Obesity – An epidemic of affluence

Being severely overweight can lead to serious cardiovascular disease and type 2 diabetes. More and more people around the world are chronically obese. With its combined insurance and reinsurance expertise, Munich Re's new International Health segment is looking for ways to minimise the risk.

The alarming increase in the prevalence of severe overweight or obesity over the last few years will be a major future challenge for the insurance industry. Severe overweight is a leading cause of type 2 diabetes, heart attack, stroke and colon cancer as well as a large number of other health problems. For example, the risk of developing diabetes is about sixty times higher for seriously overweight women than for their normal-weight counterparts.

In the US being overweight has now surpassed smoking as the leading cause of heart disease, and the trend is rising. Obesity not only applies to Western industrialised nations, but also to fast-growing economies like China and India, where more and more people are morbidly overweight. Chronic obesity has become one of the most serious threats to public health.

For Munich Re's new International Health segment, obesity is one of the hot topics of the future. By integrating the Group's experience and competence as an insurer and reinsurer, International Health is well-poised to successfully address healthcare issues worldwide. In collaboration with DKV's subsidiary ArztPartner almeda AG, DKV and Munich Re have examined the causes and trends, identified the risk obesity poses to healthcare markets, and proposed solutions.

What is obesity?

The Body Mass Index (BMI) is the internationally recognised measure most commonly used around the world to determine body fat. The BMI is calculated from body weight and height (BMI = kg/m²). Normal weight is defined as a BMI between 18.5 and 24.9. Those with a BMI of 30 or higher are classified as obese.

Obesity is not a person's genetic destiny, although families in which both parents and children are overweight might lead one to think so. Our genes have remained unchanged for centuries – unfortunately, the same cannot be said of the number of seriously overweight people. In the USA, the percentage of people suffering from obesity has increased from 13% to more than 30% since 1960. Whilst prevalence is not as high in Europe, we do see a similar trend. A very high percentage of obese people can be found in the Arab states. In China, too, a growing proportion of the population is seriously overweight.

Particularly alarming is the trend among children and young people. In Germany, the number of overweight children has more than doubled since 1980. Formerly people used to acquire a pot belly in middle age, whereas today, many children are already overweight by the age of ten. This means that their bodies will suffer 20 to 30 years longer from the detrimental effects of excess weight, including associated health problems and diseases.

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Modern lifestyle promotes weight gain

Genetically, we are designed to cope with scarcity rather than excess. Our bodies can continue to function even with little food. But we are living in a different world today. Our lifestyle has changed and our energy intake far exceeds energy expenditure. We consume more calories, eat bigger portions, and take in a diet much higher in sugar than in the past. The energy density of our food has increased considerably. Today, by the time we feel full, we have often eaten more than our bodies actually need. Higher energy density is largely a result of the way the food is processed. For example, 200 grams of boiled potatoes contain about 140 calories, the same amount of French fries around 427, and potato chips 1,080. There is an urgent need for the food industry to commit to providing "lighter fare". While some progress has been achieved in this area, a lot needs to be done. Social factors too play a major role. In Germany, obesity is much more common in the lower socio-economic classes than in the upper strata of society.

This is why nutritionists are calling for increased efforts to promote public awareness and bring about significant changes in the way people think about food. And the sooner this begins, the better, considering that a child's dietary habits start to be formed during pregnancy through a process called foetal programming. There is a pressing need for schools and companies to provide a well-balanced diet and physical exercise. Urban planners should allow more space for physical activities. The media, particularly advertising, also play an important role in shaping our food culture, and need to be aware of their responsibility.

Prevention rather than treatment

Healthcare systems should put much more emphasis on prevention. This is the only way to avoid high costs for the treatment of associated diseases. Obesity-related illnesses currently account for an estimated 2–10% of healthcare costs in the USA. According to forecasts, this percentage will increase significantly, albeit with a time lag. Type 2 diabetes, for example, usually becomes manifest in individuals who have been overweight for at least ten years.

Public health insurance does not cover treatment of the early stages of serious obesity-related conditions, e.g. endothelial dysfunction, which often marks the beginning of cardiovascular disease. By motivating patients through preventive measures to change their lifestyle at the first signs of severe overweight, and by treating obesity-related conditions early, serious long-term consequences and associated treatment costs could be reduced considerably.

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Risk management in practice

DKV's risk management strategy is based on an integrated health management approach. It uses a multi-stage model which encompasses measures ranging from prevention to intervention. Preventive risk management starts with the premium. The increased risk of obese patients is taken into account in premium calculation. The premium is reduced if the patient loses weight. Health and disease management programmes such as the almeda Gesund Leben tele-coaching programme form the second stage of the preventive risk management scheme. In the case of acute illness, DKV covers the cost of specific medical treatment for obesity. The health insurer checks whether the method recommended by the doctor is medically necessary and reimburses costs accordingly.

The tele-coaching programme operated by ArztPartner almeda AG is highly successful. More than 50% of participants have changed their eating habits and increased their physical activities. 13% have stopped smoking and around 28% have lost weight.
On the basis of a questionnaire, almeda provides individual feedback including a diet and exercise plan. Factors such as a patient's response to stress or smoking are also taken into account. A personal coach supports the patient over a period of ten months. The extent of support depends on the patient's individual profile. Technical features such as telemetric weight scales, text-message reminders and 3-D motion sensors help patients to successfully complete the programme and achieve long-term changes in behaviour. More than 1,000 patients have successfully participated in the programme aimed at promoting a healthy lifestyle.

Solutions for the international market

The Denia project currently underway in a province on the eastern coast of Spain also takes an innovative approach to healthcare. The project involves a private company providing public healthcare services. Marina Salud, a DKV subsidiary, was awarded a 15-year licence to manage all public healthcare facilities in the Denia region. Full outpatient and inpatient cover is provided for a flat-rate health insurance premium which is much less than the amount usually paid for state health insurance coverage. For this concept to be economically successful, there must be a comprehensive range of population-based prevention programmes and healthcare facilities. Again, obesity is a key issue. Marina Salud has joined THAO (Think Action Obesity), a programme aimed at increasing awareness and motivating parents and children aged 3 to 12 to become more conscious of their lifestyle and nutrition.

Preparations for adapting the almeda Gesund Leben tele-coaching programme for the international market are ongoing. A long-term study is being developed in cooperation with the Technical University of Munich, the results of which will be used for spreading the programme to other countries.

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