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
– 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
 Overweight
Global Situation of Excess weight
Ng, M., et al. (2014)
Situation of Excess Weight in Pakistan
49
43
38
38
33
Males
28
Females
20 21
19
15
Afghanistan
Bhutan
Ng, M., et al. (2014)
Pakistan
India
Bangladesh
13 13
Nepal
Objectives
 The
prevalence of overweight and obesity in
Pakistan along with its major determinants
 The
possible health consequences of overweight
and obesity in adult population
 Relative
Risks 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
 The
relative 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
Determinants
Socio-Economic &
Cultural Background
Determinants
Immediate
Factors
Food Intake
Physical Activity/
Life Style
Overweight
&
Obesity
Risk of Chronic Diseases
Health
Consequences
Economic Cost
Direct Cost
Medical expenses
Indirect Cost
Productivity loss
Economic
Consequences
Data
 Pakistan
Panel 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
Body Mass Index (BMI):
Underweight
Weight in kilograms divided
Healthy weight
by the square of the height
Overweight:
2
in metres (kg/m ).

Pre obese
 Unit

of Analysis
Adults (aged 18+)
Obese
BMI Range
< 18.5
18.5-24.9
>=25
25-29.9
>=30
Obesity Class I
30-34.9
Obesity Class II
35-39.9
Obesity Class III
>=40
WHO
Differentials in Obesity and Overweight
 Dependent
Variable: BMI
 Independent









Variables:
Age
Gender
Province
Region
Education
Wealth status
Marital Status
Familial obesity
Eating-out


HH food consumption pattern
Physical Activity & Lifestyle
variable





Working status
Type of work
Availability of Transport facility
Availability of Entertainment
Availability of Labour Saving
Domestic Techniques
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 nonoverweight 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%
Overweight
21%
Underweight
13%
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
Age
Overweight
Female
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
18.3
7.2
13.7
9.0
65+
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
Overweight
Obese
Balochistan
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
9
No education
10
8
Primary
Overweight
Secondary
Obese
9
Higher
Overweight and Obesity by Marital Status
Percentage of overweight and obese adults by marital status
23
19
15
11
10
4
Never married
Currently married
Overweight
Sep/Widow/divorced
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
5
No Overweight
One or Two
Overweight
Three or More
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
Others not in
labour force
21.5
60.2
12.8
5.5
100
15.2
62.0
17.5
5.2
Unemployed
Non-manual
workers
17.4
58.9
15.8
7.9
100
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
100
Overweight and Obesity by Occupation
Percentage of Overweight and Obese by Occupation
BMI
Occupation
Under
weight
Normal
weight
Overweight
Obese
Total
11.1
55.6
22.2
11.1
100
Professionals
Technicians & associate
professionals
7.1
50.3
29.0
13.5
100
0.7
55.3
32.6
11.3
Clerks
6.1
41.5
39.0
Service and sales workers
Skilled agriculture & fishery
workers
Crafts & related trades
workers
12.5
63.9
17.2
13.4
6.4
11.7
64.7
18.0
5.6
23.3
52.9
15.4
8.3
Plant & machine operators
6.0
57.8
28.9
Elementary occupations
14.9
60.8
19.0
Armed forces
3.0
51.5
30.3
7.3
5.2
15.2
Legislators, senior officials &
managers
100
100
100
100
100
100
100
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
6
Not Available
Avaliable
Overweight
Obese
Overweight and Obesity by Eating-Out
Percentage of Overweight and Obese by Eating out
Meals
Outside
BMI
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/
Consumption
Grains
Pulses
Oil
Sugar
Dairy Products
Eggs
Meat
Vegetables and Fruits
Soft Drinks
Below Median
Consumption
Above Median
Consumption
29.8
30.0
26.3
31.4
25.0
25.8
26.6
24.7
27.9
29.9
29.7
33.5
28.4
34.7
34.6
33.1
35.2
33.5
Regression Results
Result of Binary Logistic Regression
Dependent Variable: Body Mass Index (0 = BMI<25, 1 = BMI=>25)
Independent variables
Age
Gender
Male (Ref)
Female
Coefficient (B)
0.015
Significance
0.00
Odd ratios
1.015*
0.264
0.00
1.302*
-0.464
0.774
-0.042
0.00
0.00
0.65
0.629*
2.169*
0.959
-0.246
0.00
0.782*
-0.023
0.76
0.977
Province
Punjab (Ref)
Sindh
KPK
Balochistan
Region
Urban (Ref)
Rural
Poverty
Non-poor (Ref)
Poor
Marital Status
Never married (Ref)
Currently married
Formerly Married
Education
Work Status
Housewives (Ref)
Students
Other not in labour
force
Unemployed
Non-manual
workers
Manual workers
0.75
0.33
0.037
0.00
0.02
0.00
2.117*
1.391*
1.037*
-1.056
0.00
0.348*
-0.401
0.00
0.67*
-0.272
0.11
0.762
-0.041
0.77
0.96
-0.125
0.11
0.882
-0.232
0.02
0.793*
0.037
0.52
1.038
Car Availability
No (Ref)
Yes
Motorcycle Availability
No (Ref)
Yes
Entertainment Availability
No (Ref)
Yes
0.000
1.00
1.000
Labour Saving Techniques Availability
No (Ref)
Yes
Eating-Out
Consumption of Grains
0.264
-0.002
-0.008
0.00
0.77
0.36
1.302*
0.998
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
0.093
0.01
1.097*
0.381
0.00
1.463*
Consumption of
Vegetables and Fruits
Familial Obesity
Illness by Overweight and Obesity
Percentage of adults suffered from a disease by nutritional status
47
39
Underweight
34
Normal weight
37
Overweight
Obese
Type of Disease by BMI
Percentage Having Specific Illnesses by BMI
BMI
Illness Type
Underweight
Normal weight
Overweight
Obese
Total
10.4
2.1
12.0
3.6
18.7
6.3
24.2
8.5
14.6
6.4
6.0
8.5
6.3
6.6
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
Heart diseases
Diabetes
Reproductive problems
Respiratory
problems/TB
4.5
Disease Intensity by BMI I
Mean Days Estimates of Disease Intensity by Nutritional Status
BMI
Episodes of illness
Duration of illness
Days hospitalized
374
8
346
12
Underweight
1.8
Normal
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
on
Consultation
Expenditure on
Medicines
Expenditure on
hospitalization/lab
tests
Total
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
BMI
Regression Results
Result of Binary Logistic Regression
Dependent Variable: Obesity comorbidity (0 = No, 1 = Yes)
Independent variables
Coefficient (B)
Significance
0.036
Age
0.00
Odd ratios
1.036*
Gender
Male (Ref)
Female
0.154
0.33
1.167
Province
Punjab (Ref)
Sindh
KPK
Balochistan
0.222
0.761
-0.590
0.05
0.00
0.00
1.249*
2.141*
0.554*
Region
Urban (Ref)
Rural
-0.539
0.00
0.583*
Poverty
Non-poor (Ref)
Poor
Marital Status
Never married (Ref)
-0.337
0.02
0.714*
Currently married
0.530
0.03
1.699*
Formerly Married
0.527
0.06
1.694*
Education
Work Status
Housewives (Ref)
0.024
0.12
1.024
Students
Other not in labour force
Unemployed
Non-manual workers
Manual workers
-0.508
-0.380
-0.351
-0.030
-0.263
0.38
0.08
0.33
0.92
0.08
0.601
0.684
0.704
0.970
0.769
Normal/Low weight (Ref)
Overweight
Obesity
0.381
0.593
0.00
0.00
1.464*
1.810*
Familial Chronic illness
Consumption of Grains
Consumption of Pulses
Consumption of Oil
Consumption of Dairy Products
Consumption of Meat
0.475
-0.007
-0.534
0.061
-0.007
0.208
0.00
0.39
0.07
0.80
0.70
0.20
1.607*
0.993
0.586
1.063
0.993
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
Nutritional Status
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%
9
20%
11
Heart Disease
12
9
17
12
Diabetes
Any disease
Overweight
Obesity
22%
Total Direct Cost of Overweight and Obesity
16,450,154
11,365,690
5,084,464
3,691,343
2,231,085
961,537
1,460,258
1,584,893
1,269,548
623,355
836,903
2,106,450
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
1168
1543
2711
Heart Disease
Cost attributable to overweight
2388
5595
3207
Diabetes
Cost attributable to obesity
3557
4749
Any Disease
Cost of illness
Total Indirect Cost of Overweight and
Obesity
77,292,220
44,726,048
32,566,172
18,132,728
8,779,723
3,783,824
4,995,900
3,992,613
5,360,392
Heart Disease
Diabetes
Cost attributable to overweight
9,353,005
Cost attributable to obesity
7,776,436
10,356,291
Any Disease
Cost of illness
Average Indirect Cost of Overweight and
Obesity
124775
71303
54345
46503
35835
19895
15297
4598
6070
10668
Heart Disease
Cost attributable to overweight
20538
Diabetes
Cost attributable to obesity
26608
Any Disease
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
health expenditure
Share of direct cost of both diseases due to excess weight in private
out of pocket expenditure
16.20%
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%
26.80%
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
2779
4749
6481
15915
26608
35991
2420
3557
4614
13673
19895
25671
43,393,456,829
72,881,252,911
99,454,043,487
217,007,452,743
356,786,277,607
482,544,892,490
9.70%
16.30%
22.20%
Average direct cost
overweight
Average indirect cost
overweight
Average direct cost
obesity
Average indirect cost
obesity
Direct scaled-up cost
Indirect scaled-up
cost
Share of direct cost in
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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

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
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
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
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