronary heart disease
• Stroke
• Gallbladder disease
• Sleep apnea and respiratory problems
• Some cancers (endometrial, breast, and colon)
Health consequences ofoverweight and obesity
• Psychosocial risks
• Cardiovascular disease risks
• Other health risks (asthma, hepatic steatosis,sleep apnea and type 2 diabetes)
Consequences ofchildhood overweight
Prevalence rates of obesity U.S., 1976-2006
Source: National Health And Nutrition Examination Survey.
Healthy People 2010 Target
2005-062003-20042001-021999-20001988-941976-80
50
40
30
20
10
0
Percent
Obesity prevalence for U.S. adults By age and sex, 2005-2006
60 and over40-5920-39Total
50
40
30
20
10
0
Percent
Source: National Health And Nutrition Examination Survey.
Men
Women
2003-042001-021999-001988-941976-801971-741966-70
20
15
10
5
0
Percent
Childhood prevalence of obesity U.S., 1966-2004
Source: National Health And Nutrition Examination Survey.
6-11
2-5
12-19
Overweight and physical activity U.S., 2003-2004, ages 10-17
Source: National Survey of Children’s Health.
0.5
0.55
0.6
0.65
0.7
0.75
0.8
0.05 0.1 0.15 0.2 0.25
Overweight
Ph
ys
ica
l A
cti
vit
y
Adult obesity-attributable percentand expenditures U.S., 1998-2000
MedicaidMedicareTotal
12
10
8
6
4
80
70
60
50
40
30
20
10
Percent US$ billions
Percent (L)
Expenditures (R)
Source: Finkelstein, Fiebelkorn, and Wang, Obesity Research, 2004.
Prevalence of cardiovascular risk factorsamong overweight and obese workers 1999-2000
Metabolic syndromeType 2 diabetes
DyslipidemiaHypertension
60
50
40
30
20
10
0
Percent
NormalOverweight Obese
Source: National Health And Nutrition Examination Survey.
Prevalence and number of diabetes U.S., 1980-2005
Source: National Health Interview Survey. U.S. Bureau of the Census.
0504
0302
0100
9998
9796
9594
9392
9190
8988
8786
8584
8382
8180
6.0
5.0
4.0
3.0
2.0
16
14
12
10
8
6
4
Percent Millions
Prevalence rates (L)
Number (R)
Age-adjusted male prevalence ofdiagnosed diabetes by race U.S., 1980-2005
Source: National Health Interview Survey.
05
04
03
02
01
00
99
98
97
96
95
94
93
92
91
90
89
88
87
86
85
84
83
82
81
80
9
8
7
6
5
4
3
2
Percent
Black
White
05
04
03
02
01
00
99
98
97
96
95
94
93
92
91
90
89
88
87
86
85
84
83
82
81
80
9
8
7
6
5
4
3
2
Percent
Age-adjusted female prevalence ofdiagnosed diabetes by race U.S., 1980-2005
Source: National Health Interview Survey.
Black
White
Obesity (BMI > 30) As percent of U.S. population
Source: Milken Institute.
049994898479746964
30
25
20
15
10
5
0
Per 100,000 Population
Causes of mortality: diabetes 1960-2004, selected countries
Source: OECD HealthDivision.
United States
United Kingdom
Japan
International trends of obesity 1991-2004
Source: OECD Health Division.
2004200220001991
40
30
20
10
0
Percent
JapanFranceUnited KingdomUnited States
Diabetes and obesity 2003-2004, Selected countries
Source: OECD Health Division.
0
5
10
15
20
25
30
35
0.0 5.0 10.0 15.0 20.0 25.0
Causes of Mortality (Diabetes): Deaths per 100,000 Population
Obe
sity
Rat
es
U.S.
Japan
U.K.Greece
France
PolandHungary
Finland Germany
Netherlands
SpainLuxembourg
78%
65%
48%
6%
16%
31%
0%
20%
40%
60%
80%
100%
18-34 35-44 45-54 55-64 65-74 75+
Prevalence of hypertension U.S., 1999-2000
Hy
pe
rte
ns
ion
Pre
va
len
ce
Age
Source: Fields et al. Hypertension. 2004:44;398-404.
Obesity trends among U.S. adults 1991
Source: Behavioral Risk Factor Surveillance System.
No Data <10% 10%–14% 15%–19%
Obesity trends among U.S. adults 2006
Source: Behavioral Risk Factor Surveillance System.
State laws addressingchildhood obesity 2007
Source: Childhood Obesity Prevention Legislation, 2007, State Legislation Report.
35
30
25
20
15
10
5
0
Mandates obesity
treatment coverage (4)
Establishes state task force
(12)Mandates
BMI screening(7)
Addresses physical activity (24)
Addresses school nutrition (27)
Number of states
VIDEO SAFE
Avoidable chronic disease treatment andproductivity costs if obesity were eliminated 2008
Source: Milken Institute.
38.234.6434.1387.4836.791.59Total
10.10.6615.04.4110.11.66Stroke
52.411.2552.478.1052.445.86Heart disease
31.012.8731.0124.2131.013.48Hypertension
36.56.0234.453.1836.513.42Diabetes
30.42.7537.992.1430.411.47 Other cancers
52.00.6552.119.3652.03.15 Prostate cancer
1.70.0061.10.511.70.08 Colon cancer
34.00.4434.015.5734.02.53 Breast cancer
31.23.8531.6127.5826.317.23Cancer
PercentDiff
MillionsPercent
DiffBillions
$Percent
DiffBillions
$Disease
CasesProductivityTreatment
Economic burden of chronic disease Introduction: Two Paths, Two Choices
1. What does chronic disease currently cost us?
2. Where is the current course taking us?
3. What costs are avoidable if we make improvements inprevention and treatment?
4. What are the impacts of chronic disease at the statelevel?
5. What is the long-term impact of reducing the diseaseburden?
6. What are the conclusions and recommendations of ourfindings?
The Human Cost: Number ReportingSeven Common Chronic Diseases U.S., 2003
2.4
10.6
13.7
19.1
30.3
36.8
49.2
- 10.0 20.0 30.0 40.0 50.0 60.0 70.0
Population Reporting Condition (Millions)
Stroke
Cancers
Diabetes
Heart Disease
Mental Disorders
Hypertension
Pulmonary Conditions
Source: Medical Expenditure Panel Survey, Milken Institute.
The Human Cost: Number of PeopleReporting Selected Cancers U.S., 2003
7.7
1.1 1.0
0.4 0.3
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
Other
Cancers
Breast
Cancer
Prostate
Cancer
Lung
Cancer
Colon
Cancer
Population Reporting Condition (Millions)
Source: Medical Expenditure Panel Survey, Milken Institute.
The Human Cost
Milken Institute State Chronic Disease Index
Top QuartileSecond Third Bottom Quartile
States in Top Quartile have the Lowest Rates of Seven Common Chronic Diseases
Source: Medical Expenditure Panel Survey, Milken Institute.
The Human CostMilken Institute State Chronic Disease Index Composite Scores
Source: Milken Institute.
State Rank
Composite
Score State Rank
Composite
Score
Utah 1 100.00 Vermont 26 75.62
Alaska 2 96.58 Maryland 27 75.05
Colorado 3 95.29 Michigan 28 74.82
New Mexico 4 93.50 Ohio 29 74.71
Arizona 5 91.50 Oregon 30 74.48
California 6 89.83 Georgia 31 74.12
Hawaii 7 88.38 New Jersey 32 74.10
Idaho 8 87.68 North Carolina 33 74.08
Washington 9 86.43 Connecticut 34 73.28
Wyoming 10 83.13 Delaware 35 73.18
Minnesota 11 82.59 South Dakota 36 72.20
Texas 12 82.26 Louisiana 37 70.55
Nevada 13 80.80 Florida 38 70.15
North Dakota 14 80.64 South Carolina 39 68.76
Illinois 15 80.04 Massachusetts 40 68.65
Kansas 16 79.87 Alabama 41 68.59
Nebraska 17 79.61 Oklahoma 42 67.76
New Hampshire 18 79.29 Maine 43 67.60
Montana 19 79.05 Rhode Island 44 66.76
Virginia 20 77.68 Pennsylvania 45 66.37
Wisconsin 21 77.29 Mississippi 46 66.17
New York 22 77.26 Kentucky 47 65.98
Indiana 23 77.14 Arkansas 48 65.68
Iowa 24 76.91 Tennessee 49 65.31
Missouri 25 76.12 West Virginia 50 62.19
The Economic Cost: TreatmentExpenditures by Chronic Disease U.S., 2003
$27
$33
$45
$46
$48
$65
$0 $10 $20 $30 $40 $50 $60 $70
US$ Billions
Stroke
Diabetes
Hypertension
Pulmonary Conditions
Mental Disorders
Cancers
Heart Disease
$14
Source: Medical Expenditure Panel Survey, Milken Institute.
The Economic Cost:Lost Productivity by Source, U.S. US$ Billions, 2003
Presenteeism
Caregiver,
$80.2
Lost
Workdays
Caregiver,
$10.8
Lost
Workdays
Individual,
$127.5
Presenteeism
Individual,
$828.2
Total Lost Productivity in 2003 = $1,046.7
Source: National Health Interview Survey, Milken Institute.
The Economic Cost:Lost Productivity by Chronic Disease U.S., 2003
$22
$94
$105
$105
$171
$271
$280
$0 $50 $100 $150 $200 $250 $300 $350
US$ Billions
Stroke
Pulmonary Conditions
Heart Disease
Diabetes
Mental Disorders
Cancers
Hypertension
Source: National Health Interview Survey, Milken Institute.
Population Projections U.S., 65 and Over
202320182013200820031998199319881983
20
18
16
14
12
10
8
Percent
History Forecast
Male 65 and overFemale 65 and over
Source: U.S. Census Bureau.
Projection of Cases and TreatmentCosts Baseline vs. Optimistic Scenario Process
1. Develop Based on Aging Population
2. Develop Based on Behavioral Risk Factors andOther Demographics
3. Develop Based on Screening, Early Detectionand Medical Innovations
4. Develop Based on Different Health Care CostGrowth
5. Avoidable Cost = Difference in ExpenditureBetween Baseline and Optimistic Scenarios
Percent Growth in Number ofPeople Reporting Chronic Diseases Current Path vs. Alternative Path, U.S., 2003-2023
42%17%
54%35%
29%5%
41%-8%
39%13%
39%6%
53%33%
31%13%
65%35%
75%38%
34%9%
32%9%
51%32%
62%33%
-10% 0% 10% 20% 30% 40% 50% 60% 70% 80%
ALL CANCERS
Breast Cancer
Colon Cancer
Lung Cancer
Prostate Cancer
Other Cancer
Pulmonary Conditions
Diabetes
ALL CARDIOVASCULAR
Hypertension
Heart Disease
Stroke
M ental Disorders
Total
Current Path Alternative Path
Heart Disease
Source: Medical Expenditure Panel Survey, Milken Institute.
Avoidable Treatment Expenditures U.S., 2023
$27 $10
$63 $17
$65 $23
$92 $26
$107 $28
$109 $37
$110 $76
$0 $20 $40 $60 $80 $100 $120 $140 $160 $180 $200
Treatment Expenditures (US$ Billions)
Stroke
Diabetes
Hypertension
Pulmonary Conditions
Mental Disorders
Cancers
Heart Disease
Alternative Future
Expenditures Avoided
Source: Milken Institute.
Avoidable Productivity Losses U.S., 2023
$14
$218 $47
$182 $137
$277 $73
$480 $88
$666 $173
$587 $373
0 100 200 300 400 500 600 700 800 900 1000
Productivity Losses
(US$ Billions)
Stroke
Pulmonary Conditions
Heart Disease
Diabetes
Mental Disorders
Hypertension
Cancers
Alternative Future
Productivity Losses Avoided
$47
Source: Milken Institute.
Avoidable Economic CostsAttributable to Decline in Obesity U.S., 2023
$15
$52 $39
$100 $87
$73 $118
$85 $312
$0 $50 $100 $150 $200 $250 $300 $350 $400 $450
Avoidable Economic Impact (US$ Billions)
Stroke
Diabetes
Hypertension
Heart Disease
Cancers
Obesity Other Factors
$3
=$397
=$191
=$187
=$92
=$19
Source: Milken Institute.
Long-Term Economic Impacts Overview
• Attempt to quantify health (chronic disease) impact
– on human and physical capital formation
– the restrictions imposed on intergenerational economic growth
• Determinants of economic growth and model specification
– Historically, only few have been found to be significant in explaining growth
• Human capital’s role
– Dynamic economic growth depends upon
• health (life expectancy at 65),
• stock of labor (labor force),
• quality of labor (percent of adult population with bachelor’s degree or above),
• physical capital (real stock of equipment and structures)
– Good health increases the rate of return to investments in education
– Improves the nation’s competitiveness in the long-term
– The higher the income earner’s human capital, the greater the probability that theywill invest in their children’s and grandchildren's education
Health and Human Capital 2003
Top QuartileSecond Third Bottom Quartile
Top QuartileSecond Third Bottom Quartile
Life Expectancy at 65 Population with Bachelor’s Degree Percent
Source: Milken Institute.
U.S. Long-Term Foregone Economic Output
Change in Real GDP Between Baseline and Optimistic Scenarios
0
1
2
3
4
5
6
US
$ T
rillio
ns
2005 2010 2015 2020 2025 2030 2035 2040 2045 2050
Year
Source: Milken Institute.
Economic Burden of Chronic Disease: Conclusions and Recommendations
Conclusions:
• Lost Productivity Surpasses Treatment as the Cause of EconomicBurden
• Early Interventions and Medical Innovations Improve Quality andLongevity of Life
• Healthcare Expenditure Accounts by Disease Are Needed
• Good Health Is an Investment in Economic Growth
Recommendations:
• Incentives for Prevention and Early Intervention
– We need private-public partnerships to incentivize patients andproviders to prevent chronic disease effectively
• “Healthy Body Weight Initiative”
– We need a strong, long-term national commitment to promotehealth, wellness, and healthy body weight
Hungry Man “All Day Breakfast”
Socio-Ecological Model
The Scope of the Obesity Problem
Source: JAMA 2006;295:1549-1555.
VIDEO SAFE
Prevalence of Obesity by Family Income 1999-2004, NHANES
12%21%21%18% 22% Mexican-American
21%27%17%19% 18% Black
11%14%15%15% 17% White
Race/Ethnicity
12%18%19%17%20% 12-19.9
14%16%18%16%21% 6-11.9
8%8%9%15%11% 2-5.9
Age Group (years)
11%17%15%15%18% Girls
12%15%17%17%18% Boys
Sex
12%16%16%16%18%Overall
43.0-3.92.0-2.91.0-1.9< 1.0
Income Ratio to Poverty Threshold
Source: Freedman et al.. Childhood overweight and family income. MedGenMed. 2007 May 3;9(2):26.
A comprehensive school-based trial to determineif changes in the school environment can reduce
risk factors for type 2 diabetes
Performed at 7 sites, in 42 middle schools
Studies to Treat Or Prevent Pediatric Type-2Diabetes
• 6th Grade Cohort
• 6367 participants (57.6% ofstudents)
• 11.8 + 1.1 years (range 9-15)
• 47.5% male; 52.5 females
• Ethnicity
– 53.1% Hispanic
– 19.8% African American
– 18.8% Non-Hispanic White
– 0.5% Native American
– 7.7% Other, Mixed
• 8th Grade Pilot
• 1740 participants (47% ofstudents)
• 13.6 ± 0.6 years (range 12-16)
• 43% male, 57% female
• Ethnicity
– 53% Hispanic
– 23% African American
– 15% Non-Hispanic White
– 3% Native American
– 6% Other, Mixed
Source: Diabetes Care 29;212;2006.
20
30
40
50
60
70
80
Male Female
White Black Hispanic American Indian
Total 49%Males 51%Females 48%
20
30
40
50
60
70
80
Pe
rce
nt
Male Female
White Black Hispanic American Indian
Total 50%Males 52%Females 47%
6th grade 8th grade
Percent with BMI 85th Percentileby Gender and Race/Ethnicity 6th Grade vs. 8th Grade
Diabetes Care 29;212;2006 Presented at ADA 2007
15.9% FBG 100-125 mg/dl 39.1 % FBG 100-125 mg/dl
What does the environmentoffer youth?
• 6212 children andadolescents 4-19 year
– 30% consumed fast foodon typical day
– Children eating fast foodconsumed additional 187kcal/day
• Teens consume 2X amountof sugar than recommended= 44% from soft drinks
– Evidence – 1 extra sodaincreases risk foroverweight by 60%
• Adolescents watch 3hours TV a day
• 32% of 2-7 year olds and65% of 8-18 year olds haveTV in their bedrooms
0
5
10
15
20
25
30
35
0-2
Hours
2-3
Hours
3-4
Hours
4-5
Hours
>5
Hours
% Overweight
Sources: Ludwig DS, Peterson KE, Gortmaker SL. Lancet 2001;357:505-08.Bowman SA et al. Pediatrics2004; 113: 112-118. Pereira MA et al. Lancet 2005; 365:36-42, 4-5.
Gut
Food
Pancreas
Muscle
Insulin Glucose
Elevation of blood glucose:The hallmark of diabetes
• Type 1 diabetes - <10% of all diabetes
– Genes and the environment
– Cannot be prevented
– Destruction of pancreatic cells due toautoimmune disease
– Failure to secrete sufficient insulin
– Must take insulin everyday
• Type 2 diabetes - >90% of all diabetes
– Can be prevented – 90%overweight or obese
– Genes and the environment
– Insulin resistance and relativeinsulin deficiency
– Can take pills, and/or insulin
<4% 4%-6% 6-8% 8-10% >10%
The Global Diabesity Epidemic
Diabetes World WideDiabetes World Wide 2003 = 194 million 2003 = 194 million 2025 = 333 million 2025 = 333 million
Increase 72%Increase 72%
Diabetes Trends1990 1995
2001
Type 1 increase – 3%/year
Type 2 increase – 10-fold in 10 years
0-9 years, 0.79 per 1000 10-19 years, 2.80 per 1000
The SEARCH Study
1.82 cases per 1000 youth
Total cases 154,369 in 2001
Source: Pediatrics 2006;118:1510.
Diabetes is the 2nd MostCommon Chronic Childhood
Type 2 diabetes in theyoung: there has been aglobal increase
•Children in both developedand developing nations
•The risk of type 2 diabetesis linked to obesity(associated with•changing dietary andlifestyle patterns)
• NHANES 1999-2002
– 0.5% of adolescents
– 39,005 US teens withT2D
• Australia
– Aboriginal children
• Doubling to 1.3%
• Canada
– 4% prevalence inNative Canadian
• Different in Europe
– 0.5% of children havetype 2
Sources: Duncan, Arch Pediatr Adolesc Med 2006;160:523; Geiss, Am J Prevent Med 2006;30:371
More children worldwide aredeveloping type 2 diabetesIDF Atlas of Diabetes 2006: Type 2 diabetes key facts
9
8
7
6
5
1975 1980 1985 1990 1995
10
20
30
40
50
60
70
80
Ty
pe
2 d
iab
ete
sin
cid
en
ce O
be
sity
(%)
Type 2 diabetes
Obesity
Pediatric type 2 diabetes in Japan
4 fold rise in 6-15 year olds, type 2 has now overtaken type 1 in Japan … Challenge of best treatment
Source: Kitigawa T et al. Clin Pediatr (Phila) 1998; 37: 111-115.
Standard Approaches to Therapy Resultin Prolonged Exposure to Elevated Glucose
Source: Brown JB et al. Diabetes Care. 2004;27:1535-1540.
Intensive Therapy for Diabetes
Source: DCCT Research Group. N Engl J Med. 1993;329:977-986; Ohkubo Y, et al. Diabetes Res Clin Pract. 1995;28:103-117; UKPDS 33: Lancet. 1998;352: 837-853; Stratton IM, et al. Brit Med J. 2000;321:405-412.
Reduction in Incidence of Complications
Diabetes is Serious Even in KidsA Cause of Morbidity and Mortality
Type 1 versus Type 2 Outcomes in Youth In Australia
Diabetes Care 29:1300,06
Opportunity to Improve U.S. DiabetesTreatment Standards
Source: The Lancet, Vol. 356, August 26, 2000.
“The age-adjusted death rate for diabetes in the USA hasincreased 30% since 1980.”
Uncontrolled diabetes destroyspeople’s lives
HEALTHY Study
Decrease percent of students with risk factors for
type 2 diabetes compared to control
The cohort is over 6,367 6th graders, followed to 8th grade
Type 2 Diabetes PreventionResults of Randomized Trials
The Diabetes Prevention Program
A Randomized Clinical Trial to Prevent Type 2 Diabetes in Persons at High Risk
The U.S. Diabetes Prevention Program
Lifestyle vs. Placebo
U.S. Diabetes Prevention Program
Source: DPP Research Group NEJM, 2002.
Lifestyle vs. Placebo
• Compared with the placebo intervention, thelifestyle intervention was cost-saving in participantsyounger than 45 years of age and cost effective inall age groups.
• From the perspective of a health system, thelifestyle intervention was highly cost-effective,costing only $1100 per QALY.
DPP
• How do we bring the DPP to the 50 millionAmericans at imminent risk?
- It requires behavior change to increase physicalactivity and improve nutrient and calorie intake
• To replicate the DPP
- Lifestyle coaching (1 coach for 25-30patients)
- Cost per patient: $3,540 over 3 years
- We would need 1,500,000 coaches at acost of 5.3 billion dollars
The Public Health Question of MyGeneration of Health Care Providers
We Need to Translate the DPP
This cannot be done in the Health Care Setting
It must move to Community Venues
The Workplace
Established Lifestyle Programs – combiningphysical activity and nutrition coaching and
support
Use technology for enhancement, maintenance
DPP Results
Kids N Fitness ProgramA Program for Weight Maintenance
Change in mean BMI Percentiles Baselineto Follow-up Mean time elapsed 9.1 months +/- 1.7
70
72
74
76
78
80
82
Baseline Follow-up
Intervention Control
Economic and Public Health Approaches
• Positive Analysis: Explain how health is determined
• Private Costs and Benefits drives Behavior
• Normative Analysis:
• Social vs Private Costs and Public Interventions
• Maximize health is not sensible policy objective
• Highways, airports, etc
• Transportation Induced Mortality vs TechnologicalChange and Obesity
Discussed Work Today
• Lakdawalla, D., T. Philipson, and J., Bhattacharya, (2005) "WelfareEnhancing Technological Change and The Growth in Obesity",American Economic Review, v 95 (2), pp 253-257.
• Philipson, T., and R., Posner, (2003), “The Long Run Growth ofObesity as a Function of Technological Change, Perspectives inBiology and Medicine, Summer, v 46, No 3, 87-108. [Also NBERWorking Paper # 7423].
• Lakdawalla, D., and T. Philipson. “Labor Supply and Weight”,Journal of Human Resources, 2006.
• Lakdawalla, D., and T. Philipson. “The Growth in Obesity andtechnological Change: A Theoretical And Empirical Examination.”NBER Working Paper #8446
• Philipson, T., and R., Posner, “ Is The Obesity Epidemic a PublicHealth Problem? A Decade of Research on The Economics ofObesity”, forthcoming, Journal of Economic Literature.
Historical Growth in Weight
Source: Costa D. and R. Steckel (1995), NBER Historical WP #76.
Calories Produced per Person-Day 1906-1998
Source: USDA’s Economic Research Service.
Food Price Time Series
Technological Change & Obesity
Economic Forces Have Been Neglected
• Agricultural TC: Price of Calorie ConsumptionFallen
– Specialization In Production: Agriculture
– Specialization in Preparation: Home vs. Market
• Female Labor Supply + Value of Speed
• Productivity Enhancing TC: Price of CalorieSpending Has Risen
– Pay, as opposed to get Paid, to Exercise
– Labor to Leisure : Gym +Jogging (Total Up)
Why Both Forms of TechnologicalChange ?
• Together Imply: weight rises, calorie intake ambiguous,and price falls
• Fall in Food Prices Alone:
• Cannot Explain Lack of Time Series CorrelationBetween Weight and Calorie Intake
• More Sedentary Technologies Alone:
• Cannot Explain Increases in Calorie Intake
• Demand Explanations (“Food Culture”):• Demand increase alone cannot explain the 3 time
trends together
Earned vs. Unearned Income Effects
• Asset Market vs. Labor market Effects
• Income Effects Within vs. Across Countries
• Public Redistribution Effects
• Future Time-Series dependent on which effectdominates.
Empirical Analysis
• The Effect of Physical Activity at work on BMI– Strenuousness from Dictionary of Occupational Titles
– Merge with data from NHIS (1976-1994) and NLSY(1978-1996)
• Exploit NLSY features– Estimate long-run effects of occupation on weight
– Assess Endogeneity of occupation and weight
• Main Results : Work Effects & Decomposition– Weight differences due work-career 3.3 BMI
• Large relative to secular trends
Alternative Explanations
• Nutritional Knowledge– Wrong Time Trend-Know More Now– Knowledge and Health Covary but Endogenous
• Weight as Signal– Time Trend Difficult to Explain
• Genetics– Speed Difficult To Explain– Interaction (not Nurture vs Nature) explains price effects
• Market Preparation & Fast Food– Producer=Consumer Interest ?– Fast Food Implication of Technological Change and
Value of (Female)Time– Fast Food Share Less Than 10 % of Calories
Public Policy and Obesity
• Positive Analysis• Programs Assessed in Light of Forces of Growth• Example: Public Education & Food Labeling
• Information Ability to Explain Time Trend ?
• Normative Analysis
• Over-weight in Pareto Sense ?• If Yes: Non-Linear Taxes on Calories
• Addiction and Government• Insurance Externalities: Medicare and Social
Security• Smoking Analogy• Fiscal Externalities Really The Issue?
• Obesity Public Health Problem ?
Calories CountReport of the
Working Group on Obesity
Department of Health and Human ServicesFood and Drug Administration
Prevalence rates of overweightand obesity in the United States, adults 1995-2006
Source: Behavioral Risk Factor Surveillance System.
200620052004200320022001200019991998199719961995
40
35
30
25
20
15
Percent
Overweight
Obese
Physical activity 2001 and 2005
Source: National Health Interview Survey.
2001 2005
83MilkenInstitute_v1
Obesity RoundtableMilken Institute Global Conference
April 28, 2008
Steve BurdChairman, President & CEO
Safeway Inc.
84MilkenInstitute_v1
US Healthcare Costs Rising Rapidly
25.9%
22.0%
18.7%
16.2%
13.8%12.4%
9.1%7.2%
'70 '80 '90 '00 '05 '10 '15 '20
$ Billion
$75 $255 $717 $1,359 $2,016 $2,992 $4,437 $6,580
Sources: Centers for Medicare and Medicaid Services (CMS), Office of the Actuary; Safeway analysis
Healthcare Costs - % of GDP
85MilkenInstitute_v1
We Believe this is a Very Solvable Problem
70% of healthcare costs are driven by behavior
74% of all costs are confined to four chronicconditions
Obesity is the most important and pervasive costdriver . . . the condition and its costs can be reversed
Every private sector company can experience percapita cost declines without cost-shifting orgovernment help
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“Big Four” Chronic Conditions Dominate Costs
33%
20%
11%
10%
9%
17% 100%
Cardio-
vascular
Disease
Cancer Diabetes Over-
weight &
Obesity
Other
Chronic
All Other Total
Healthcare
Cost
Source: CDC, HHS
Cost Distribution by Disease State - 2005
74% of Total Costs
Nearlyall can
improve
80%Type 2
40% / 60%80%Heart dis,
stroke % Preventable / Manageable
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Cardiovascular Risk FactorsOverweight & Obese vs. Normal Weight
8.3
2.6 2.5
1.11.4
4.4
3.4
1.6
Metabolic
Syndrome
Hypertension Type II Diabetes Dyslipidemia
Obese Overweight
Times Normal Weight Risk
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Elements of the Solution
Understanding energy balance – calories in andcalories out
– 3,500 calories = 1 pound
– Pull both levers simultaneously; lots of combinations
Managing calories in
– Healthy alternatives: what you choose to eat
– Recipes and preparation
– Portion control
Exercise and social networking
– Small (10 members) support networks
– Realistic goals and timeframes
– Short interval reporting; sharing what works
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Elements of the Solution
Personal movement and exercise program
– Cardio and weight training
– Many possible activities to achieve burn target
– Physical trainer can help get people started
KFS: Each individual defines his / her own program
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Food Industry Obesity Challenge
CEO commitments
– 10+ CEO working group developing the details
– 30+ CEOs / companies will be recruited
Three areas of focus
– Understanding energy balance
– Physical education back in the schools
– Walking the talk . . . reducing obesity in our employeepopulation
Deliverable: Proven template for national action
Timeframe: 18 months