Journal of Physical Activity and Health 2006, 3,148-163
© 2006 Human Kinetics, Inc.
The Economic Cost of Physical Inactivity
and Excess Weight in American Adults
David Chenoweth and Joe Leutzinger
Background: Physical inactivity and excess weight in American adults have
reached epidemic levels. This article describes how cost data from previously
conducted analyses in several states were used to quantify the costs of physical
inactivity and excess weight among American adults. Methods: Medical and workers’ compensation cost data on selected medical conditions were obtained from
various health plans and state agencies in seven states. Productivity loss norms
were obtained from published studies. Results: The estimated financial burden
which includes direct medical care, workers’ compensation, and productivity loss
costs among the seven states is $93.32 billion for physical inactivity and $94.33
billion for excess weight. The estimated nationwide cost of these risk factors is
approximately $507 billion with projected costs exceeding $708 billion in 2008.
Projected cost-savings of $31 billion per year could be realized with a 5% drop in
these risk factors. Conclusion: The cost of physical inactivity and excess weight
among American adults is significant. More research on best-of-class interventions
to curtail the high prevalence of these risk factors is needed.
Key Words: exercise, obesity, economic, cost, excess weight, overweight
Living a sedentary lifestyle is normal for most Americans. In fact, physical inactivity and excess weight are at epidemic rates in the US.1-3 These contemporary crises
are major risk factors for premature illness, disability, and death, and contribute
significantly to the nation’s medical care costs.4-7 In addition, these risk factors also
cost the nation billions of dollars annually in lost productivity because a portion
of personal productivity is related to an individual’s health.8
One of the most publicized economic cost analyses of excess weight revealed
estimated costs of the risk factor at nearly $100 billion (in 1995 dollars).4 Moreover, some research suggests that excess weight is a more expensive risk factor
than cigarette smoking or alcohol abuse, despite receiving less attention in clinical
practice over the past decade.6 Yet, a more recent estimate puts the cost of excess
weight and its complications between $75 billion and $117 billion annually.9
Financial cost studies have also been conducted on physical inactivity.10-12
One study suggested that medical costs alone due to physical inactivity costs are
approximately $24 billion annually.10 These data suggest that enormous costChenoweth is President of Chenoweth & Associates, Inc. and Professor at East Carolina University,
Greenville, NC 27858. Leutzinger is President of Health Improvement Solutions, Inc. and Academy
for Health & Productivity Management, Omaha, NE.
148
Economic Cost of Physical Inactivity & Excess Weight
149
savings to the nation’s medical care system could be realized if a portion of sedentary persons were to increase their level of physical activity. For example, annual
cost savings of approximately $5 billion could be realized if 10% of the sedentary
population would adopt a walking program.11 One study that is believed to be the
first ever to examine medical costs associated with various levels of physical activity included a review of the actual medical expenditures of over 35,000 adults.12
The study revealed that physically active adults used approximately $1000 less in
annual medical care services than their inactive peers. Moreover, the study’s authors
calculated cost-savings of $76.6 billion (2000 dollars) if all inactive Americans
became physically active. In another study of over 19 million adults, costs tied to
physical inactivity were estimated to be $57 billion (1999 dollars) with approximate
cost-savings of $8.4 billion (2001 dollars) if 10% of sedentary Americans became
physically active.12
Recently, several state-wide economic analyses were conducted by the authors
to calculate the costs of physical inactivity and excess weight.13-20 These states
included California, Massachusetts, Michigan, New York, North Carolina, Texas,
and Washington. Collectively, these seven states are home to nearly 77 million adults
or about one of every three adults in the US.21 Moreover, these states are located
in different regions of the nation and thus represent varying demographic profiles,
risk factor prevalence rates, and medical care cost inflation trends.22
In 1996, the Surgeon General’s Report on Physical Activity and Health (SGR)
noted that physical inactivity is a primary risk factor for cardiovascular disease,
the nation’s leading cause of death.23 Physical inactivity is also linked to a host
of other health conditions—excess weight, diabetes, osteoporosis, mental health
disorders, and some cancers.1 State-specific physical inactivity prevalence rates
used in this analysis are as follows: California (49.5%), Massachusetts (69%),
Michigan (55.2%), New York (59.1%), North Carolina (59.6%), Texas (69.0%),
and Washington (57.9%). At the time of these state-specific analyses, an operational
definition of physical inactivity was used as follows: less than 30 min of moderate
physical activity most, if not all, days of the week.
According to the National Heart, Lung, and Blood Institute,24 approximately
61% or 113 million adults in the US are overweight or obese, with:
• At least 34% (63 million) considered overweight (body-mass index of 25.0 to
29.9), and
• At least 27% (50 million) considered obese (body-mass index ≥ 30)
The American Heart Association estimates that 107 million American adults
are overweight and an additional 43 million American adults are obese.25 In the
past 20 y, excess weight rates have reportedly increased more than 60% among
the adult population.26
Although “weight” has the advantage of being well understood and easily
measurable, weight alone does not provide enough information to constitute an
accurate measure of a nation’s health status.27 In contrast, “overweight” has the
advantage of encompassing both the population at higher risk for developing excess
weight as well as the population experiencing excess weight.27 Moreover, numerous
studies indicate that even moderate weight gain or moderate overweight significantly increases health risk factors.3, 10, 27 Thus, excess weight was classified in this
150
Chenoweth and Leutzinger
analysis as a BMI of 25 and above. State-specific prevalence rates of excess weight
used in this analysis are as follows: California (34.97%), Massachusetts (52.9%),
Michigan (59%), New York (56.9%), North Carolina (59%), Texas (59.8%), and
Washington (55.1%). Demographically, the aggregate profile of these states is
closely representative of the US:
Characteristics
Persons with some type of health insurance
Females
Males
18 – 64 y of age
65+ y of age
Caucasian
Hispanic and Latino
African American
Asian
American Indian/Alaska Native
US
7-States
89%
51%
49%
55%
12%
72.5%
12.2%
12.0%
3.2%
0.1%
85%
50.9%
49.1%
61.9%
12.4%
75.1%
12.5%
12.3%
3.6%
0.9%
Methods
The scope of these state-wide analyses was based on a cost appraisal framework
which includes three major cost units: 1) medical care, 2) workers’ compensation,
and 3) productivity loss. Tables 1 and 2 list the targeted medical conditions associated with excess weight and physical inactivity. A Proportionate Risk Factor Cost
Appraisal™ (PRFCA) framework was used to factor in claims and charges for all
of the targeted medical conditions (see Table 3). The PRFCA methodology was
Table 1
Medical Conditions Associated with Excess Weight42-70
Condition
A. MUSCULO-SKELETAL
Osteoarthritis of knee and hip
Rheumatoid arthritis
Low back pain
B. NEOPLASM (cancer)
Breast in women
Breast in men
Esophagus/gastric
Colorectal
Endometrial
Renal cell
DRG #
ICD code
221, 222, 237
242/244/245/246
243
715.0-715.9
714
724.1-724.5
274-275
274-275
154-156
172-173/148-49/179
354-55/357-59
318/319
174-175
175.9
150.1-151.0
153.0-154.1
182.0-182.8
189.0-189.1
Economic Cost of Physical Inactivity & Excess Weight
Condition
C. CIRCULATORY
Cardiovascular disease
Hypertension
Deep vein thrombosis
Chronic venous insufficiency
Stroke
D. NERVOUS SYSTEM
Carpal tunnel syndrome
Pain
E. METAB/ENDO/NUTRITION
Diabetes (NIDDM)
Gout
Impaired immune response
F. DIGESTIVE
Gallbladder disease
Liver disease
End stage renal disease
Bil. & alcoholic pancreatitis
DRG #
ICD code
103-112/120-145
134
128
402-405/412-414.9
401
437.6
459.81
430.0-436
14-17*
6
354.0-354.1
307.8-307.80
294
250.0-250.9
274.0-274.9
279.0-279.9
488-490
195-198
199-203
316-317
577.0-577.1
575.0-575.9
570.0-573.9
585-586
87-88
518.5-519
780.5-780.57
G. Sign/Symptom/Ill-def.
Impaired respiratory function
Sleep apnea
Urinary stress incontinence
788.3-788.39
H. PREGNANCY
Obstetric & gynecological
complications
354, 358, 366,
368, 370, 372
640-648 and
660-669
418
910.1-919.9
992
996-999
I. INJURY & POISONING
Infections following wounds
Heat disorders
Surgical complications
151
452-453
* Coded as NERVOUS.
developed over 20 y ago as an econometric cost accounting tool for the health
management industry. Essentially, it uses a combination of economic, epidemiological, and health risk appraisal principles that were initially used when the field of
prospective medicine was developed in the early 1960s.28 Calculations performed
in each framework include 1) computing an average payment per outpatient and
inpatient claim, 2) computing the ratio of outpatient to inpatient claims and payments, 3) multiplying the average payment by its respective ratio to determine
a net cost, 4) combining the two net costs to determine a composite cost, and 5)
152
Chenoweth and Leutzinger
Table 2
Medical Conditions Associated with Physical Inactivity71-86
MDC: Cancer
Colon cancer
DRG #
ICD code
152,159,179
230.3
294
250.0
MDC: Endocrine & metabolic
Diabetes >35 y of age
250.9
MDC: Circulatory
Essential hypertension
Hypertensive heart disease
Hypertensive renal disease
Hypertensive heart & renal disease
Acute myocardial infarction
Acute & subacute ischemic heart disease
Old myocardial infarction
Angina pectoris
Coronary atherosclerosis
Congestive heart failure
Unspecified heart disease
Subarachnoid hemorrhage
Intra-cerebral hemorrhage
Unspecified intracerebral hemorrhage
Occlusion of precerebral arteries
Occlusion of cerebral arteries
Trans cerebral ischemia
Acute ill-defined cardiovascular disease
Other cerebral vascular disease
Late effects of cerebral vascular disease
Atherosclerosis
Heart transplant
Coronary bypass
MDC: Musculo-skeletal
Rheumatoid arthritis
Osteoarthritis
134
134
316 & 317
122
140 & 143
132 & 133
127
014-017
014-017
014-017
014-017
014-017
014-017
014-017
014-017
014-017
132 & 133
103
106 & 107
241
245
401
402.9
403
404
410
411
412
413
414
428.9
429.9
430
431
432
433
434
435
436
437
438
440
440.9
714
715-715.9
Pain in joint
719.4
Stiffness in joint
Lumbago
Backache
Polymyalgia rheumatica
Synovitis & tenosynovitis
719.5
724.2
724.5
725
727
243
248
Economic Cost of Physical Inactivity & Excess Weight
DRG #
153
ICD code
729
Rheumatism
Osteoporosis
Strain/sprain of back
243
733
847.9
MDC: Mental
Neurotic depression*
Depressive disorder
Anxiety states
426
426
427
300.4
311
300
* Excludes brief depressive reaction and prolonged depressive reaction.
multiplying the composite cost by each risk factor weight, risk factor prevalence
rate, and number of claims to determine a cost for each of the respective risk factors. Intrinsic in the PRFCA framework is its ability to measure each risk factor
cost individually to reduce the prospect of double counting. This phenomenon can
occur if analysts (incorrectly) assume that all physically inactive persons are also
overweight or obese.
Six of the seven state-wide analyses included specific workers’ compensation
claims tied to physical inactivity and excess weight. Of the targeted major diagnostic
categories (MDCs), musculo-skeletal is the one MDC that is most closely tied to
workers’ compensation claims. Compensable musculo-skeletal injuries and costs in
this analysis were based on 1) a substantial percentage of workers’ compensation
costs associated with musculo-skeletal conditions, and 2) a substantial percentage
of workers’ compensation-based musculo-skeletal claims associated with physical
inactivity and excess weight.29 Nationally, most workers’ compensation claims have
a musculo-skeletal origin and nearly 50% of these claims are sprains or strains
commonly associated with cumulative trauma disorders (CTDs).30 CTDs are among
the costliest work-related conditions in the US and more common in physically
inactive persons.28 Nonetheless, it should be noted that musculo-skeletal sprains
and strains are one of the few side effects of physical activity and that this was not
accounted for in our analysis.
Six of the seven state-wide analyses highlighted in this article include an investigation of the possible relationship between physical inactivity, excess weight, and
productivity loss. Much of the risk factor-based productivity research published
in the past decade has evolved from worksite case studies.31-38 Productivity studies, in particular, are hampered by the shift from manufacturing and piecework to
providing information and services.
In general, four major categories of worker productivity have been identified
in much of the literature: absenteeism, disability, worker performance, and presenteeism. The latter is a relatively new entity that was added to the productivity
mix in the late 1990s and is defined as productivity loss that occurs when workers
are on the job but not fully functioning.8
To figure productivity loss costs associated with physical inactivity and excess
weight, productivity loss cost values were computed across three of the four outcome
measures (absences, short-term disability, and presenteeism). A baseline number
of hours lost for both physical inactivity and excess weight was assigned to each
of the preceding measures. Table 4 highlights an example of estimated lost hours
used in one of the state-wide cost analyses.
421
3
424
Risk Factor
Cig. Smoking
Low Fiber/Hi Fat diet
Age > 40
Family Hx
High alcohol intake
Obesity
Phys Inactivity
Race:AfrAmer
No BSE
Env. Exposure
No mammogram
No PSA/DRE
Diabetes
Inpatient
Total
Composite
934
934
934
934
934
934
934
934
934
934
934
934
934
# Claims
x R.F. Wt.
0.2
0.08
0.05
0.25
0.04
0.11
0.08
0.04
0.03
0.03
0.03
0.03
0.03
1
15,760
360,420
344,660
Total paid
CANCER
x%w/RF
0.35
0.7
0.5
0.3
0.0715
0.592
0.596
0.27
0.125
0.654
0.175
0.24
0.064
5,253.33
818.66
Avg paid/claim
(Neoplasm)
x# claims
424
424
424
424
424
424
424
424
424
424
424
424
424
Total
0.026
0.974
Ratio: Out/In
A Sample Framework of a Proportionate Risk Factor Cost Appraisal
Outpatient
Site
Table 3
equals R.F.Cost
27721.12
22176.89
9900.4
29701.2
1132.60
25788.56
18882.04
4276.97
1485.06
7769.83
2079.08
2851.31
760.35
153,765.09
136.58
797.38
Net cost
933.97
Composite
154
Chenoweth and Leutzinger
16.65
19.8
36.45
Short term disability
Presenteeism
28.75
13
15.75
Absences
Excess weight
Presenteeism
Short term disability
Absences
Avg hours lost
per year
2000
2000
2000
2000
2000
2000
Workload
per year
0.0182
0.0099
0.0083
0.0143
0.0065
0.0078
Lost hours as %
of workload
Productivity Loss Cost Outcome Measures
Physical inactivity
Table 4
36,929
36,929
36,929
36,929
36,929
36,929
Average
compens.
19,222,932,336
0.3497
Subtotal
x % with risk
6,720,337,000
9,611,466,168
5,228,215,113
4,383,251,055
14,300,483
14,300,483
14,300,483
0.495
x % with risk
7,515,559,226
7,551,866,275
15,182,947,930
Subtotal
3,432,666,489
4,119,199,786
Productivity loss
cost per year
14,300,483
14,300,483
14,300,483
# workers
Economic Cost of Physical Inactivity & Excess Weight
155
156
Chenoweth and Leutzinger
Results
Cost computations conducted on selected medical conditions generated direct medical care costs of approximately $3 billion for physical inactivity and approximately
$2.9 billion for excess weight (2003 dollars). Workers’ compensation costs tied to
targeted musculo-skeletal conditions in six states (excluding Texas) tallied nearly
$1 billion. Productivity loss costs tied to physical inactivity in six states (excluding
Texas) were approximately $54 billion. In contrast, productivity loss costs tied to
excess weight were analyzed in three states (California, North Carolina, and Massachusetts) and were estimated at approximately $31 billion. Overall, the financial
cost of physical inactivity among the seven states was approximately $92.32 billion
and approximately $94.33 billion for excess weight.
To calculate estimated national costs for physical inactivity and excess weight,
a multiplier of 2.72 [210 million divided by 77 million] was applied to the multistate composite costs. Physical inactivity costs for all US adults is estimated to be
approximately $251.11 billion ($92.32 billion × 2.720; excess weight costs among
US adults is estimated to be approximately $256.57 billion [$94.33 billion × 2.72].
Combined physical inactivity and excess weight costs are estimated to total more
than $507 billion in 2003 dollars. The preceding cost estimates may be conservative because workers’ compensation and productivity loss costs related to each of
the risk factors were not measured in the state of Texas. Including Texas’ costs
within the multi-state analysis would have increased the overall cost estimate for
excess weight because Texas is home to nearly 1 of every 13 adults in the US. The
authors speculate this cost omission alone is responsible for at least $5.3 billion
of unaccounted medical care costs based on findings reported in a recent study.7
Finally, “hidden costs” associated with excess weight—bariatric lifts and heavyduty beds needed for hospitalized obese patients, for example—which probably
exceed $1 billion each year,39 were not included in the multi-state or national cost
estimates. Overall, the preceding cost estimates for physical inactivity and excess
weight are considerably higher than those published in other cost analyses.3-7, 10-12
The authors attribute the discrepancies to the following factors:
• Different cost units measured: the bulk of the multi-state cost analyses included
three cost units (medical, workers’ compensation, and productivity loss) while
other published cost analyses focused solely on medical care and/or a single
aspect of productivity loss (e.g., workdays lost).
• Database differences: medical care data used in the multi-state analyses reflected
actual claims data that were provided by health plans insuring an average of 60%
of each state’s adult population; in contrast, other cost analyses used self-reported
data that may or may not reflect actual medical care utilization patterns.
• Methodological differences: cost estimates generated in the multi-state analyses
were based on the PRFCA framework using retrospective claims data; in contrast, other cost analyses used applied predictive modeling techniques on selfreported claims data or applied relative risk estimates on published estimates
of disease costs. Note that when adjusted for inflation, PRFCA – generated
costs for obesity among California adults—$7.97 billion16—differ less than
4% from those reported in the RTI-CDC study—$7.68 billion.7
Economic Cost of Physical Inactivity & Excess Weight
157
Despite the preceding differences, both the multi-state cost analyses and other
independently-conducted analyses conclude that physical inactivity and excess
weight costs create a huge financial toll in the US. For example, the combined
estimated cost of $507 billion for physical inactivity and excess weight—based
on the seven-state cost analyses—actually exceeds the average annual financial
growth of the gross domestic product (GDP) in the US.40 Arguably, costs associated
with physical inactivity and excess weight will continue to rise as more American
adults live longer and exhibit one or both of these risk factors. In fact, if the rise
in excess weight from 1980 to 20002, 9, 41 continues over the next two decades,
excess weight rates will rise approximately 1% per year, resulting in nearly 75%
of all American adults being overweight and about two-thirds of this group being
obese. In addition to this disturbing prognosis, costs tied to these risk factors are
expected to continue upward. For example, if medical care costs continue to rise
approximately 10.25%a per year, workers’ compensation costs continue to rise at
least 4.47%b, and employment cost (productivity loss) indices rise at least 4.10%c
per year, then physical inactivity and excess weight-related costs (combined) will
increase from $507 billion in 2003 to nearly $709 billion in 2008 or a cumulative
(5-y) increase of 40% (see Figure 1).d
Figure 1—Actual (2003) and projected (2004-2008) physical inactivity and excess weightrelated costs at an adjusted inflation rate of 6.90% based on three rates of weighted intercommodity inflation. Projections are adjusted for an estimated 1.17% annual growth in the
number of American adults and a 1% increase in the excess weight prevalence rate; the current
physical inactivity rate of 60% is expected to remain unchanged during this timeframe.
Discussion
Despite our best attempts to accurately measure the financial cost of physical inactivity and excess weight in American adults, there are several limitations within
this analysis that should be noted. First, it was virtually impossible to clearly
distinguish persons in the target population who are either physically inactive or
exhibit excess weight versus those who have both risk factors. Thus, it is likely that
158
Chenoweth and Leutzinger
there is some portion of medical care, workers’ compensation, and lost productivity costs tied to physical inactivity that is attributed to the concomitant effects of
having excess weight. Conversely, it is likely that some portion of total excess
weight-specific costs may be due to the concomitant effects of physical inactivity.
Therefore, each of these risk factor estimates should be viewed as approximate,
not absolute, costs. Second, the PRFCA framework is a composite computational
technique which consists of actual health care utilization, health care payments,
epidemiological, and risk factor prevalence data obtained from various sources.
Since the data sectors were obtained from multiple sources, there was no attempt to
assess the overall validity of the framework prior to its use in this analysis. Third,
although there is strong evidence showing the direct relationship between each of
the two risk factors and specific medical conditions, the evidence is not as strong
regarding the direct impact of each risk factor on specific workers’ compensation
conditions or lost productivity. Thus, cost estimates applied to the latter cost sectors
should be viewed accordingly.
If the current percentage of American adults who are physically inactive and
overweight could be reduced 5%, the nationwide financial toll from these modifiable risk factors could be substantially reduced as shown in Table 5. The potential
cost-reduction standard of 5% was selected because it closely represents the actual
annual percentage increase in excess weight among the seven analyzed states from
1991 to 2000 as well as reflecting Healthy People 2010 goals.1
If American adults do not reduce their current physical inactivity and excess
weight levels, they will bear an increasingly heavy cost burden as more aging,
physically inactive, and obese adults incur premature and chronic illnesses. In
essence, physical inactivity and excess weight-related costs are projected to rise
more than 40% from 2003 to 2008. Nonetheless, even a 5% drop in the percentage of
physically inactive and overweight adults could produce cost-avoidance benefits of
nearly $156 billion over this timeframe, or approximately $31 billion per year. Yet,
it should be noted that achieving such results will come at some financial cost.
Overall, this cost analysis shows that the epidemics of physical inactivity and
excess weight have profound health, productivity, and economic consequences for
Americans. Because risk factor prevalence rates used in the multi-state cost analyses
were generally conservative, projected cost estimates and potential cost-avoidance
benefits are also conservative. Yet, despite the conservative nature of the cost analyses, even a modest 5% drop in physical inactivity and excess weight prevalence
rates would collectively generate a cost-avoidance value of about $31 billion per
year. In economic terms, consider what $31 billion could do to enhance the health
Table 5 Aggregate Costs: Physical Inactivity & Excess Weight
(in billions $)
2004
2005
2006
2007
2008
No reduction
542.70
580.14
620.12
662.97
708.70
5% reduction
515.56
551.13
589.11
629.82
673.26
Cost-avoidance
27.14
29.01
31.01
33.15
35.44
Economic Cost of Physical Inactivity & Excess Weight
159
and lives of many Americans. For example, a monetary value of this magnitude
could be used to pay for or assist with funding basic medical care coverage for
approximately 8.8 million households throughout the US that currently have no
health insurance.87 Consequently, economists contend that newly-insured working
adults (who comprise nearly two-thirds of currently uninsured households) would
have more financial resources to contribute to the US economy.88
All stakeholders within the communities across the nation must take some
responsibility for these epidemic numbers. Making this and other cost analyses more
available and known among these stakeholder groups is needed to help all parties and
individuals realize the magnitude of these problems. For example, efforts by medical
and allied health professionals to motivate inactive and obese Americans to engage
in simple exercise on a regular basis, such as walking, can reduce a person’s risk of
many health problems tied to inactivity and excess weight.11 It is the authors’ hope
that this analysis and other published reports on these issues will serve notice to the
nation to take physical inactivity and excess weight seriously. Moreover, the findings
from this analysis should encourage multiple stakeholders’ policy-level decisionmaking to consider using a new and straightforward framework to understand the
financial cost of these epidemics, as well as having resources to measure potential
benefits. For example, a recently developed web-based cost calculation tool has been
developed for calculating the direct and indirect cost of physical inactivity. The cost
tool is available for public use at: www.activelivingleadership.org
While various efforts are currently underway in many communities, it is our
opinion that many of these interventions need to be revised to provide more supportive environmental conditions and financial incentives to encourage more adults
to lead more active lifestyles.
References
1. US Dept of Health and Human Services. Healthy People 2010. (Conference Edition,
in two vols.) Washington, January 2000.
2. Mokdad A, Serdula M, Dietz W, Bowman B, Marks J, Koplan J. The spread of the
excess weight epidemic in the United States, 1991-1998. JAMA, 1999; 282:16,15191522.
3. Must A., Spadano J, Coakley EH, Field AH, Colditz G, Dietz WH. The disease burden
associated with overweight and excess weight. JAMA, 1998; 282:16, 1523-1529.
4. Wolf A, Colditz G. Current estimates of the economic cost of excess weight in the
United States. Obes Res. 1998; 6:2, 97-106.
5. Thompson D, Brown J, Nichols G, Elmer P, Oster G. Body mass index and future
healthcare costs: a retrospective cohort study. Obes Res. 2001; 9: 210-218.
6. Sturm R. DataWatch: the effects of obesity, smoking, and drinking problems and costs.
Health Affairs, 2002;21:2, 245-251.
7. Finklestein E, Fiebelkorn I, Wang G. State-level estimates of annual medical expenditures attributable to obesity. Obes Res., 2004;12;18-24.
8. Burton W, Conti D. The real measure of productivity. Business & Health, 1999;17:11,
34-36.
9. Colditz G. Economic costs of obesity and inactivity. Med Sci Sports Exerc. 1999;31(11
Suppl); S663-S667.
10. US Dept of Health and Human Services. The Surgeon General’s call to action to prevent
and decrease obesity [Rockville, MD]: US Dept of Health and Human Services, Public
Health Service, Office of the Surgeon General; 2001.
160
Chenoweth and Leutzinger
11. Jones T, Eaton C. Cost-benefit analysis of walking to prevent coronary heart disease.
Arch Fam Med. 1994; 3:703-710.
12. Pratt M., Macera C, Wang G. Higher direct medical costs associated with physical
inactivity. Physician and Sportsmedicine. 2000;28:10, 63-70.
13. Chenoweth D. Sitting around, burning money. Business & Health, 2001;19:27-28.
14. Be Active North Carolina, Inc. The financial cost of physical inactivity, obesity, type 2
diabetes, and low fruit/vegetable intake among North Carolina adults. Durham, NC:
June 2004.
15. Chenoweth D. The economic cost of physical inactivity in New York State. Am Med
Athletic Assoc Q, Spring 2000; 14:5-8.
16. Chenoweth D. The economic costs of physical inactivity, obesity and overweight in
California adults during 2000: a technical analysis: Sacramento, CA: California Dept
of Health and Human Services, Cancer Prevention and Nutrition Section and Epidemiology and Health Promotion Section, April 2005.
17. Chenoweth D. The medical cost of high serum cholesterol in Harris County, Texas,
2001. Texas J Med. 2004:100:49-53.
18. The financial cost of selected risk factors among adults in the Commonwealth of Massachusetts. Massachusetts Dept of Public Health, Boston: 2004.
19. The financial cost of physical inactivity among adults in the State of Michigan. Michigan
Fitness Foundation, Lansing, MI: 2003.
20. The financial cost of physical inactivity among adults in Washington. Washington State
Dept of Health and the Washington Coalition to Promote Physical Activity, Olympia,
WA: 2004.
21. Resident population of the 50 states, 1990 and 2000. US Census Bureau.
22. State trends in health risk factors and receipt of clinical preventive services among US
adults. JAMA. 2002; 287:2858-2867.
23. The Surgeon General’s Report on Physical Activity and Health (1996). US Dept of
Health & Human Services, Washington.
24. National Institutes of Health. National Heart, Lung, and Blood Institute, NHLBI’s
Framingham heart study finds strong link between overweight/obesity and risk for
heart failure. NIH news release, July 31, 2002,Washington.
25. American Heart Association, 2001 Biostatistical Fact Sheet—Risk Factors: Overweight
and Obesity. Dallas, TX.
26. Dietz W. Excess weight trends in America. Congressional hearing, Washington, May
21, 2002.
27. American Obesity Association. Healthy Weight 2010: Objectives for Achieving and
Maintaining a Healthy Population: The AOA’s Supplement to Healthy People 2010,
January 2000 [www.obesity.org/AOA_HP2010.htm]
28. Hall J, Zwemer J. Prospective Medicine. Indianapolis, IN: Methodist Hospital Press,
1979.
29. Mandelker J. Cumulative trauma increases workers’ compensation claims. Occup
Health & Safety. 1993;62:29-32.
30. 2001 Occupational Disability Guidelines, 6th ed. Work Loss Data Institute, San Antonio,
TX.
31. Aldana S, Pronk N. Health promotion programs, modifiable health risks, and employee
absenteeism. J Occup Environ Med. 2001;43:34-46.
32. Edington D. A workers’ productivity index. Presentation at the 2000 Association for
Worksite Health Promotion Annual Conference, September 15, 2000, Orlando, FL.
33. Goetzel R, Guindon A, Turshen J, Ozminkowski R. Health and productivity management: establishing performance measures, benchmarks, and best practices. J Occup
Environ Med. 2001;43:10-7.
34. Burton W, Conti D, Yu Chen C, Schultz A, Edington D. The role of health risk factors
and disease on workers’ productivity. J Occup Environ Med. 1999;41:863-877.
Economic Cost of Physical Inactivity & Excess Weight
161
35. Health and Productivity Management: Consortium Study. American Productivity and
Quality Center, 1998, Houston, TX.
36. Lechner L, de Vries H, Adriannsen S, Drabbels L. Effect of an employee fitness program
on reduced absenteeism. J Occup Environ Med. 1997;39:827-831.
37. Goetzel R, Hawkins K, Ozminkowski R, Wang W. The health and productivity cost
burden of the top 10 physical and mental health conditions affecting six large U.S.
employers in 1999. J Occup Environ Med. 2003;45:5-14.
38. Stewart W, Ricci J, Chee E, and Morganstein D. Lost productive work time costs from
health conditions in the United States: results from the American productivity audit. J
Occup Environ Med. 2003;45:1234-1246.
39. Rundle R. Obesity’s hidden costs. The Wall St. J. May 1, 2002, section B, 3-4.
40. Current dollars and “real” GDP, National Economic Accounts, 2004. [www.bea.doc.gov/
bea/dn1.htm]
41. Behavioral Risk Factor Surveillance Survey (1999 and 2000). Centers for Disease
Control and Prevention, Atlanta, GA.
42. Lee IM, Manson J, Henneken C, Paffenbarger R. Body weight and mortality: a 27 year
follow-up of middle-aged men. JAMA. 1993;270:2823-2828.
43. Pi-Sunyer F. Short-term medical benefits and adverse effects of weight loss. Ann Int
Med. 1993;119:722-726.
44. Giovannucci E, Rimm E, Asherio A, Stamfer M, Colditz G, Willett W. Alcohol lowmethionine-low-folate diets, and risk of colon cancer in men. J Natl Cancer Inst.
1995;87:265-273.
45. Ballard-Barbash R, Swanson C. Body weight: estimation of risk for breast and endometrial cancers. Am J Nutr. 1996;63 (suppl):437.
46. Hsing A. Risk factors for male breast cancer. Cancer Caus Con. 1998;9:269-275.
47. Marchard L, Wilkens L, Kolonel L, Hankin T, Lyu LC. Associations of sedentary
lifestyle, obesity, smoking, alcohol use, and diabetes with the risk of colorectal cancer.
Cancer Res. 1997;57:4787-4794.
48. Russo A, Francheski S, La Vecchia C, Dal Maso L, Maurizio M, Conti E. Body size
and colorectal cancer. Int J Cancer. 1998;78:161-165.
49. Shoff S, Newcomb P. Diabetes, body size, and risk of endometrial cancer. Am J Epidemiol. 1998;148:234-240.
50. Chow W. Excess weight and risk of renal cell cancer. Cancer Epidemiol. 1996;5:17-21.
51. Maggio C, Pi-Sunyer F. The prevention and treatment of excess weight: applications
to type 2 diabetes. Diabetes Care. 1997;20:1744-1766.
52. Emmerson B. The management of gout. New Engl J Med. 1996;334:445-451.
53. Zerah F, Hart A, Perlemuter L, Lorino A, Atlan G. Effects of obesity on respiratory
resistance. Chest. 1993;103:1470-1476.
54. Keniston R., Meadows K, Meyers L, Nathan P. Obesity as a risk factor for slowing of
sensory conduction of the median nerve in industry. J Occup Environ Med. 1992;34:
379-383.
55. Fontaine K, Cheskin L, Barofsky J. Health-related quality of life in obese persons
seeking treatment. J Fam Practice. 1996; 43:265-279.
56. Bray G. Obesity and reproduction. Hum Reprod. 1997; 2:26-32.
57. Morin K. Perinatal outcomes of obese women: a review of the literature. J Obstet
Gynecol. 1998;27:431-440.
58. Isaacs J. Obstetric challenges of massive obesity complicating pregnancy. J Perinatol.
1994;14:10-14.
59. Norman R, Clark AM. Obesity and reproductive disorders: a review. Reprod Fertil
Dev. 1998;10:55-63.
60. Sahi T. Body mass index, cigarette smoking, and other characteristics as predictors of
self-reported, physician-diagnosed gallbladder disease in male college alumni. Am J
Epidemiol. 1998;147:644-651.
162
Chenoweth and Leutzinger
61. Suazo-Barahona J. Obesity: a risk factor for severe acute biliary and alcoholic pancreatitis. Am J Gastroenterol. 1998; 93:1324-1328.
62. Powers D, Wallin J. End stage renal disease in specific ethnic and racial groups. Arch
Int Med. 1998;158:793-800.
63. Kaplan L. Leptin, obesity and liver disease. Gastroenterol. 1998;115:997-1001.
64. Kyzer S, Charuzi I. Obstructive sleep apnea in the obese. World J Surg. 1998;22:9981001.
65. Ahmed Q. Cardiopulmonary pathology in patients with sleep apnea/human hypoventilation syndrome. Hum Pathol. 1997;28:264-269.
66. Kulpa P. Conservative treatment of urinary stress incontinence. The Physician and
SportsMedicine. 1996, 24:7.
67. Rasmussen K. Obesity as a postpartum urinary symptom. Acta Obstretr et Gynecol
Scan. 1997;96:359-362.
68. Gottshild M. Obesity in nutritional immunologic, hormonal, and clinical outcome
parameters in burns. J Am Diet Assoc. 1993;93:1261-1268.
69. Choban P. Increased Incidence of nosocomial infections in obese surgical patients. Am
Surg. 1995;61:1001-1005.
70. Chung N. Obesity and the occurrence of heat disorders. Milit Med. 1996;16:739742.
71. Broocks A, Bandelow B, Pekrun G, Meyer T, Bartmann T. Comparison of aerobic
exercise, clomipramine, and placebo in the treatment of panic disorder. Am J Psychiatry.
1998;155:603-609.
72. Segar M, Katch V, Roth R, Garcia A, Porter T, Glickman S. The effect of aerobic
exercise on self-esteem and depressive and anxiety symptoms among breast cancer
survivors. Oncol Nurs Forum. 1998;25:107-113.
73. Forrester B, Weaver M, Brown K, Phillips J, Hilyer J. Personal health risk predictors
of occupational injury among 3,415 municipal employees. J Occup Environ Med.
1996;38:515-521.
74. Bigas S, Battie M. Risk factors for industrial back problems. Seminars in Spine Surgery.
1993; 4: 2-11.
75. Mueller B. Factors affecting individual injury experience among petroleum drilling
workers. J Occup Environ Med.1987;29:126-131.
76. Tsai S, Bernacki E, Dowd C. The work relationship between work-related and non-work
related injuries. J Community Health. 1991;16:205-212.
77. Cooper C, Sutherland V. Job stress, mental health, and accidents among off-shore
workers in the oil and gas extraction industries. J Occup Med. 1987;29:119-125.
78. Han T. The prevalence of low back pain and associations with body fatness, fat distribution, and height. Int J Obes Rel Metab Disord. 1997; 21:600-607.
79. Goldberg R. Lifestyle and biological factors associated with atherosclerotic disease in
middle aged men. Arch Int Med. 1995;155:686-693.
80. Kannel W, Larson M. Long-term epidemiological predictions of coronary disease.
Cardiol. 1993;82, 137-152.
81. Kannel W, Wilson P. An update on coronary risk factors. Contemp Iss Cardiol. 1995;
79:951-971.
82. Levy D. A multifactorial approach to coronary disease risk assessment. J Clin Exp
Hypertens. 1993;15:1077-1086.
83. Murabito J. Women and cardiovascular disease: contributions from the Framingham
Heart Study. JAMA. 1995;50:35-39.
84. Wilson P. Established risk factors and coronary artery disease: the Framingham study.
Am J Hypertens. 1994;7:7-12.
85. Wilson P, Evans J. Coronary artery disease prediction. Am J Hypertens. 1993; 6:309313.
Economic Cost of Physical Inactivity & Excess Weight
163
86. Lee I, Paffenbarger R. Physical activity and stroke incidence. Stroke. 1998;29:20492054.
87. National Association of Health Underwriters. Number of uninsured Americans
continues to rise. August 26, 2004. Accessed on September 20, 2005, available at:
www.nahu.org
88. Kaiser Commission on Medicaid and the Uninsured. The Henry J. Kaiser Family Foundation. The uninsured: a primer—key facts about Americans without health insurance.
November 2004.
Notes
Median inflation rate based on 1) projected medical inflation rates (11.12% in 2004, 10.69% in 2005,
9.78% in 2006, 9.47% in 2007, and 9.38% in 2008) provided by the Centers for Medicare & Medicaid
Services (Office of the Actuary), Washington, DC and 2) employment cost index provided by Bureau
of Labor Statistics.
b
Workers’ Compensation Research Institute. (www.wcrinet.org/benchmarks)
c
Bureau of Labor Statistics, US Department of Labor (www.bls.gov/news.release/eci.t01.htm)
d
Aggregate inflation rate of 6.90% based on the following distribution of actual costs reported in the
7-state analyses: medical care (0.453% × 10.25%) plus productivity loss (0.491% × 4.10%) plus workers’ compensation (0.056% × 4.47%)
a