How Much Money Is Spent On Obesity Each Year

Int J Environ Reticuloendothelial system Public Health. 2022 Apr; 14(4): 435.

Economic Saddle of Obesity: A Systematic Literature Reappraisal

Maximilian Tremmel

¹Institute for Health chec Informatics, Biometrics and Epidemiology (IBE), LMU Munich, 81377 Bavaria, Germany

Ulf-G. Gerdtham

²Wellness Economics Unit, Department of Clinical Sciences, Lund University, 22381 Lund, Sweden; es.ul.dem@mahtdreg.flu (U.-G.G.); es.ul.dem@ahas.bijnas (S.S.)

³Centre for Primary winding Health Care Inquiry, Faculty of Medicine, Lund University/Region Skåne, Skåne University Hospital, S-22241 Lund, Skåne, Sverige

⁴Economics department, Lund University, S-22363 Lund, Skåne, Sweden

Peter M. Nilsson

⁵Department of Clinical Sciences, Lund University, Skåne University Hospital, S-20502 Malmö, Skåne, Sweden; es.ul.dem@nosslin.retep

Sanjib Saha

²Health Economic science Social unit, Department of Clinical Sciences, Lund University, 22381 Lund, Sverige; es.ul.dem@mahtdreg.flu (U.-G.G.); es.ul.dem@ahas.bijnas (S.S.)

³Centre for Elemental Health Care Research, Faculty of Medicine, Lund University/Region Skåne, Skåne University Infirmary, S-22241 Lund, Skåne, Sweden

Paul A. Scuffham, Theoretical Editor

Received 2022 Spoil 5; Accepted 2022 Apr 16.

Abstract

Background: The rising preponderance of obesity represents an important public wellness issue. An assessment of its costs whitethorn be useful in providing recommendations for insurance policy and conclusion makers. This systematic review aimed to assess the economic burden of obesity and to identify, measure and depict the diametric obesity-related diseases included in the hand-picked studies. Methods: A systematised literature seek of studies in the English language was carried out in Medline (PubMed) and WWW of Scientific discipline databases to select price-of-illness studies calculating the price of obesity in a study population aged ≥18 age with obesity, As defined by a body mass index of ≥30 kg/m², for the whole selected country. The time frame for the analytic thinking was January 2011 to September 2022. Results: The included twenty dollar bill three studies reported a substantial economic burden of obesity in both formed and developing countries. There was considerable heterogeneity in methodological approaches, target populations, survey time frames, and perspectives. This prevents an informative comparison between most of the studies. Specifically, there was avid variety in the enclosed fleshiness-overlapping diseases and complications among the studies. Conclusions: Thither is an urgent need for in the public eye health measures to prevent obesity in order to redeem societal resources. Furthermore, international consensus is required along standardized methods to calculate the cost of obesity to improve homogeneity and comparability. This aspect should also be advised when including fleshiness-related diseases.

Keywords: obesity, be of illness, obesity-related disease, burden of fleshiness

1. Introduction

Obesity is a condition in which fat accumulates in the consistence to a point where IT is a risk agent or marker for a number of chronic diseases including diabetes, cardiovascular diseases (CVDs) and cancer, and has adverse effects on total health [1,2,3]. Body mass index (BMI), calculated as weight in kg (kilo) metameric by meridian in meters squared, is one of the most commonly used screening tools to measure and characterize corpulency. A BMI of 25 to <30 kg/m² is defined equally fleshy and BMI ≥ 30 kilo/m² is classified as obese [4,5].

Obesity constitutes an important scourge to national and global public health in terms of prevalence, incidence and profitable burden. In 2022, much 2.1 billion people, intimately 30% of the global population, were overweight or obese and 5% of the deaths worldwide were attributable to obesity. If the incidence continues at this rate, almost half of the world's adult population testament exist overweight or obese by 2030 [6].

Corpulency also imposes a large economic burden connected the individual, and on families and nations [7,8]. In 2022 the global economic impact of obesity was estimated to be US $2.0 trillion Oregon 2.8% of the global gross domestic product (GDP) [6]. Besides excess health care outgo, obesity also imposes costs in the imprint of lost productivity and foregone economic outgrowth Eastern Samoa a result of lost work years, lower productiveness at work, mortality and permanent disability. It has been described in recent studies and reviews that thither is a gradient between increasing BMI and costs attributable to corpulency [9,10,11,12].

Monetary value of illness (COI) studies help policy makers understand the economic gist of a peculiar disease. Such COI studies identify different components of costs of specific diseases or disease-connected complications in polar sectors of the club, which may have been rescued if the disease had not existed. They are conducted from different perspectives that determine the types of cost included in the psychoanalysis. These perspectives measure costs to the beau monde, health care for systems, participants and their families and third-party payers [13,14]. Moreover, COI studies have a significant role publicly health in formulating and prioritizing healthcare policies and allocating healthcare resources by estimating the measure of costs attributable to a disease [15].

Systematic lit reviews correspond a in order way to identify relevant studies, to summarize the results, to critically analyse the methods of the studies and, at length, to scuttlebutt and urge improvements for ulterior research. Systematic reviews in the context of monetary value of corpulency (COO) summarize the results of available studies in order to provide a high level of grounds on the cost burden imputable obesity, which May aid decision makers to develop policies to take on the burden of corpulency [16].

There hold been a number of lit reviews happening COO [17,18,19,20,21,22,23,24,25,26,27,28] including studies from before 2011. Since 2011, however, ripe methods such every bit microsimulation modelling [29,30,31] have been used and have led to new findings, requiring encourage, systematic exploration. Furthermore, just about reviews have included studies that were specific to a undivided country operating theater celibate, e.g., the Army [18,26], Canada [24] or European Economic Community [21,22,27], and deliver excluded studies from all complete the world. Some reviews have included studies that accounted for direct costs [23,26,28], while others have included only related costs [25]. Direct costs include all direct medical checkup and not-medical costs for diagnosis, treatment and transportation [32]. Indirect costs are the productivity exit cost repayable to morbidity and early mortality [33]. Moreover, approximately studies let in costs for both overweight and corpulency and Doctor of Osteopathy not separately severalise the be burden [21,26].

Additionally, none of the reviews has systematically analysed the obesity-related co-morbidities enclosed in the price calculation. Since obesity itself is not only a disease but also a adventure factor for other diseases, IT is important to study which CO-morbidities undergo been included in the different COO analyses. The attributable burden of obesity differs crossways studies. Attributable burden is determined by the Centennial State-morbidities included in a monetary value calculation. It would be interesting to see how, in the included studies, these co-morbidites are adjusted for in the overall cost calculation.

Two latterly published systematic reviews have attempted to explore the problems joint with the methodological heterogeneousness of studies [10] and performed a quality appraisal of the analysed studies [12]. Nevertheless, there is shut up a methodological heterogeneity inside COO studies and a lack of systematic reviews examining the different obesity-maternal diseases enclosed in these studies.

The objective of this study was to: (1) perform a regular review to measure the economic loading of adult obesity; and (2) identify and describe different corpulency-related diseases included in the selected studies.

2. Methodology

This in order follow-up has been performed in accordance with the Favored Reporting Items for Systematised Reviews and Meta-Analyses guidelines [34]. Moreover, the Campbell and Cochrane Economics Methods Group guidelines throw been followed including search criteria, data extraction, deductive reasoning and critical analysis.

2.1. Search Strategy

A systematic search was performed to describe relevant articles published in databases from 1 January 2011 until 14 September 2022. The databases used were Medline and Web of Science. Additional publications were searched on Google Bookman from the reference lists of included studies and reviews by to and fro snowball searches. The details of the searching scheme with key words and first hits are provided in Appendix A to ensure reproducibility and transparency of the work.

2.2. Inclusion and Exclusion Criteria

We included studies that satisfied the following criteria: (1) obesity was settled as BMI ≥ 30 kg/m²; (2) the estimation was based on the entire country and a representative universe; (3) the estimated COO could be either direct or indirect Oregon both; (4) estimated costs were proper to fleshiness and not overweight; (5) the inquiry was reportable in English in a equal-reviewed journal; and (6) studies with whatever perspective (e.g., societal, health care or third-political party payers) in cost estimations.

Studies were excluded if they were: (1) economic evaluations such equally cost-strength, cost-utility OR cost-benefit analyses; (2) reviews, notes, commentaries, or editorials accompanying obesity; Oregon (3) COO studies that enclosed children aged <18 years and pregnant women; (4) Articles describing report communications protocol operating room study design were likewise excluded.

2.3. Pick and Data Extraction

Following each search in the above mentioned databases, the first hits were exported into EndNote. After removing the duplicates, all titles and abstracts were screened to select the relevant studies based on the comprehension and exclusion criteria. The excerpt of the papers was done separately aside two of the Colorado-authors (Maximilian Tremmel and Sanjib Saha) who then patterned the comparison of studies past reviewing a unselected taste of enclosed and excluded studies later the initial screening. After removing studies that met the exclusion criteria during the initial screening, the full text of the left over studies was assessed against the inclusion criteria and any differences were discussed and a consensus was reached. A flow chart of the field pick procedure is conferred in Figure 1.

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Flow chart depiction the process of the take selection for the systematic review.

Information were extracted on two issues: (1) the results; and (2) the methodology used to derive the results. Other information was gathered also, such as perspective, analyze time frame, sample sizing, aim radical, inclusion of cost items, and price reduction rate. Moreover, we too collected information on types of obesity-bound up co-morbidities included in the studies.

3. Results

We included twenty-leash studies in this review [29,30,31,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54]. Elaborate characteristics of these studies are presented in Table 1. Eleven studies [29,30,38,39,40,44,45,46,50,53,54] used a top-down (population-based) go up and eleven studies applied a bottom-up (individual-based) approach [31,35,36,37,41,42,43,47,48,51,52] to cypher the costs attributable to obesity. The top-down approach estimates worldly costs by using aggregate information on mortality, morbidity, infirmary admissions, undiversified practice consultations, disease-related costs, and other health-related indicators along with universe attributable divide (PAF) surgery universe attributable risk (PAR) to calculate due to costs [55,56,57]. The measures of PAF and/or PAR were used in seven studies [38,40,44,45,46,50,53], while four studies did non mention the approach to estimating the costs [29,30,39,41]. Uncomparable study [54] used population traceable prevalence (Mammilla), which takes into story that risk factors and their congenator risks (RRs) can shift time.

Put over 1

Characteristics of the included studies.

Author, Publication Yr, Country	Objective	Linear perspective	Time Frame	Sample Size	Aim Group	Cost as Reported (Costing Yr)	Direct Costs Included Items	Method acting	Indirect Costs Included Items	Method	Discount Grade
Alter et al., 2012, Canada [35]	To estimate elongate-terminus health concern expenditures	Health care	11.5 years	9398	<65 years, BMI ≥ 18.5 and without pre-existing heart disease	Additive per-capita costs complete entirely time frame: CAD $8294.67 (2006)	Hospitalization costs, visits to the GP, medication, cardiac proceeding costs	Preponderance-based, bottom-up approach, ex post facto	Non included	Non relevant	N.M.
An, 2022, USA [36]	To estimate annual wellness care expenses by modeling	Healthcare	1 class	125,955	≥18 long time	Yearly per-capita costs: US $6899 (2011)	Due expenses, inpatient and outpatient costs, power-based medical provider services, emergency room services, medicine	2 PM; Prevalence-founded, bottom-ahead border on, retrospective	Not included	Not pertinent	N.M.
Andreyeva et atomic number 13., 2022, USA [37]	To underestimate annual productivity loss	Social group *	1 twelvemonth	14,975	Employed American adults	US $8.65 billion (2012)	Not enclosed	Prevalence-based, bottom-up approach, retrospective	Exit of productivity due to work absenteeism	Overall average lucre	N.M.
Bahia et alii., 2012, Brazil [38]	To estimate wellness care costs	Wellness care	3 years	54,339	Brazilians ≥18 age	US $1.1 million (2010)	Inpatient and outpatient costs	Preponderance-based, top-downward approach, ex post facto	Not included	Not relevant	N.M.
Cawley & Meyer-hoefer, 2012, US [39]	To estimate time period direct health upkeep costs	Health charge	1 yr	23,689	20–64 years	Annual per-capita costs: US $2741 (2005)	Inpatient and outpatient costs, medication, dental, vision, home health care for services and medical equipment	2 PM; prevalence-based, top side-down come nea, retrospective	Non included	Not under consideration	N.M.
De Oliveira et al., 2022, Brasil [40]	To estimate annual direct wellness care costs	Health care	1 class	188,461	Complete Brazilians with access to the public wellness system	Total costs: US $269.6 million and 64.2 million for pathologic obesity (2011)	Inmate and outpatient costs, bariatric surgery, medications, orthotics, prosthetics, medical consultations and identification procedures	Prevalence-based, top-down approach, retrospective	Non included	Not relevant	N.M.
Doherty et al., 2012, Democracy of Ireland [41]	To estimate health care costs	Healthcare	1 year	10,184	≥18 years	Total costs: 31.5 million (primary &A; secondary wellness care) (-)	Visits to the GP, inmate costs, day case (inpatient)	Bottom-up approach, retrospective	Not enclosed	Not relevant	N.M.
Effertz et al.., 2022, Germany [42]	To approximation annual societal costs	Third-party payer	1 year	146,000	Insured population in Germany	Total costs: €63.04 billion; Direct costs: €29.39 1000000000; Indirect costs: €33.65 billion (-)	Nursing costs, rehabilitation treatments, business compensations for line of work integrations, accidents, medication	Prevalence-based, bottom-finished approach, retrospective	Sickness absence, nursing care, early retirement pension off, pension for widows and orphans, renewal, unemployment, premature deathrate	HCA	2%
Kang et aliae., 2011, Korea [53]	To estimate period social group costs	Social group	1 year	1,910,194	Population aged ≥ 20 long time	Tote up costs: US $1786 billion Direct costs: U.S.A $1080 billion Indirect costs: US $705.8 million (2005)	Inpatient and outpatient costs and medication	Relative incidence-based, top-down approach, ex post facto	Loss of productivity due to premature deathrate and sickness absence; time costs, dealings costs and nursing fees	HCA	6%
Konnopka et alii., 2011, Germany [44]	To estimate annual social group costs	Societal	1 year	Entire population	Entire grown population	Total costs: €9.873 million Frank costs: €4.854 million Wandering costs: €5.019 million (2002)	Inpatient and outpatient costs, reclamation, administration and research	Preponderance-supported, upper side-falling come nea, backward	Loss of productivity ascribable sickness petit mal epilepsy, early retirement and premature mortality	HCA	5%
Konig et al., 2022, Germany [43]	To approximation social group costs	Societal	3 months	3108	Universe aged 58–82	Direct per-capita costs: €1244 (2008)	Inpatient and outpatient costs, medication, dental prostheses, paid community breast feeding internal care and folksy care	Population-based, bottom-up go up, retroactive	Not enclosed	Not relevant	N.M.
Krueger et Alabama., 2022, Canada [45]	To call annual societal costs by pretense modelling	Societal	1 year	-	17–100 years	CAD $1.0 billion (2013)	Infirmary care, physician services, medication, wellness research and other wellness care expenditures	Prevalence-based, top-refine approach, retrospective	Red of productivity due to short-condition disability, long disability and premature mortality	HCA	N.M.
Lehnert et aluminum., 2022, Deutschland [46]	To estimate annual societal costs	Societal	1 year	Entire population	Entire adult population	Total costs: €12.2 million Direct costs: €6.05 million Indirect costs: €6.19 jillio (2008)	Inpatient and outpatient costs, rehabilitation, wellness protection, ambulance, giving medication, research, investments and education	Preponderance-based, top-down approach, retrospective	Loss of productivity due to sickness petit mal epilepsy, early retirement and untimely mortality rate	HCA	5%
Lehnert et al., 2022, Deutschland [47]	To idea annual productivity loss	Social *	1 year	7990	18–65 long time and employed	Annual for each person costs: €772.0 (2009)	Non included	Bottom-raised approach, retrospective	Loss of productivity in paid work cod to absenteeism	HCA	N.M.
Lette et al., 2022, Germany, The Netherlands, Czech Republic [54]	To estimate annual health care costs	Health care	1 year	Total universe	Population aged ≥ 20 years	Annual direct costs: Diamond State: €5.1 billion; NL: €528.3 million; CZ: €108.3 million (-)	Non mentioned	Prevalence-based, top-down approach, retrospective	Not included	Not relevant	N.M.
Mora et alii., 2022, Spain [48]	To estimate wellness care costs by modelling	Health care	7 long time	452,108	Entire adult population	Annual per-capita costs: US $1382.42 Increase in annual per-capita costs: US $381.17 (2010)	Visits to the GP, specialist and emergency care, hospitalization, laboratory, radiology and other diagnostic tests and medication	2PM; Prevalence-based, bottom-up approach, prospective	Not enclosed	Not relevant	N.M.
Neovius et al., 2012, Sweden [49]	To approximate life-time productivity losses	Social *	Life-time (38 long time)	45,920	19–65 years	Total lifetime productiveness loss: €95,400 (2003)	Not included	Not relevant	Lifetime loss of productivity; illness petit mal epilepsy; disablement pension and premature fatality rate	HCA (FCA)	3%
Pitayatienanan et al., 2022, Thailand [50]	To estimate period of time societal costs	Societal *	1 year	N.M.	Entire adult population	Total costs: US $725.3 million Direct costs: America $333.6 million Indirect costs: United States of America $391.8 million (2009)	Inmate and outpatient costs	Prevalence-based, top-down access, retrospective	Loss of productivity due to previous mortality and hospital-related absenteeism	HCA	3%
Rtveladze et al., 2022, Mexico [29]	To predict healthcare costs by microsimulation	Health care	1 year	North American country adults	Entire adult population	Healthcare US $806 million (2010)	Total costs for health care and disease-related costs	Incidence-based, top-down approach, expected	Non included	Not relevant	N.M.
Rtveladze et alibi., 2022, Brazil [30]	To predict healthcare costs by microsimulation	Wellness tending	1 twelvemonth	Brazilian adults	≥20 years	US $5.81 1000000000 (2010)	Inpatient costs, medication, consultation, direction of complications	Incidence- based, top-down approach, prospective	Not included	Not relevant	N.M.
Su et al., 2022, US Army [31]	To predict societal costs aside microsimulation	Societal	5 years	5221	20–85 long time	Total per-capita costs: US $33,900 Direct per-capita costs: US $20,200 (2013)	N.M.	Worst-up approach, prospective	Loss of productivity imputable absenteeism and disability	N.M.	N.M.
Wang et aliae., 2022, USA [51]	To predict wellness care costs past modelling	Health care	1 year	117,948	Every last taxpayers and employers	US $69 zillion for intense obesity (2014)	Bariatric surgery, nutrition consultation, weight deprivation programme, medication	2 PM; prevalence-based, bottom-up approach	Not included	Not relevant	N.M.
Yang & Zhang, 2022, USA [52]	To predict the social group costs aside model computer simulation	Third base-party remunerator	Lifetime (from 65 years on)	28,906	Entire full-grown population ripe ≥ 65	Total lifespan per-capita costs: US $171,482 (2012)	Inpatient and outpatient costs, physician services, LTC, medication	2 PM; Incidence-based, bottom-up approach, prospective	Non included	Not relevant	N.M.

The bottom-up approach calculates the resources misused and productivity loss in individuals with the wellness problem in question, obesity in this case. The per-capita costs are then extrapolated to the whole universe with the health problem, supported relevant epidemiological data [58]. The items that were included in the estimation of the patient-level information included drug medication all told cardinal studies, merely the other items, e.g., hospitalization costs, physician visit costs, inmate and outpatient costs, varied across all studies. E.g., whereas An [36] included out-of-pocket expenses, inmate and outpatient costs, office-founded medical provider services, ER services and medication, Effertz et al. [42] considered nursing costs, renewal treatments, and commercial enterprise compensations for job integrations, accidents, and medication.

There were 17 studies from developed countries [31,35,36,37,39,41,42,43,44,45,46,47,48,49,51,52,54] and six studies from developing countries [29,30,38,40,50,53] according to the International Economic Situation and Prospects (WESP) report. Reported to the WESP and Organization for Economic Co-surgical procedure and Development (OECD), there is no established convention for the designation of "matured" and "nonindustrial" countries, but in common practice, Japan, Canada, the USA and Continent countries, for instance, are considered "developed" countries, while Mexico and Brazil are advised to cost "nonindustrial" countries [59]. There were six studies from Germany [42,43,44,46,47,54], sixer from the United States of America [31,36,37,39,51,52], three from Brazil [30,38,40] and two from Canada [35,45].

In five studies [36,39,48,51,52] two-way models were accustomed calculate the healthcare expenses attributable to obesity. In cardinal-part models, the probability of the medical expenditures is calculated first; thereafter IT is multiplied by the amount of expenses conditional connected the front of these expenses. A microsimulation model was designed and applied past Rtveladze et al. for Brazil [30] and Mexico [29]. Both these studies hired the 2-stage modelling process developed by the GB Foresight working party [60] and results were FALSE for leash divinatory scenarios (no BMI reduction, a 1% simplification, operating room a 5% reduction in BMI across the population). The example predicted the costs for Mexico to rise from US $806 million (2010) to US $1.7 billion in 2050. For Brazil, the costs were estimated to addition from US $5.8 billion (2010) to US $10.1 one thousand million (2050). Another microsimulation model (Markoff-settled microsimulation) was formulated by Su et al. [31], which predicted the 5-year and 10-year total economic burden of each person attributable to corpulency at U.S.A $33,900 and US $70,200 (2013), severally.

Studies as wel varied in terms of inclusion of direct costs and indirect costs, i.e., in terms of perspective of analysis (Prorogue 1). Direct medical costs include costs for the treatment and management of the diseases, e.g., inpatient or outpatient care. Candid non-medical costs let in, e.g., transportation costs to healthcare providers. Indirect costs include archaeozoic mortality costs and morbidity costs attributable sickness petit mal epilepsy and informal care costs [13]. In six studies [42,44,45,46,50,53], both direct and oblique costs were included and thus a societal perspective was misused. In twelve studies [29,30,35,36,38,39,40,41,43,48,51,52] only direct costs were calculated and therefore a healthcare perspective was ill-used. However, one of these studies [43] described this method acting as a societal position rather than a wellness care perspective.

Indirect costs only were calculated in two studies [47,49]. In a study from the USA [52], target costs were estimated from a third-party payer position and in some other study from Germany [42] both direct and indirect costs were estimated from a 3rd-party remunerator view. The third-party payer perspective includes insurance companies, governmental agencies, and employers. The Medicaid perspective, a government broadcast financed by federal, state and topical anesthetic funds for persons of every ages inside certain income limits, was used in the U.S. study piece in the German study, the perspective of the "Techniker Krankenkasse" insurance fellowship was used. The informal costs and cozy caregiver costs were included in merely two studies [43,53].

We found a substantial variation in the items that were included while estimating the direct toll (Table 1). For instance, in one take from Brazil, by Bahia et al. [38], only inpatient and outpatient costs were included for the approximation of the honest costs, while in another Brazilian study, by de Oliveira et al. [40], costs for bariatric surgery, medication, orthotics, prosthetics, medical consultation and diagnostic procedures were additionally included. There was also variation in the reckoning of discursive costs. Out of nine studies, in eight studies [42,44,45,46,47,49,50,53] researchers used the human great approach (HCA) to calculate the secondary costs. Neovius et al. secondhand the friction cost approach (FCA) As well as the HCA to estimate the indirect COO for Swedish men [49]. The HCA measures lost product, in terms of lost earnings of a patient. For mortality or permanent disability costs, the HCA multiplies the earnings destroyed at each age by the probability of living to that maturat [57]. In the FCA, only when the production losses during the time information technology takes to replace a worker [57] are measured. Andreyeva et al. used moderate earnings to measure indirect costs [37].

We further gathered information on the obesity-related diseases included in each of the studies listed in Table 2. In 14 studies, researchers mentioned obesity-related diseases in the cost calculation [29,30,31,35,38,40,44,45,46,47,50,52,53,54]. The costs of diabetes were included in whol of these 14 studies, leash of which [35,51,53] included both Type 1 and Type 2 diabetes. Additionally, all of the studies, except one [35], considered CVDs. Therefore, diabetes and CVDs were the most unremarkably considered comorbidities of corpulency in the elite studies. In addition to diabetes and CVDs regarded Eastern Samoa comorbidities of obesity, some hypertension [29,30,31,35,38,40,44,46,47,50,53,54] and cancer [29,30,31,37,40,44,45,46,50,52,53,54] were included in xii studies. However, these studies differ with regard to the eccentric of malignant neoplastic disease included in the cost depth psychology.

Postpone 2

Fleshiness-related diseases included in the studies.

Author, Year, Country	Diabetes	CVDs	Hyper-Tension	Cancer	Metabolic process Disorders	Musculo-Skeletal Disorders	Knowledge Orcus-Orders	Digestive Diseases	Other
Alter et al., 2012, Canada [35]	√		√				√
Bahia et aliae., 2012, Brazil [38]	√	√	√	√	√	√
de Oliveira et al., 2022, Brazil [40]	√	√	√	√	√	√
Kang et AL., 2011, Korea [53]	√	√	√	√		√			√
Konnopka et al.., 2011, Germany [44]	√	√	√	√				√	√
Krueger et al., 2022, Canada [45]	√	√		√	√	√		√	√
Lehnert et al., 2022, Germany [47]	√	√	√				√		√
Lehnert et alia., 2022, German (UPDATE) [46]	√	√	√	√				√	√
Lette et alibi., 2022, DE, NL, CZ [54]	√	√	√	√		√
Pitayatienanan et al., 2022, Thailand [50]	√	√	√	√	√	√	√	√	√
Rtveladze et al., 2022, Mexico [29]	√	√	√	√		√
Rtveladze et atomic number 13., 2022, Brazil [30]	√	√	√	√		√
Su et al.., 2022, USA [31]	√	√	√	√	√	√	√	√	√
Yang &adenylic acid; Zhang, 2022, USA [52]	√	√		√	√

For lesson, Konnopka et al. [44] enclosed neoplasms of the gorge, stomach, colon, liver, gallbladder, pancreas, biological time breast, cervix uteri, ovary, prostate gland, and kidney, non-Hodgkin's lymphoma, multiple myeloma, and leukaemia, while Kang et atomic number 13. [53] included only colon cancer among the cancers. Furthermore, musculoskeletal disorders were considered in nine [29,30,31,38,40,45,50,53,54], metabolism disorders in six [31,38,40,45,50,52] and organic process diseases in five studies [31,44,45,46,50]. Four studies [31,35,47,50] have besides included body part disorders such as clinical depression. All of the abovementioned diseases were included only in the studies aside Pitayatienanan et al. [50] and Su et al. [31].

Ii studies estimated the obesity burthen in Brazil from a health care perspective. Bahia et Camellia State. [38] calculated the costs over 3 age from 2008 to 2010 to be US $1.1 billion per year and de Oliveira et al. [40] gave the onus of obesity in 2010 As USA $269.6 jillio. Both studies used the PAF and a top-down approach. Bahia et al. [38] collected data from the national wellness database from 2008 to 2010 and the costs echoic the average costs for 3 years. De Oliveira et al. [40] used Ministry of Health Information to estimate the one-year healthcare costs.

Konnopka et al. [44] utilized the concept of attributable fractions based on German prevalence data and relative risks from US studies as well as statistics from the German Federal Statistics Part and the German Retirement Insurance Billet. These results were updated past Lehnert et al. [46] 6 years later using the same method to calculate the monetary value burden. The overall period societal (direct and indirect) costs attributable obesity increased from €9.8 cardinal in 2002 to €12.2 million in 2008. Other study from Germany [42], using a different method based on claims data from a German wellness insurance company, estimated the total costs for third-party payers to beryllium €63.0 jillio per year. Konig et al. [43] estimated the average 3-month individual health caution costs (as wel including informal care) in Germany to be €1244 (2008) using questionnaire data from an 8-year followup contact of a large population-based potential cohort meditate styled "Epidemiologische Studie zu Chancen der Verhütung, Früherkennung und optimierten Therapie chronischer Erkrankungen in der älteren Bevölkerung" (the ESTHER sketch). Yet another German study [54] estimated the total national health maintenance costs at €5.1 million, using the OBCOST tool to estimate incidence, prevalence and death rate (IPM) to calculate the COO.

For Canada, the annual social group costs were estimated to be CAD $1.0 billion, accordant to Krueger et atomic number 13. [45] victimization data from the 2012 Canadian Profession Health Survey. Kang et al. [53] included 1,910,194 Korean individuals in their discipline to calculate the period social costs, which in 2005 amounted to US $1786 billion. Annual societal costs were besides estimated in a subject area in Thailand [50] and costs attributable to corpulency were US $725.3 million in 2009. For Sweden, Neovius et al. [49] estimated that the total lifetime productivity loss referable obesity was €95,400 per man in 2003. This study was based on a 38-year followup of 45,920 Swedish men who were performing mandatory military draft tests at mature 18.7 ± 0.5 years.

Organize per-capita costs of obesity were reported in seven studies [31,35,36,37,43,48,52] and indirect per-capita costs were measured in one study in Sweden [49]. When comparison the results of two studies in the U.S. [36,39] estimating annual direct costs per capita, the costs increased from US $2741 in 2005 to US $6899 in 2011. Both these studies used data from the Learned profession Expenditure Panel Survey. Alter et al. [35] estimated the direct per-capita costs attributable to obesity over a time frame of 11.5 years to be CAD $8294.67 (2006) piece the direct per-capita costs concluded a lifetime (>65 age) amounted to U.S.A $171,482 (2010) in the US [52]. Total per-capita costs in the United States Army were expected, using a Markov-supported microsimulation, to be US $33,900 and US $70,200 (2013) finished a fourth dimension frame of 5 and 10 years, severally [31].

4. Discussion

In this paper, we have performed a systematic lit review of recent toll of obesity (COO) studies. We have found that there is tranquillise a bulky heterogeneousness across the ready COO literature. Although there is a substantial planetary literature happening COO, we have found that a review and synthesis of the results supported homogeneous methods and costing approaches is hindered by a comfortable range of sources, as well as methodological approaches, perspectives, target groups and enclosed diseases, secondhand to estimate the prevalence of obesity.

A key issue of COI studies is the PAF applied to calculate the divide of costs attributable to obesity. There are No agreed recommendations or guidelines along what fraction of the co-morbidities can make up attributed to obesity and what divide can make up attributed to the atomic number 27-morbidities themselves. Since obesity is a complex disease experimental condition with a good deal different co-morbidity, what fraction of the co-morbidities is attributed to obesity has much influence on the be calculation. The PAF is deliberate by using the RRs for co-morbidities related to corpulency. In the literature review, we institute different methods for calculation of RRs and, later, PAF. For example, Lette et al. [54] applied historic period- and gender-specific RRs and used obesity-related co-morbidities from the Comparative Quantification of Health Risks [61]. Bahia et al. [38] chosen co-morbidities settled on two conditions: firstly, those RRs are ≥1.20 for diseases and secondly, that RRs are ≥1.10 but <1.20 for diseases that are a satisfying problem for public health referable high prevalence plac. The authors calculated the RRs by playing meta-analyses. The different methods for calculation of PAF can lead to an ended—operating theatre an underestimation of costs attributable to obesity and can hence make it difficult for comparison between studies.

Our literature review included studies that are supported various approaches for calculating the disease burden of obesity (Table 1). Each approach has advantages and disadvantages. The top-down approach is simple, transparent, and cheaper and faster than the bottom-up approach. A disadvantage of the top-down approach is that all possible unsupportive variables need to make up adjusted for when estimating the PAF. For a complex disease such as fleshiness, this approach may underestimate operating theatre overestimation the costs derived from co-morbidities. The bottom-up approach, on the other hand out, calculates the mean per-person costs, which are then extrapolated to the whole population. In that case, the long-suffering sample size needs to personify unbiased and representative of the national universe. This mightiness require extensive resources and may non live always practical (e.g., for estimating the future price) [62]. Then again, this approach is more comprehensive and reasoned, and enables detection of the unevenness related to differences in important demographic characteristics 'tween patients [58]. Microsimulation models can predict the future cost and can incorporate data from early countries, if data are missing in a specific case or if information from another country are acknowledged to be valid and sufficiently reliable to be incorporated. A disadvantage of microsimulations is that a number of assumptions are made that Crataegus laevigata or may not live validated; these assumptions have to be chequered using sensitivity psychoanalysis to evaluate how sensitive indicators can react to changes in input parameters. This outgrowth makes the role model complex and sometimes makes it difficult to understand [63].

The study by Lehnert et aliae. [46] aimed to update the analyse by Konnopka et alia. [44] and used the same method, perspective and target group in Germany. Therefore, these studies provide a effective movie of the increase in the societal COO in Germany, from €9.8 zillion in 2002 to €12.2 one thousand thousand in 2008. Researchers argued that the main number one wood hind end the cost increases was the salary increase in the preponderance of overweight and obesity in Germany between 2002 and 2008. This series of studies from Germany, using the aforementioned methods to measure the COO, English hawthorn provide a valid command about the development of COO between these two time points and gives a dear example of how COO studies derriere be conducted in a structured and logical way. Nevertheless, the costs estimated in these two studies dissent crucially from those reported by Krueger et al. [45] who used a similar approach to idea the yearly COO in Canada. Although the universe of Canada is less than half of the universe of Germany, these authors estimated the one-year COO at Dog $1.0 billion. This variation in estimated costs can be explained by the approaches to calculating the risk factor exposure of corpulency. The two studies from Germany used relative risks (RR) data from studies conducted in the USA to calculate the PAF. Even though estimates of RR were well-balanced for important confounders such as gender, age, race and smoking status in both studies, transfer of training of costs to the German population causes incertitude. By contrast, the study from Canada used RR information from a previously conducted lit review on studies of the general population of Western countries. Whereas Konnopka et aliae. [44] used European nation preponderance data and RRs from the US studies, Krueger et alia. [45] utilized self-reportable data from the Canadian Community Health Go over to calculate the risk factor exposure. Furthermore, the 2 studies enclosed different diseases in the cost computing. Krueger et al. [45] excluded hypertension spell Konnopka et aliae. [44] excluded metabolic process and musculoskeletal disorders in the costing access, which whitethorn explain some of the variation in estimated costs.

We included three studies from Brazil which calculated direct COO. Bahia et al. [38] collected data of the national health database from 2008 to 2010 and their estimated cost of US $1.1 billion reflects the average of 3 long time. DE Oliveira et al. [40] also used a uppermost-down approach with Ministry of Health data to estimate the annual wellness care costs, which amounted to US $269.6 million. Rtveladze et Camellia State. [30] used a microsimulation framework (Monte Carlo simulation), which requires county-specified disease relative incidence data, to predict health care costs from 2010 to 2050. Their results are limited by the lack of body politic-particularized relative incidence and, e.g., cancer mortality data, American Samoa they used data from the U.S.A, which has led to an overestimate of costs because Brazilian per capita health care spending is nearly eight times lower compared with the USA. When comparison these three study results, several limitations have to be five-pointed retired: e.g., Bahia et al. [38] victimised RR data from countries some other than Brazil since no data were free settled on Brazilian cohorts. In addition, obesity prevalence rates were obtained from self-reported weight and superlative, which method acting may lead to either overrating OR underrating of costs attributable to obesity, when either overly many a OR excessively few people are categorized as obese, settled on soul-reported weight and tallness. On the other hand, de Oliveira et Camellia State. [40] used the PAR of obesity to calculate the costs for pathologic corpulency, which crapper lead to an underestimation of costs; also, they obtained RR data from cohort studies and meta-analyses published in international journals. Consequently, the different data sources accustomed estimate the RR relevant for the cost calculation need to be reasoned. When comparing these costs with costs in developed countries, it should be borne in brain that the Brazilian public wellness system has a large unmet demand for bariatric surgery, and consequently, that there may be an underestimation of COO in Brazil collectable to unmet needs [64].

Another characteristic of studies enclosed in that recapitulation was the modest time skeletal frame of the analyses. In only six studies [31,35,38,48,49,52] was the time frame of the analyses longer than 1 year. Su et al. [31] reported per-capita costs in the USA over a time frame of 5 and 10 years. Alter et al. [35] investigated a time frame of 11.5 years to idea the cumulative per-capita costs. Additionally, a propensity score matching method based connected operative confounders such as years, gender, socioeconomic status, smoking, physical activity, psychosocial stress and comorbidity, and a sensitivity analysis were performed, only the results did not change. Nevertheless, these results are finite past the exclusion of patients aged 65 and older, which English hawthorn imply an underestimate of the costs and hinder a useful compare with, e.g., the study by Yang et al.. [52], who measured lifetime costs from 65 years onward.

Some studies failing to merged a discount rate (Table 1) [29,30,31,35,36,37,38,39,40,41,43,45,47,48,51,52,54]. Discounting allows calculation of the naturally occurring rate of payments that wish be made in the future and should be practical when the length of the depth psychology is longer than 1 year, otherwise the calculated costs might overestimate the true costs. Effertz et al. [42] organized discounting in a 1-year time systema skeletale of analysis, whereas for example Alter et al. [35] did non apply any discounting terminated a time figure of 11.5 years. Moreover, the discount rates also change among studies. Effertz et al. [42] used a discount rate of 2% while Kang et al. [53] discounted the costs at a rate of 6%. Hence, the costs rumored by Effertz et al. [42] mightiness overestimate the true costs, while the costs calculated by Kang et al. [53] might underestimate them. There is no agreement on the discount rate rate to be used in the scientific literature, although the World Health Organization (WHO) has recommended exploitation a 3% bank discount [65].

Moreover, it should be pointed unsuccessful that single four studies [31,35,47,50] include costs for mental disorders as a relevant obesity-concerned disease. According to Vigo et al. [66], the burden of psychical disorders still seems to live underestimated even though e.g., depression as a psychic disquiet is on the rise globally, reported to the World Health Organization [67]. A recent systematic review [68] investigated the relationship between fleshiness and depression among full-grown men and women. The results indicate that there is a bidirectional relationship 'tween obesity and depression. Consequently, excluding Depression and unusual mental disorders from the obesity-akin diseases whitethorn jumper lead to an underestimation of costs. For example, the societal costs of depression in Germany were estimated at €15.6 billion per yr [69].

The International Agency for Research into Cancer (IARC) [70] and the Planetary Cancer Research Fund (WCRF) [71] report that rough-cut cancers in obese people are endometrial, oesophageal, body part, postmenopausal breast, prostate and nephritic cancer and adenocarcinoma. To a lesser extent inferior malignancies associated with obesity are cancerous melanoma, thyroid cancers [72], leukaemia, not-Alan Hodgkin's lymphoma, and multiple myeloma [73]. Nonetheless, there was a crucial heterogeneousness between the studies that enclosed different types of Cancer the Crab. Kang et al. [53] only included colon cancer as an corpulency-related disease, while Konnopka et atomic number 13. [44] and Lehnert et alia. [46] included stomach, kidney, liver, gallbladder, cervix, ovary cancers and non-Hodgkin's lymphoma, multiple myeloma, and leukaemia in addition to the common cancers in obese people mentioned by the IARC and WCRF. Su et al. [31] included 16 other types of obesity-related cancers in their work. The reported costs due to cancers need to be interpreted with the noesis that different types of cancer were enclosed in the different studies, which may have light-emitting diode to over- or underestimation of costs. Ascribable the fact that cancers create a big cost burden for smart set [74], there is a need for calibration when including cancers in the corpulency-related costs. Within the twelve studies that have mentioned the included obesity-related diseases, one study, by Su et al. [31], included obesity-lineal liver diseases, such as not-alcoholic fatty liver disease (NAFLD), liver fibrosis and cirrhosis of the liver of the liver, which are also associated with obesity [75,76]. For example, NAFLD, a very informal chronic liver disease universal, is on the rise following the trend of profit-maximising prevalence of obesity, and is the second most common indication for liver transplantation, and an important cause of hepatocellular carcinoma [77]. Also, hepatic steatosis is known to be an associated comorbidity of obesity [78]. Consequently, we recommend considering liver-colored diseases when costs of obesity and similar diseases are calculated.

We found three studies, from the USA [37], Germany [47] and Sweden [49], in which only indirect costs due to fleshiness were calculated. While Andreyeva et AL. [37] used overall average net income to calculate the costs, Lehnert et Alabama. [47] and Neovius et alibi. [49] victimised the HCA. Therefore, it has to be noted that using boilersuit average earnings may overestimate medium earnings for obese workers, especially women, in light of grounds that obesity is related to with forward socioeconomic position [79]. Neovius et al. [49] res publica that using an FCA, compared with the HCA, reduced the estimated productivity losses past about 80%. Therefore, it may be beneficial to account periphrastic costs both using HCA and FCA approach.

Summarizing these results, we can state that obesity is responsible for a large fraction of costs, not only to the health care system just also to club at larger. As we declared previously, almost half of the world's grown universe will be overweight or obese by 2030 if the prevalence continues on the current trend [6] and consequently also the costs attributable to obesity will increase. A expedient example for speedily rising costs attributable to obesity from these selected studies are the two mentioned studies from Germany [44,46]. The results of the two papers together demonstrate that total societal costs in Federal Republic of Germany due to fleshiness have increased from €9.8 million to €12.2 million between 2002 and 2008. Therefore, public wellness interventions should focalise on the prevention of obesity as presently American Samoa attainable, ideally at a young geezerhoo. A possible option would be to focus on go web site wellness publicity (WHP) to gain physical activity and healthy lifestyles at the workplace, peculiarly every bit obesity has been found to be connected with absenteeism, disability pension and gross work impairment [80]. Higher physical activity busy may non only leave to a reduction in BMI and obesity, but also increase the health status of the employees. This may in turn further reduce squint costs imputable absenteeism and disability pension.

Furthermore, the definition of the various perspectives used in the studies should be discussed, since the term "societal" as a perspective was ill-used variously in different studies. The societal perspective should include entirely costs (related and indirect) except transfer payments (a shift of resources so much A social security benefits or Medicare or Medicaid payments) [57]. E.g., Lehnert et al. [47] and Neovius et al. [49] who only calculated indirect costs of obesity delineate theirs as a social perspective. Konig et al. [43] exclusive estimated direct costs, yet also used the term "social group" to describe their perspective.

A limitation of this review is that we single used Medline, Web of Scientific discipline and Google Scholar to search for studies, which Crataegus oxycantha have limited the number of potentially eligible studies. In addition, we only examined articles published in West Germanic language. Furthermore, the absence of international standardized methods and considerable heterogeneity between the study designs of these COO studies hinders the closing of a cosmopolitan limited review. Another limitation of this study is that we did not aim to execute a prize appraisal of the chosen studies, also due to the fact that there are no validated guidelines to perform a superior check for COI studies. Furthermore, we considered obesity to be a fixed specify even though it has been discussed in the recent literature that obesity may be a impermanent state, e.g., depending on age cohorts or menstruation effects [81].

5. Conclusions

The studies low-level review show that obesity is responsible for a large fraction of costs, both for health care systems and for society. Heterogeneity is a stellar limitation among the COI literature generally and the COO literature in particular, which hinders a conclusive comparison of the different studies. We recommend that obesity-related diseases and complications should be included more consistently. We also recommend that additional obesity-related diseases be thoughtful in further COO studies, such atomic number 3 liver and mental diseases which take by and large been uncared-for thus far.

Acknowledgments

This systematic lit review was based by grants from the Swedish Lung Foundation (2006-0169); Region Skåne; Lund University; and the Research Council of Sweden.

Appendix A: Details of the Research Scheme with Keywords and First Hits.

MeSH-Damage used in MedLine (initial hits: 1348):

((((((((((((((cost [MeSH Terms]) OR absenteeism [MeSH Price]) OR presenteeism [Meshwork Footing]) Operating theater productivity [MeSH Terms]) OR sick leave [MeSH Terms]) OR health cost, employer [MeSH Terms]) OR compensations, workers [MeSH Terms]) OR disability leaves [MeSH Terms]) Operating theatre premature mortality [MeSH Terms]) AND ("2011/01/01"[PDat]: "2016/09/13" [PDat]) AND Humans [Ensnarl] AND English [lang])) Operating room ((((((((((((costs and cost analytic thinking [MeSH Terms])) OR economics [MeSH Terms]) OR cost benefit analysis [MeSH Terms]) Oregon cost allocation [Net Terms]) OR cost of unwellness [Meshwork Terms]) Operating room cost control [MeSH Terms]) Operating theatre health give care costs [MeSH Damage]) OR direct service costs [MeSH Terms]) OR infirmary costs [MeSH Terms]) OR employer wellness costs [Enmesh Terms]) OR drug costs [MeSH Terms])) AND ("2011/01/01" [PDat]: "2016/09/13" [PDat]) AND Mankind [Mesh] AND English [lang])) AND (((((obesity, morbid [MeSH Terms]) OR ((((opposing-obesity agents [MeSH Terms]) OR obesity, abdominal [MeSH Terms]) OR obesity [MeSH Terms]) OR overweight [MeSH Terms])) OR Body part obesity metabolous syndrome [MeSH Terms]) Beaver State Anti-Fleshiness Agents [MeSH Footing]));

Terms used for Vane of Science search (initial hits: 4137):

Absenteeism, presenteeism, productivity, sick forget, health cost, workers' compensations, disability leaves, premature mortality, costs and cost psychoanalysis, economic science, cost welfare analysis, cost allocation, cost of illness, cost ascendance, healthcare costs, direct service costs, hospital costs, employer wellness costs, anti-obesity agents, abdominal fleshiness, obesity, overweight, abdominal obesity, metabolic syndrome, Opposed-Obesity Agents;

Initial hits for both MEDLINE and Web of Science: 5485

Writer Contributions

Maximilian Tremmel and Sanjib Saha planned and designed the systematic literature search; Maximilian Tremmel performed the systematic literature search; Sanjib Saha contributed to the search scheme, and the selection and extraction of literature; Maximilian Tremmel analysed and extracted the literature; Maximilian Tremmel wrote the first draft; Sanjib Saha, Ulf-G Gerdtham and Peter M. Brigit Nilsson contributed to the committal to writing of the manuscript. All the authors have record the net version of the manuscript.

Conflicts of Interest

The authors hold none infringe of involvement.

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