ArticlesDoes obesity contribute as much to morbidity as poverty or smoking?
Introduction
The US is experiencing an increasing prevalence of overweight and obesity among men and women and across age groups–the ‘obesity epidemic’.1, 2 This development runs counter to a key objective of the nation's public health effort, Healthy People 2000, to decrease overweight prevalence, and contrasts with declines in prevalence of other health risk behaviors, such as cigarette smoking or alcohol consumption.3 Far more people now are overweight or obese than are smokers or problem drinkers.
Obesity is associated with increased health care costs, increased all-cause mortality rates and increased risk for coronary heart disease, osteoarthritis, diabetes mellitus, hypertension, dyslipidemia and certain types of cancer.4, 5, 6, 7, 8, 9, 10, 11, 12, 13 Even modest weight reductions can have substantial lifetime health and economic benefits.14, 15, 16, 17, 18
However, different health risk factors compete for attention and time of physicians, patients and public education programs, making priority setting difficult. Recent federal efforts have focused on reducing disparities in health status and healthcare due to poverty and low socioeconomic status. Poverty or low socioeconomic status also strongly affect mortality rates and health status, independent of health risk behaviors.19, 20, 21, 22, 23, 24, 25 Poverty, therefore, would be a reasonable parameter against which to evaluate the importance of behavior-associated health risks such as overweight and obesity, smoking, or heavy drinking.
Making a health risk behavior a public policy or clinical practice priority could have a substantial impact on reducing that risk in the population. For example, smoking quite possibly has received the most public attention among risk factors, in part due to annual reports by the Surgeon General for over 25 years and numerous primary care interventions. In 1992, 75% of internists asked about smoking among almost all their patients–a result that met the Healthy People 2000 target–and 63% asked about alcohol use.3 Even a lower smoking assessment rate of 67% measured in a 1991 survey, which was deplored as falling short of national health objectives,26 nonetheless exceeded the Healthy People 2000 goals for physician advice about exercise (50%), as well as actual exercise counseling rates in 1992–there are no separate goals for weight counseling.3, 27, 28
In this paper, we use data from a national household survey fielded in 1998 to compare the associations of poverty, weight and other risk factors (smoking, heavy drinking) with the occurrence of chronic medical conditions and with physical and mental health-related quality of life, as assessed by the SF-12 scales. We expect obesity to be associated with lower health-related quality of life through increased prevalence of chronic conditions. However, its effects could also occur through other mechanisms such as reduced functional lung capacity or decreased physical activity, which would result in persistent effects of overweight on morbidity after controling for chronic conditions.
There are few empirical precedents for anticipating which health risks have the strongest impact on morbidity: obesity, poverty, smoking, or heavy drinking. One Dutch study found that poverty is a stronger predictor than behavioral risk factors in explaining mortality differences by educational status;29 other studies were either more ambiguous or did not provide comparative data. Studies have found that obesity is associated with lower quality of life, and weight loss with increased quality of life, especially in the domains of vitality and physical functioning.30, 31, 32, 33 However, these studies did not compare the effects of obesity and poverty or other health behaviors on health-related quality of life.
Section snippets
Methods
We analyze data from Healthcare for Communities (HCC), a national household phone survey fielded in 1997/1998.34 HCC reinterviewed adult participants of the Community Tracking Study (CTS), on average 15 months after their CTS interview. The CTS sample is representative of the US civilian, non-institutionalized population.35 The CTS included a sample clustered within 60 randomly selected US communities, as well as a geographically dispersed sample.
HCC selected 14 985 from a random sample of 30
Results
According to the HCC survey, 36% of the population are overweight, but not obese (25≤BMI<30), and 23% are obese (BMI≥30). These estimates are almost identical to the results from the Third National Health and Nutrition Examination Survey.40 Tables 1 (for women) and 2 (for men) provide descriptive statistics of health status and sociodemographics by weight category. Individuals with BMI in the normal range have on average 1.1 chronic conditions, overweight individuals 1.3, individuals in the
Discussion
A cross-sectional analysis of data from a household sample found that obesity has as strong, or even stronger, an association with both occurrence of chronic medical conditions, and physical health-related quality of life, as poverty, lifetime smoking history, or recent heavy drinking. Moreover, a larger proportion of the population is obese (BMI≥30, 23%) than are poor (14%), heavy drinkers as identified by AUDIT (6%), or daily smokers (19%). These findings reinforce prior recommendations that
Acknowledgements
Financial support was provided by the Robert Wood Johnson Foundation, which funded Health Care for Communities.
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