Chapter 7
The Economics of Overweight and Obesity

Obesity has become a crucial health problem for our nation, and these findings show that the medical costs alone reflect the significance of the challenge. Of course, the ultimate cost to Americans is measured in chronic disease and early death. We must take responsibility both as individuals and working together to reduce the health toll associated with obesity.

—Tommy G. Thompson, former U.S. Department of Health and Human Services Secretary, commenting on estimates that U.S. obesity-attributable medical expenditures reached $75 billion in 2003 and that taxpayers finance about half of these costs through Medicare and Medicaid, in a press release from the Centers for Disease Control and Prevention, January 21, 2004

The economic impact of obesity is considerable. The World Bank estimated the cost of obesity in the United States as 12% of the national health-care budget in the late 1990s. The increasing prevalence of overweight and obesity in the United States has resulted in a corresponding increase in direct and indirect health-care costs. Direct health-care costs are those incurred for preventive measures, diagnostic, and treatment services. Examples of direct health-care costs are physician office visits, hospital and nursing home charges, prescription drug costs, and special hospital beds to accommodate obese patients. Indirect costs are measured in terms of decreased earnings—lost wages and lower productivity resulting from inability to work because of illness or disability, as well as the value of future earnings lost by premature mortality (death). Table 7.1 shows the categories of direct and indirect costs associated with physical inactivity, overweight, and obesity among adults in California.

According to the American Obesity Association (AOA), the Social Security Administration pays about $77 million per month to the approximately 137,000 people who met obesity requirements for disability under criteria used prior to May 15, 2000, when a new policy was issued (http://www.obesity.org/subs/disability/). Most people who qualified for benefits under the earlier policy suffered from obesity-related muscular or skeletal problems that prevented them from working.

There also are personal costs of obesity—obese workers may earn less than their healthy-weight counterparts because of job discrimination. Many insurance companies, particularly in the life insurance sector, charge higher premiums with increasing degrees of overweight. When obesity compromises physical functioning and limits activities of daily living, affected individuals may require assistance from home health aides, durable medical equipment such as walkers or wheelchairs, or other costly adaptations to accommodate disability.

THE HIGH COST OF OVERWEIGHT AND OBESITY

In 1999 the AOA commissioned the Lewin Group, a health economics consulting firm, to conduct a cost analysis of fifteen conditions causally related to obesity. These obesity-related conditions were arthritis, breast cancer, heart disease, colorectal cancer, Type 2 diabetes, endometrial cancer, end-stage renal disease, gallbladder disease, hypertension, liver disease, low back pain, renal cell cancer, obstructive sleep apnea, stroke, and urinary incontinence. Using data from the National Health Interview Survey and the third National Health and Nutrition Examination Survey (NHANES III, conducted between 1988 and 1994), the researchers established prevalence rates of each condition and computed the percentage of the cost of each disease attributable to obesity. This analysis fixed the direct health-care costs of obesity at $102.2 billion in 1999.

According to the Weight-control Information Network (WIN) of the National Institute of Diabetes and Digestive and Kidney Diseases, the U.S. government's lead agency responsible for biomedical research on nutrition and obesity and part of the National Institutes of Health (NIH), the estimated annual medical spending attributable to overweight and obesity was about $93 billion in 2002. The WIN estimated the total cost as $117 billion, with an additional $33 billion spent on weight-loss products and services. Estimates of the medical care costs, direct and indirect as well as total cost of overweight and obesity in the United States, vary depending on how the conditions are defined, whether overweight and obesity are considered together or separately, and which costs and obesity-related conditions are included in the estimates and projections. For example, the WIN total cost is based on epidemiological studies that defined obesity and overweight as body mass index (BMI) equal to or greater than twenty-nine.

Economists Eric A. Finkelstein and Ian C. Fiebelkorn of RTI International, an independent, nonprofit research corporation, and Guijing Wang of the Centers for Disease Control and Prevention (CDC) examined costs attributable to people who were overweight, which they defined as BMI between 25 and 29.9, and obese, which they defined as BMI of 30 or higher ("National Medical Spending Attributable to Overweight and Obesity: How Much, and Who's Paying?" Health Affairs, http://content.healthaffairs.org/cgi/content/full/hlthaff.w3.219v1/DC1, May 14, 2003). Using data from a nationally representative sample of 9,867 adults aged nineteen and older, derived from the 1998 Medical Expenditure Panel Survey and linked to the 1996 and 1997 National Health Interview Surveys, they computed the fraction of medical spending associated with being overweight and obese. Because of including both overweight and obesity-related costs, they estimated annual medical spending due to overweight and obesity to be as much as $93 billion in 2002—9.1% of U.S. health expenditures.

The researchers also reported that among people under age sixty-five, medical expenditures for people who are overweight or obese are approximately 37% higher than for those of normal weight and observed that about half of these costs are financed by the federal and state government public assistance programs Medicare and Medicaid. (The majority of Medicare enrollees are people aged sixty-five and older. Medicaid is the entitlement program that uses federal and state funds for the provision of health-care insurance to people less than sixty-five years of age who cannot afford to pay for private health insurance.) This study was the first to assess the effect of being overweight or obese on select payers, including individuals, private insurers, Medicare, and Medicaid.

The combined prevalence of overweight and obesity averaged 53.6% across all insurance categories, and was largest, 56.1%, among people enrolled in Medicare. Because obesity is associated with chronic diseases such as cancer, heart disease, and diabetes, obesity-related expenditures for older adults (people aged sixty-five and older) were significantly higher than among younger populations.

The researchers found that overall annual medical costs for an obese person were about 37.7% more, or $732 higher, than the costs for people of normal weight. An obese Medicare recipient incurred medical expenses of $1,486 more a year than one of healthy weight, and an obese Medicaid recipient cost $864 more than a normal-weight Medicaid recipient. For people with private health insurance the per capita increase among obese people was $423.

In an updated study, "State-Level Estimates of Annual Medical Expenditures Attributable to Obesity" (Obesity Research, vol. 12, no. 1, January 2004), Finkelstein and his colleagues estimated that in 2003 Medicare and Medicaid spent $75 billion treating obesity-related diseases. In this study the researchers calculated state-level estimates of total, Medicare, and Medicaid obesity-attributable medical expenditures. According to the CDC 1999–2000 National Health and Nutrition Examination Survey, which is based on measured heights and weights, among Medicare recipients, obesity prevalence ranges from 12% in Hawaii to 30% in Washington, D.C.

The percentage of annual medical expenditures in each state attributable to obesity ranged from 4% in Arizona to 6.7% in Alaska. Medicare expenditures connected to obesity ranged from 3.9% in Arizona to 9.8% in Delaware. For Medicaid recipients, the percentages were considerably higher because of the higher prevalence of obesity among Medicaid recipients—from 7.7% in Rhode Island (where 21% of Medicaid recipients were obese) to 15.7 % in Indiana (where 44% of Medicaid recipients were obese).

State-level estimates ranged from totals of $87 million in Wyoming to $7.7 billion in California. Obesity-attributable Medicare estimates range from $15 million in Wyoming to $1.7 billion in California, and Medicaid estimates ranged from $23 million in Wyoming to $3.5 billion in New York. (It is important to remember that state-level spending is largely a function of population, so it is reasonable that the less populous Wyoming would spend fewer state and federal dollars than population-dense California and New York.)

Health economist Eric Finkelstein observed that the amount of Medicare and Medicaid dollars spent on obesity-related illnesses was just slightly less than that spent to treat smoking-related illnesses. In a January 21, 2004, news release from RTI International, former U.S. Department of Health and Human Services Secretary Tommy G. Thompson responded to the results of the study, with the assertion that "This report further drives home the point that we must stem the tide of the obesity epidemic in this country. These findings are a dramatic illustration of the devastating economic impact obesity has on health-care delivery systems across the nation."

Obesity Costs in California Exceed $21 Billion

The California Department of Health Services reported even higher costs than those estimated in the RTI/CDC report—nearly $25 billion in private and pub-lic medical services, lost productivity, and workers' compensation. The state health department attributed these costs to the 59% of adults in California who are obese or overweight. In the January 23, 2004, issue of the Los Angeles Times Susan Foerster, chief of cancer prevention and nutrition for the California Department of Health Services, explained that her department is examining the factors that may explain the relatively recent jump in obesity in the state. Foerster cited "car-dominated or unsafe neighborhoods and limited access to fresh fruits and vegetables" as possible sources of the state's surge in obesity, and stated that "It's not a matter of simply pushing away from the table or getting up off the couch—the increase in rates over time has been a function of changed lifestyles and changed environment" (Lisa Richardson, "Fat of the Land: Obesity Costs State, U.S. Billions, Studies Say," Los Angeles Times, January 23, 2004).

Research that analyzed medical claims data for the year 2000 estimated that direct and indirect costs related to overweight, obesity, and inactivity cost the State of California $11.2 billion annually in lost productivity, $10.2 billion in medical care, and $388 million in workers' compensation. (See Table 7.1.) The research report projected conservative cost estimates totaling more than $28 billion for 2005 (The Economic Costs of Physical Inactivity, Obesity, and Overweight in California Adults during 2000: A Technical Analysis, Cancer Prevention and Nutrition Section, California Department of Health Services, April 2005). Figure 7.1 shows how the costs attributable to physical inactivity, overweight, and obesity steadily increased between 2000 and 2005. The researchers calculated that even modest improvement of these modifiable risk factors would yield substantial savings. For example, a 5% increase in the percentage of physically active and leaner adults could have produced in cost savings of approximately $1.3 billion annually, or $6.4 billion by 2005. A 10% increase would have yielded savings of about $2.6 billion per year or $13 billion from 2001 to 2005. (See Figure 7.2.)

MEDICAL CARE AND HEALTH-RELATED COSTS

In addition to 2001 estimates of total direct and indirect costs of overweight and obesity, the WIN publishes statistics that specify the portion that obesity-related diseases contribute to these costs. Heart disease related to overweight and obesity generated direct costs of $8.8 billion (17% of the total direct cost of heart disease, independent of stroke), and Type 2 diabetes cost $98 billion (http://win.niddk.nih.gov/statistics/index.htm#econ). A significant contribution to increasing diabetes-related costs is hospitalization. Table 7.2 shows hospital discharges in 1990, 2000, and 2003 that were attributable to diabetes. Increases were registered among men aged forty-five-sixty-four and sixty-five-seventy-four, and among both men and women aged seventy-five years and over.

In contrast, just 17% of the total cost of hypertension—$4.1 billion—was direct costs related to overweight and obesity. Of the $3.4 billion total cost of gallbladder disease, $3.2 billion was related to overweight and obesity, and of the $21.2 billion total cost of osteoarthritis, the direct cost linked to overweight and obesity was $5.3 billion.

Of the $2.9 billion total cost of breast cancer, $1.1 billion was considered direct cost related to overweight and obesity. For endometrial cancer the direct cost was $310 million of the $933 million total cost, and for colon cancer the direct cost was $1.3 billion of the $3.5 billion total cost.

The WIN researchers also calculated indirect costs of $58.8 billion in 2001, comparable to the economic toll of cigarette smoking. The indirect costs attributed to specific diseases included $15.9 billion for osteoarthritis, $187 million for gallbladder disease, $1.8 billion for breast cancer, $623 million for endometrial cancer, and $2.2 billion for colon cancer.

According to the WIN, the cost of lost productivity related to obesity (BMI greater than 30) among Americans aged seventeen to sixty-four is about $3.9 billion annually. This dollar figure translates into 39.3 million lost work days, 62.7 million physician office visits, 239 million days of restricted activity, and 89.5 million bed-days (days when people remained in bed rather than performing their activities of daily living) related to obesity.

Another study conducted by health economist Roland Sturm and psychiatrist Kenneth Wells at the RAND Corporation, a nonprofit research organization that analyzes challenges facing the public and private sectors, compared effects of obesity, smoking, heavy alcohol consumption, and poverty on chronic health conditions and health expenditures ("The Effects of Obesity, Smoking, and Problem Drinking on Chronic Medical Problems and Health Care Costs," Health Affairs, vol. 21, no. 2, March-April 2002). Sturm and Wells found that obese individuals spent more on both health-care services and medication than daily smokers and heavy drinkers. For example, obese individuals spent about 36% more than the general population on health-care services, compared with a 21% increase for daily smokers and a 14% increase for heavy drinkers. Further, obese people spent 77% more on medications. The only variable with a greater effect on health-care expenditures was aging—and aging trumped obesity only on expenditures for medications. The investigators concluded that obesity generates significantly higher health-care expenditures and affects more individuals than smoking, heavy drinking, or poverty.

Although it is well documented that obese people incur higher health-care costs at a given point in time, until recently, the effects of rising rates of obesity on spending growth had not been quantified. Investigator Kenneth E. Thorpe and his colleagues found that health-care spending was about 36% higher for obese adults under sixty-five, and they sought to estimate the share of spending growth attributable to three obesity related comorbidities—diabetes, hyperlipidemia, and heart disease including hypertension. An analysis of data from the 1987 National Medical Expenditure Survey and the 2001 Medical Expenditure Panel Survey revealed that increases in the proportion of, and spending on, obese people relative to people of normal weight accounted for 27% of the increase in per capita spending between 1987 and 2001. This increase was attributable to spending for diabetes (38%), hyperlipidemia (22%), and heart disease (41%). Increases in obesity prevalence alone accounted for 12% of the growth in health-care spending. The investigators concluded that future cost-containment efforts should address the increasing prevalence of obesity

and the institution of effective approaches to weight loss for people who are obese (Kenneth E. Thorpe et al., "The Impact of Obesity on Rising Medical Spending," Health Affairs, October 20, 2004).

Hospital Costs of Childhood and Adolescent Obesity.

Researchers Guijing Wang and William H. Dietz of the CDC examined trends in obesity-linked diseases among children and adolescents and their related economic costs. In "Economic Burden of Obesity in Youths Aged Six to Seventeen Years: 1979–1999" (Pediatrics, vol. 109, no. 5, May 2002), the researchers reported the results of an analysis and comparison of data from the 1979–81 and 1997–99 National Hospital Discharge Surveys conducted by the National Center for Health Statistics. When the researchers adjusted hospital costs to reflect 2001 dollars, they found that hospital costs linked to childhood obesity and three specific obesity-related

illness—diabetes, sleep apnea, and gallbladder disease—had more than tripled since 1981, from $35 million to $127 million per year.

Days spent in the hospital for obesity-related disease more than doubled, from 152,000 during 1979–81 to 310,000 days during 1997–99. The average length of hospital stays increased by about a third, from 5.3 to seven days. The researchers observed that this increase in average length of stay occurred during a time when U.S. hospital stays overall were shortening, and asserted that longer lengths of stay for children with obesity-related medical problems underscored the severity of these problems.

The researchers concluded that the increase in the percentage of discharges with obesity-related diseases was most likely a reflection of the medical consequences of the obesity epidemic. They wrote, "Although the numbers of percentage are small, the increases are substantial, especially for obesity (197% increase), sleep apnea (436%), and gallbladder disease (228%). These data may suggest that the increasing prevalence of obesity in children and adolescents has led to increased hospital stays related to obesity-associated diseases. The increasing proportion of hospital discharges with obesity-associated diseases in the last twenty years may also reflect the impact of increasing severity of obesity."

Insurance Coverage for Obesity Treatment

Although the Medicare and Medicaid programs spend billions on obesity-related illnesses, neither entitlement program covers treatment for obesity itself. Medicaid does not cover obesity treatment, and under Medicare, hospital and physician services for obesity are generally excluded. Historically, Medicare has covered treatment when obesity results from a disease such as hypothyroidism or Cushing's disease and when weight loss is medically necessary to treat a disease such as diabetes, hypertension, or heart disease. It also provides coverage for surgical treatment of obesity when it is medically appropriate and the surgery is to correct an illness that caused the obesity or was aggravated by the obesity.

Until 2004 Medicare justified excluding coverage for obesity treatment by asserting that obesity is not a disease; however, in July 2004 the Centers for Medicare & Medicaid Services, which administers Medicare, eliminated language from its policy (that "obesity itself cannot be considered an illness") that had been used to deny coverage for weight-loss treatment. While the decision stopped short of designating obesity a disease and does not specifically grant coverage for weight-loss treatment, it enables individuals, physicians, and companies to apply to Medicare for reimbursement for a variety of weight-loss therapies. Since private insurance companies often use Medicare as a model for their coverage and benefits, some health-care industry observers believe the Medicare decision will pressure other payers to cover weight-loss treatments.

In view of the high prevalence of obesity among the populations covered by Medicaid—the poor and minori-ties—and the significant Medicaid expenditures for obesity-related illnesses, many health-care industry observers believe it is short-sighted that twenty-nine states specifically exclude coverage of antiobesity products in state Medicaid programs. Just nine states—Alaska, California, Kentucky, Montana, North Carolina, Oregon, Rhode Island, Washington, and Wisconsin—cover antiobesity pharmaceuticals through Medicaid. Arizona covers antiobesity pharmaceuticals through a specific managed health-care plan. Some health-care analysts, and advocacy groups including the AOA, contend that it is difficult to reconcile this limited coverage of obesity in light of Medicaid coverage for inpatient and outpatient alcohol detoxification and rehabilitation; chemical dependency treatment and drug rehabilitation; and services for sexual impotence.

In January 2005 Edolphus Towns (D-NY) introduced a bill in the U.S. House of Representatives that would amend title XIX of the Social Security Act to require states that provide Medicaid prescription drug coverage to cover drugs medically necessary to treat obesity. However, this act (H.R. 286, known as the "Medicaid Obesity Treatment Act of 2005") was referred to the Subcommittee on Health in February 2005 and by the end of 2005 had not made it out of committee.

According to the AOA, many health insurance plans do not provide reimbursement for weight-loss treatment. Further, few private insurance indemnity plans or managed-care organizations (health maintenance organizations and preferred-provider organizations are examples of managed-care plans) appear to cover the costs of obesity treatment independent of whether the service is a medically supervised weight-loss program, surgery, or a prescription drug. The AOA notes that most employer-funded health insurance plans do not pay for obesity treatment or services, including medications, diet supplements, appetite control programs, gastric bypasses, or other surgeries. During 2005 at least five states—Georgia, Hawaii, Maryland, Montana, and Virginia—considered legislation that would require health insurance coverage for weight-loss programs.

The Pharmacy Benefit Management Institute, Inc. (PBMI), an independent organization that is not affiliated with any employee benefits program or pharmaceutical manufacturer, periodically surveys employers to determine the extent, cost, and coverage of their pharmacy benefits. The Institute analyzes survey data and trends in a national research report entitled Benefit Design Survey Report. The 2004 survey queried 375 companies that provide coverage to nearly twelve million beneficiaries. The PBMI study found that antiobesity drugs, including appetite suppressants, were excluded from coverage by more than 80% of employers.

Although reluctance to cover antiobesity drugs is driven by concern about cost—many payers may find that the rising prevalence of obesity and its comorbidities require higher prescription drug costs than drug treatment of obesity itself. For example, research conducted by Medco Health Solutions, a national prescription benefit management company, found that Americans with metabolic syndrome account for $4 of every $10 spent on prescription drugs for adults. (Metabolic syndrome is the name given to conditions that often occur together—obesity, diabetes, high blood pressure, and high triglycerides that can lead to cardiovascular disease.) Drug treatment of metabolic syndrome skyrocketed 36% between 2002 and 2004 and prescription costs for adults with metabolic syndrome averaged $4,116 in 2004—4.2 times the average (Linda Johnson, "Study: Metabolic Syndrome Brings Big Costs," Associated Press, May 7, 2005).

SHOULD OVERWEIGHT PEOPLE PAY MORE FOR HEALTH INSURANCE COVERAGE?

Since overweight and obese people incur higher medical costs, should they be required to pay higher premiums for health insurance? During 2003 at least one Maryland legislator, Joan F. Stern, suggested this highly controversial move. In a July 11, 2003, interview with Steven Dennis, "Shape Up or Shell Out?" in The Gazette, Stern, who had lost thirty pounds at the time of her proposal, said that higher premiums for the overweight and discounts for people of healthy weights would improve health, help pay for the cost of medical treatment for obesity, and would reduce health insurance costs. She explained that "You can be as fat as you want, but when you become a burden on the health-care system, when you start going to the emergency room, when you start having to take insulin and these other drugs, the insurance premiums of everyone else go up and some people won't be able to afford it because of folks who abuse the system—and it really is abusing the system." Her plan would not penalize people whose obesity was caused by a medical problem such as Cushing's disease and would prevent insurance companies from denying coverage to obese people.

In his article, reporter Dennis observed that after an earlier story about her proposal appeared in The Gazette, Stern softened her position because she feared that she would be viewed as attacking overweight people. She shifted her focus to insurance coverage for obesity treatments and insurance incentives tied to reducing obesity. In addition she advocated requiring daily physical education in schools, improving school nutrition standards, and revamping school menus.

While Stern may have reconsidered her position about higher health insurance premiums for obese people, George Washington University Law School professor John F. Banzhaf III is a staunch advocate of such a policy. He maintains that the current practice of charging all insurance subscribers the same rates unfairly forces normal-weight people to subsidize treatment for obesity. Banzhaf asserts that higher insurance premiums would give obese people another incentive to lose weight and observes that this policy would be consistent with others such as requiring smokers to pay more for life insurance, and drivers who have car accidents to pay higher automobile insurance rates.

In June 2004 Banzhaf petitioned the U.S. Department of Health and Human Services to reverse its 1987 decision prohibiting health insurance companies from charging different health insurance premiums for people who are obese. On September 28, 2004, Banzhaf received a letter from the Centers for Medicare and Medicaid Services (CMS) in response to his petition. The CMS stated that it could theoretically allow federally qualified HMOs to use obesity as a factor in predicting use of health services but observed that no federally approved HMO had asked to do so. According to the CMS, even if it changed its position on obesity under Title XIII, community rating provisions would have very limited effect in light of subsequently enacted provisions contained in the Health Insurance Portability and Accountability Act of 1996 (HIPPA) that prohibit discrimination against individuals based on health status. The CMS also asserted that federal law does not prevent insurers from offering premium discounts or rebates in return for adherence to programs designed to improve health; however, federal regulations limit this exception to incentives provided to wellness programs that meet specific criteria. The discount cannot exceed 10% to 20%; it must be designed to promote good health and not be a ploy to raise rates for certain individuals; it must be available to all similarly situated individuals; individuals must be offered an alternative way to qualify for the incentive; and plan materials must describe the availability of the alternatives. Although Banzhaf's Web site (http://banzhaf.net/obesitylinks) trumpeted the CMS response as a far-reaching change in legislative policy, terming it "Govt. Rules Health Insurance Companies Can Charge the Obese More to Help Encourage Them to Lose Weight and to Pay More of Medical Costs of Obesity," CMS did not in fact, change its policy.

Critics of higher premiums for overweight and obese people counter that since smokers and people who consume alcohol excessively do not pay higher health insurance premiums under most plans, obese people should not be asked to pay higher premiums. A 2005 Gallup Poll found that two-thirds of Americans believed that charging obese people higher insurance premiums was unjustified (Personal Weight Situation, August 2005). Executive director of the AOA Morgan Downey believes that economic incentives would not be effective inducements for weight loss, and observes that the entire premise of insurance is to share risk across a population that varies in terms of health and illness. Other health-care industry observers contend that some health insurance companies already discriminate against obese people by denying them coverage or imposing higher deductibles (the fixed dollar amount subscribers must pay before their health benefits begin). Finally, opponents observe that overweight people might be forced to drop their health insurance coverage altogether should it become too expensive, and that more obese people might rely on publicly funded programs, ultimately shifting obesity-related medical costs to taxpayers.

Obese People Pay More for Health Care

Researchers at the Institute for the Study of Health at the University of Cincinnati Academic Health Center found that adults with clinically severe obesity (also known as morbid obesity, defined as 100 pounds or more over ideal body weight or BMI ≥40) had health-care costs that were nearly twice those of their normal weight peers (David Arterburn et al., "Impact of Morbid Obesity on Medical Expenditures in Adults," International Journal of Obesity, vol. 29, no. 3, March 1, 2005). The researchers analyzed the records of 16,262 adults from the 2000 Medical Expenditure Panel Survey. Per capita healthcare expenditures were calculated for BMI categories, based on self-reported height and weight, and adjusted for age, gender, race, income, education level, type of health insurance, marital status, and smoking status.

The researchers found that in 2000, medical expenditures for people with clinically severe obesity were 81% higher than expenditures for normal-weight adults, 65% more than for overweight adults, and 47% more than those of obese adults. The excess costs resulted from greater spending on physician office visits, outpatient hospital care, inpatient hospital care, and prescription drugs. The investigators estimated that $56 billion in U.S. health-care expenditures in 2000 were linked to excess body weight—up 12% from 1998.

FUNDING OBESITY RESEARCH

During the last four decades, considerable progress has been made in identifying the causes of obesity and developing treatments. Despite the enhanced understanding of the origins of obesity, increasing numbers of Americans continue to become overweight and obese. The AOA, along with myriad medical professional organizations and advocacy groups, contends that public funding for obesity research is woefully inadequate in view of the size and scope of this public health problem. In addition to insufficient NIH funding for obesity research, the AOA cites inequities in research grants awarded by the NIH—although more grants have been awarded to obesity research than in past years, obesity still receives a disproportionately small share of grant funding.

Table 7.3 shows NIH funding for a variety of diseases and research areas for fiscal year 2003 and 2004 as well as estimates for 2005 and 2006. Funding for obesity research increased $18 million from fiscal year 2004 to fiscal year 2005 but is not anticipated to increase for fiscal year 2006. However, the 2006 allocation for obesity research is 16% greater than the amount provided in 2003 and is expected to be comparable to the allocation for heart disease.

WEIGHING THE PRICE BUSINESS PAYS

Employers report that obese employees incur substantially higher health-care costs than normal-weight employees. In "Watching the Corporate Waistline" (Forbes, August 4, 2003), Kasia Moreno reported that at Bank One the average health-care costs of an obese worker totaled $6,822 over three years, while non-obese employees averaged health-care costs of $4,496. Although Bank One charges workers who smoke $28 per month more in health premiums than it does nonsmokers, obese employees are not asked to contribute to offset their excess health-care costs. Bank One's medical director, Dr. Wayne Burton, asserted that the company does not wish to be viewed as "discriminating against obese workers, or to create the impression that it considers obesity a purely behavioral issue."

According to the U.S. Department of Health and Human Services (HHS) in Prevention Makes Common "Cents" (September 2003), U.S. companies pay $13 billion per year for medical-care costs to treat obesity-related diseases, lower productivity, and absenteeism. Health insurance costs ($8 billion) make the greatest contribution to the total, followed by paid sick leave ($2.4 billion), life insurance ($1.8 billion), and disability insurance ($1 billion). According to the National Business Group on Health, a consortium of large employers that researches and develops solutions to health-service delivery challenges, higher health-care utilization rates, such as 45% more inpatient hospital days, produce higher health-care expenditures—36% higher for inpatient and outpatient care and 77% higher prescription drug spending ("Healthy Weight, Healthy Lifestyles," 2006). About 8% of private employer medical claims are attributable to overweight and obesity, and in 2004, obesity-related disabilities cost employers an average of $8,720 per claimant per year for wage indemnity.

These findings are consistent with an earlier estimate of $12.7 billion reported by David Thompson and his colleagues in "Estimated Economic Costs of Obesity to U.S. Business" (American Journal of Health Promotion, vol. 13, no. 2, November-December 1998). The investigators attributed approximately $2.6 billion to mild obesity (BMI between 25 and 28.9) and $10.1 billion to moderate to severe obesity (BMI equal to or greater than 29). Health insurance expenditures were $7.7 billion of the total, representing 43% of all spending by U.S. business on coronary heart disease, hypertension, Type 2 diabetes, hypercholesterolemia, stroke, gallbladder disease, osteoarthritis of the knee, and endometrial cancer. Obesity-attributable business expenditures for paid sick leave, life insurance, and disability insurance amounted to $2.4 billion, $1.8 billion, and $800 million respectively.

Another study, "Obesity and Absenteeism: An Epidemiologic Study of 10,825 Employed Adults" (American Journal of Health Promotion, vol. 12, no. 3, January-February 1998), conducted by Larry Tucker and his colleagues at Brigham Young University in Provo, Utah, sought to determine the extent of the relationship between obesity and absenteeism due to illness. The investigators analyzed specific variables—age, gender, family income, length of workweek, obesity, and cigarette smoking—and data about absenteeism for 10,825 employed men and women. They found that obese employees were more than twice as likely to experience high-level absenteeism (seven or more absences due to illness during the past six months), and 1.49 times more

likely to suffer from moderate absenteeism (three to six absences due to illness during the last six months) than their normal-weight counterparts.

A study conducted by Dee Edington, director of the University of Michigan's Health Management Research Center, and his colleagues confirmed that overweight and obese people have medical bills up to $1,500 greater a year than individuals of healthy weight. The study "Excess Costs Associated with Excess Risks in a Consortium of Companies" (American Journal of Health Promotion, January-February 2003) looked at about 178,000 adults in the General Motors health-care plan, which includes workers, retirees, and their family members. Researchers compared medical costs incurred to body weight, using federal categories that classified subjects as ranging from underweight to greatly obese. Medical costs rose with increasing weight—the average cost for normal or healthy-weight subjects was $2,225. The lowest category of overweight was slightly higher, at $2,388, but costs rose sharply after that, reaching $3,753 for the most severely obese subjects.

Obesity-Related Disability

In "Estimated Economic Costs of Obesity to U.S. Business," Thompson and his colleagues estimated that businesses spent approximately $800 million on obesity-attributable disability insurance during the late 1990s. Many industry observers believe that the price business pays for obesity-related disability is destined to rise as sharply as the prevalence of obesity has increased in the United States.

RAND researchers Darius N. Lakdawalla, Jayanta Bhattacharya, and Dana P. Goldman assert that obesity is a key cause of the more than 50% increase in disability rates over the last two decades, particularly among younger Americans. In "Are the Young Becoming More Disabled?" (Health Affairs, vol. 23, no. 1, 2004), Lakdawalla and his colleagues analyzed data from the National Health Interview Survey, an annual nationwide government survey of about 36,000 households. They identified disability trends among people ages eighteen to sixty-nine between 1984 and 2000 and found significant growth in reported disability rates among those under fifty years but not among the elderly.

The investigators reported that "Obesity accounts for about half the increased disability among those ages eighteen to twenty-nine." For those thirty to thirty-nine years old, the number reporting disabilities increased from 118 per 10,000 people to 182 per 10,000 people from 1984 to 1996. Among people forty to forty-nine years old, the number rose from 212 per 10,000 to 278 per 10,000 in the same period. Among people aged fifty to fifty-nine, disability rose only among those who were obese. The number of disability cases resulting from musculoskeletal problems and diabetes grew more rapidly than those from other problems during the length of the study, and the proportion that was diabetes-related doubled. The RAND researchers cautioned that the increase in the disability rate could translate into higher health-care costs in the future. Since people with disabilities generally use more medical services, should this trend persist, it could generate additional costs to the nation's already enormous health-care bill.

To address this issue, the National Business Group on Health established the Institute on the Costs and Health Effects of Obesity, which aims to:

• Serve as a source of information and resources for large employers about the health and cost consequences of obesity and related chronic conditions.
• Provide employer tool kits to jump-start efforts to offer employees healthy options and information.
• Propose innovative solutions that large employers can implement to control costs related to obesity. This will include identifying effective strategies to decrease the incidence of obesity and delay the onset or decrease the incidence of several chronic conditions among the U.S. workforce.
• Develop and disseminate clear messages emphasizing that obesity is preventable, as well as messages that communicate obesity as a health and well-being issue, rather than a cosmetic issue.

During 2005–06, the Institute was focused on several initiatives, including educating senior company managers about the economic benefits of obesity prevention; demonstrating the impact of obesity on productivity; educating employers about developments in pharmacotherapy and their implications for employers; and helping employers promote healthy weight through healthy dining at work.

THE HIGH COST OF LOSING WEIGHT

The AOA estimates that at any given moment approximately 40% of women and 25% of men are trying to lose weight, and more than seventy million Americans are dieting. In 2004 Americans spent about $46 billion to lose weight, and a report conducted by a market research firm that has tracked the weight-loss products and services market since 1989 forecasts that substantial annual growth in the U.S. weight-loss industry will produce a $61 billion industry in 2008 (U.S. Weight Loss & Diet Control Market, 8th edition, Tampa, FL: Marketdata Enterprises, February 15, 2005).

Marketdata reported that Americans consumed more diet soft drinks, and their share of the total soft drink market has reached near historical highs. Diet soft drinks dominated in terms of sales, generating more than $15 billion in 2004, and health clubs ranked second. The most rapid growth occurred in do-it-yourself, over-the-counter diet aids, which are less costly alternatives to medically supervised weight-loss and commercial programs.

With no new prescription weight-loss drugs slated to debut until 2006, (when rimonabant is scheduled to reach the market) and the growing popularity of the African herb Hoodia, Marketdata forecast 16% growth in this segment. Citing the success of heavily advertised products such as Trim Spa, Cortislim, Hyroxycut, and Xenadrine, Marketdata predicted growth of 11.5% per year, to $703 million in 2008.

Marketdata also tracked the increase in weight-loss surgeries, which skyrocketed to a record 140,000 procedures and represented a $3.5 billion market in 2004. On January 1, 2005 several major insurers stopped covering these procedures, which average $25,000, and as a result, Marketdata anticipates a slight decline—about 15% in 2005, as surgeons and hospitals agitate to improve reimbursement and organize consumer financing plans. The Marketdata report predicted that growth in the number of weight-loss surgeries would resume in 2006.

Along with commercial weight-loss centers, medically supervised weight-loss programs, and prescription diet drugs, such products as diet books, audio and video programs, Web-based diet and nutrition services, low-calorie and low-carbohydrate food products, meal replacements, and over-the-counter appetite suppressants compete for consumer dollars. As the low-carbohydrate diet craze subsides, more dieters are returning to structured commercial programs such as Weight Watchers, LA Weight Loss, Jenny Craig, and other chains. Marketdata estimates that revenue from weight loss centers will grow 11% to $2 billion. An estimated 7.1 million American dieters use such programs. Small local or regional chains of ten-fifty centers are growing as well.

The most affluent dieters, primarily in New York City and Los Angeles, are purchasing home delivery of diet foods. Companies including Zone Chefs, NutriSystem, Jenny Direct (Jenny Craig), Seed Live Cuisine, Sunfare, and Nutropia are catering to this market. The cost averages $10-$40 per day for home-delivered diet food, and dieters can spend as much as $1,200 per month. Weight-loss camps are also expected to grow in popularity and enrollment as the childhood obesity rate climbs.

The Marketdata report estimated that 20,500 registered dietitians offer some form of weight-loss counseling, either in private practices or as consultants or employees of health clubs, hospitals, and other health-related facilities. A typical customized, six-month plan costs an average of $802. Nutritionists, who are not licensed dieticians and whose training varies widely from people without degrees to highly-trained professionals with graduate degrees in nutritional science, also provide weight-loss counseling. Their services average $643.

Another study, Weight Loss Market: Products, Services, Foods and Beverages (Norwalk, CT: Business Communications Company, Inc., 2003), described the total U.S. market for weight-loss products and forecast growth to $157.64 billion in 2007. Like the Marketdata report, this study confirmed the preeminence of the low-calorie food and beverage market, and predicted increasing use and greater acceptance of artificial sweeteners in non-carbonated beverages, including refreshment, sports, and energy products. Supplements such as coenzyme Q10 (an antioxidant), the amino acid carnitine, and the mineral chromium (believed to aid glucose tolerance) were named the third largest product/service segment, after low-calorie foods and low-calorie beverages.

There is no question that the array of low-calorie, low-fat, and low-carbohydrate food products and dietary supplements to promote weight loss is expanding. Further, many of the most popular diet regimens promote their own high-priced brands and formulations, including frozen dinners, snack bars, muffin mixes, and ice cream. In "The Atkins Low Evidence Revolution" (Nutrition Action, vol. 31, no. 1, January-February 2004), David Schardt reported that Atkins dieters pay a hefty price for Atkins-brand foods—a twelve-ounce box of pasta cost $5.99, four cups of instant soup cost $12, and fifteen brownies cost $32. However, the 2005 bankruptcy filing by Atkins Nutritionals and a cooling of the "low-carb craze" diminished enthusiasm for the firm's diet foods, many of which have been relegated to the "sale" and "bargain" sections of markets.

Schardt observed that even Dr. Phil McGraw, the therapist turned talk-show host and weight-loss adviser, promotes his own line of nutrition shakes, bars, and weight management supplements. Dr. Phil offers two different supplement formulations, designed for either apple- or pear-shaped body types, that involve taking a basic regimen of twelve pills containing twenty-three vitamins and minerals, carnitine, and a variety of herbs. The basic regimen costs $60 dollars for a one-month supply, and Dr. Phil recommends taking an additional regimen of ten pills to intensify weight loss, which cost an additional $60 for a one-month supply. Schardt observed that scientific evidence supporting the claims that these supplements enhance weight loss is scanty and that consumers wishing to supplement their diets with vitamins and minerals could easily do so by consuming far fewer pills, at a fraction of the price of these brand name products.

Weight Loss Market: Products, Services, Foods and Beverages also anticipated continued growth of weight-loss centers, where the AOA estimates as much as $2 billion is spent each year, and predicted growth of the Internet-based weight-loss programs. Weight Watchers, one of the acknowledged market leaders in the weight-loss program market sector (with U.S. membership of about nine million people in 2005), suffered a drop of 2.4% in attendance in 2003 at its North American meetings. Industry observers attributed the decline to the current enthusiasm for such low-carbohydrate diets as the Atkins and South Beach regimens. However, the popularity of low-carbohydrate diets peaked in 2004, and many analysts believe that Weight Watchers' tried-and-true formula of portion control, healthy diet, and exercise will continue to attract people seeking to lose weight, reenergizing corporate finances. Kathleen Heaney, an analyst with the Maxim Group in New York, asserted that consumers "typically end up at Weight Watchers after several other diet attempts have failed" and asserted that if anything, Weight Watchers' potential market in the United States has been drastically underestimated—its potential is about 100 million clients (Eric Wahlgren, "The Skinny on Weight Watchers," BusinessWeek, November 17, 2003).

A review of popular diets in Consumer Reports ("Rating the Diets from A to Zone," vol. 70, no. 6, June 2005), gave Weight Watchers high marks in terms of safety, efficacy, and flexibility—its program allows people who prefer not to cook to use its branded controlled-calorie meals. This review, coupled with endorsement from celebrity spokesperson Sarah Ferguson, the Duchess of York, will likely stimulate a resurgence of interest and participation in Weight Watchers. In "Diet Stocks for the Post-Atkins Age" (Fortune, October 31, 2005), Matthew Boyle noted that Weight Watchers had indeed seen an increase in attendance during 2005, as dieters turned away from low-carb lifestyles and returned to more traditional programs.

In addition to Weight Watchers, the Consumer Reports article recommended the very low-fat Ornish diet for vegetarians and the Slim-Fast diet for people who are not inclined to cook since Slim-Fast drinks and bars replace part of breakfast and lunch and dieters need to prepare just one meal per day.

Medical and Behavioral Treatments

Although the greatest proportion of outlays for weight loss are for food products and commercial weight-loss programs, in "Screening and Interventions for Obesity in Adults: Summary of the Evidence for the U.S. Preventive Services Task Force" (Annals of Internal Medicine, vol. 139, no. 11, December 2, 2003), Kathleen McTigue and her colleagues observed that medical and behavioral treatment options for obesity involve considerable cost. "Intensive counseling programs require a large amount of time and a substantial staffing commitment. Based on average wholesale price, one-year supplies of orlistat (brand name Xenical, 120 mg three times daily) and sibutramine (brand name Meridia, 15 mg daily) cost $1,445.40 and $1,464.78 respectively." It is important to note that consumers generally purchase prescription drugs at retail rather than wholesale prices, so their costs are considerably higher than those reported by McTigue and her colleagues.

The average weight-loss surgery costs about $25,000, and the availability of medical insurance coverage for these surgical procedures varies by state and health insurance provider. Researchers at the Agency for Healthcare Research and Quality (AHRQ) found that while surgical and drug treatment of obesity have skyrocketed since 1998, with the number of surgeries increasing by 400% between 1998 and 2002, coverage policies remain uneven among insurers. Hospital costs for bariatric surgery grew to $948 million in 2002. Surgical costs reflect both the fees associated with the invasive procedure and the long-term follow-up that patients who have undergone the surgery require (William E. Encinosa et al., "Use and Costs of Bariatric Surgery and Prescription Weight-Loss Medications," Health Affairs, vol. 24, no. 4, July-August 2005).

Long-term Savings

While surgical treatment of obesity is a relatively recent phenomenon, research has revealed that its costs are offset by a reduction in future utilization of healthcare services and a resultant reduction in health-care costs. Nicholas Christou and his colleagues followed 1,035 patients who had undergone bariatric surgery and a control group of age- and gender-matched severely obese patients who had not undergone bariatric surgery for five years. The researchers found that weight-loss surgery significantly decreased overall mortality as well as the development of new health-related conditions in severely obese patients. During the five-year period, the number of hospitalizations, total in-hospital days, and physician visits were significantly lower in the surgery group compared with the controls. Similarly, the total direct health-care costs were significantly lower in the surgery group when compared with the controls for all diagnoses except digestive disorders. On average, the total direct health-care costs for individuals in the control group was 45% higher than those of the bariatric surgery patients (Nicholas V. Christou et al., "Surgery Decreases Long-term Mortality, Morbidity, and Health Care Use in Morbidly Obese Patients" Annals of Surgery, vol. 240, no. 3, September 2004).

The finding that weight loss reduces health-care utilization and costs was confirmed by research performed at Kaiser Permanente Northwest Center for Health Research in Portland, Oregon. Gregory Nichols and his colleagues compared medical costs for two groups of patients who participated in the Kaiser weight-loss program, "Freedom from Diets" from 1996 to 2000: 458 patients who lost more than 5% of weight and 457 patients who failed to lose weight. The investigators also created a control group of 2,290 patients who did not participate in the program and did not lose weight. The investigators found that the regional health plan saved nearly $850 overall in per-person medical costs the year after an overweight member lost 5% or more body weight in a voluntary program. They calculated that the health plan would save $2,500 over five years, and observed that the savings would be real, even in view of the observation that most patients would regain the weight lost. Another Kaiser Permanente study described drug savings as the key cost efficiency during the first two years after bariatric surgery. Pharmaceutical costs decreased by $510 per person among surgical patients, but costs increased in candidates who did not have the surgery (North American Association for the Study of Obesity 2004 annual scientific meeting, Las Vegas, Nevada, November 16, 2004).

CATERING TO AN EXPANDING MARKET

On one hand, we have to make the world safe for a fatter population, but the more we adjust our world to accept our weight, the harder it is to motivate us to do the healthier thing and lose the weight. If we tacitly readjust our world, in some sense we are responding to reality. At the same time, there is no doubt that making those adjustments makes it easier to live bigger.

—Arthur Caplan, chairman of the ethics department at the University of Pennsylvania School of Medicine ("Plus-Size People, Plus-Size Stuff," CBSNews.com, November 10, 2003)

Along with increased costs, many businesses have discovered that they must literally expand their products and services to meet the needs of overweight and obese consumers. An Associated Press article "Plus-Size People, Plus-Size Stuff" (CBSNews.com, November 10, 2003) described a wide array of products—from scales that weigh people as heavy as 1,000 pounds and steering wheels for drivers who do not fit behind standard wheels to seat-belt extenders and super-size towels—designed to meet the needs of obese Americans.

Service industries have also responded. In "That Tough First Step" (Los Angeles Times, January 26, 2004), Jeannine Stein reported that gyms are reaching out to attract and meet the special needs of people who are overweight and want to exercise. Some provide personal trainers who assist overweight clients to use equipment safely, design realistic exercise regimens, and maintain motivation. Other gyms affiliate with medical centers and health professionals to offer nutritional counseling, support groups, and exercises suitable for people who are overweight, including aquatic exercise programs in pools. Health clubs, gyms, and fitness programs not only understand the health benefits they can offer overweight clients but also the financial benefits they can realize by tapping into this market of people who have previously stayed away from gyms.

There are even new food emporiums that cater to the needs of people seeking to lose weight. Shops that offer a broader range of low-carbohydrate food products than generally available in local supermarkets are opening throughout the country. Jane Allen described the proliferation of stores that sell reformulated versions of "forbidden" high-carbohydrate foods in "Shops for the Low-Carb Set" (Los Angeles Times, January 12, 2004). The first low-carb retail outlet opened in 1997 in Boca Raton, Florida, and according to LowCarbiz, an online trade publication, a new store opened every other week in 2004. The shops stock low-carbohydrate bagels, muffins, pancakes, pasta, tortillas, cake mixes, and macaroni and cheese, as well as sugar-free sweets, puddings, and low-carb cheesecakes. Allen noted that many first-time shoppers are shocked by the high prices of these specialty foods—a bag of salty snacks can cost $5 and a cream-filled cake may cost as much as $9. High prices for low-carbohydrate food products and declining interest in low-carb diets during 2005 closed many low-carbohydrate food emporiums and prompted others to expand their inventories to include other diet foods, including those formulated for low-fat and low glycemic impact regimens.

According to the NPD Group, a market research firm, in 2000 women spent more than $17 billion on clothing sizes 16 and up, a 22% increase from the previous year. NPD data revealed that plus-size fashion grew 4% to 6% from 1997 through 2001 while growth in the balance of the apparel industry has hovered around 2% to 4%. Liz Claiborne was one of the first designers to lend her name to a full-figure line, Elisabeth, in the late 1980s. Other fashion houses, including Tommy Hilfiger, Ralph Lauren, Dana Buchman, Marissa Christina, and Jennifer Lopez followed. In 2004 plus-size clothing accounted for more than one-quarter of all retail clothing sales for women, and such major retailers as The Gap, Banana Republic, Old Navy, Macy's, J.C. Penney Co., Target, and Nordstrom compete with specialty stores that are exclusively devoted to large sizes such as Lane Bryant and Casual Male Big and Tall.

In 2001 Hot Topic, a California-based company that specializes in stylish clothing for teenagers and young women, launched a chain of six stores called Torrid, that offered fashion-forward plus-size clothing for young women. By 2005 seventy-six Torrid stores offered an array of shiny, sparkly, and frequently revealing clothing and lingerie for young women who wear larger sizes. According to the industry trade group Cotton, Inc., in 2004 about 30% of young women aged sixteen to twenty-four wore at least a size 12, and more than 60% lamented that they could not find fashionable clothing in larger sizes. The popularity of the Torrid chain is easily explained by the growing market it caters to—the NPD group reported that the plus-size market is the fastest growing segment in the apparel industry—up 49% from 2000 and projected to reach $47 billion in 2005.

In "The Widening of America, or How Size 4 Became a Size" (New York Times, January 20, 2004), health writer Jane Brody asserted that Americans' increasing girth has prompted size inflation throughout the fashion and apparel industry. Brody reported that the apparel industry has accommodated expanding Americans by increasing sizes such that women's size 4 in 2004 would previously have been a size 8, and a present day size 8 would formerly have been a size 12. Men's clothing also has expanded with pants that were formerly "regular" now designated as "slim cut" and easy fit, loose fit, and baggy styles to accommodate excess weight.

Demands for larger, sturdier hospital beds and stretchers to accommodate extremely heavy patients, special imaging equipment such as computed tomography scans and magnetic resonance imaging to accommodate obese patients, bigger blood pressure cuffs, recliners constructed to hold 350 pounds, automobiles that comfortably seat obese drivers and passengers, and devices that enable people who cannot bend over to put on their socks and shoes have prompted the design and manufacture of these and other specialty products. Even morticians have observed and responded to the obesity epidemic. In "On the Final Journey, One Size Doesn't Fit All These Days" (New York Times, October 5, 2003), Warren St. John reported that when the founders of Goliath Casket Company in Lynn, Indiana, opened their business in the late 1980s they sold just one triple-wide casket—the largest model they made—per year. During 2003 the company shipped about five of the over-sized coffins, which measure forty-four inches across compared to the twenty-four-inch standard model, per month. David Hazelett, president of Astral Industries, another coffin builder in Indiana, acknowledged the issue and added that the problem affects every aspect of the funeral industry. Hazelett explained that "The standard-size casket is meant to go in the standard-size vault, and the standard size vault is meant to go into the standard size cemetery plot." St. John discovered that hearse manufacturers have increased the width of their vehicles' rear doors, cemeteries have increased their standard burial plot size to accommodate wider vaults, and mausoleums have constructed larger crypts to accommodate oversize coffins.

In an article in the Birmingham (Alabama) Post-Herald (April 19, 2005), Mike Hauser, marketing director of the Ridout funeral homes and cemeteries explained that newer parts of the company's cemeteries now are laid out with wider spaces for graves to accommodate larger bodies. In the case of an extremely large casket and vault, families that purchased a family plot can allow the grave to take up two spaces rather than one. In 2004 the Batesville Casket Company in Indiana, one of the nation's largest casket makers, introduced thirteen new oversized models and now offers a total of fifty-three oversized models. The Goliath Casket Company also has continued to increase the size of its offerings. Sales at Goliath Casket doubled in 2004, and the company anticipated selling 800 "supersized" caskets in 2005. It recently introduced a fifty-two-inch casket—slightly wider than a standard pickup bed size—with extra supports intended for bodyweights between 650 and 1,200 pounds.

Naturally, these oversized accommodations carry additional costs, and as a result some families opt for cremation. For the most severely obese, cremation may not, however, be an option. The executive director of the Cremation Association of North America reported that most crematoria are not equipped to handle bodies weighing more than 500 pounds.