Have you seen the new GLP-1 agonists? They only got approved for obesity last year, and might actually make a dent. The next generation are apparently even better.
Making these cheaper, more available, and with non-needle delivery are all worthy interventions, more tractable imo than the policy steering you described. But I don't know if they need charity, the market is vast.
GLP agonists are absolutely game changers in the obesity medicine space. (I’m a rehab physician with an interest in obesity medicine and recently have been offered positions in obesity clinics, largely to prescribe these medications). Basically clinics do counselling, dietician, etc., but really need physicians to prescribe these medications because they are so effective. Currently available by injection in Canada, but an oral one is coming. The GLP-1 agonist are covered by most insurance in Canada.
CBT for binge eating disorder also seems to have emerging evidence. Teaching people to feel their feelings instead of feeding them is very helpful. In terms of diets, I’ve seen a lot of evidence support low carbohydrate interventions, and I recommend dietdoctor.com and The Obesity Code (Jason Fung) to my patients.
Diabetes/Insulin resistance leads to most of the disability I see, as a disability specialist. I just presented a poster on this at a conference.
Hey Gavin, good question. My intuition is that:
On cost-effective policy interventions, the relevant costs are for us to try to convince governments to adopt them, not the government costs themselves, and the outcomes should be weighed by our probability of success. Government costs can of course matter for the probability of success, though.
Impacts on government spending and revenues would also be outcomes, not direct costs. If I recall correctly, some studies have found that people with obesity (or with diabetes or who smoke) cost less healthcare than average over their lifetimes, although health issues may also cost them productivity. Plausibly these indirect effects are all dominated by the direct effects on people with obesity, at least in the short term.
I think that a major offsetting factor may be the utility derived from eating to excess and the opportunity cost of spending time in exercise.
Though, it probably makes sense to be healthy for individuals (benefits exceed costs), I would think the costs make it a much closer to the margin to be prioritizing mass interventions. Avoiding contracting malaria, for instance, is less likely to have significant personal costs, while providing immense benefits.
Sure, being healthy is a great thing to promote, but I suspect the significant costs involve this from approaching being a super effective cause area.
Disclaimer: This report represents a very shallow dive into this cause area; approximately 7-8 hours was spent on this report. With more time, I would address some of the key uncertainties in this report and areas where I spent less time, which I imagine could update me moderately. I would invite anyone who has expertise or knowledge about the area to please comment or send me a message!
Obesity is defined as a BMI > 30 for adults, and a BMI more than 3 standard deviations above the WHO median for children (WHO). Globally, the 2019 GBD study reports that high BMI contributes to 5.02 million deaths (95% CI 3.22 to 7.11), which represents over 7% of the deaths from any cause (GBD 2019). Further, high BMI contributes to 160 million DALYs (95% CI 106-219). Roughly 60% of this burden is due to obesity (BMI > 30), and 40% due to being overweight (25<BMI<30) (GBD 2019). A significant amount of this burden is due to an increased risk of cardiovascular disease, diabetes, chronic kidney disease and cancer. As noted by Our World in Data: “To put this into context: this was close to four times the number that died in road accidents, and close to five times the number that died from HIV/AIDS in 2017.”
On an individual level, In 2016, more than 1.9 billion adults, 39% of all adults in the world, were overweight; 650 million, 13% of all adults in the world, were obese. In conjunction, over 340 million children and adolescents aged 5-19 were overweight or obese in 2016 (WHO, 2018). In fact, most of the world’s population now live in countries where being overweight and obese kill more people than being underweight.
In conjunction with hopefully quite clearly being a very significant scale issue, and perhaps most concerningly, the rate of obesity is rapidly increasing. In the last 30 years, rates of obesity have more than tripled (González-Muniesa et al 2017). This is in part driven due to rapidly increasing rates of obesity in middle income countries, especially those within the Asia Pacific region. In fact, it seems that middle income countries, in the last decade, have seen a particularly significant rise in rates of obesity; more details on the burden of obesity by country are in the following paper from Dai et al 2020
Proportion of the world with obesity over time
In addition to the health cost, the economic and social costs of obesity are significant. Although our estimates here are less robust, a recent pilot study (Okunogbe et al 2021) has estimated the economic impact of obesity at between 0.8 - 2.4% of annual GDP in eight countries. For instance, in the UK, Frontier Economics estimates the social annual cost of obesity in the UK at around £58 billion, equivalent to around 3% of the 2020 UK GDP. Economic costs for an individual may be between US$2000-7000 per year (Tremmel et al 2017), According to a McKinsey report from 2014, the direct economic impact of obesity is the third highest of any social burden, behind smoking and armed violence & war, but above illiteracy, climate change, outdoor air pollution, road traffic accidents and undernutrition.
There do seem to be a number of potentially very cost effective interventions to reduce the burden of obesity. For this section, I predominantly relied on the following reports’ estimations - McKinsey 2014 report, the Harvard CHOICES cost-effectiveness study (Gortmaker et al 2015) - as well as a few other sources.
Based on them, health policy interventions are likely to the interventions that are most-cost-effective and beat the ‘bar’:
There are many things that are unlikely to be highly cost-effective, I have just included some examples below
Overall, it seems like advocacy for regulations and policies might be an extremely cost-effective intervention; it seems unlikely that other interventions would meet the bar, although this could deal with more rigorous research.
It is difficult to assess how neglected this space is; in lieu of a exhaustive comprehensive assessment of this space, I will offer some broad heuristics which I have garnered from my global health work in the space, and from some light research:
Overall, although I didn’t investigate this thoroughly, and despite the fact that there are some major funders in this space, I would be moderately confident that cost-effective obesity interventions are overall still neglected.
It is unclear how tractable working on reducing the burden of obesity is and how tractable it is compared to other NCD risk factors (e.g. smoking, outdoor pollution). There are some theoretical reasons why we might think that this is tractable- countries have made pledges to reduce obesity, it is not a prohibitively costly or difficult space for organisations to enter, and I anticipate that funding would not be a major issue given that it is a significant global problem.
However, despite this theoretic evidence that obesity interventions should be tractable:
Based on the analysis above, I did a very brief search for organisations that I think are doing promising work. Overall:
As mentioned above, it seems surprising that more progress on obesity hasn’t been made, especially considering there are interventions that we know to be highly cost-effective. This makes me think that there are some reasons that make this space particularly difficult from a tractability perspective. I am not sure what they are.
2. Are there non-policy interventions that are cost-effective?
I anticipate that there are many countries where policy work may be quite difficult; this might be due to the opposition from other stakeholders, or due to baseline challenges in policy work within that country. It would be interesting to therefore see if there are any non-policy options that are cost-effective, as these might have greater potential for scalability.
Solved by Ozempic?