The American Heart Association (AHA) has used the National Health and Nutrition Examination (NHANES) survey data set to estimate the likely burden of cardiovascular disease in the next quarter-century. The headline is that increasing obesity and high blood pressure will lead to an increase in the rate of cardiovascular disease, and overall cardiovascular disease costs will triple over this period.
First the good news. The AHA projections suggest that the rate of adult behavior that increases risk of heart disease will generally improve over this time period. Fewer will smoke, fewer will have a poor diet and more will exercise. Fewer will have high cholesterol due to more effective treatment. However, fewer will sleep well, and better sleep has been associated with a lower risk of cardiovascular disease.
But there’s more bad news. More than half of adults had hypertension as of 2020, and this study projects that rate to exceed 61% by 2050. Almost one in six adults (16.3%) has diabetes; that number will increase to more than one in four (26.8%). Some of the increase in cardiovascular disease is due to the aging of our population, but much is due to increased risk factors including obesity, hypertension and diabetes.
A separate set of researchers used these projections to estimate the cost of cardiovascular disease. The researchers used inflation-adjusted dollars, so this increase is due to increasing disease and utilization, not simply due to prices increasing each year.
Much of the increased medical costs are in those over age 65 and is borne by Medicare. In the commercial population, cardiovascular disease causes substantial economic productivity loss as well as increased medical costs.
Behavioral risk factors for premature heart disease are generally declining, but not enough to blunt the increasing risk from obesity and an aging population. Higher rates of cardiovascular disease will lead to higher medical costs and more lost productivity.
Implications for employers:
The Office of the Actuary of the Centers for Medicare and Medicaid Services (CMS) published its projections of medical costs through 2023 in Health Affairs. They estimate that medical costs will rise to $7.7 trillion by 2023, 19.7% of gross domestic product. This increase is driven by the expectation that medical inflation will continue to outpace overall inflation and economic growth. Some of this increase is due to our aging population, but more is due to faster growth in health care prices.
The Office of the Actuary estimated that the annual cost per member for private health insurance would increase from $6,838 in 2023 to $10,576 in2032. Private health insurance is mostly people on employer-sponsored health insurance, although the category also includes individual health insurance purchased on the marketplaces. The researchers projected that employer-sponsored health insurance would gain 2.5 million beneficiaries when the marketplace subsidies from the Inflation Reduction Act expire in 2026, although retirement of the youngest baby boomers means that 4.3 million fewer people will be on employer-sponsored health insurance in 2032 compared to 2024.
Implications for employers:
The Commonwealth Fund released its report on maternity care in the U.S. and 13 other developed countries. The maternal mortality numbers are no surprise, and exceptionally bad for Black U.S. moms. The researchers report that almost two-thirds (65%) of maternal deaths were during the postpartum period, up to a year after delivery. They note that the U.S. is different from these other countries in a few ways.
Although the Commonwealth Fund doesn’t emphasize this point, almost a quarter of postpartum deaths in the U.S. are attributed in part to issues around mental health.
Implications for employers:
Many think that Americans are getting more obese because they are eating more and exercising less. But there’s substantial evidence to the contrary.
I was recently on a panel in Cleveland with Robert Lustig, a pediatric endocrinologist and emeritus UCSF professor. He’s the author of several books, including Obesity Before Birth Maternal and Prenatal Influences on the Offspring (2010) and Fat Chance: Beating the Odds against Sugar, Processed Food, Obesity, and Disease (2013).
He showed data on caloric intake — which has been steady over the last two decades, while obesity levels have soared.
He also noted that Americans’ exercise levels have increased. The portion of Americans who exercise enough to meet guidelines has grown in the last quarter-century. Guidelines recommend either 150-300 minutes of moderate exercise or 75-150 minutes of vigorous exercise each week.
So, what is the cause of increasing obesity in the U.S. and around the globe?
Clearly, there are some foods that have a higher “glycemic index,” which is why carbohydrates, especially those that are highly processed, cause more insulin release and more weight gain than eating protein or fat. This explains why very low-carbohydrate diets (like ketogenic diets) are effective in promoting weight loss.
Lustig focuses on ultra-processed foods and obesogens. Foods that have been heavily processed have high glycemic indexes, which stimulate insulin secretion and fat storage. We eat highly processed sugar-coated breakfast cereals instead of whole-grain oatmeal, for instance.
Obesogens are a large set of synthetic chemicals that cause obesity even without excessive caloric intake. These include plastics and pesticides. They can be found in food packaging and personal care products. This category includes “forever chemicals” that have been in nonstick cookware and stain-resistant fabrics. Many are “endocrine disruptors,” which change human metabolism and can lead to weight gain. Endocrine disruptor exposure before birth and in early childhood is associated with later obesity. Clinical studies have shown that those with higher blood levels of PFAS (perfluorinated alkylate substance, a forever chemical) regain more weight after stopping a diet than those with lower blood levels of this chemical.
Implications for employers:
Body Mass Index (BMI), which is used to assess whether people are underweight, normal weight, overweight, or obese, wasn’t designed to support clinical decision making. This measure is only modestly correlated with metabolic obesity. However, there aren’t great practical alternatives.
BMI was initially designed by a Belgian mathematician seeking to assess obesity in the overall population, not to judge the health of individuals. The measure doesn’t include waist size, and abdominal obesity is at higher risk than obesity around the hips. It isn’t adjusted for age. Athletes with large muscle mass are misidentified as obese, and Asian people can be obese with adverse metabolic health even with BMIs in the “normal” range. Those with normal BMIs but more belly fat measured by waist circumference have increased mortality. The American Medical Association recommended de-emphasizing BMI last year.
The ideal measure of obesity should be highly correlated with whether a person has fat in and around their organs. This is the type of fat which dramatically increases the risk of diabetes and cardiovascular, kidney and liver disease.
There are alternatives to BMI, but each has its disadvantages. None can be assessed remotely, and many require highly trained examiners or expensive equipment:
Implications for employers:
Jeff is an internal medicine physician and has led WTW’s clinical response to COVID-19 and other health-related topics. He has served in leadership roles in provider organizations and a health plan and is an Assistant Professor at Harvard Chan School of Public Health.
