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The Economics of Overweight and Obesity

The Economics of Overweight and Obesity

The economic impact of obesity is considerable. According to the American Obesity Association (AOA), in ''Costs of Obesity'' (May 2, 2005,, the World Bank estimates the cost of obesity in the United States was 12% of the national health-care budget in the late 1990s. The increasing prevalence of overweight and obesity in the United States has resulted in a corresponding increase in direct and indirect health-care costs. Direct health-care costs are those incurred for preventive measures, diagnostic, and treatment services. Examples of direct health-care costs are physician office visits, hospital and nursing home charges, prescription drug costs, and special hospital beds to accommodate obese patients. Indirect costs are measured in terms of decreased earnings: lost wages and lower productivity resulting from the inability to work because of illness or disability, as well as the value of future earnings lost by premature mortality (death).

There are also personal costs of obesity: obese workers may earn less than their healthy-weight counterparts because of job discrimination. Many insurance companies, particularly in the life insurance sector, charge higher premiums with increasing degrees of overweight. When obesity compromises physical functioning and limits activities of daily living, affected individuals may require assistance from home health aides, durable medical equipment such as walkers or wheelchairs, or other costly adaptations to accommodate disability.


The National Center for Chronic Disease Prevention and Health Promotion (NCCDHP) calculates and compares in Chronic Disease Prevention(August 16, 2007, the economic burden of several chronic diseases including obesity. Table 7.1 shows that the direct health costs resulting from overweight and obesity—$75 billion—are comparable to those resulting from tobacco use. Because obesity has been linked to all the other chronic conditions described in Table 7.1 except tobacco use, it may be argued that some percentage of the costs attributed to arthritis, cancer, diabetes, heart disease, and stroke are also attributable to obesity. For example, Kathleen M. McTigue et al. estimate in ''Screening and Interventions for Obesity in Adults: Summary of the Evidence for the U.S. Preventive Services Task Force'' (Annals of Internal Medicine, vol.139, no. 11, December 2, 2003) that the direct costs of obesity are 5.7% of the total U.S. health care expenditures; however, the lifetime costs of cardiovascular disease increase by 20% with mild obesity, 50% with moderate obesity, and by almost 200% with clinically severe or extreme obesity. The NCCDHP also reports that hospital costs for treatment of overweight and obese children and teens more than tripled from 1983 to 2003.

According to Anne M. Wolf, JoAnn E. Manson, and Graham A. Colditz, in ''The Economic Impact of Overweight, Obesity, and Weight Loss'' (Robert H. Eckel, ed., Obesity: Mechanisms and Clinical Management, 2003), the estimated annual medical spending attributable to overweight and obesity was about $93 billion in 2002. Wolf, Manson, and Colditz estimate the total cost as $117 billion, with an additional $33 billion spent on weightloss products and services. Estimates of the medical care costs, direct and indirect as well as total cost of overweight and obesity in the United States, vary depending on how the conditions are defined, whether overweight and obesity are considered together or separately, and which costs and obesity-related conditions are included in the estimates and projections. For example, Wolf, Manson, and Colditz's total cost is based on epidemiological studies that defined obesity and overweight as a body mass index (BMI) equal to or greater than 29.

Disease/risk factorsMorbidity (illness)Mortality (death)Direct cost/indirect cost
ArthritisArthritis affects 1 in 5, or 46 million, US adults, making it one of the most common chronic conditions. Over 40%, or nearly 19 million, adults with arthritis and other related rheumatic because of their arthritis. By 2030, nearly 67 million (25%) of U.S. adults will have doctor-diagnosed arthritis. In addition, adults with arthritis-attributable activity limitation are projected to increase from 16.9 million (7.9%) to 25 million (9.3% of the US adult population) by 2030.From 1979-1998, the annual number of arthritis are limited in their activities conditions (AORC) deaths rose from 5,537 to 9,367. In 1998, the crude death rate from AORC was 3.48 per 100,000 population.The total costs attributable to arthritis and other rheumatic conditions (AORC) in the United States in 2003 was approximately $128 billion ($80.8 billion in medical care expenditures and $47 billion in earnings losses). This equaled 1.2% of the 2003 U.S. gross domestic product.
CancerAbout 1.3 million people in the U.S. are diagnosed with cancer each year.Cancer is the second leading cause of death in the United States. In 2003, an estimated 556,000 people died of cancer.NIH (National Institutes of Health) estimates that the overall costs for cancer in the year 2006 at 206 billion: of this amount, $78 billion for direct medical costs and more than $128 billion for indirect costs such as lost productivity.
DiabetesMore than 20.8 million Americans have diabetes, and about 6.2 million don't know that they have the disease.Diabetes is the sixth leading cause of death. Over 200,000 people die each year of diabetes-related complications.The estimated economic cost of diabetes in 2002 was $132 billion. Of this amount, $92 billion was due to direct medical costs and $40 billion to indirect costs such as lost workdays, restricted activity, and disability due to diabetes.
Heart disease and strokeMore than 79 million Americans currently live with a cardiovascular disease.More than 1.4 million Americans die of cardiovascular diseases each year, which amounts to one death every 36 seconds.The cost of cardiovascular disease and stroke in the United States in 2007 is projected to be $431.8 billion including direct and indirect costs.
Overweight/obesityIn 2003-2004 over 66 million adults, or 32% of the adult population, were obese. Over 125 million or 17.1% of children and adolescents 2-19 years of age are overweight.The latest study from CDC (Centers for Disease Control and Prevention) scientists estimates that about 112,000 deaths are associated with obesity each year in the United States.Direct health costs attributable to obesity have been estimated at $52 billion in 1995 and $75 billion in 2003. Among children and adolescents, annual hospital costs related to overweight and obesity more than tripled over the past two decades.
TobaccoAn estimated 45.1 million adults in the United States smoke cigarettes even though this single behavior will result in death or disability for half of all regular users.Tobacco use is responsible for approximately 438,000 deaths each year.The economic burden of tobacco use is enormous: more than $75 billion in medical expenditures and another $92 billion in indirect costs.

In ''State-Level Estimates of Annual Medical Expenditures Attributable to Obesity'' (Obesity Research, vol. 12, no. 1, January 2004), an analysis of medical spending attributable to obesity, Eric A. Finkelstein, Ian C. Fiebelkorn, and Guijing Wang estimate that in 2003 Medicare and Medicaid spent $75 billion treating obesity-related diseases. In this study the researchers calculated statelevel estimates of total, Medicare, and Medicaid obesity-attributable medical expenditures.

According to the press release ''Obesity Costs States Billions in Medical Expenses'' (January 21, 2004, by the Centers for Disease Control and Prevention (CDC), the 1999-2000 National Health and Nutrition Examination Survey indicates that among Medicare recipients, obesity prevalence ranges from 12% in Hawaii to 30% in Washington, D.C. The percentage of annual medical expenditures in each state attributable to obesity ranges from 4% in Arizona to 6.7% in Alaska. Medicare expenditures connected to obesity range from 3.9% in Arizona to 9.8% in Delaware. For Medicaid recipients, the percentages are considerably higher due to the higher prevalence of obesity among Medicaid recipients—from 7.7% in Rhode Island (where 21% of Medicaid recipients are obese) to 15.7% in Indiana (where 44% of Medicaid recipients are obese).

State-level estimates range from totals of $87 million in Wyoming to $7.7 billion in California. Obesity-attributable Medicare estimates range from $15 million in Wyoming to $1.7 billion in California, and Medicaid estimates range from $23 million in Wyoming to $3.5 billion in New York. (It is important to remember that state-level spending is largely a function of population, so it is reasonable that a less populous state such as Wyoming will spend less state and federal dollars than a population-dense state such as California or New York.)

Obesity Costs in New Mexico

Eldo E. Frezza, Mitchell S. Wachtel, and Bradley T. Ewing developed an economic model intended to assess the impact of obesity on a state's economy. They evaluated the cost of obesity in terms of lost business output, employment, and income for the state of New Mexico and reported their findings in ''The Impact of Morbid Obesity on the State Economy: An Initial Evaluation'' (Surgery for Obesity Related Diseases, vol. 2, no. 5, September-October 2006). The investigators find that obesity cost the state more than seventy-three hundred jobs and its economic effect exceeded $1.3 billion-the impact on labor accounted for nearly $200 million and reduced state and local tax revenues totaled more than $48 million—accounting for 2.5% of New Mexico's gross state product.

Obesity Increases Health Expenditures

In ''Differences in Disease Prevalence As a Source of the U.S.-European Health Care Spending Gap'' (Health Affairs, vol. 26, no. 6, October 2, 2007), Kenneth E. Thorpe, David H. Howard, and Katya Galactionova examine spending in the United States and Europe for the ten most costly medical conditions. Their analysis reveals that nearly twice as many adults in the United States are obese compared to those in Europe—33% of Americans, compared to 17% of people in ten of the largest European countries—which results in higher numbers of Americans being afflicted with cancer, diabetes, and other chronic conditions. The treatment of obesity-related chronic diseases adds $100 billion to $150 billion to U.S. annual health expenditures.


Besides estimates of total direct and indirect costs of overweight and obesity, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the U.S. government's lead agency responsible for biomedical research on nutrition and obesity, specifies in Statistics Related to Overweight and Obesity(June 2000, the portion that obesity-related diseases contribute to these costs. In 2000 heart disease related to overweight and obesity generated direct costs of $6.9 billion (17% of the total direct cost of heart disease, independent of stroke), and the total cost of Type 2 diabetes was $63.1 billion (direct cost, $32.4 billion; indirect cost, $30.7 billion). A significant contribution to increasing diabetes-related costs is hospitalization. Table 7.2 shows hospital discharges in 1990, 2000, and 2004 that were attributable to diabetes. Increases were registered among men aged sixty-five to seventyfour and among both men and women aged seventy-five years and over.

In contrast, the total costs of overweight and obesity in 2000 that were related to other types of diseases were: osteoarthritis, $17.2 billion (direct cost, $4.3 billion; indirect cost, $12.9 billion); hypertension (high blood pressure), $3.2 billion (17 percent of the total cost of hypertension); colon cancer, $2.8 billion (direct cost, $1 billion; indirect cost, $1.8 billion); breast cancer, $2.3 billion (direct cost, $840 million; indirect cost, $1.5 billion); and endometrial cancer, $790 million (direct cost, $286 million; indirect cost, $504 million).

According to the Weight-control Information Network (WIN), in Statistics Related to Overweight and Obesity(June 2007,, the cost of lost productivity related to obesity among Americans aged seventeen to sixty-four is about $3.9 billion annually. This dollar figure translates into $239 million in days of restricted activity, $89.5 million in bed-days (days when people remained in bed rather than performing their activities of daily living), $62.7 million in physician office visits, and $39.3 million in lost workdays related to obesity.

In another study, Roland Sturm of the RAND Corporation compares in ''The Effects of Obesity, Smoking, and Problem Drinking on Chronic Medical Problems and Health Care Costs'' (Health Affairs, vol. 21, no. 2, March-April 2002) the effects of obesity, smoking, heavy alcohol consumption, and poverty on chronic health conditions and health expenditures. Sturm finds that obese individuals spent more on both health-care services and medication than daily smokers and heavy drinkers. For example, obese individuals spent about 36% more than the general population on health-care services, compared to a 21% increase for daily smokers and a 14% increase for heavy drinkers. Furthermore, obese people spent 77% more on medications. The only variable with a greater effect on health-care expenditures was aging—and aging trumped obesity only on expenditures for medications. Sturm concludes that obesity generates significantly higher health-care expenditures and affects more individuals than smoking, heavy drinking, or poverty.

Even though it is well documented that obese people incur higher health-care costs at a given point in time, until recently the effects of rising rates of obesity on spending growth had not been quantified. Kenneth E. Thorpe et al. find in ''The Impact of Obesity on Rising Medical Spending'' (Health Affairs, October 20, 2004) that health-care spending was about 36% higher for obese adults under sixty-five. Furthermore, they seek to estimate the share of spending growth attributable to three obesity-related comorbidities (the coexistence of two or more diseases): diabetes, hyperlipidemia, and heart disease including hypertension. Their analysis reveals that increases in the proportion of, and spending on, obese people relative to people of normal weight accounted for 27% of the increase in per capita spending between 1987 and 2001. This increase was attributable to spending for heart disease (41%), diabetes (38%), and hyperlipidemia (22%). Increases in obesity prevalence alone accounted for 12% of the growth in health-care spending. Thorpe et al. conclude that future cost-containment efforts should address the increasing prevalence of obesity and the institution of effective approaches to weight loss for people who are obese.

[Data are based on a sample of hospital records]
DischargesDays of care
Sex, age, and first-listed diagnosis199020002004199020002004
Both sexes Number per 1,000 population
Total, age adjusteda, b125.2113.3118.4818.9557.7568.7
Total, crudeb122.3112.8119.2784.0554.6574.1
All agesa, b113.099.1102.6805.8535.9541.1
Under 18 yearsb46.340.943.6233.6195.6201.5
Injuries and poisoning6.
       Fracture, all sites2.
18-44 yearsb 57.945.046.5351.7217.5225.6
HIV infection**3.0*5.43.9
Alcohol and drugc3.
Serious mental illnessd3.4*5.35.747.1*43.643.4
Diseases of heart3.02.72.916.39.410.1
Intervertebral disc disorders2.
Injuries and poisoning13.
       Fracture, all sites4.02.52.822.712.815.5
45-64 yearsb 140.3112.7118.4943.4570.4612.4
HIV infection*0.1*0.50.4***4.1
Malignant neoplasms10.
       Trachea, bronchus, lung2.70.90.819.15.25.4
Alcohol and drugc3.53.54.429.715.819.6
Serious mental illnessd2.5*4.04.734.8*34.642.2
Diseases of heart31.726.423.9185.0101.595.7
       Ischemic heart disease22.617.714.7128.263.854.3
              Acute myocardial infarction7.45.94.655.827.823.7
       Heart failure3.13.43.921.017.320.7
Cerebrovascular diseases4.13.83.440.719.817.6
Injuries and poisoning11.68.810.982.649.868.9
       Fracture, all sites3.
65-74 yearsb 287.8264.9268.52,251.51,489.71,442.3
Malignant neoplasms27.917.619.1277.6121.2128.7
       Large intestine and rectum3.
       Trachea, bronchus, lung6.
Serious mental illnessd2.5*3.42.843.839.926.4
Diseases of heart69.470.665.0487.2331.9280.9
       Ischemic heart disease42.039.735.0285.2171.2141.8
              Acute myocardial infarction14.012.510.8122.466.556.7
       Heart failure11.813.613.993.177.670.9
Cerebrovascular diseases13.813.212.5114.859.056.9
Hyperplasia of prostate14.
Injuries and poisoning17.617.917.4139.0105.7109.7
       Fracture, all sites4.
              Fracture of neck of femur (hip)1.5*2.01.7*18.1*15.910.9

Hospital Costs of Childhood and Adolescent Obesity

Guijing Wang and William H. Dietz of the CDC examine trends in obesity-linked diseases among children and adolescents and their related economic costs. In ''Economic Burden of Obesity in Youths Aged 6 to 17 Years: 1979-1999'' (Pediatrics, vol. 109, no. 5, May 2002), the researchers report the results of an analysis and comparison of data from the 1979-81 and 1997-99 National Hospital Discharge Surveys conducted by the National Center for Health Statistics. When Wang and Dietz adjust hospital costs to reflect 2001 dollars, they find that hospital costs linked to childhood obesity and three specific obesity-related illness—diabetes, sleep apnea, and gallbladder disease—had more than tripled since 1981, from $35 million to $127 million per year.

[Data are based on a sample of hospital records]
DischargesDays of care
Sex, age, and first-listed diagnosis199020002004199020002004
Male—Con. Number per 1,000 population
75 years and overb 478.5467.4483.14,231.62,888.02,815.5
Malignant neoplasms41.021.921.3408.3165.2149.0
       Large intestine and rectum5.44.23.980.744.134.0
       Trachea, bronchus, lung5.43.03.953.418.327.0
Serious mental illnessd**40.5*32.624.5
Diseases of heart106.2113.3113.1855.7600.9579.0
       Ischemic heart disease49.153.045.1398.1276.1237.9
              Acute myocardial infarction23.123.021.6227.5136.5152.0
       Heart failure31.830.936.6248.6178.6193.7
Cerebrovascular diseases30.230.224.9298.3171.2129.9
Hyperplasia of prostate17.96.86.0109.221.617.6
Injuries and poisoning31.233.633.4341.3257.7207.8
       Fracture, all sites13.714.414.3145.1*119.291.2
              Fracture of neck of femur (hip)
All agesa, b139.0127.7134.9840.5581.0599.6
Under 18 yearsb46.439.642.4218.7161.5184.4
Injuries and poisoning4.33.13.416.7*12.012.6
       Fracture, all sites1.
18-44 yearsb 146.8124.8136.2582.0401.1445.5
HIV infection*0.30.2**2.11.6
Alcohol and drugc1.6**10.8*9.2
Serious mental illnessd3.7*5.45.954.3*41.143.1
Diseases of heart1.
Intervertebral disc disorders1.
Injuries and poisoning6.74.35.336.618.122.4
       Fracture, all sites1.
45-64 yearsb 131.0110.2117.3886.5533.6571.8
HIV infection***0.3***
Malignant neoplasms12.76.15.8107.434.736.9
       Trachea, bronchus, lung1.70.50.714.83.45.0
Alcohol and drugc1.*7.17.8
Serious mental illnessd4.04.65.560.542.751.8
Diseases of heart16.614.613.3101.159.557.1
       Ischemic heart disease9.97.86.657.429.525.6
              Acute myocardial infarction2.
       Heart failure2.22.92.716.313.615.0
Cerebrovascular diseases3.03.52.832.119.516.2
Injuries and poisoning9.
       Fracture, all sites3.12.72.425.013.313.8

Days spent in the hospital for obesity-related disease more than doubled and the average length of hospital stays increased by about a third, from 5.3 to 7 days. Wang and Dietz observe that this increase in average length of stay occurred during a time when U.S. hospital stays overall were shortening and assert that longer lengths of stay for children with obesity-related medical problems underscored the severity of these problems.

Wang and Dietz conclude that the increase in the percentage of discharges with obesity-related diseases was most likely a reflection of the medical consequences of the obesity epidemic. They state, ''Although the numbers of percentage are small, the increases are substantial, especially for obesity (197% increase), sleep apnea (436%), and gallbladder disease (228%). These data may suggest that the increasing prevalence of obesity in children and adolescents has led to increased hospital stays related to obesity-associated diseases. The increasing proportion of hospital discharges with obesity-associated diseases in the last 20 years may also reflect the impact of increasing severity of obesity.''

*Estimates are considered unreliable.
aEstimates are age adjusted to the year 2000 standard population using six age groups: under 18 years, 18-44 years, 45-54 years, 55-64 years, 65-74 years, and 75 years and over.
bIncludes discharges with first-listed diagnoses not shown in table.
cIncludes abuse, dependence, and withdrawal. These estimates are for non-federal short-stay hospitals only and do not include alcohol and drug discharges from other types of facilities or programs such as the Department of Veterans Affairs or day treatment programs.
dThese estimates are for non-federal short-stay hospitals only and do not include serious mental illness discharges from other types of facilities or programs such as the Department of Veterans Affairs or long-term hospitals.
[Data are based on a sample of hospital records]
DischargesDays of care
Sex, age, and first-listed diagnosis199020002004199020002004
Female—Con. Number per 1,000 population
65-74 yearsb 241.1246.1251.41,959.31,397.11,374.0
Malignant neoplasms20.914.113.8189.8101.0101.3
       Large intestine and rectum2.41.71.934.915.217.3
       Trachea, bronchus, lung2.*17.516.5
Serious mental illnessd3.94.03.962.846.347.3
Diseases of heart45.152.142.6316.9256.0199.7
       Ischemic heart disease24.423.318.4153.8113.977.2
              Acute myocardial infarction7.58.05.858.152.832.2
       Heart failure9.512.810.484.069.159.7
Cerebrovascular diseases11.312.
Injuries and poisoning17.818.319.6166.2109.9114.6
       Fracture, all sites8.47.78.897.343.847.4
              Fracture of neck of femur (hip)*59.621.123.6
75 years and overb 409.6458.8462.43,887.12,830.82,653.9
Malignant neoplasms22.117.615.6257.3125.7103.6
       Large intestine and rectum4.63.42.869.828.428.8
       Trachea, bronchus, lung2.
Serious mental illnessd4.24.73.578.449.237.4
Diseases of heart84.699.194.6672.8523.4485.2
       Ischemic heart disease33.735.531.0253.2185.5155.6
              Acute myocardial infarction13.116.514.8125.9110.791.0
       Heart failure28.632.531.9240.8183.4171.9
Cerebrovascular diseases29.627.624.5302.0156.8129.2
Injuries and poisoning46.344.745.1489.2275.4284.0
       Fracture, all sites31.530.028.3352.7190.0168.8
              Fracture of neck of femur (hip)18.817.916.3236.3125.3101.4
Notes: Excludes newborn infants. Diagnostic categories are based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Rates are based on the civilian population as of July 1. Starting with Health, United States, 2003, rates for 2000 and beyond are based on the 2000 census. Rates for 1990-1999 use population estimates based on the 1990 census adjusted for net under enumeration using the 1990 National Population Adjustment Matrix from the U.S. Census Bureau. Rates for 1990-1999 are not strictly comparable with rates for 2000 and beyond because population estimates for 1990-1999 have not been revised to reflect the 2000 census.

In ''Incremental Hospital Charges Associated with Obesity As a Secondary Diagnosis in Children'' (Obesity, vol. 15, no 7, 2007), Susan J. Woolford et al. of the University of Michigan find that even when obesity was the secondary diagnosis resulting in a hospital stay, obese children's lengths of stay were longer and their hospital costs were significantly higher than those of healthy weight children. For example, hospital charges were significantly higher for discharges with obesity as a secondary diagnosis versus those without: appendicitis ($14,134 versus $11,049), asthma ($7,766 versus $6,043), and pneumonia ($12,228 versus $9,688).

Insurance Coverage for Obesity Treatment

Even though the Medicare and Medicaid programs spend billions on obesity-related illnesses, neither entitlement program covers treatment for obesity itself. Medicaid does not cover obesity treatment, and under Medicare, hospital and physician services for obesity are generally excluded. Historically, Medicare has covered treatment when obesity results from a disease such as hypothyroidism (deficiency of the thyroid hormone, which is produced by the thyroid gland) or Cushing's disease (a condition in which excess cortisol, a hormone released in response to stress, is secreted by the pituitary gland) and when weight loss is medically necessary to treat a disease such as diabetes, hypertension, or heart disease. It also provides coverage for surgical treatment of obesity when it is medically appropriate and the surgery is to correct an illness that caused the obesity or was aggravated by the obesity.

Until 2004 Medicare justified excluding coverage for obesity treatment by asserting that obesity is not a disease; however, in CMS Manual System: Pub. 100-03 Medicare National Coverage Determinations (October 1, 2004, the Centers for Medicare and Medicaid Services (CMS), which administers Medicare, eliminated language from its policy (that ''obesity itself cannot be considered an illness'') that had been used to deny coverage for weight-loss treatment. The decision stopped short of designating obesity a disease and does not specifically grant coverage for weight-loss treatment; regardless, it enables individuals, physicians, and companies to apply to Medicare for reimbursement for a variety of weightloss therapies. Because private insurance companies often use Medicare as a model for their coverage and benefits, some health-care industry observers believe the Medicare decision will pressure other payers to cover weight-loss treatments.

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 excludes drugs used for weight loss; however, the CMS states in ''Medicare Program; Policy and Technical Changes to the Medicare Prescription Drug Benefit'' (Federal Register, vol. 72, no. 101, May 25, 2007) that weight-loss drugs may be covered by Medicare when they are prescribed for a ''medically accepted indication'' such as clinically severe obesity. However, according to the AOA, in the fact sheet ''Obesity, Medicaid, and Medicare'' (May 2, 2005,, the plans administering the outpatient prescription drug benefit that became effective in 2006 will not include weight-loss drugs.

In view of the high prevalence of obesity among the populations covered by Medicaid—the poor and minorities—and the significant Medicaid expenditures for obesity-related illnesses, many health-care industry observers believe it is shortsighted that many states specifically exclude coverage of antiobesity products in their Medicaid programs. For example, Morgan Downey indicates in ''Insurance Coverage for Obesity Treatments'' (May 2, 2005, that ten states—Illinois, Indiana, Nevada, New Hampshire, New York, Ohio, Oklahoma, South Carolina, South Dakota, and Wyoming—do not cover antiobesity pharmaceuticals through Medicaid. California, Delaware, Hawaii, Kentucky, Maine, Massachusetts, Mississippi, Montana, New Mexico, Oregon, Rhode Island, Vermont, and Virginia cover orlistat, sibutramine, and phentermine in their Medicaid programs; however, in some states coverage is limited to people with clinically severe obesity, Type 2 diabetes, or hyperlipidemia, an excess of fats called lipids, chiefly cholesterol and triglycerides, in the blood. Some healthcare analysts and advocacy groups including the AOA contend that it is difficult to reconcile this limited coverage of obesity in light of Medicaid coverage for inpatient and outpatient alcohol detoxification and rehabilitation; chemical dependency treatment and drug rehabilitation; and services for sexual impotence.

According to the AOA, many health insurance plans do not provide reimbursement for weight-loss treatment. Furthermore, few private insurance indemnity plans or managed-care organizations (e.g., health maintenance organizations and preferred-provider organizations) appear to cover the costs of obesity treatment independent of whether the service is a medically supervised weight-loss program, surgery, or a prescription drug. The AOA notes that most employer-funded health insurance plans do not pay for obesity treatment or services, including medications, diet supplements, weight-control programs, or bariatric surgeries.

The Pharmacy Benefit Management Institute, Inc. (PBMI), an independent organization that is not affiliated with any employee benefits program or pharmaceutical manufacturer, periodically surveys employers to determine the extent, cost, and coverage of their pharmacy benefits. The PBMI publishes survey data and trends in Prescription Drug Benefit Cost and Plan Design Report (2007, The 2007 survey queried 340 companies that provide coverage to 6.2 million beneficiaries. The PBMI study finds that 82.7% of employers exclude weight-loss products from their coverage.

The reluctance to cover antiobesity drugs is driven by concern about cost, in that many payers may determine that the rising prevalence of obesity and its comorbidities require higher prescription drug costs than drug treatment of obesity itself. For example, the article ''Study: Metabolic Syndrome Brings Big Costs'' (Associated Press, May 6, 2005) reports that Medco Health Solutions, a national prescription benefit management company, found that Americans with metabolic syndrome account for $4 out of every $10 spent on prescription drugs for adults. (Metabolic syndrome is the name given to conditions that often occur together—obesity, diabetes, high blood pressure, and high triglycerides that can lead to cardiovascular disease.) Drug treatment of metabolic syndrome skyrocketed 36% between 2002 and 2004, and prescription costs for adults with metabolic syndrome averaged $4,116 in 2004, which was 4.2 times the average.

OVERWEIGHT WORKERS MAY PAY MORE FOR HEALTH INSURANCE COVERAGE. New federal regulations, which were reported in ''Nondiscrimination and Wellness Programs in Health Coverage in the Group Market; Final Rules'' (Federal Register, vol. 71, no. 239, December 13, 2006) and which took effect on July 1, 2007, for some groups and on January 1, 2008, for others, permit companies to charge overweight employees more for their health insurance than their healthy-weight peers.

According to Eve Tahmincioglu, in ''No Fatties Here'' (, September 10, 2007), Stephen Glick, the administrator of the Chamber Insurance Trust, asserts that most small business owners are choosing to incentivize rather than penalize obese workers by offering them gifts and other rewards for successful weight-loss efforts rather than forcing them to pay higher premiums.

Obese People Pay More for Health Care

David Arterburn, Matthew L. Maciejewski, and Joel Tsevat of the University of Cincinnati find in ''Impact of Morbid Obesity on Medical Expenditures in Adults'' (International Journal of Obesity, vol. 29, no. 3, 2005) that adults with clinically severe obesity (also known as morbid obesity, defined as one hundred pounds or more over ideal body weight or a BMI greater than 40) had health-care costs that were nearly twice those of their normal-weight peers. The researchers analyzed the records of 16,262 adults from the 2000 Medical Expenditure Panel Survey. Per capita health-care expenditures were calculated for BMI categories, based on selfreported height and weight, and adjusted for age, gender, race, income, education level, type of health insurance, marital status, and smoking status.


During the last four decades, considerable progress has been made in identifying the causes of obesity and developing treatments. Despite the enhanced understanding of the origins of obesity, increasing numbers of Americans continue to become overweight and obese. The AOA, along with myriad medical professional organizations and advocacy groups, contends that public funding for obesity research is woefully inadequate in view of the size and scope of this public health problem. Besides insufficient National Institutes of Health (NIH) funding for obesity research, the AOA cites inequities in research grants awarded by the NIH—even though more grants have been awarded to obesity research than in past years, obesity still receives a disproportionately small share of grant funding.

Table 7.3 shows NIH funding for a variety of diseases and research areas for fiscal years 2003 through 2007 as well as an estimates for 2008. Funding for obesity research peaked in fiscal year 2006 and was anticipated to decline slightly in fiscal year 2008.


Obese employees incur substantially higher healthcare costs than normal-weight employees. Obesity significantly increases health expenditures and absenteeism. In ''The Costs of Obesity among Full-Time Employees'' (American Journal of Health Promotion, vol. 20, no. 1, September-October, 2005), Eric A. Finkelstein, Ian C. Fiebelkorn, and Guijing Wang find that about 30% of the total costs result from increased absenteeism, and even though workers with clinically severe obesity represent just 3% of the employed population, they account for 21% of the costs due to obesity. The investigators report that overweight and obesity-related costs ranged from $175 per year for overweight male employees to $2,485 per year for obese female employees. The costs of obesity alone (excluding overweight) for a company with one thousand employees were estimated as a staggering $285,000 per year.

According to the U.S. Department of Health and Human Services, in Prevention Makes Common ''Cents'' (September 2003,, U.S. companies pay $13 billion per year for medical-care costs to treat obesity-related diseases, lower productivity, and absenteeism. Health insurance costs ($8 billion) make the greatest contribution to the total, followed by paid sick leave ($2.4 billion), life insurance ($1.8 billion), and disability insurance ($1 billion). The National Business Group on Health, a consortium of large employers that researches and develops solutions to health-service delivery challenges, states in the fact sheet ''Healthy Weight, Healthy Lifestyles: Primary Fact Sheet for the Institute on the Costs and Health Effects of Obesity'' (February 1, 2006, that higher health-care utilization rates, such as 45% more inpatient hospital days, produce higher health-care expenditures—36% higher for inpatient and outpatient care and 77% higher prescription drug spending. About 8% of private employer medical claims are attributable to overweight and obesity, and in 2004 obesity-related disabilities cost employers an average of $8,720 per claimant per year for wage indemnity.

[Dollars in millions and rounded]
Research/disease areasFY 2003 actualFY 2004 actualFY 2005 actualFY 2006 estimateFY 2007 estimateFY 2008 estimate
Acute respiratory distress syndrome$77$72$72$74$74$73
Agent orange & dioxin182020171717
Allergic rhi nitis (hay fever)223444
Alzheimer's disease658633656643643642
American Indians/Alaska Natives108134140155153152
Antimicrobial resistance181203217221221220
Assistive technology126131138182181181
Ataxiate langiectasia10910999
Attention deficit disorder (ADD)103104107116115115
Autoimmune disease591584589598597593
Basic behavioral and social science9381,0521,0651,0621,0561,054
Batten disease889887
Behavioral and social science2,6842,9323,0443,0012,9932,981
Brain cancer164187157178178177
Brain disorders4,7404,8214,7844,7324,7114,704
Breast cancer693708700718717716
Burden of illness424429433508507506
Cerebral palsy182223182120
Cervical cancer929496979696
Charcot-Marie tooth diseaseN/AN/AN/A766
Child abuse and neglect researchN/AN/A40383736
Childhood leukemia706260535353
Chronic fatigue syndrome655554
Chronic liver disease and cirrhosis348362410408407406
Chronic obstructive pulmonary disease545563676766
Climate changeN/A6357505050
Clinical research8,0288,4958,7198,7858,8078,786
Clinical trials2,7232,8772,8632,7672,7642,756
Colo-rectal cancer295297284269270269
Complementary and alternative medicine296309306301298298
Conditions affecting unborn children111113108103103102
Cooley's anemia554742424242
Cost effectiveness researchN/A126134143143143
Crohn's disease505359646464
Cystic fibrosis11712889858585
Dental/oral and craniofacial disease401410415413410409
Diagnostic radiology717750788712711710
Diethylstilbestrol (DES)889888
Digestive diseases1,1371,2371,2371,2521,2501,245
Digestive diseases—(gallbladder)777777
Digestive diseases—(peptic ulcer)171818171616
Down syndrome231915141413

In ''Obesity and Workers' Compensation'' (Archives of Internal Medicine, vol. 167, no. 8, April 23, 2007), Truls Østbye, John M. Dement, and Katrina M. Krause of the Duke University Medical Center sought to determine the relationship between BMI and the number and types of workers' compensation claims, associated costs, and lost workdays. They find that obese employees filed more workers' compensation claims. Employees with BMIs greater than or equal to 40 had twice the rate of claims as workers at healthy weights. The number of lost workdays was nearly thirteen times higher among obese workers, medical claims costs were seven times higher, and indemnity claims costs were eleven times higher among the heaviest employees, compared to their healthy-weight coworkers.

[Dollars in millions and rounded]
Research/disease areasFY 2003 actualFY 2004 actualFY 2005 actualFY 2006 estimateFY 2007 estimateFY 2008 estimate
Drug abuse (National Institute on Drug Abuse only)9669921,006990987987
Duchenne/Becker muscular dystrophy161817181616
Emerging infectious diseases1,3621,8071,8721,8571,8531,835
Eye disease and disorders of vision688693715705702702
Facioscapulohumeral muscular dystrophyN/A22222
Fetal alcohol syndrome292528292828
Fibroid tumors (uterine)151315151414
Food safety208294329316315312
Fragile X syndrome192022202020
Frontotemporal dementia (FTD)N/A2129333333
Gene therapy410391355356355354
Gene therapy clinical trials393731323232
Genetic testing426401422417417417
Global warming climate changeN/AN/A24585858
Health disparities2,4302,5902,6992,7662,7572,751
Health effects of climate change158165159157158157
Health services873887940929921920
Heart disease2,0132,1102,0872,0872,0822,081
Heart disease: coronary heart disease429416397398410410
Hodgkin's disease171718212121
Homicide and legal interventions131512111111
HPV and/or cervical cancer vaccines151416141414
Human fetal tissue262324232322
Human genome1,1001,1181,0841,0651,0631,061
Huntington's disease454948484747
Hyperbaric oxygen342222
Infant mortality/(LBW)523513504478477474
Infectious diseases2,4413,0553,1883,1323,1183,085
Inflammatory bowel disease586470727272
Injury (total) accidents/adverse effects349361353355352350
Injury—childhood injuries242526282828
Injury—trauma, (head and spine)234243241233231229
Injury—traumatic brain injury748087858584
Injury—unintentional childhood injury212022252524
Interstitial cystitis202426252525
Kidney disease393388427434430429
Lead poisoning141415151414
Liver cancerN/AN/A82888888
Liver disease388403454450449447
Lung cancer296297289266266265

In ''Excess Costs Associated with Excess Risks in a Consortium of Companies'' (American Journal of Health Promotion, January-February 2003), Dee W. Edington et al. confirm that overweight and obese people have medical bills up to $1,500 greater per year than individuals of healthy weight. The researchers looked at 178,000 adults in the General Motors health-care plan, which includes workers, retirees, and their family members. Edington et al. compared medical costs incurred to body weight, using federal categories that classified subjects as ranging from underweight to greatly obese. Medical costs rose with increasing weight—the average cost for normal or healthy-weight subjects was $2,225. The lowest category of overweight was slightly higher, at $2,388, but costs rose sharply after that, reaching $3,753 for the most severely obese subjects.

[Dollars in millions and rounded]
Research/disease areasFY 2003 actualFY 2004 actualFY 2005 actualFY 2006 estimateFY 2007 estimateFY 2008 estimate
Lyme disease302827242424
Macular degeneration535958606060
Malaria vaccine233044354545
Mental health1,7621,8181,8481,8241,8171,814
Mental retardation190190192188187185
Mind and body146157152136136136
Minority health2,0912,2882,4042,4232,4152,411
Mucopolysaccharidoses (MPS)91010101010
Multiple sclerosis99101110110109107
Muscular dystrophy393940404040
Myasthenia gravis545999
Myotonic dystrophyN/A66766
Networking information technology R&DN/A492509423417409
Organ transplantation314328358363362360
Orphan drug1,1381,1791,2281,2551,2531,248
Osteogenesis imperfecta989555
Otitis media151615171616
Ovarian cancer119112106102102102
Paget's disease566666
Pain conditions, chronic199223229220217216
Parkinson's disease230224225208207205
Pediatric AIDS318280279276275274
Pediatric research initiative164148145141139139
Pelvic inflammatory disease544433
Perinatal—birth, preterm (LBW)407393394374372370
Perinatal—neonatal respiratory distress syndrome91110877
Perinatal period, conditions or iginating in perinatal period430428429407403401
Pick's diseaseN/A11111
Pneumonia & influenza184287317351366376
Polycystic kidney disease373425323232
Prostate cancer379378373348348347
Regenerative medicine571585591614616613
Rett's syndrome566555
Reye's syndrome0.80.90.910.40.3
Rural health169178199202202201
Sexually transmitted diseases/herpes220237252264263262
Sickle cell disease959091919090
Sleep disorders197196189199197196
Smoking and health532537533517515515
Spina bifida171310111010

Obesity-Related Disability

In ''Estimated Economic Costs of Obesity to U.S. Business'' (American Journal of Health Promotion, vol. 13, no. 2, November-December 1998), David Thompson et al. estimate that businesses spent approximately $800 million on obesity-attributable disability insurance during the late 1990s. Many industry observers believe that the price businesses pay for obesity-related disability is destined to rise as sharply as the prevalence of obesity has increased in the United States.

*Includes research on HIV/AIDS, its associated opportunistic infections, malignancies, & clinical manifestations as well as basic science that also benefits a wide spectrum of non-AIDS disease research.
N/A = Data not available.
[Dollars in millions and rounded]
Research/disease areasFY 2003 actualFY 2004 actualFY 2005 actualFY 2006 estimateFY 2007 estimateFY 2008 estimate
Spinal cord injury898989666564
Spinal muscular atrophy131415151515
Stem cell research517553609643641639
Stem cell research—human embryonic202440383737
Stem cell research—non-human embryonic1138997110110109
Stem cell research—human non-embryonic191203199206206205
Stem cell research—non-human non-embryonic192236273289288287
Stem cell research involving umbilical cord blood/placenta171918191919
Stem cell research involving umbilical cord blood/placenta—human161615161616
Stem cell research involving umbilical cord blood/placenta-non—human233444
Substance abuse1,4621,4961,5081,4901,4851,484
Sudden infant death syndrome698184777675
Teenage pregnancy323026212120
Temporomandibular muscle/joint disorder161720171717
Topical microbicides586666888899
Tourette syndrome171613131313
Transmissible spongiform encephalopathy (TSE)313337353535
Tuberculosis vaccine131826222221
Tuberous sclerosis8109999
Urologic diseases551595576536532532
Uterine cancer343539282726
Vaccine related1,0661,6101,4501,4491,4861,507
Vaccine related (AIDS)405452511566564571
Vector-borne diseases296419447464462457
Violence against women212022201818
Violence researchN/AN/A121113110109
West Nile virus374343854263
Women's health3,4973,4783,5513,4983,4893,496
Youth violenceN/AN/A69676665

Darius N. Lakdawalla, Jayanta Bhattacharya, and Dana P. Goldman assert in ''Are the Young Becoming More Disabled?'' (Health Affairs, vol. 23, no. 1, 2004) that obesity is a key cause of the more than 50% increase in disability rates over the last two decades, particularly among younger Americans. After analyzing data from the National Health Interview Survey, an annual nationwide government survey of about thirty-six thousand households, the researchers identify disability trends among people aged eighteen to sixty-nine between 1984 and 2000 and find significant growth in reported disability rates among those under fifty years but not among the elderly.

Lakdawalla, Bhattacharya, and Goldman report that ''obesity accounts for about half the increased disability among those ages eighteen to twenty-nine.'' For those thirty to thirty-nine years old, the number reporting disabilities increased from 118 per 10,000 people in 1984 to 182 per 10,000 people in 1996. Among people forty to forty-nine years old, the number rose from 212 per 10,000 to 278 per 10,000 during this same period. Among people aged fifty to fifty-nine, disability rose only among those who were obese. The number of disability cases resulting from musculoskeletal problems and diabetes grew more rapidly than those from other problems during the length of the study, and the proportion that was diabetes-related doubled. Lakdawalla, Bhattacharya, and Goldman caution that this increase in the disability rate could translate into higher health-care costs in the future. Because people with disabilities generally use more medical services, should this trend persist, it could generate additional costs to the nation's already enormous health-care bill.

Soham Al Snih et al. of the University of Texas Medical Branch looked at the relationship between obesity, disability, and mortality by following the health of 12,725 adults aged sixty-five or older. In ''The Effect of Obesity on Disability vs. Mortality in Older Americans'' (Archives of Internal Medicine, vol. 167, no. 8, April 23, 2007), the researchers report that over the course of eleven years, 3,570 subjects became disabled and 2,019 died. Subjects with a low BMI (less than 18.5, which is considered underweight) and obese subjects (BMI greater than 30) were significantly more likely to experience disability and death. Snih et al. conclude that ''disability-free life expectancy is greatest among subjects with a BMI of 25 to less than 30.''


The AOA estimates in ''Consumer Protection'' (May 2, 2005, that at any given moment approximately 40% of women and 25% of men are trying to lose weight, and that forty-five million Americans diet each year. Americans spend about $30 billion per year to lose or prevent weight gain. The market research firm Marketdata forecasts in U.S. Weight Loss and Diet Control Market (2005) that a substantial annual growth in the U.S. weight-loss industry will produce a $61 billion industry in 2008.

Marketdata reports that in 2004 Americans consumed more diet soft drinks and that their share of the total soft drink market reached a near historical high. Diet soft drinks dominated in terms of sales, generating more than $15 billion in 2004, and health clubs ranked second. The most rapid growth occurred in do-it-yourself, over-the-counter (nonprescription) diet aids, which are less costly alternatives to medically supervised weight-loss and commercial programs.

With no new prescription weight-loss drugs on the horizon and the growing popularity of the African herb hoodia, Marketdata forecasts a 16% growth in this segment. Citing the success of several heavily advertised products, Marketdata predicts growth of 11.5% per year, to $703 million in 2008.

Along with commercial weight-loss centers, medically supervised weight-loss programs, and prescription diet drugs, products such as diet books, audio and video programs, Web-based diet and nutrition services, lowcalorie and low-carbohydrate food products, meal replacements, and over-the-counter appetite suppressants compete for consumer dollars. As the low-carbohydrate diet craze subsides, more dieters are returning to structured commercial programs such as Weight Watchers, LA Weight Loss, Jenny Craig, and other chains. Marketdata estimates that revenue from weight-loss centers will grow 11% to $2 billion. An estimated 7.1 million American dieters use such programs. Small local or regional chains of ten to fifty centers are growing as well.

According to Marketdata, the most affluent dieters, primarily in big cities, are purchasing home delivery of diet foods. Companies including Zone Chefs, NutriSystem, Jenny Direct (Jenny Craig), Seed Live Cuisine, Sunfare, and Nutropia are catering to this market. The cost averages $10 to $40 per day for home-delivered diet food, and dieters can spend as much as $1,200 per month. Weight-loss camps are also expected to grow in popularity and enrollment as the childhood obesity rate climbs.

Marketdata estimates that in 2004, 20,500 registered dietitians offered some form of weight-loss counseling, either in private practices or as consultants or employees of health clubs, hospitals, and other health-related facilities. A typical customized, six-month plan costs an average of $802. Nutritionists, who are not licensed dieticians and whose training varies widely from people without degrees to highly trained professionals with graduate degrees in nutritional science, also provide weight-loss counseling. Their services average $643 for a six-month contract.

Another study, The U.S. Market for Weight Loss Products and Trends (2005) by Marigny Research Group, describes the total U.S. market for weight-loss products and forecasts emerging trends in the U.S. market for weight-loss foods and beverages, where the low-fat and low-carbohydrate diets and foods may have peaked in popularity, spurring consumers to explore low-sugar and low glycemic index products. Like the Marketdata report, this study confirms the preeminence of the low-calorie food and beverage market and predicts increasing use and greater acceptance of artificial sweeteners in noncarbonated beverages, including refreshment, sports, and energy drinks, and meal replacement bars.

In Weight Loss Market: Products, Services, Foods, and Beverages (2003), Jack Baen also anticipates continued growth of weight-loss centers. Because the popularity of low-carbohydrate diets peaked in 2004, many analysts believe that conventional, ''sensible'' diets such as Weight Watchers' tried-and-true formula of portion control, healthy diet, and exercise will continue to attract people seeking to lose weight, thereby reenergizing corporate finances. According to Eric Wahlgren, in ''The Skinny on Weight Watchers'' (BusinessWeek, November 17, 2003), Kathleen Heaney, an analyst with the Maxim Group in New York, opines that consumers ''typically end up at Weight Watchers after several other diet attempts have failed'' and asserts that if anything, Weight Watchers' potential market in the United States has been drastically underestimated—its potential is about one hundred million clients.

The article ''Rating the Diets from A to Zone'' (Consumer Reports, vol. 70, no. 6, June 2005), a review of popular diets, gives Weight Watchers high marks in terms of safety, efficacy, and flexibility—its program allows people who prefer not to cook to use its branded controlled-calorie meals. The article also recommends the low-fat Ornish diet for vegetarians and the Slim-Fast diet for people who are not inclined to cook because Slim-Fast drinks and bars replace part of breakfast and lunch and dieters need to prepare just one meal per day.

Medical and Behavioral Treatments

Even though the greatest proportion of outlays for weight loss are for food products and commercial weightloss programs, McTigue et al. observe that medical and behavioral treatment options for obesity involve considerable cost. The researchers state that ''intensive counseling programs require significant time and staffing commitment. Based on average U.S. wholesale price, a 1-year supply of orlistat (120 mg 3 times daily) is $1,445.40 and of sibutramine (15 mg daily) is $1,464.78.'' It is important to note that consumers generally purchase prescription drugs at retail rather than at wholesale prices, so their costs are considerably higher than those reported by McTigue et al.

According to the WIN, in ''Gastrointestinal Surgery for Severe Obesity'' (December 2004,, weight-loss surgery costs from about $20,000 to $35,000, and the availability of medical insurance coverage for these surgical procedures varies by state and health insurance provider. William E. Encinosa, Didem M. Bernard, and Claudia A. Steiner find in ''National Trends in the Costs of Bariatric Surgery'' (Bariatrics Today, vol. 3, 2005) that even though the number of bariatric surgeries has increased over 1,000%, from 16,000 procedures performed in 1992 to more than 180,000 performed in 2006, coverage policies remain uneven among insurers. National hospital costs for bariatric surgeries increased by more than ten times, from $173 million in 1998 to $1.7 billion in 2003. Surgical costs reflect both the fees associated with the invasive procedure and the long-term follow-up that patients who have undergone the surgery require.

Long-Term Savings

Even though surgical treatment of obesity is a relatively recent phenomenon, research reveals that its costs are offset by a reduction in future utilization of healthcare services and a resultant reduction in health-care costs. Jane Salodof MacNeil reports in ''Slimmed-down Health Plan Members Lower Medical Costs'' (Medscape Today, November 17, 2004) that Gregory A. Nichols et al. of the Kaiser Permanente Northwest Center for Health Research in Portland, Oregon, compared medical costs for two groups of patients who participated in the Kaiser weight-loss program ''Freedom from Diets'' from 1996 to 2000: 458 patients who lost more than 5% of weight and 457 patients who failed to lose weight. The investigators also created a control group of 2,290 patients who did not participate in the program and did not lose weight. Nichols et al. found that the regional health plan saved nearly $850 overall in per-person medical costs the year after an overweight member lost 5% or more body weight in a voluntary program. The researchers calculated that the health plan would save $2,500 over five years and noted that the savings would be real, even in view of the observation that most patients would regain the lost weight. According to MacNeil, another Kaiser Permanente study described drug savings as the key cost efficiency during the first two years after bariatric surgery. Pharmaceutical costs decreased by $510 per person among surgical patients, but costs increased in candidates who did not have the surgery.

Other research confirms cost savings, but in ''Obesity, Weight Management, and Health Care Costs: A Primer'' (Disease Management, vol. 10, no. 3, 2007), a review of the available evidence, Keith H. Bachman cautions that ''the cost-effectiveness of obesity-related interventions is highly dependent on the risk status of the treated population, as well as the length, cost, and effectiveness of the intervention. Bariatric surgery offers high initial costs and uncertain long-term cost savings. From the perspective of a payor, obesity management services are as cost-effective as other commonly offered health services, though not likely to offer cost savings.''


On one hand, we have to make the world safe for a fatter population, but the more we adjust our world to accept our weight, the harder it is to motivate us to do the healthier thing and lose the weight. If we tacitly readjust our world, in some sense we are responding to reality. At the same time, there is no doubt that making those adjustments makes it easier to live bigger.

—Arthur Caplan of the University of Pennsylvania School of Medicine, ''Plus-Size People, Plus-Size Stuff'' (Associated Press, November 10, 2003)

Along with increased costs, many businesses have discovered that they must literally expand their products and services to meet the needs of overweight and obese consumers. The article ''Plus-Size People, Plus-Size Stuff'' (Associated Press, November 10, 2003) describes a wide array of products—from scales that weigh people as heavy as one thousand pounds and steering wheels for drivers who do not fit behind standard wheels to seat-belt extenders and supersized towels—designed to meet the needs of obese Americans.

Service industries have also responded. In ''That Tough First Step'' (Los Angeles Times, January 26, 2004), Jeannine Stein reports that gyms are reaching out to attract and meet the special needs of people who are overweight and want to exercise. Some provide personal trainers who assist overweight clients to use equipment safely, design realistic exercise regimens, and maintain motivation. Other gyms affiliate with medical centers and health professionals to offer nutritional counseling, support groups, and exercises suitable for people who are overweight, including aquatic exercise programs in pools. Health clubs, gyms, and fitness programs understand not only the health benefits they can offer overweight clients but also the financial benefits they can realize by tapping into this market of people who have previously stayed away from gyms.

According to Deborah Yao, in ''Stores Target Plus-Size Market'' (Associated Press, April 24, 2006), the market research firm NPD Group reports that from March 2005 to February 2006 sales of plus-sized women's apparel rose by nearly 7% to $19 billion. In ''Demand for Plus-Size Girls' Apparel Expanding'' (Los Angeles Times, October 9, 2007), Marshal Cohen, an analyst with the NPD Group, opines that the children's plus-sized market could grow to 18% of the total children's apparel market of more than $35 billion. The article ''Expanding Plus-Size and Big-and-Tall Clothing Market Estimated to Reach $107 Billion by 2012'' (PRNewswire, June 26, 2007) notes that another market research firm, Packaged Facts, predicts that the plus-sized clothing market will grow by 41% from 2006 to 2012, with commensurate growth in sales, from $47.1 billion in 2006 to almost $65 billion in 2012.

Hot Topic, a California-based company that specializes in clothing for teenagers and young women, launched in 2001 a chain of six stores called Torrid that offer fashion-forward plus-sized clothing for young women. By 2007 Hot Topic noted in the press release ''Hot Topic, Inc. Reports 1st Quarter Loss of $0.02 Per Share; Provides Guidance for the Second Quarter of 2007'' (May 23, 2007, that 131 Torrid stores offered an array of clothing and lingerie for young women who wear larger sizes.

In ''The Widening of America, or How Size 4 Became a Size 0'' (New York Times, January 20, 2004), Jane E. Brody asserts that Americans' increasing girth has prompted size inflation throughout the fashion and apparel industry. Brody reports that the apparel industry has accommodated expanding Americans by increasing sizes such that a women's size 4 in 2004 would previously have been a size 8, and a size 8 would formerly have been a size 12. Men's clothing has also expanded with pants that were formerly ''regular'' now designated as ''slim cut'' and easy fit, loose fit, and baggy styles to accommodate excess weight.

Similarly, the article ''Obesity Products Help Americans Live Large'' (Associated Press, April 17, 2006) states that an expanding girth has created market demand for products to contain it—such as ''husky'' baby seats, extra sturdy chairs, larger doorways to accommodate wider wheelchairs, and sponges on sticks to help larger bathers clean hard-to-reach areas.

Demands for larger, sturdier hospital beds and stretchers to accommodate extremely heavy patients, special imaging equipment such as computed tomography scans and magnetic resonance imaging to accommodate obese patients, bigger blood pressure cuffs, recliners constructed to hold 350 pounds, automobiles that comfortably seat obese drivers and passengers, and devices that enable people who cannot bend over to put on their socks and shoes have prompted the design and manufacture of these and other specialty products. Even morticians have observed and responded to the obesity epidemic. In ''On the Final Journey, One Size Doesn't Fit All These Days'' (New York Times, September 28, 2003), Warren St. John reports that when the founders of Goliath Casket Company in Lynn, Indiana, opened their business in the late 1980s, they sold just one triple-wide casket—the largest model they made—per year. During 2003 the company shipped about five of the oversized coffins, which measure forty-four inches across, compared to the twenty-four-inch standard model, per month. David A. Hazelett, the president of Astral Industries, another coffin builder in Indiana, acknowledges the issue and adds that the problem affects every aspect of the funeral industry. Hazelett explains that ''the standardsize casket is meant to go in the standard-size vault, and the standard-size vault is meant to go into the standard-size cemetery plot.'' St. John reports that hearse manufacturers have increased the width of their vehicles' rear doors, cemeteries have increased their standard burial plot size to accommodate wider vaults, and mausoleums have constructed larger crypts to accommodate oversized coffins.

According to Daniel Connolly, in ''Obesity Creates Need for Oversized Caskets'' (Birmingham Post-Herald, April 20, 2005), Mike Hauser, the marketing director of Ridout funeral homes and cemeteries, explains that newer parts of the company's cemeteries are being laid out with wider spaces for graves to accommodate larger bodies. In the case of an extremely large casket and vault, families that purchased a family plot can allow the grave to take up two spaces rather than one. Connolly notes that the Batesville Casket Company in Indiana, one of the nation's largest casket makers, introduced thirteen new oversized models in 2004; by 2005 it offered a total of fifty-three oversized models. Connolly states that the Goliath Casket Company has also continued to increase the size of its offerings. Sales at Goliath Casket doubled in 2004, and the company sold about eight hundred oversized caskets. The company makes forty-four-inch, forty-eight-inch, and fifty-two-inch-wide caskets, which are constructed with extra supports intended for body weights between 650 and 1,200 pounds. The fifty-two-inch-wide casket is slightly wider than a standard pickup bed size.

Naturally, these oversized accommodations carry additional costs, and as a result some families opt for cremation. For the most severely obese, cremation may not, however, be an option. St. John notes that Jack Springer, the executive director of the Cremation Association of North America, explains that most crematoria are not equipped to handle bodies weighing more than five hundred pounds.

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