Obesity in the Kaiser Permanente Patient Population and Positive Outcomes of Online Weight-Management Programs
The Permanente Journal
Abstract and Figures
We review what is known about the effects of obesity in the Kaiser Permanente (KP) population and discuss outcomes for two nationally available effective online programs, HealthMedia Balance(®) (Balance) and 10,000 Steps(®). Obese KP patients often have health problems related to overweight and report difficulties with self-care, yet with the proper support, they can avail themselves of effective treatment to manage both obesity and associated conditions that affect quality of life. Clinicians should be aware of potential problems with functional status and self-care in their obese patients, provide brief assessment and advice, and refer obese patients to effective national and regional weight-management programs.
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... The goal of 10,000 steps daily was reinforced during group sessions and quantified with use of a pedometer or equivalent means. [21][22][23] ...
Context
There are insufficient data on the long-term, nonsurgical, nonpharmacologic treatment of obesity.
Objective
To determine changes in weight over 5 years in participants enrolled between April 1, 2007, and December 31, 2014, in a medically supervised weight management program at Kaiser Permanente Northern California Medical Centers. The program consisted of 3 phases: Complete meal replacement for 16 weeks; transition phase, 17 to 29 weeks; and lifestyle maintenance phase, 30 to 82 weeks.
Design
Retrospective observational study of 10,693 participants (2777 available for analysis at 5 years); no comparator group.
Main Outcome Measures
Average change in weight from baseline to follow-up.
Results
Average age was 51.1 (standard deviation = 12.4) years, and 72.8% were women. Average baseline weight in the entire cohort was 112.9 kg (standard error [SE] = 0.23). Weight (kg) significantly changed over time: 4 months, −17.3 (SE = 0.12); 1 year, −14.2 (SE = 0.12); 2 years, −8.6 (SE = 0.14); 3 years, −6.9 (SE = 0.17); 4 years, −6.5 (SE = 0.16), and 5 years, −6.4 (SE = 0.29); p < 0.0001). In those with 5-year follow-up, weight loss between 5.0 and 9.9% below baseline occurred in 16.3% (SE = 0.004, 95% CI = 15.3% – 17.2%) and weight loss of 10.0% or more of baseline occurred in 35.2% (SE = 0.01, 95% CI = 33.6% – 36.7%).
Conclusion
The average weight change of obese adults who participated in a medically supervised weight management program, with available 5-year data, was a statistically and clinically significant 5.8% weight loss from baseline.
We are pleased that our article ( [1][1] ) has stimulated Butte and Ellis ( [2][2] ) to ask the question, “How much change in energy balance would be required to prevent weight gain in children?” The primary point of our article was that we need to set more realistic and specific goals for
To assess the relationship between body mass index (BMI) and future healthcare costs.
We undertook a retrospective cohort study of the relationship between obesity and future healthcare costs at Kaiser Permanente Northwest Division, a large health maintenance organization in Portland, Oregon. Study subjects (n = 1286) consisted of persons who responded to a 1990 health survey that was mailed to a random sample of adult Kaiser Permanente Northwest Division members who were 35 to 64 years of age; had a BMI > or = 20 kg/m(2) (based on self-reported height and weight); did not smoke cigarettes; and did not have a history of coronary heart disease, stroke, human immunodeficiency virus, or cancer. Subjects were stratified according to their BMI in 1990 (20 to 24.9, 25 to 29.9, and > or = 30 kg/m(2); n = 545, 474, and 367, respectively). We then tallied their costs (in 1998 US dollars) for all inpatient care, outpatient services, and prescription drugs over a 9-year period (1990 through 1998).
For persons with BMIs of 20 to 24.9 kg/m(2), mean (+/-SE) annual costs of prescription drugs, outpatient services, inpatient care, and all medical care averaged 848 (+/-59), 1631 (+/-120), respectively, over the study period. Cost ratios (95% confidence intervals) for persons with BMIs of 25 to 29.9 kg/m(2) and > or = 30 kg/m(2), respectively, were 1.37 (1.12 to 1.66) and 2.05 (1.62 to 2.55) for prescription drugs, 0.96 (0.83 to 1.13) and 1.14 (0.97 to 1.37) for outpatient services, 1.20 (0.81 to 1.86) and 1.38 (0.91 to 2.14) for inpatient care, and 1.10 (0.91 to 1.35) and 1.36 (1.11 to 1.68) for all medical care.
Future healthcare costs are higher for persons who are overweight, especially those with BMIs > or = 30 kg/m(2).
The obesity epidemic shows no signs of abating. There is an urgent need to push back against the environmental forces that are producing gradual weight gain in the population. Using data from national surveys, we estimate that affecting energy balance by 100 kilocalories per day (by a combination of reductions in energy intake and increases in physical activity) could prevent weight gain in most of the population. This can be achieved by small changes in behavior, such as 15 minutes per day of walking or eating a few less bites at each meal. Having a specific behavioral target for the prevention of weight gain may be key to arresting the obesity epidemic.
To examine in middle-aged adults the effect of medical care costs of large, rapid weight gain compared to weight maintenance.
: Retrospective cohort study for a 3-y time period.
Population-based sample (N=15174) of men and women members of a large managed care organization, aged 35-65 y, with a body mass index (BMI) >25 kg/m(2) at baseline. Health-care utilization and costs were measured at baseline and over the 3-y follow-up period.
Mean age at baseline was 49.7 y and mean BMI was 31.5 kg/m(2). During the 3-y follow-up period, 40.8% were classified as weight maintainers (+/-4 pounds), 45.3% gained 5-19 pounds, and 13.9% gained >/=20 pounds. A weight gain of >/=20 pounds was significantly associated with increased total medical care costs in all subgroups evaluated. Among all subjects, for those who gained >/=20 pounds compared to those who maintained weight, the adjusted 3-y increase in costs was 561 dollars. Among the subgroup with baseline comorbidities, the adjusted 3-y change in total medical care costs was 711 dollars. Multivariate analyses showed no significant differences between those who gained 5-19 pounds and those who maintained weight. Baseline BMI and comorbidities were also significant predictors of change in medical care costs, independent of weight gain.
A large 3-y weight gain (>/=20 lb) in middle-aged overweight and obese adults is associated with a correspondingly larger increase in total medical care costs compared to weight maintainers. The prevention of large weight gains holds promise for significantly reducing future medical care costs. Future studies should examine the causes of rapid weight gain and evaluate approaches to prevent and reverse such weight gain.
This statement summarizes the U.S. Preventive Services Task Force (USPSTF) recommendations on screening for obesity in adults based on the USPSTF's examination of evidence specific to obesity and overweight in adults and updates the 1996 recommendations on this topic. The complete USPSTF recommendation and rationale statement on this topic, which includes a brief review of the supporting evidence, is available through the USPSTF Web site (www.preventiveservices.gov), the National Guideline Clearinghouse (www.guideline.gov), and in print through the Agency for Healthcare Research and Quality Publications Clearinghouse (telephone, 800-358-9295; e-mail, ahrqpubs@ahrq.gov). The complete information on which this statement is based, including evidence tables and references, is available in the accompanying article in this issue and in the summary of the evidence and systematic evidence review on the Web sites already mentioned. The summary of the evidence is also available in print through the Agency for Healthcare Research and Quality Publications Clearinghouse.
Background: Obesity poses a considerable and growing health burden. This review examines evidence for screening and treating obesity in adults. Data Sources: MEDLINE and Cochrane Library (January 1994 through February 2003). Study Selection: Systematic reviews; randomized, controlled trials; and observational studies of obesity's health outcomes or efficacy of obesity treatment. Data Extraction: Two reviewers independently abstracted data on study design, sample, sample size, treatment, outcomes, and quality. Data Synthesis: No trials evaluated mass screening for obesity, so the authors evaluated indirect evidence for efficacy. Pharmacotherapy or counseling interventions produced modest (generally 3 to 5 kg) weight loss over at least 6 or 12 months, respectively. Counseling was most effective when intensive and combined with behavioral therapy. Maintenance strategies helped retain weight loss. Selected surgical patients lost substantial weight (10 to 159 kg over 1 to 5 years). Weight reduction improved blood pressure, lipid levels, and glucose metabolism and decreased diabetes incidence. The internal validity of the treatment trials was fair to good, and external validity was limited by the minimal ethnic or gender diversity of volunteer participants. No data evaluated counseling harms. Primary adverse drug effects included hypertension with sibutramine (mean increase, 0 mm Hg to 3.5 mm Hg) and gastrointestinal distress with orlistat (1% to 37% of patients). Fewer than 1% (pooled samples) of surgical patients died; up to 25% needed surgery again over 5 years. Conclusions: Counseling and pharmacotherapy can promote modest sustained weight loss, improving clinical outcomes. Pharmacotherapy appears safe in the short term; long-term safety has not been as strongly established. In selected patients, surgery promotes large amounts of weight loss with rare but sometimes severe complications.
Obesity is an independent risk factor for a variety of chronic diseases and is therefore a potential source of avoidable excess health care expenditures. Previous studies of obesity and health care costs have used group level data, applying estimates of population-attributable risks to estimates of US total costs of care for each obesity-related disease.
To quantify the association between body mass index (BMI) and health services use and costs stratified by age and use source at the patient level, a level of detail not previously reported.
In 17,118 respondents to a 1993 health survey of members of a large health maintenance organization, we ascertained through computerized databases all hospitalizations, laboratory services, outpatient visits, outpatient pharmacy and radiology services, and the direct costs of providing these services during 1993.
There was an association between BMI and annual rates of inpatient days, number and costs of outpatient visits, costs of outpatient pharmacy and laboratory services, and total costs (P < or = .003). Relative to BMI of 20 to 24.9, mean annual total costs were 25% greater among those with BMI of 30 to 34.9 (rate ratio, 1.25; 95% confidence interval, 1.10-1.41), and 44% greater among those with BMI of 35 or greater (rate ratio, 1.44; 95% confidence interval, 1.22-1.71). The association between BMI and coronary heart disease, hypertension, and diabetes largely explained these elevated costs.
Given the high prevalence of obesity and the associated elevated rates of health services use and costs, there is a significant potential for a reduction in health care expenditures through obesity prevention efforts.
This paper compares the effects of obesity, overweight, smoking, and problem drinking on health care use and health status based on national survey data. Obesity has roughly the same association with chronic health conditions as does twenty years' aging; this greatly exceeds the associations of smoking or problem drinking. Utilization effects mirrors the health effects. Obesity is associated with a 36 percent increase in inpatient and outpatient spending and a 77 percent increase in medications, compared with a 21 percent increase in inpatient and outpatient spending and a 28 percent increase in medications for current smokers and smaller effects for problem drinkers. Nevertheless, the latter two groups have received more consistent attention in recent decades in clinical practice and public health policy.
Obesity has clinical and economic consequences. Few studies have compared health care resource utilization between age- and sex-matched obese and nonobese persons.
We conducted a retrospective study in obese and nonobese individuals matched by age, sex, medical clinic, and selected exclusionary diagnoses. Data collected included hospitalizations, outpatient visits, professional claims, and prescriptions over 1 year. Costs were assigned to medical resources based on market prices using publicly available costs. Comorbid conditions were determined using a chronic disease score (CDS) index. Groups were compared on types and costs of resources consumed. Regression models were used to examine the effect of body mass index (BMI) on costs while controlling for age and chronic diseases.
A total of 539 obese and 1225 nonobese persons were examined. Obese patients had more hospitalizations (P<.001), prescription drugs (P<.001), professional claims (P<.001), and outpatient visits (P = .005). Obese patients used more cardiovascular, intranasal allergic rhinitis, asthma, ulcer, diabetes, thyroid, and analgesic drugs. Total costs between groups were different (median of 333.24 for nonobese patients; P<.001). Cost differences were primarily due to medications (P<.001). Predictors of total costs were age, sex, BMI, and CDS. For each unit BMI increase, costs increased 2.3% (P<.001). For each CDS unit increase, costs increased 52.9% (P<.001).
Over 1 year, health care costs for obese persons are higher than for nonobese persons, primarily because of prescription drugs.