Researchers analyzed records from more than 5,600 senior citizens
who took part in the long-running national Health and Retirement Study
(HRS), examining how their body mass index (BMI) related to end-of-life
measures, such as their use of hospice services. Results indicated that
people with higher BMIs were less likely to enter hospice care, and
among those who did, seniors with obesity spent fewer days in hospice
than those with lower BMIs.
The study also found that about 60 percent of the seniors in the
study died at home—an experience that most Americans say they would
choose for their own deaths. But that percentage dropped as BMI rose.
In all, Harris says, the findings point to a larger issue that will
become more urgent as the increasingly overweight American population
ages. “Obesity is a complex disease, and this study has shown another
side of its effect on patients and the health care system. Patients with
obesity may need extra help, but they deserve the best health care and
better health outcomes.”
The researchers focused on Medicare claims in the last six months
of the participants’ lives, looking at use of hospice services and
controlling for gender, race, marital status, multiple medical
conditions and household assets. They also had information from surveys
of the participants’ loved ones about their end-of-life care in addition
to all participants’ last measured BMI.
Fifteen percent of participants were obese, with BMIs over 30, and 2
percent were morbidly obese, with BMIs over 40. Another 31 percent were
overweight, with BMIs between 25 and 29.9.
The differences in end-of-life care also translated into
differences in cost. In the last six months of life for a person with a
normal BMI, the Medicare system spent about $43,000 for all types of
care. For an obese person, the costs for that same period were about
$3,500 higher.
Although the study didn’t look at the reasons why people with
obesity received less hospice care, senior author Jennifer Griggs, M.D.,
M.P.H., a professor at the University of Michigan Medical School, suspects that several factors may be involved.
One possibility is that obesity can mask the changes physicians
typically use to determine when it is time for a person to enter
hospice, which include more pronounced cheekbones, collarbones and
pelvic bones due to end-of-life weight loss. These changes in body
weight are more noticeable in leaner patients. “To refer a patient for
hospice, you have to believe that they are in the dying process,” Griggs
notes.
“Many policies focus on preventing or reducing obesity in the U.S.,
but we will also need policies to encourage the provision of
high-quality care for people with obesity,” Dr. Harris said. “More
attention should be paid to payment structures that recognize the
challenges involved with health care for men and women with obesity.”
The study was funded by the Robert Wood Johnson Foundation, U.S. Department of Veterans Affairs, and National Institutes of Health; the HRS is funded by the National Institute on Aging grant U01AG009740.
Harris is an assistant professor of obstetrics, gynecology and
reproductive sciences at Pitt who participated in the Robert Wood
Johnson Clinical Scholars Program at the University of Michigan. Griggs
is a professor of hematology/oncology in the University of Michigan
Medical School who also holds a joint appointment at the University of
Michigan School of Public Health.
Other authors include current and former IHPI members Elena Byhoff,
M.D., M.Sc., Chithra Perumalswami, M.D., M.Sc., and Kenneth Langa,
M.D., Ph.D. Alexi Wright, M.D., M.P.H., of the Dana Farber Cancer
Institute, is a co-author.