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velop at least one of a range of debilitating conditions which can drastically reduce quality of life. These include musculoskeletal disorders, respiratory difficulties, skin problems and infertility, which are often costly in terms of absence from work and use of health resources. Table 1.3 lists the health problems that are most commonly associated with overweight and obesity. In developed countries, excessive body weight is also frequently associated with psychosocial problems.

The risk of developing metabolic complications is exaggerated in people who have central obesity. This is related to a number of structural differences between intra-abdominal and subcutaneous adipose tissues which makes the former more susceptible to both hormonal stimulation and changes in lipid metabolism. People of Asian descent who live in urban societies are particularly susceptible to central obesity and tend to develop NIDDM and CHD at lower levels of overweight than other populations.

Overview of the Economic Costs

Conservative estimates clearly indicate that obesity represents one of the largest costs in national health care budgets, accounting for up to 6% of total expenditure in several developed countries (Table 1.4). In the USA in 1995, for example, the overall direct costs attributed to obesity (through hospitalizations, outpatients, medications and allied health professionals' costs) were approximately the same as those of diabetes, 1.25 times greater than those of coronary heart disease, and 2.7 times greater than those of hypertension (5). The costs associated with pre-obesity (BMI 25-30 kg/m2) are also substantial because of the large proportion of individuals involved.

The economic impact of overweight and obesity does not only relate to the direct cost of treatment in the formal health care system. It is also important to consider the cost to the individual in terms of ill health and reduced quality of life (intangible costs), and the cost to the rest of society in terms of lost productivity due to sick leave and premature disability pensions (indirect costs). Overweight and obesity are responsible for a considerable proportion of both. Thus, the cost of lost productivity attributed to obesity in the USA in 1994 was $3.9 billion and reflected 39.2 million days of lost work. In addition, there were 239 million restricted-activity days, 89.5 million bed-days, and 62.6 million physician visits.

Estimates of the economic impact of overweight and obesity in less developed countries are not available. However, the relative costs of treatment if available are likely to exceed those in more affluent countries for a number of reasons. These include the accompanying rise in coronary heart disease and other non-communicable diseases, the need to import expensive technology with scarce foreign exchange, and the need to provide specialist training

Low risk Moderate risk High risk

Table 1.4 Conservative estimates of the direct economic costs of obesity

Country Year Obesity definition Estimated direct costs % National health care costs

USA 1995 BMI >30 US$52 billion 5.7

Australia 1989/90 BMI >30 AUD$464 million >2

Netherlands 1981-89 BMI >25 Guilders 1 billion 4

France 1992 BMI >27 FF12 billion 2

Table 1.5 Estimated world prevalence of obesity

Population aged >15 Prevalence of Approximate estimate (mid-point) of years (millions) obesity (%) number of obese individuals (millions)

Established market economies

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