Health and Economic Consequences of

Obesity and Overweight in Pakistan

Maryam Naeem Satti
MS Health Economics Thesis

Supervisors:
Dr Durre Nayab
Dr Mahmood Khalid

6th March, 2015

PIDE
 Introduction
 Overweight – weight above than what is
considered healthy
 Obesity – condition of excessive fat
accumulation in the body
 Global health problem affecting both
developed and developing nations
 Poses serious health and financial burden
 Influenced by many factors - hereditary
tendencies, environmental, behavioural factors,
ageing, pregnancies
Global Situation of Excess weight

Ng, M., et al. (2014)

Situation of Excess Weight in Pakistan

49

43
38
38
33
28 Males

Females
20 21 19
15
13 13

Afghanistan Bhutan Pakistan India Bangladesh Nepal

Ng, M., et al. (2014)

Objectives
 Theprevalence of overweight and obesity in
Pakistan along with its major determinants

 The
possible health consequences of overweight
and obesity in adult population

 RelativeRisks of selected obesity co-morbidities

for overweight and obese individuals

 The
cost of illness attributable to overweight and
obesity in adults
Hypotheses
 Obesity and overweight is highly prevalent in
Pakistani adults and differentials exist among
different population groups

 Overweight and obesity have negative implication

on the health of adult population

 Therelative risks of selected chronic diseases are

high for overweight and more precisely obese
individuals

A sizeable proportion of total illness cost is

attributable to overweight and obesity
Rational of the Study
 Double burden of nutrition impose pressure on
health care sector of the country
 Determinants – identify groups most at risk
 Identifies burden of the risk factor on the
individuals
 Priority setting in health sector given limited
resources
 Base for future interventions, policy and
research studies
 Cost of obesity has remained an unattended
area regarding obesity research in Pakistan
Framework
Proximate Socio-Economic &
Determinants Cultural Background

Determinants
Immediate
Food Intake Physical Activity/
Factors
Life Style

Overweight
&
Obesity

Health
Risk of Chronic Diseases Consequences

Economic Cost

Direct Cost Indirect Cost Economic

Medical expenses Productivity loss Consequences
Data

 PakistanPanel Household Survey, 2010

(Conducted by PIDE)

 Nutrition
data available for all ages and gender
 Data available for Social and Economic aspects
 Detailed food consumption is available
 Detailed Health module is available
 Data requirement for costing is available
Methodology
 Measure of Prevalence of Obesity:

Classification BMI Range

 Body Mass Index (BMI):
Underweight < 18.5
Weight in kilograms divided
Healthy weight 18.5-24.9
by the square of the height
Overweight: >=25
in metres (kg/m ).
2
Pre obese 25-29.9
Obese >=30
 Unit of Analysis Obesity Class I 30-34.9
 Adults (aged 18+) Obesity Class II 35-39.9
Obesity Class III >=40
WHO
Differentials in Obesity and Overweight
 Dependent Variable: BMI
 Independent Variables:
 Age  HH food consumption pattern
 Gender  Physical Activity & Lifestyle
 Province variable
 Region  Working status
 Education  Type of work
 Wealth status  Availability of Transport facility
 Marital Status  Availability of Entertainment
 Familial obesity  Availability of Labour Saving
Domestic Techniques
 Eating-out
Health Consequences of
Obesity and Overweight
 Dependent Variables:
 Prevalence of illness
 Type of disease
 Intensity of disease
 Episodes of illness
 Duration of illness

 Days of Hospitalization

 Independent Variable: BMI

Cost of Illness – Attributable to
Overweight and Obesity I
 Cost of illness methodology – How much role a risk
factor play in causing a particular disease and
ultimately places an impact on society or a part of
society

 Risk Factor – Overweight and Obesity

 Illness (Obesity co-morbidities)– Diabetes, Heart

diseases

 Prevalence Vs. Incidence approach

Measures the costs of an illness in one period, usually a
year, regardless of the date of onset
Cost of Illness – Attributable to
Overweight and Obesity II

 Time Frame – One year i.e. 2010

 Perspective – Individual Patient

Other perspectives include societal, Health care
system, third party payers, businesses, government

 Cost – Opportunity cost

The value of the forgone opportunity to use in a
different way those resources that are used or lost due
to illness
Cost of Illness – Attributable to
Overweight and Obesity III

 Cost Components
 Direct cost
 Direct medical cost - Consultation fee, medicines,
laboratory tests and hospitalization
 Indirect medical cost – Transportation

 Indirect cost
 Productivity loss due to mortality
 Productivity loss due to morbidity

 Perceived impaired days due to illness – self-reported

Cost of Illness – Attributable to
Overweight and Obesity IV
 Human Capital Approach
(Copper & Rice, 1976; Hodgson & Meiners, 1982; Segel, 2006)

 To value Days lost due to illness

 Potential productivity loss not actual
 Measures lost production in terms of lost wages

Individuals
 Employed – Actual wages
 Unemployed – If unemployed due to disease use opportunity
cost and if unemployed due to other reason then zero wage
 Housewives – Opportunity cost Vs. Replacement cost
 Students – National mean wages
 Elderly/Not working neither willing to work – Replacement cost
for informal care
Steps Involved in Estimating Cost of
Obesity I
 Estimating prevalence of overweight and
obesity
 Estimating Relative risks for selected
comorbidities
Relative risk - prevalence of a particular illness
in overweight and obese versus non-
overweight and non-obese

1 No difference
<1 less risk in the exposed group

>1 more risk in the exposed group

Steps Involved in Estimating Cost of
Obesity II
 Calculating Population Attributable Fractions
(PAFs) - How much the proportion of illness is
attributable to overweight and obesity
𝑃(𝑅𝑅 − 1)
[𝑃 𝑅𝑅 − 1 + 1]

 Calculate Direct and indirect cost

 Multiply PAFs with cost to yield the cost of
illness attributable to overweight and obesity.
Sensitivity Analysis
 Deterministic sensitivity analysis
 How sensitive the outcome is to the
different parameters used in the analysis
 One-way sensitivity analysis: Alter one
parameter
 Relative risk is varied arbitrarily by ± 5, 10,
15 and 20 percent and change in cost is
observed
Prevalence of Overweight and Obesity
In Adults

Obese
9% Underweight
13%
Overweight
21%

Normal
weight
57%
Excess Weight by Age
Percentage of adults having excess weight by age

40 40
37

28 28

17

18-24 25-34 35-44 45-54 55-64 65+

Overweight and Obesity by Gender
Percentage of overweight and obese adults by gender

22
20

11
6

Males Females

Overweight Obese
Overweight and Obesity by Age and Gender
Percentage of Overweight and Obese by Age and Gender

Male Female
Age
Overweight Obese Overweight Obese

18-24 13.5 3.3 22.5 3.8

25-34 16.6 5.2 27.2 8.6

35-44 25.8 7.5 26.5 16.6

45-54 27.0 7.2 26.0 17.5
55-64 23.7 8.2 21.3 14.4
65+ 18.3 7.2 13.7 9.0
Overweight and Obesity by Province
Prevalence (%) of overweight and obesity by province

45
40
35
30
25
20
15
10
5
0
Punjab Sindh KPK Balochistan
Overweight Obese
Overweight and Obesity by Region
Prevalence (%) of overweight and obesity by region

22
21

12
8

Urban Rural
Overweight Obese
Overweight and Obesity by Poverty
Percentage of overweight and obese adults by poverty status

22
17

10
5

Non-poor Poor
Overweight Obese
Overweight and Obesity by Education
Percentage of overweight and obese adults by education

25
23
21
19

10 9
9 8

No education Primary Secondary Higher

Overweight Obese
Overweight and Obesity by Marital Status

Percentage of overweight and obese adults by marital status

23

19
15

11
10

Never married Currently married Sep/Widow/divorced

Overweight Obese
Overweight and Obesity by Familial Obesity
Percentage of Overweight and Obese Adults by Number of Overweight
Persons in the Family other than the Respondent

37

26

18
15
11

No Overweight One or Two Three or More

Overweight Obese
Overweight and Obesity by Work Status
Percentage of Overweight and Obese by Work Status
BMI
Work Status
Underweight Normal weight Overweight Obese Total

Housewives 12.0 50.4 24.8 12.8 100

Students 21.5 60.2 12.8 5.5 100

Others not in
15.2 62.0 17.5 5.2
labour force 100
Unemployed 17.4 58.9 15.8 7.9 100
Non-manual
workers
4.5 50.4 32.2 12.9 100
Manual workers 13.8 61.6 18.6 5.9 100
Total 13.3 56.9 21.1 8.7 100
Overweight and Obesity by Occupation
Percentage of Overweight and Obese by Occupation
BMI
Occupation Under Normal
Overweight Obese Total
weight weight
Legislators, senior officials &
managers
11.1 55.6 22.2 11.1 100

Professionals 7.1 50.3 29.0 13.5 100

Technicians & associate
professionals
0.7 55.3 32.6 11.3 100
Clerks 6.1 41.5 39.0 13.4 100
Service and sales workers 12.5 63.9 17.2 6.4 100
Skilled agriculture & fishery
workers
11.7 64.7 18.0 5.6 100
Crafts & related trades
workers
23.3 52.9 15.4 8.3 100
Plant & machine operators 6.0 57.8 28.9 7.3 100
Elementary occupations 14.9 60.8 19.0 5.2 100
Armed forces 3.0 51.5 30.3 15.2 100
Overweight and Obesity by Transport Facility
Prevalence (%) of overweight and obesity by availability of transport
facility (car or motorcycle)

24

20

11
8

Not Available Available

Overweight Obese
Overweight and Obesity by Entertainment
Facility
Prevalence (%) of overweight and obesity by availability of entertainment
facility (television, computer and internet)
25

17

11
6

Not Available Available

Overweight Obese
Overweight and Obesity by Labour
Saving Domestic Techniques
Prevalence (%) of overweight and obesity by availability of labour saving
devices (refrigerator, microwave oven, cooking range or washing machine)

27

15 14

Not Available Avaliable

Overweight Obese
Overweight and Obesity by Eating-Out
Percentage of Overweight and Obese by Eating out
BMI
Meals
Outside Underweight Normal weight Overweight Obese Total

Total
No 13.5 56.5 21.3 8.6 100
Yes 13.8 54.6 21.1 10.4 100
Urban
No 12.1 54.2 22.1 11.6 100
Yes 6.3 49.8 23.7 20.3 100
Rural
No 14.1 57.4 21.1 7.4 100
Yes 15.1 55.5 20.7 8.7 100
Overweight and Obesity by Food
Consumption
Percentage having Excess Weight by Food Consumption
Food Items/ Below Median Above Median
Consumption Consumption Consumption
Grains 29.8 29.9
Pulses 30.0 29.7
Oil 26.3 33.5
Sugar 31.4 28.4
Dairy Products 25.0 34.7
Eggs 25.8 34.6
Meat 26.6 33.1
Vegetables and Fruits 24.7 35.2
Soft Drinks 27.9 33.5
Regression Results
Result of Binary Logistic Regression
Dependent Variable: Body Mass Index (0 = BMI<25, 1 = BMI=>25)
Independent variables Coefficient (B) Significance Odd ratios
Age 0.015 0.00 1.015*
Gender
Male (Ref)
Female 0.264 0.00 1.302*
Province
Punjab (Ref)
Sindh -0.464 0.00 0.629*
KPK 0.774 0.00 2.169*
Balochistan -0.042 0.65 0.959
Region
Urban (Ref)
Rural -0.246 0.00 0.782*
Poverty
Non-poor (Ref)
Poor -0.023 0.76 0.977
Marital Status
Never married (Ref)
Currently married 0.75 0.00 2.117*
Formerly Married 0.33 0.02 1.391*
Education 0.037 0.00 1.037*
Work Status
Housewives (Ref)
Students -1.056 0.00 0.348*
Other not in labour
-0.401 0.00 0.67*
force
Unemployed -0.272 0.11 0.762
Non-manual
-0.041 0.77 0.96
workers
Manual workers -0.125 0.11 0.882
Car Availability
No (Ref)
Yes -0.232 0.02 0.793*
Motorcycle Availability
No (Ref)
Yes 0.037 0.52 1.038
Entertainment Availability
No (Ref)
Yes 0.000 1.00 1.000
Labour Saving Techniques Availability
No (Ref)
Yes 0.264 0.00 1.302*
Eating-Out -0.002 0.77 0.998
Consumption of Grains -0.008 0.36 0.992
Consumption of Pulses -0.014 0.94 0.987
Consumption of Oil 0.482 0.00 1.619*
Consumption of Dairy Products 0.007 0.51 1.007
Consumption of Meat -0.115 0.23 0.891
Consumption of Eggs 0.065 0.01 1.067*
Consumption of Soft Drinks 0.092 0.11 1.096
Consumption of Sugar -0.025 0.73 0.975
Consumption of
0.093 0.01 1.097*
Vegetables and Fruits
Familial Obesity 0.381 0.00 1.463*
Illness by Overweight and Obesity
Percentage of adults suffered from a disease by nutritional status

47

39 37
34

Underweight Normal weight Overweight Obese

Type of Disease by BMI
Percentage Having Specific Illnesses by BMI
BMI
Illness Type
Underweight Normal weight Overweight Obese Total

Heart diseases 10.4 12.0 18.7 24.2 14.6

Diabetes 2.1 3.6 6.3 8.5 4.5
Reproductive problems 6.4 6.0 8.5 6.3 6.6
Respiratory
problems/TB 12.0 5.4 3.6 4.9 5.9
Hepatitis/Jaundice 6.2 4.9 6.2 4.7 5.3
Intestinal/Renal/Kidney
problems 8.1 6.8 6.4 6.5 6.8
Others 54.7 61.4 50.2 45.0 56.2
Total 100 100 100 100 100
Disease Intensity by BMI I
Mean Days Estimates of Disease Intensity by Nutritional Status

BMI Episodes of illness Duration of illness Days hospitalized

Underweight 1.8 374 8

Normal
346 12
weight 1.8
Overweight 1.8 414 10

Obese 1.6 527 11

Total 1.8 385 11

Disease Intensity by BMI II
Mean Days Estimates of Disease Intensity (Obesity Comorbidities only) by
Nutritional Status

BMI Episodes of illness Duration of illness Days hospitalized

Underweight 2.0 646 5

Normal
weight 1.8 645 8
Overweight 1.7 697 7
Obese 1.4 743 18
Total 1.7 678 8
Health Care Expenditure by BMI
Mean Health Care Expenditure on Illness by BMI

Expenditure Expenditure on
on Expenditure on hospitalization/lab Total
BMI Consultation Medicines tests expenditure

underweight 1133 6547 1125 8804

normal weight
1186 6702 967 8854

overweight 1438 8780 1392 11610

obese 2189 8226 1655 12069
Total 1345 7298 1157 9800
Regression Results
Result of Binary Logistic Regression
Dependent Variable: Obesity comorbidity (0 = No, 1 = Yes)
Independent variables Coefficient (B) Significance Odd ratios
Age 0.036 0.00 1.036*
Gender
Male (Ref)
Female 0.154 0.33 1.167
Province
Punjab (Ref)
Sindh 0.222 0.05 1.249*
KPK 0.761 0.00 2.141*
Balochistan -0.590 0.00 0.554*
Region
Urban (Ref)
Rural -0.539 0.00 0.583*
Poverty
Non-poor (Ref)
Poor -0.337 0.02 0.714*
Marital Status
Never married (Ref)
Currently married 0.530 0.03 1.699*
Formerly Married 0.527 0.06 1.694*
Education 0.024 0.12 1.024
Work Status
Housewives (Ref)
Students -0.508 0.38 0.601
Other not in labour force -0.380 0.08 0.684
Unemployed -0.351 0.33 0.704
Non-manual workers -0.030 0.92 0.970
Manual workers -0.263 0.08 0.769
Nutritional Status
Normal/Low weight (Ref)
Overweight 0.381 0.00 1.464*
Obesity 0.593 0.00 1.810*
Familial Chronic illness 0.475 0.00 1.607*
Consumption of Grains -0.007 0.39 0.993
Consumption of Pulses -0.534 0.07 0.586
Consumption of Oil 0.061 0.80 1.063
Consumption of Dairy Products -0.007 0.70 0.993
Consumption of Meat 0.208 0.20 1.231
Consumption of Eggs 0.023 0.58 1.023
Consumption of Soft Drinks 0.099 0.25 1.104
Consumption of Sugar -0.047 0.72 0.954
Consumption of Vegetables and Fruits -0.047 0.47 0.954
 Relative Risks

Relative Risks of Selected Obesity Co-morbidities for Overweight and Obese

Adults

Diseases Overweight Obesity

Heart Disease 1.60 2.06

Diabetes 1.93 2.61

Any of Two 1.67 2.18

Population Attributable Fractions
100% 100% 100%

29%
20% 12 22%
9 9

11 17 12

Heart Disease Diabetes Any disease

Overweight Obesity
Total Direct Cost of Overweight and Obesity
16,450,154

11,365,690

5,084,464

3,691,343
2,231,085 1,584,893
961,537 1,460,258
623,355 2,106,450
1,269,548 836,903
Heart Disease Diabetes Any Disease

Cost attributable to overweight Cost attributable to obesity Cost of illness

Average Direct Cost of Overweight and
Obesity

19481

15175
13810

8306
3557
5595
2388
2711
1168 4749
3207
1543
Heart Disease Diabetes Any Disease

Cost attributable to overweight Cost attributable to obesity Cost of illness

Total Indirect Cost of Overweight and
Obesity
77,292,220

44,726,048

32,566,172

18,132,728
7,776,436
8,779,723 9,353,005
3,783,824 3,992,613
10,356,291
4,995,900 5,360,392

Heart Disease Diabetes Any Disease

Cost attributable to overweight Cost attributable to obesity Cost of illness

Average Indirect Cost of Overweight and
Obesity
124775

71303

54345
46503
35835 19895
15297

10668 26608
4598 20538
6070
Heart Disease Diabetes Any Disease

Cost attributable to overweight Cost attributable to obesity Cost of Illness

 Scaled-up Cost I

Scaling-up of Annual Cost Attributable to Overweight and Obesity to the

Whole Population (in Rupees)

Direct cost of heart disease due to excess weight 44,545,438,925

Indirect cost of heart disease due to excess weight 175,294,366,558

Direct cost of diabetes due to excess weight 28,335,813,985

Indirect cost of diabetes due to excess weight 181,491,911,049

Direct cost for both diseases due to excess weight 72,881,252,911

Indirect cost for both diseases due to excess weight 356,786,277,607
Total cost for both diseases due to excess weight 429,667,530,518
 Share of Scaled-up Cost in
National Figures

Share of Scaled-up Cost Attributable to Overweight and Obesity in National

Expenditures (in Percentages)

Share of direct cost of both diseases due to excess weight in national

16.20%
health expenditure
Share of direct cost of both diseases due to excess weight in private
26.80%
out of pocket expenditure
Share of direct cost of both diseases due to excess weight in GDP 0.40%
Share of indirect cost of both diseases due to excess weight in GDP 1.95%
Share of total cost of both diseases due to excess weight in GDP 2.35%
 Sensitivity Analysis Results
Result of Sensitivity Analysis

Parameter and Cost - 20 percent Original + 20 percent

RR overweight 1.34 1.67 2

RR obesity 1.75 2.18 2.62

Average direct cost
2779 4749 6481
overweight
Average indirect cost
15915 26608 35991
overweight
Average direct cost
2420 3557 4614
obesity
Average indirect cost
13673 19895 25671
obesity
Direct scaled-up cost 43,393,456,829 72,881,252,911 99,454,043,487

Indirect scaled-up
217,007,452,743 356,786,277,607 482,544,892,490
cost
Share of direct cost in
9.70% 16.30% 22.20%
Health Expenditure
Conclusions
 Prevalence of excess weight is highly prevalent
among the adults of Pakistan
 Physical activity came out to be the significant
determinant of excess weight
 Along with certain social factors, familial obesity
is also a significant factor – draws attention to
the family
 Excess weight came out to be a major risk
factor for heart disease and diabetes
 A sizeable proportion of illness and its cost
incurred by the individuals is attributed to
overweight and obesity
Policy Recommendations

 Determinants – most vulnerable group should

be targeted for interventions
 Target families instead of individuals
 Advocacy about adoption of active lifestyle
 Health professionals should advocate their
patients
 To lower the burden of obesity from
individuals:
 Control and Prevention
 Cost sharing schemes
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Questions?

Comments?