OECD Health Policy Studies The Heavy Burden of Obesity The Economics of Prevention PUBE 2 THE HEAVY BURDEN OF OBESITY © OECD 2019 3 Foreword It has been nearly a decade since the OECD published its flagship report on obesity, Fit not Fat. During the intervening years, countries have put in place innovative and, in some cases, ambitious policies to turn the tide on the obesity epidemic. Unfortunately, though, the end is not in sight yet. Overweight and obesity rates have continued to climb to 58% of the adult population across OECD countries. Childhood and morbid obesity have gone from a rare event to a common occurrence. Obesity now poses an alarming burden on individuals, societies and economies in OECD countries and beyond. This report demonstrates that there is a strong economic case for investing in prevention to tackle obesity. By linking its advanced microsimulation model with the OECD long-term projection model, this report simulates the impact of obesity on health expenditure and the wider economy in 52 countries to 2050. The analysis shows how obesity not only reduces life expectancy but also damages pupils’ school performances, workforce productivity, and negatively impacts GDP. But there is a good news. Every dollar spent on preventing obesity generates an economic return of up to six dollars – making prevention interventions an excellent investment. Different policy packages can reduce this burden while saving money. This report is a clear illustration of how better policies can lead to better lives. By investing in prevention, policymakers have the opportunity to halt the rise in obesity for future generations, and benefit economies. There is no more excuse for inaction. THE HEAVY BURDEN OF OBESITY © OECD 2019 4 Acknowledgements The Organisation for Economic Co-operation and Development (OECD) work on overweight, diet and physical activity was conducted on behalf of its Health Committee, between 2016 and 2019. Michele Cecchini oversaw the project and coordinated the production of the final report. He also led the production of Chapter 1. Chapter 2 was led by Christina Xiao. Chapters 3 and 7 as well the country notes were led by Sabine Vuik. She also contributed to the production of the report. Marion Devaux led Chapter 4 while Yevgeniy Goryakin led Chapters 5 and 6 as well as the special focus to Chapter 6. Aliénor Lerouge led the modelling team with support from Alexandra Aldea and Leila Fardeau. Yvan Guillemette from the Economics Department ran the analyses on the OECD GDP long-term model and contributed to Chapters 3 and 6 as well as the special focus to Chapter 6. Andrea Feigl and Sahara Graf supported the main authors and gave a significant contribution to different sections of the report. Kei Nakagawa and Ivan Tzintzun provide support for analyses on labour market outcomes in, respectively, Japan and Mexico. Many more people deserve credit for the work presented in this book. The production of this report benefited greatly from the inputs and comments received from other OECD colleagues, national experts, member states representatives and other stakeholders. Within OECD, authors would like to thank Lucy Hulett and Suzanne Parandian for the editorial assistance. Lukasz Lech and Guillaume Haquin provided administrative assistant. Paul Gallagher and Spencer Wilson helped sharpening the key messages from this work. Thanks also go to Thierry Pellegrini and Arnaud Atoch for their support on IT, software and programming issues – their contribution was critical to the various analyses and effective management of very large quantities of data. Stefano Scarpetta, Mark Pearson and Francesca Colombo provided senior leadership and advice throughout the project. Franco Sassi provided inputs in the initial phases of the designing of the project. Colleagues from the Trade and Agriculture Directorate as well as Francesca Borgonovi from the Education Directorate provided inputs and comments on issues related to their respective areas of work. Special thanks go to Attila Balogh (European Commission) who followed the development of the project since its conceptualisation and provided inputs throughout. The OECD maintains a close partnership with the World Health Organization (WHO) in its work on public health and authors would like to thank Chizuru Nishida for her inputs and comments on the different drafts of the report. At WHO Europe, authors would like to acknowledge Joao Breda. Preliminary versions of the chapters of this book were presented and discussed at meetings of the OECD Expert Group on the Economics of Public Health (EGEPH) chaired by Cristina Gutierrez Delgado and at meetings of the OECD Health Committee chaired by Bjorn-Inge Larsen and Olivia Wigzell. Country experts and delegates are too many to name individually, but authors would like to thank in particular delegates from Australia, Austria, Canada, Colombia, Germany, Ireland, Japan, Spain, Sweden, the United States, the European Commission and the Joint Research Centre of the European Commission for their constructive comments throughout the process. In addition, authors would like to thank delegates and experts participating in the work of the Trade and Agriculture Directorate, specifically participants to the 2018 meeting of the Food Chain Analysis Network, as well as the Chair and delegates of the Working THE HEAVY BURDEN OF OBESITY © OECD 2019 5 Party on Agricultural Policies and Markets. Finally, authors would like to acknowledge useful comments from the Business and Industry Advisory Committee to the OECD (BIAC) and the Trade Union Advisory Committee to the OECD (TUAC). The work was funded through regular contributions from OECD member countries and received support from grants from the Health Programme of the European Union, and from the Governments of France and Italy. The contents of this book do not necessarily reflect the views of individual OECD member countries, or those of the European Commission. This publication has been produced with the financial and substantive assistance of the European Union. The contents of this report are the sole responsibility of the OECD and can in no way be taken to reflect the views of the European Union. THE HEAVY BURDEN OF OBESITY © OECD 2019 6 Table of contents Foreword 3 Acknowledgements 4 Acronyms and abbreviations 11 Executive summary 14 1 The heavy burden of obesity 16 1.1. A growing obesity epidemic drives negative health and economic effects 18 1.2. Unhealthy lifestyles are on the rise, and morbid obesity is growing 18 1.3. Obesity and associated chronic diseases damage health and the economy 20 1.4. The policy response to obesity has been insufficient 27 1.5. Innovative public health actions have a positive impact on population health and are an excellent investment for OECD countries 30 1.6. Public health policies may affect industry revenues but countermeasures exist to minimise additional costs 35 1.7. Conclusions: tackling obesity and its related unhealthy lifestyles is an excellent investment 38 Notes 39 2 Overweight, poor diet and physical activity: Analysis of trends and patterns 40 2.1. Why is obesity a public health concern? 41 2.2. Defining determinants of overweight: diet, physical activity, and sedentary behaviour 52 2.3. Conclusions 60 References 61 Annex 2.A. Additional analyses 67 3 The economic burden of obesity 73 3.1. To make the economic case for investing in obesity prevention and treatment, its impact needs to be quantified 75 3.2. Overweight and related diseases will reduce life expectancy in OECD countries by 2.7 years 80 3.3. Overweight will account for over 8% of total health expenditure in OECD countries 83 3.4. Overweight has a negative impact on the labour market, through absenteeism, presenteeism, unemployment and early retirement 85 3.5. At a macroeconomic level, GDP in OECD countries is 3.3% lower due to overweight 87 3.6. Investment in the prevention and treatment of overweight is needed to reduce its impact on health and the economy 90 References 92 THE HEAVY BURDEN OF OBESITY © OECD 2019 7 Annex 3.A. Additional analyses 95 Notes 99 4 The relationship between childhood obesity and educational outcomes 100 4.1. The relationship between childhood obesity and educational outcomes is mediated by different factors 101 4.2. There is a clear association between childhood obesity and school performance in OECD countries 106 4.3. A potential causal effect of childhood obesity on educational outcomes is found in five countries 110 4.4. The short-term and long-term consequences of childhood obesity are of concern for individuals and societies 114 4.5. Reducing childhood obesity will help build better future lives and stronger societies 115 References 117 Annex 4.A. Further analyses on inequality 120 5 Promoting healthier diets and active lifestyles: policies and best practices 123 5.1. Introduction 124 5.2. Multi-sectoral response is needed to target overweight determinants 126 5.3. Policy toolkit: what options work? 129 5.4. Conclusion 153 References 154 Notes 167 6 Impact of obesity policies on health and the economy 168 6.1. Introduction 170 6.2. Policies to tackle overweight and to promote healthy lifestyles: innovative policy options to upscale efforts 171 6.3. Policies to tackle overweight and unhealthy lifestyles: what works? 179 6.4. Combining policies into coherent prevention strategies has greater impact 189 6.5. Conclusions 194 References 195 Annex 6.A. Additional analyses 198 Notes 207 7 Special focus: the health and economic impact of food reformulation 208 7.1. Food reformulations present opportunities for effective public-private cooperation in overweight control 209 7.2. What would be the effect of a global deal to scale up food reformulation worldwide? 213 7.3. Conclusion 217 References 218 Notes 219 8 The impact of obesity policies on the food and drink industry 220 8.1. Introduction 221 8.2. Product reformulation and its impact on the food industry 222 8.3.