This chapter provides an overview of the economic costs of obesity in the United States with a particular focus on the costs of obesity related to women’s health care. The chapter begins by briefly introducing the relationship of obesity with health problems that often result in increased costs. Costs, both direct and indirect, are defined, and overall costs associated with obesity are reviewed. The chapter then largely addresses the costs of obesity related to women’s health care, particularly obstetrical and gynecological services.

Costs of obesity and its comorbidities are both direct and indirect. Direct costs include the medical care interventions to treat morbidity associated with obesity. Indirect costs include costs that are secondary to obesity, increases in premature mortality, reduction in productivity, and increases in insurance costs.

Direct Costs

Direct costs include direct patient care services, such as outpatient and inpatient health services, laboratory and radiological tests, and drug therapy. Obese individuals incur, on average, annual medical care expenditures of $732 higher than individuals of normal weight.¹ A systematic review of the direct costs of obesity found that obese individuals have medical costs approximately 30% higher than their normal-weight peers.² Annual spending due to obesity has been estimated at 9.1% of annual medical spending in the United States.³ A more recent study, which employed Medical Expenditure Panel Survey (MEPS) data, estimated that medical care associated with obesity is 20.6% of U.S. health care expenditures.⁴ It is estimated that Medicare and Medicaid are responsible for approximately 42% of this spending.³

Indirect Costs

Indirect costs, which are more difficult to measure than direct costs, can be defined as resources forgone as a result of a health condition and fall into various categories. Indirect costs include higher disability insurance premiums, decreased labor market productivity, and premature mortality. Published research findings offer a wide range of estimates for the total indirect costs of obesity; direct comparison of results across studies is difficult due to a set of methodological issues, including the date of measurement, representativeness of the sample, and scope of measurement.⁵

Indirect costs include the value of lost work; days missed from work are a cost to both employees (in lost wages) and employers (in work not completed). Obese employees miss more days from work due to short-term absences, long-term disability, and premature death than nonobese employees.⁶ The cost of absenteeism for obese and morbidly obese was estimated at $4.2 billion each year.⁷ These individuals may also work at less than full capacity (also known as presenteeism). The costs of absenteeism and presenteeism resulting from obesity among full-time employees based on 2006 MEPS data were estimated at $73.1 billion annually, with roughly two-thirds of those costs associated with approximately one-third of employees with a body mass index (BMI) over 35. Wang et al.⁸ estimated that absenteeism and presenteeism associated with a high BMI result in a loss of between 1.7 and 3 million productive person-years in working US adults. The probability of total employer costs increasing partly due to disability, workers’ compensation claims, and days of work lost increases for individuals with a BMI of 25 and higher.⁹

Indirect costs also include costs of insurance. Employers pay higher life insurance premiums and pay out more for workers’ compensation for employees who are obese than for employees who are not.¹⁰

Obesity is associated with premature mortality. Obesity and overweight in adulthood are associated with large decreases in life expectancy and increases in early mortality, similar to the decreases related to smoking.¹¹ Not only is overall life expectancy decreased, but also quality of life is diminished. A number of studies found that obesity impairs health-related quality of life (HRQL), and that higher degrees of obesity are associated with greater impairment.¹² Groessel et al.¹³ found that for every 20 people living 1 year with obesity the result is the loss of 1 quality-adjusted life-year (QALY), translating into nearly 3 million QALYs lost each year in the United States.

The health of women is negatively affected by obesity. Obese women (and men) are dramatically at risk for diabetes, which is associated with higher risk of cardiovascular diseases. Low-back pain, knee osteoarthritis, and depression may also be linked to obesity in women.¹⁴ Overweight and obese individuals are also at higher risk for developing hypertension.¹⁵

Women, compared to men, suffer a disproportionate burden of disease, and cost, associated with obesity,⁴ particularly from lower HRQL and late-life mortality.¹⁶ For the purposes of this chapter, however, the discussion focuses on the direct, rather than indirect, costs of provision of care associated with women’s health.

Obesity in Pregnancy

In the United States, more than one-half of pregnant women are overweight or obese, putting them at higher risk of a number of complications of pregnancy, including gestational diabetes mellitus, hypertension, preeclampsia, cesarean delivery, and postpartum weight retention. In addition, obese women are more prone to intrapartum, operative, and postoperative complications.¹⁷ These conditions result in increased use of health care services, including longer stay, more use of ancillary testing, more medications, and increased use of ambulatory services, particularly physician visits.¹⁸ Pathi, Esen, and Hildreth¹⁹ found that morbidly obese women had higher rates of use of ultrasound scans, more antenatal visits, and a longer stay in the hospital and that the baby of an obese mother is 10 times more likely to be admitted to the special care baby unit. Galtier-Dereure, Boegner, and Bringer²⁰ found that women with a BMI over 29, compared to normal-weight controls, had a longer hospital stay of 4.3 days, on average, often due to more frequent cesarean deliveries and postoperative endometritis.