Article

Economic Evaluation of Weight Loss Interventions in Overweight and Obese Women*

July 2006
Obesity 14(6):1093-106

July 2006
14(6):1093-106

DOI:10.1038/oby.2006.125

Source
PubMed

Authors:

Karen Kuntz

University of Minnesota Twin Cities

Cam Donaldson

Glasgow Caledonian University

Sue Goldie

Harvard University

To conduct a clinical and economic evaluation of outpatient weight loss strategies in overweight and obese adult U.S. women. This study was a lifetime cost-use analysis from a societal perspective, using a first-order Monte Carlo simulation. Strategies included routine primary care and varying combinations of diet, exercise, behavior modification, and/or pharmacotherapy. Primary data were collected to assess program costs and obesity-related quality of life. Other data were obtained from clinical trials, population-based surveys, and other published literature. This was a simulated cohort of healthy 35-year-old overweight and obese women in the United States. For overweight and obese women, a three-component intervention of diet, exercise, and behavior modification cost 12,600 US dollars per quality-adjusted life year gained compared with routine care. All other strategies were either less effective and more costly or less effective and less cost-effective compared with the next best alternative. Results were most influenced by obesity-related effects on quality of life and the probabilities of weight loss maintenance. A multidisciplinary weight loss program consisting of diet, exercise, and behavior modification provides good value for money, but more research is required to confirm the impacts of such programs on quality of life and the likelihood of long-term weight loss maintenance.

A Systematic Review of Methods to Predict Weight Trajectories in Health Economic Models of Behavioral Weight Management Programs: The Potential Role of Psychosocial Factors

Article

Full-text available

Dec 2019

Objectives. There is limited evidence on the long-term effectiveness of behavioral weight management interventions, and thus, when conducting health economic modeling, assumptions are made about weight trajectories. The aims of this review were to examine these assumptions made about weight trajectories, the evidence sources used to justify them, and the impact of assumptions on estimated cost-effectiveness. Given the evidence that some psychosocial variables are associated with weight-loss trajectories, we also aimed to examine the extent to which psychosocial variables have been used to estimate weight trajectories and whether psychosocial variables were measured within cited evidence sources. Methods. A search of databases (Medline, PubMed, Cochrane, NHS Economic Evaluation, Embase, PSYCinfo, CINAHL, EconLit) was conducted using keywords related to overweight, weight management, and economic evaluation. Economic evaluations of weight management interventions that included modeling beyond trial data were included. Results. Within the 38 eligible articles, 6 types of assumptions were reported (weight loss maintained, weight loss regained immediately, linear weight regain, subgroup-specific trajectories, exponential decay of effect, maintenance followed by regain). Fifteen articles cited at least 1 evidence source to support the assumption reported. The assumption used affected the assessment of cost-effectiveness in 9 of the 19 studies that tested this in sensitivity analyses. None of the articles reported using psychosocial factors to estimate weight trajectories. However, psychosocial factors were measured in evidence sources cited by 11 health economic models. Conclusions. Given the range of weight trajectories reported and the potential impact on funding decisions, further research is warranted to investigate how psychosocial variables measured in trials can be used within health economic models to simulate heterogeneous weight trajectories and potentially improve the accuracy of cost-effectiveness estimates.

Economic Evaluations of Adult Weight Management Interventions

Article

Full-text available

Mar 2012
Appl Health Econ Health Pol

One of the challenges when undertaking economic evaluations of weight management interventions is to adequately assess future health impacts. Clinical trials commonly measure impacts using surrogate outcomes, such as reductions in body mass index, and investigators need to decide how these can best be used to predict future health effects. Since obesity is associated with an increased risk of numerous chronic diseases occurring at different future time points, modelling is needed for predictions. To assess the methods used in economic evaluations to determine health impacts of weight management interventions and to investigate whether differences in methods affect the cost-effectiveness estimates. Eight databases were systematically searched. Included studies were categorized according to a decision analytic approach and effect measures incorporated. A total of 44 articles were included; 21 evaluated behavioural interventions, 12 evaluated surgical procedures and 11 evaluated pharmacological compounds. Of the 27 papers that estimated future impacts, eleven used Markov modelling, seven used a decision tree, five used a mathematical application, two used patient-level simulation and the modelling method was unclear in two papers. The most common types of effects included were co-morbidity treatment costs, heath-related quality of life due to weight loss and gain in survival. Only 12 of the studies included heath-related quality of life gains due to reduced co-morbidities and only one study included productivity gains. Despite consensus that trial-based analysis on its own is inadequate in guiding resource allocation decisions, it was used in 39% of the studies. Several of the modelling papers used model structures not suitable for chronic diseases with changing health risks. Three studies concluded that the intervention dominated standard care; meaning that it generated more quality-adjusted life-years (QALYs) for less cost. The incremental costs per QALY gained varied from $US235 to $US56,836 in the remaining studies using this outcome measure. An implicit hypothesis of the review was that studies including long-term health effects would illustrate greater cost effectiveness compared with trial-based studies. This hypothesis is partly confirmed with three studies arriving at dominating results, as these reach their conclusion from modelling future co-morbidity treatment cost savings. However, for the remaining studies there is little indication that decision-analytic modelling disparities explain the differences. This is the first literature review comparing methods used in economic evaluations of weight management interventions, and it is the first time that observed differences in study results are addressed with a view to methodological explanations. We conclude that many studies have methodological deficiencies and we urge analysts to follow recommended practices and use models capable of depicting long-term health consequences.

What is the clinical effectiveness and cost-effectiveness of using drugs in treating obese patients in primary care? A systematic review

Article

Full-text available

Feb 2012
HEALTH TECHNOL ASSES

Obesity [defined as a body mass index (BMI) ≥ 30 kg/m(2)] represents a considerable public health problem and is associated with a significant range of comorbidities and an increased mortality risk. The primary aim of the management of obesity is to achieve weight reduction in the interests of health. For obese patients who cannot achieve or maintain a healthy weight by non-pharmacological means, drug therapy is recommended in combination with non-pharmacological interventions such as dietary modifications and exercise. To evaluate the clinical effectiveness and cost-effectiveness of three pharmacological interventions in obese patients. Clinical effectiveness data used in the meta-analysis were sourced from articles identified in a systematic review of the literature. Data used to inform transitions to obesity-related comorbidities were derived from the General Practice Research Database (GPRD). The results of the meta-analysis and GPRD analyses informed the economic model supplemented by data from the Health Survey for England and other UK-specific data sourced from the literature. A systematic literature review was conducted of the clinical effectiveness and cost-effectiveness of orlistat, sibutramine and rimonabant within their licensed indications for the treatment of obese patients. Electronic bibliographic databases including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, The Cochrane Library databases and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched in January 2009, and the reference lists of relevant articles were checked. Studies were included if they compared orlistat, sibutramine or rimonabant with lifestyle and/or exercise advice (standard care), placebo or metformin. Overall, 94 studies involving 24,808 individuals were included in the clinical meta-analysis. Eighty-three trials included data on weight change, 41 included data on BMI change and 45 and 36 studies reported on 5% and 10% body weight loss, respectively. Overall, the results show that the active drug interventions are all effective at reducing weight and BMI compared with placebo. In the case of sibutramine, the higher dose (15 mg) resulted in a greater reduction than the lower dose (10 mg). Generally, the data quality of the trials included was low with poor reporting of standard errors and standard deviations. Results from the BMI risk models derived from the GPRD showed consistent increases in risk with increasing BMI. Adjustments for key confounders, such as age, sex and smoking status, were found to be statistically significant at the 5% level, in all risk models. Applying linear models to estimate BMI trajectories, for the diabetic cohort, an average increase in BMI of 0.040 per year for both men and women was observed. The non-diabetic cohort model showed an increase in BMI of 0.175 per year for women and 0.145 per year for men. The results of the cost-effectiveness analyses suggest that sibutramine 15 mg dominates the other three active interventions and the net benefit analyses show that sibutramine 15 mg is the most cost-effective alternative for thresholds > £2000 per quality-adjusted life-year (QALY). However, both sibutramine and rimonabant have been withdrawn because of safety concerns relating to potential treatment-induced fatal adverse events. If the proportion of patients who experienced a fatal adverse event was > 1.8% (1.5%, 1.0%) for sibutramine 15 mg (sibutramine 10 mg, rimonabant) the treatment would not be considered cost-effective when using a threshold of £20,000 per QALY. The clinical review did not include all possible lifestyle comparators, with the inclusion limited to only those trials included one of the active drug interventions. We also excluded all studies not reported in English. Although the clinical review included data from 94 studies, the quality of data was generally low, particularly in terms of the reporting of standard deviation. There was also inconsistency between the results of the mixed-treatment comparison (MTC) and the pair-wise analyses. The MTC of anti-obesity treatments shows that all the active treatments are effective at reducing weight and BMI. The economic results show that, compared with placebo, the treatments are all cost-effective when using a threshold of £20,000 per QALY, and, within the limitations of the data available, sibutramine 15 mg dominates the other three interventions. This work has highlighted many areas of methodological research that could be explored, including assessing inconsistencies within a network to determine differences between the results of pair-wise and MTC analyses; the use of meta-regression methods to look for effect modifiers; exploring the effect of local publication bias; and the use of joint models to analyse the repeated measures of BMI and the time-to-event processes simultaneously. The National Institute for Health Research Health Technology Assessment programme.

The clinical effectiveness and costeffectiveness of long-term weight management schemes for adults: A systematic review

Article

Full-text available

Jan 2011
HEALTH TECHNOL ASSES

To assess the long-term clinical effectiveness and cost-effectiveness of multicomponent weight management schemes for adults in terms of weight loss and maintenance of weight loss. Bibliographic databases were searched from inception to December 2009, including the Cochrane Library, MEDLINE (Ovid), EMBASE (Ovid), and MEDLINE In-Process & Other Non-Indexed Citations. Bibliographies of related papers were screened, key conferences and symposia were searched and experts were contacted to identify additional published and unpublished references. For the clinical effectiveness review, two reviewers independently screened titles and abstracts for eligibility. Inclusion criteria were applied to the full text of retrieved papers by one reviewer and checked by a second reviewer using a pre-piloted inclusion flow chart. The studies were long-term randomised controlled trials (RCTs) of adult participants who were classified by body mass index as overweight or obese. Interventions were multicomponent weight management programmes (including diet, physical activity and behaviour change strategies) that assessed weight measures. Programmes that involved the use of over-the-counter medicines licensed in the UK were also eligible. For the cost-effectiveness review two reviewers independently screened studies for inclusion. Cost-effectiveness, cost-utility, cost-benefit or cost-consequence analyses were eligible. Data were extracted using a standardised and pre-piloted data extraction form. The quality of included studies was assessed using standard criteria. Studies were synthesised through a narrative review with full tabulation of results. A total of 3358 references were identified, of which 12 were included in the clinical effectiveness review. Five RCTs compared multicomponent interventions with non-active comparator groups. In general, weight loss appeared to be greater in the intervention groups than in the comparator groups. Two RCTs compared multicomponent interventions that focused on the diet component. In these studies there were no statistically significant differences in weight loss between interventions. Four RCTs compared multicomponent interventions that focused on the physical activity component. There was little consistency in the pattern of results seen, in part owing to the differences in the interventions. In one RCT the intervention focused on the goal-setting interval and it appeared that weight loss was greatest in those given daily goals compared with weekly goals. Overall, where measured, it appeared that most groups began to regain weight at further follow-up. Of the 419 studies identified in the cost-effectiveness searches, none met the full inclusion criteria. Two economic evaluations are described in our review; however, caution is required in their interpretation, as they did not meet all inclusion criteria. Lifetime chronic disease models were used in these studies and the models included the costs and benefits of avoiding chronic illness. Both studies found the interventions to be cost-effective, with estimates varying between -£473 and £7200 (US$12,640) per quality-adjusted life-year gained; methodological omissions from these studies were apparent and caution is therefore required in the interpretation of these results. Long-term multicomponent weight management interventions were generally shown to promote weight loss in overweight or obese adults. Weight changes were small however and weight regain was common. There were few similarities between the included studies; consequently an overall interpretation of the results was difficult to make. There is some evidence that weight management interventions are likely to be cost-effective, although caution is required as there were some limitations in the two cost-evaluation studies described. The National Institute for Health Research Health Technology Assessment programme.

Economic Evaluation of Lifestyle Interventions for Preventing Diabetes and Cardiovascular Diseases

Article

Full-text available

Aug 2010
Int J Environ Res Publ Health

Lifestyle interventions (i.e., diet and/or physical activity) are effective in delaying or preventing the onset of diabetes and cardiovascular disease. However, policymakers must know the cost-effectiveness of such interventions before implementing them at the large-scale population level. This review discusses various issues (e.g., characteristics, modeling, and long-term effectiveness) in the economic evaluation of lifestyle interventions for the primary and secondary prevention of diabetes and cardiovascular disease. The diverse nature of lifestyle interventions, i.e., type of intervention, means of provision, target groups, setting, and methodology, are the main obstacles to comparing evaluation results. However, most lifestyle interventions are among the intervention options usually regarded as cost-effective. Diabetes prevention programs, such as interventions starting with targeted or universal screening, childhood obesity prevention, and community-based interventions, have reported favorable cost-effectiveness ratios.

EFFECT OF MINDFULNESS MEDITATION AND HOME-BASED RESISTANCE EXERCISE ON WEIGHT LOSS, WEIGHT LOSS BEHAVIORS, AND PSYCHOSOCIAL CORRELATES IN OVERWEIGHT ADULTS

Article

Sep 2008

Kelliann Davis

Behavioral weight loss programs typically result in short-term weight loss of approximately 7-10%. However, it is important to continue to develop innovative weight loss treatments for the overweight and obese to improve upon this weight loss and related outcomes. PURPOSE: To examine the effect of mindfulness meditation and home-based resistance exercise on weight loss, weight loss behaviors, and various psychosocial correlates in overweight adults across a 6-month behavioral weight loss intervention. METHODS: Seventy-one subjects (BMI = 32.9+3.7 kg/m2; age = 45.1+8.3 years) participated in a 6-month behavioral weight loss intervention. Subjects were randomly assigned to one of three treatment groups: standard behavioral weight loss program (SBWL, n=24), SBWL plus resistance exercise (RT, n=23), or SBWL plus mindfulness training (MD, n=24). All participants were instructed to decrease energy intake to 1200-1500 kcal/d and dietary fat intake to 20-30% of total energy intake, increase physical activity to 300 min/wk, and attend weekly group meetings. SBWL+RT consisted of the addition a resistance training component using resistance tubing and exercise balls. SBWL+MD consisted of mindfulness training using meditation, yoga, and mindful eating techniques. Body weight, process measures of weight loss (physical activity, energy intake, eating behavior inventory), and psychosocial correlates of weight loss (eating and physical activity self-efficacy, outcome expectations (benefits) and barriers to exercise, dietary restraint and disinhibition, and body image) were measured at 0, 3, and 6 months. RESULTS: Weight significantly decreased in all groups at 6 months (p<0.05), but did not differ between groups (SBWL= -6.1±2.4 kg; SBWL+RT= -8.8±1.9 kg, SBWL+MD= -8.0±0.2 kg). Physical activity significantly increased in all groups at 3 months (average increase = 833+439 kcal/wk) (p<0.05), but did not differ between groups. Adoption of weight loss eating behaviors increased in all groups (p<0.05) with no significant difference between groups. Physical activity and eating self-efficacy, dietary restraint, and most subscales of body image increased over the 6-month intervention, while dietary disinhibition, perceived hunger, and overall exercise barriers decreased significantly over time, with no difference between the groups. Significant decreases in body weight were correlated with improvements in physical activity and weight loss eating behaviors (p<.05), but not with decreases in energy intake. Significant correlates of physical activity included perceived barriers to physical activity (negative), physical activity self-efficacy (positive), and some subscales of body image (positive). Significant correlates of weight loss eating behaviors included body image (positive), eating self-efficacy (positive), dietary restraint (positive), dietary disinhibition (negative), and perceived hunger (negative). CONCLUSIONS: The behavioral weight loss intervention resulted in significant weight loss and improvements in physical activity and eating behaviors. However, the addition of resistance exercise or mindfulness training did not improve these short-term outcomes. It remains important that alternative behavioral approaches be examined over a longer duration to improve weight-related outcomes in overweight adults.

An Economic Evaluation of a Weight Loss Intervention Program for People with Serious Mental Illnesses Taking Antipsychotic Medications

Article

Full-text available

Jul 2015
ADM POLICY MENT HLTH

Individuals with serious mental illnesses suffer from obesity and cardiometabolic diseases at high rates, and antipsychotic medications exacerbate these conditions. While studies have shown weight loss and lifestyle interventions can be effective in this population, few have assessed intervention cost-effectiveness. We present results from a 12-month randomized controlled trial that reduced weight, fasting glucose, and medical hospitalizations in intervention participants. Costs per participant ranged from $4365 to $5687. Costs to reduce weight by one kilogram ranged from $1623 to $2114; costs to reduce fasting glucose by 1 mg/dL ranged from $467 to $608. Medical hospitalization costs were reduced by $137,500.

Cost-effectiveness of a Primary Care Intervention to Treat Obesity

Article

Full-text available

Aug 2013

Background: Data on the cost-effectiveness of the behavioral treatment of obesity are not conclusive. The cost-effectiveness of treatment in primary care settings is particularly relevant. Methods: We conducted a within-trial cost-effectiveness analysis of a primary care-based obesity intervention. Study participants were randomized to: Usual Care (UC; quarterly visits with their primary care provider); Brief Lifestyle Counseling (BLC; quarterly provider visits plus monthly weight loss counseling visits) or Enhanced Brief Lifestyle Counseling (EBLC; all above interventions, plus choice of meal replacements or weight loss medication). A health-care payer perspective was used. Intervention costs were estimated from tracking data obtained prospectively. Quality-adjusted life years (QALYs) were estimated with the EuroQol-5D. We estimated cost per kilogram-year of weight loss and cost per QALY. Results: Weight losses after 2 years were 1.7, 2.9 and 4.6 kg for UC, BLC and EBLC, respectively (P=0.003 for comparison of EBLC vs UC). The incremental cost per kilogram-year lost was $292 for EBLC compared with UC (95% confidence interval (CI): $219-$437). The short-term incremental cost per QALY was $115,397, but the 95% CI were undefined. Comparison of short-term cost per kg with published estimates of longer-term cost per QALY suggested that the intervention could be cost-effective over the long term (≥ 10 years). Conclusions: A primary care intervention that includes monthly counseling visits and a choice of meal replacements or weight loss medication could be a cost-effective treatment for obesity over the long term. However, additional studies are needed on the cost-effectiveness of behavioral treatment of obesity.

Health state preferences associated with weight status in children and adolescents

Article

Full-text available

Feb 2011
BMC Pediatr

Childhood obesity is a substantial public health problem. The extent to which health state preferences (utilities) are related to a child's weight status has not been reported. The aims of this study were (1) to use a generic health state classification system to measure health related quality of life and calculate health utilities in a convenience sample of children and adolescents and (2) to determine the extent to which these measures are associated with weight status and body mass index (BMI). We enrolled 76 children 5-18 years of age from a primary care clinic and an obesity clinic in Boston MA. We administered the Health Utilities Index (HUI) and used the HUI Mark 3 single- and multi-attribute utility functions to calculate health utilities. We determined BMI percentile and weight status based on CDC references. We examined single-attribute and overall utilities in relation to weight status and BMI. Mean (range) age was 10.8 (5-18) years. Mean (SD) BMI percentile was 76 (26); 55% of children were overweight or obese. The mean (SD) overall utility was 0.79 (0.17) in the entire sample. For healthy-weight children, the mean overall utility was higher than for overweight or obese children (0.81 vs. 0.78), but the difference was not statistically significant (difference 0.04, 95% CI -0.04, 0.11). Our results provide a quantitative estimate of the health utility associated with overweight and obesity in children, and will be helpful to researchers performing cost effectiveness analyses of interventions to prevent and/or treat childhood obesity.

Association of clinically significant weight loss with number of patient visits and months of attendance at an Australian multidisciplinary weight management clinic

Article

Full-text available

Mar 2022

Despite the obesity epidemic, there are relatively few multidisciplinary obesity services in Australia, and only limited data on the effectiveness of these services. The aim of this study was to evaluate the effectiveness of a university hospital‐based weight management clinic—the ‘Healthy Weight Clinic’ in supporting patients to achieve clinically significant weight loss (≥5% reduction in body weight), weight maintenance, and changes in body composition. A retrospective review was conducted to determine weight and associated health outcomes in patients who attended an initial consultation in the first 2 years of the clinic—between March 2017 and March 2019. Follow up was at least 1 year for all patients. Patients who underwent bariatric surgery were excluded. Of 213 total patients, 172 patients attended more than one follow‐up consultation for lifestyle modification. Mean weight change and percentage total weight change at last follow‐up was −6.2 kg (SD 7.4) and − 6.0% (SD 6.9), respectively. For every additional clinic follow‐up, there was 21.4% increased odds of achieving clinically significant weight loss, and for every additional month of follow‐up, there was 10.1% increased odds of achieving clinically significant weight loss. Twenty percent of patients (34/172) maintained ≥5% of initial body weight loss for at least 1 year. Body composition measurements were also favourable, with significant changes in percentage skeletal muscle mass of +0.8% (SD 1.5) and in percentage fat mass by −1.4% (SD 3.2). Regular support in a structured holistic multidisciplinary obesity service enables patients to achieve clinically meaningful weight loss and improved skeletal muscle mass to body fat ratio, and maintain this loss for at least 1 year. Improved weight loss was associated with more patient visits and longer duration of attendance at the clinic.

Coverage of Obesity Treatment: A State-by-State Analysis of Medicaid and State Insurance Laws

Article

Jul 2010

Objectives We determined whether state Medicaid programs cover recommended treatments for adult and pediatric obesity and to what extent states regulate the treatment and coverage of obesity by private insurers. Methods We conducted a state-by-state document review of Medicaid manuals and private insurance laws and regulations. Results Eight state Medicaid programs appear to cover all recommended obesity treatment modalities for adults. Only 10 states appear to reimburse for obesity-related treatment in children. In the small-group insurance market, 35 states expressly allow obesity to be used for rate adjustments, while 10 states do so in the individual market. Two states expressly allow obesity to be used in eligibility decisions in the individual market. Five states provide for coverage of one or more treatments for obesity in both small-group and individual markets. Conclusions Very few states ensure coverage of recommended treatments for adult and pediatric obesity through Medicaid or private insurance. Most states allow obesity to be used to adjust rates in the small-group and individual markets and to deny coverage in the individual market.

Cost-effectiveness of habit-based advice for weight control versus usual care in general practice in the Ten Top Tips (10TT) trial: Economic evaluation based on a randomised controlled trial

Article

Full-text available

Aug 2018

Objective Ten Top Tips (10TT) is a primary care-led behavioural intervention which aims to help adults reduce and manage their weight by following 10 weight loss tips. The intervention promotes habit formation to encourage long-term behavioural changes. The aim of this study was to estimate the cost-effectiveness of 10TT in general practice from the perspective of the UK National Health Service. Design An economic evaluation was conducted alongside an individually randomised controlled trial. Setting 14 general practitioner practices in England. Participants All patients were aged ≥18 years, with body mass index ≥30 kg/m². A total of 537 patients were recruited; 270 received the usual care offered by their practices and 267 received the 10TT intervention. Outcomes measures Health service use and quality-adjusted life years (QALYs) were measured over 2 years. Analysis was conducted in terms of incremental net monetary benefits (NMBs), using non-parametric bootstrapping and multiple imputation. Results Over a 2-year time horizon, the mean costs and QALYs per patient in the 10TT group were £1889 (95% CI £1522 to £2566) and 1.51 (95% CI 1.44 to 1.58). The mean costs and QALYs for usual care were £1925 (95% CI £1599 to £2251) and 1.51 (95% CI 1.45 to 1.57), respectively. This generated a mean cost difference of −£36 (95% CI −£512 to £441) and a mean QALY difference of 0.001 (95% CI −0.080 to 0.082). The incremental NMB for 10TT versus usual care was £49 (95% CI −£1709 to £1800) at a maximum willingness to pay for a QALY of £20 000. 10TT had a 52% probability of being cost-effective at this threshold. Conclusions Costs and QALYs for 10TT were not significantly different from usual care and therefore 10TT is as cost-effective as usual care. There was no evidence to recommend nor advice against offering 10TT to obese patients in general practices based on cost-effectiveness considerations. Trial registration number ISRCTN16347068; Post-results.

Weight Loss Maintenance Strategies Among Rural Breast Cancer Survivors: The Rural Women Connecting for Better Health Trial

Article

Sep 2016
OBESITY

Objective: Obesity is a risk factor for breast cancer recurrence. Rural women have higher obesity rates compared with urban women and are in need of distance-based interventions that promote long-term weight loss. Methods: In this two-phase trial, rural breast cancer survivors who lost >5% of their starting weight during a 6-month lifestyle intervention (delivered through weekly group conference calls) were randomized to one of two 12-month interventions for weight loss maintenance: continued biweekly phone-based group counseling or mailed newsletters. The primary outcome was weight regain from 6 to 18 months. Secondary outcomes included dichotomous measures of weight change and costs. Results: Mean weight loss at 6 months was 14.0 ± 5.1%. Participants in the group phone condition regained less weight (3.3 ± 4.8 kg) compared with participants in the newsletter condition (4.9 ± 4.8 kg; P = 0.03). At 18 months, 75.3% of participants in the group phone condition remained ≥5% below baseline weight compared with 57.8% in the newsletter condition (P = 0.02). Incremental cost-effectiveness ratios were $882 to keep one more person ≥5% below baseline weight. Conclusions: A lifestyle intervention incorporating group phone-based support improved the magnitude of weight loss maintained and increased the proportion of survivors who maintained clinically significant reductions.

Strategies for Primary Prevention of Coronary Heart Disease Based on Risk Stratification by the ACC/AHA Lipid Guidelines, ATP III Guidelines, Coronary Calcium Scoring, and C-Reactive Protein, and a Global Treat-All Strategy: A Comparative--Effectiveness Modeling Study

Article

Full-text available

Sep 2015
PLOS ONE

Background: Several approaches have been proposed for risk-stratification and primary prevention of coronary heart disease (CHD), but their comparative and cost-effectiveness is unknown. Methods: We constructed a state-transition microsimulation model to compare multiple approaches to the primary prevention of CHD in a simulated cohort of men aged 45-75 and women 55-75. Risk-stratification strategies included the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the treatment of blood cholesterol, the Adult Treatment Panel (ATP) III guidelines, and approaches based on coronary artery calcium (CAC) scoring and C-reactive protein (CRP). Additionally we assessed a treat-all strategy in which all individuals were prescribed either moderate-dose or high-dose statins and all males received low-dose aspirin. Outcome measures included CHD events, costs, medication-related side effects, radiation-attributable cancers, and quality-adjusted-life-years (QALYs) over a 30-year timeframe. Results: Treat-all with high-dose statins dominated all other strategies for both men and women, gaining 15.7 million QALYs, preventing 7.3 million myocardial infarctions, and saving over $238 billion, compared to the status quo, far outweighing its associated adverse events including bleeding, hepatitis, myopathy, and new-onset diabetes. ACC/AHA guidelines were more cost-effective than ATP III guidelines for both men and women despite placing 8.7 million more people on statins. For women at low CHD risk, treat-all with high-dose statins was more likely to cause a statin-related adverse event than to prevent a CHD event. Conclusions: Despite leading to a greater proportion of the population placed on statin therapy, the ACC/AHA guidelines are more cost-effective than ATP III. Even so, at generic prices, treating all men and women with statins and all men with low-dose aspirin appears to be more cost-effective than all risk-stratification approaches for the primary prevention of CHD. Especially for low-CHD risk women, decisions on the appropriate primary prevention strategy should be based on shared decision making between patients and healthcare providers.

Challenging Obesity: Patient, Provider, and Expert Perspectives on the Roles of Available and Emerging Nonsurgical Therapies

Article

Jul 2015
OBESITY

Objective: Adult obesity is recognized as a chronic disease. According to principles of chronic disease management, healthcare professionals should work collaboratively with patients to determine appropriate therapeutic strategies that address overweight and obesity, specifically considering a patient's disease status in addition to their individual needs, preferences, and attitudes regarding treatment. A central role and responsibility of healthcare professionals in this process is to inform and educate patients about their treatment options. Although current recommendations for the management of adult obesity provide general guidance regarding safe and proper implementation of lifestyle, pharmacological, and surgical interventions, healthcare professionals need awareness of specific evidence-based information that supports individualized clinical application of these therapies. More specifically, healthcare professionals should be up-to-date on approaches that promote successful lifestyle management and be knowledgeable about newer weight loss pharmacotherapies, so they can offer patients with obesity a wide range of options to personalize their treatment. Accordingly, this educational activity has been developed to provide participants with the latest information on treatment recommendations and therapeutic advances in lifestyle intervention and pharmacotherapy for adult obesity management. Design and methods: This supplement is based on the content presented at a live CME symposium held in conjunction with ObesityWeek 2014. Results: This supplement provides an expert summary of current treatment recommendations and recent advances in nonsurgical therapies for the management of adult obesity. Patient and provider perspectives on obesity management are highlighted in embedded video clips available via QR codes, and new evidence will be applied using clinically relevant case studies. Conclusions: This supplement provides a topical update of obesity management, including clinical practice examples, for healthcare professionals who treat or provide care for adults with obesity.

Medication costs during an 18 month clinical trial of obesity treatment among patients encountered in primary care

Article

Full-text available

Dec 2015

Weight loss often leads to reductions in medication costs, particularly for weight-related conditions. We aimed to evaluate changes in medication costs from an 18 month study of weight loss among patients recruited from primary care. Study participants (n = 79, average age = 56.3; 75.7 % female) with average BMI of 39.5 kg/m(2), plus one co-morbid condition of either diabetes/pre-diabetes, hypertension, abnormal cholesterol, or sleep apnea, were recruited from 2 internal medicine practices. All participants received intensive behavioral and dietary treatment during months 0-6, including subsidized access to portion-controlled foods for weight loss. From months 7-18, all participants were offered continued access to subsidized foods, and half of participants were randomly assigned to continue in-person visits ("Intensified Maintenance"), while the other half received materials by mail or e-mail ("Standard Maintenance"). Medication costs were evaluated at months 0, 6, and 18. Participants assigned to Intensified Maintenance maintained nearly all their lost weight, whereas those assigned to Standard Maintenance regained weight. However, no significant differences in medication costs were observed within or between groups during the 18 months of the trial. A reduction of nearly $30 per month (12.9 %) was observed among all participants from month 0 to month 6 (active weight loss phase), but this difference did not reach statistical significance. A behavioral intervention that led to clinically significant weight loss did not lead to statistically significant reductions in medication costs. Substantial variability in medication costs and lack of a systematic approach by the study team to reduce medications may explain the lack of effect. The trial was registered at (NCT01220089) on September 23, 2010.

The efficacy of 12 weeks supervised exercise in obesity management

Article

Full-text available

Aug 2014

The objective of this randomized controlled trial was to investigate the effect of adding either aerobic training (AT) or resistance training (RT) to a multidisciplinary teamed (MDT) educational weight management programme on the health-related fitness of morbidly obese individuals. Males (n = 9) and females (n = 24) aged between 24 and 68 years with a body mass index (BMI) of ≥40 kg m(2) (≥35 kg m(2) with comorbidities) undertaking a weight management programme were recruited (Completion: M = 8, F = 19). Participants were randomly allocated to either AT (n = 12), RT (n = 11) or CON (n = 10). AT and RT undertook three structured ∼60 min moderate intensity sessions weekly, two supervised gym-based and one structured home-based session for 12 weeks; CON undertook usual care alone. Anthropometric, psychological and functional capacity measures were obtained pre- and post-intervention. Both exercise interventions elicited improvements compared with CON in the: shuttle walk test (AT [Δ 207.0 ± 123.0 metres, 68.0%, P = 0.04], RT [Δ 165.0 ± 183.3 m, 48.8%, P = 0.06], CON [Δ -14.3 ± 38.7 m, -6.2%]), triceps skin-fold (P ≤ 0.001), self-efficacy (P = 0.005) and interest/enjoyment (P = 0.006). RT displayed additional improvements compared with CON in BMI (RT [Δ -1.02 ± 0.91 kg·m(2) , -2.5%, P = 0.033], AT [Δ -1.84 ± 2.70 kg·m(2) , -4.3%, P = 0.142], CON [Δ -0.31 ± 1.47 kg·m(2) , -0.6%]), waist circumference (P = 0.022), competence (P = 0.019), biceps skin-fold (P = 0.012) and medial calf skin-fold (P = 0.013). No significant differences were observed between exercise modalities. Regardless of exercise mode, the addition of supervised and structured exercise to a MDT weight management programme significantly improved anthropometric, functional and psychological measures in obese participants with a BMI of ≥35 kg·m(2) . © 2014 The Authors. Clinical Obesity © 2014 World Obesity.

Identification of Psychological Dysfunctions and Eating Disorders in Obese Women Seeking Weight Loss: Cross-Sectional Study

Article

Full-text available

Mar 2014

Objective. The aim of this study is to analyse associations between eating behaviour and psychological dysfunctions in treatment-seeking obese patients and identify parameters for the development of diagnostic tools with regard to eating and psychological disorders. Design and Methods. Cross-sectional data were analysed from 138 obese women. Bulimic Investigatory Test of Edinburgh and Eating Disorder Inventory-2 assessed eating behaviours. Beck Depression Inventory II, Spielberger State-Trait Anxiety Inventory, form Y, Rathus Assertiveness Schedule, and Marks and Mathews Fear Questionnaire assessed psychological profile. Results. 61% of patients showed moderate or major depressive symptoms and 77% showed symptoms of anxiety. Half of the participants presented with a low degree of assertiveness. No correlation was found between psychological profile and age or anthropometric measurements. The prevalence and severity of depression, anxiety, and assertiveness increased with the degree of eating disorders. The feeling of ineffectiveness explained a large degree of score variance. It explained 30 to 50% of the variability of assertiveness, phobias, anxiety, and depression. Conclusion. Psychological dysfunctions had a high prevalence and their severity is correlated with degree of eating disorders. The feeling of ineffectiveness constitutes the major predictor of the psychological profile and could open new ways to develop screening tools.

Cost-utility analysis of a randomized controlled weight loss trial among lactating overweight/obese women

Article

Full-text available

Jan 2014
BMC PUBLIC HEALTH

Background: Overweight and obesity among young, adult women are increasing problems in Sweden as in many other countries. The postpartum period may be a good opportunity to improve eating habits and lose weight in a sustainable manner. The aim was to make a cost-utility analysis of a dietary behavior modification treatment alongside usual care, compared to usual care alone, among lactating overweight and obese women. Methods: This study was a cost-utility analysis based on a randomized controlled and longitudinal clinical diet intervention. Between 2007-2010, 68 women living in Sweden were, after baseline measurement at 8-12 weeks postpartum, randomly assigned to a 12-week dietary behavior modification treatment or control group. Inclusion criteria were: self-reported pre-pregnancy body mass index (BMI) 25-35 kg/m2, non-smoker, singleton term delivery, birth weight > 2500 g, intention to breastfeed for 6 mo and no diseases (mother and child). The women in the intervention group received 1.5 hour of individual counseling at study start and 1 hour at follow-up home visits after 6 weeks of intervention, with support through cell phone text messages every two wk. Dietary intervention aimed to reduce dietary intake by 500 kcal/day. The control group received usual care. Weight results have previously been reported. Here we report on analyses carried out during 2012-2013 of cost per quality adjusted life years (QALY), based on the changes in quality of life measured by EQ-5D-3 L and SF-6D. Likelihood of cost-effectiveness was calculated using Net Monetary Benefit method. Results: Based on conservative assumptions of no remaining effect after 1 year follow-up, the diet intervention was cost-effective. Costs per gained QALY were 8 643 - 9 758 USD. The likelihood for cost-effectiveness, considering a willingness to pay 50 000 USD for a QALY, was 87-93%. Conclusions: The diet intervention is cost-effective. Trial registration: ClinicalTrials.gov Identifier: NCT01343238 Registered April 27, 2011.The regional ethics committee in Gothenburg, Sweden, approved the study on November 15, 2006.

Cost effectiveness of primary care referral to a commercial provider for weight loss treatment, relative to standard care: A modelled lifetime analysis

Article

Full-text available

Dec 2013
INT J OBESITY

Background: Because of the high prevalence of overweight and obesity, there is a need to identify cost-effective approaches for weight loss in primary care and community settings. Objective: To evaluate the long-term cost effectiveness of a commercial weight loss programme (Weight Watchers) (CP) compared with standard care (SC), as defined by national guidelines. Methods: A Markov model was developed to calculate the incremental cost-effectiveness ratio (ICER), expressed as the cost per quality-adjusted life year (QALY) over the lifetime. The probabilities and quality-of-life utilities of outcomes were extrapolated from trial data using estimates from the published literature. A health sector perspective was adopted. Results: Over a patient's lifetime, the CP resulted in an incremental cost saving of AUD 70 per patient, and an incremental 0.03 QALYs gained per patient. As such, the CP was found to be the dominant treatment, being more effective and less costly than SC (95% confidence interval: dominant to 6225 per QALY). Despite the CP delaying the onset of diabetes by ∼10 months, there was no significant difference in the incidence of type 2 diabetes, with the CP achieving <0.1% fewer cases than SC over the lifetime. Conclusion: The modelled results suggest that referral to community-based interventions may provide a highly cost-effective approach for those at high risk of weight-related comorbidities.

Adults with Greater Weight Satisfaction Report More Positive Health Behaviors and Have Better Health Status Regardless of BMI

Article

Full-text available

Jan 2013
J Obes

Background. Prior studies suggest that weight satisfaction may preclude changes in behavior that lead to healthier weight among individuals who are overweight or obese. Objective. To gain a better understanding of complex relationships between weight satisfaction, weight-related health behaviors, and health outcomes. Design. Cross-sectional analysis of data from the Aerobics Center Longitudinal Study (ACLS). Participants. Large mixed-gender cohort of primarily white, middle-to-upper socioeconomic status (SES) adults with baseline examination between 1987 and 2002 (n = 19,003). Main Outcome Variables. Weight satisfaction, weight-related health behaviors, chronic health conditions, and clinical health indicators. Statistical Analyses Performed. Chi-square test, t-tests, and linear and multivariate logistic regression. Results. Compared to men, women were more likely to be dieting (32% women; 18% men) and had higher weight dissatisfaction. Men and women with greater weight dissatisfaction reported more dieting, yo-yo dieting, and snacking and consuming fewer meals, being less active, and having to eat either more or less than desired to maintain weight regardless of weight status. Those who were overweight or obese and dissatisfied with their weight had the poorest health. Conclusion. Greater satisfaction with one's weight was associated with positive health behaviors and health outcomes in both men and women and across weight status groups.

The long-term cost-effectiveness of obesity prevention interventions: Systematic literature review

Article

Jan 2012
OBES REV

Obesity prevention provides a major opportunity to improve population health. As health improvements usually require additional and scarce resources, novel health technologies (interventions) should be economically evaluated. In the prevention of obesity, health benefits may slowly accumulate over time and it can take many years before an intervention has reached full effectiveness. Decision-analytic simulation models (DAMs), which combine evidence from diverse sources, can be utilized to evaluate the long-term cost-effectiveness of such interventions. This literature review summarizes long-term economic findings (defined as ≥ 40 years) for 41 obesity prevention interventions, which had been evaluated in 18 cost-utility analyses, using nine different DAMs. Interventions were grouped according to their method of delivery, setting and risk factors targeted into behavioural (n=21), community (n=12) and environmental interventions (n=8). The majority of interventions offered good value for money, while seven were cost-saving. Ten interventions were not cost-effective (defined as >50,000 US dollar), however. Interventions that modified a target population's environment, i.e. fiscal and regulatory measures, reported the most favourable cost-effectiveness. Economic findings were accompanied by a large uncertainty though, which complicates judgments about the comparative cost-effectiveness of interventions.

Clinical and economic considerations of antiobesity treatment: A review of orlistat

Article

Full-text available

Jul 2010

Armineh Zohrabian

The objective of this study was to review the current knowledge about the use of orlistat from clinical and economic perspectives, and to assess this drug's public health impact. Weight reduction by current antiobesity drugs, compared to placebo, is at most around 5 kg. Orlistat, the most studied antiobesity drug, is associated with the least-severe adverse effects, but compared with other drugs in its class it also delivers the most modest weight loss versus placebo (less than 3 kg). Orlistat appears to have a favorable risk/benefit profile, and cost-effectiveness ratios seem to be within a range that is generally considered acceptable. In the short-term, orlistat is related to reduced diabetes incidence and to slightly improved blood pressure and lipid profiles. Long-term clinical effects have been largely unstudied, however, and this study did not find reports that considered mortality as an endpoint. Given a very low continuation with orlistat treatment in the population and very modest and, apparently, only short-term clinical effects, orlistat is not likely to have a significant impact on the population health. Public health approaches of improving environmental and social factors to foster healthier food choices and increase physical activity remain essential for addressing the obesity epidemic.

Cost-Effectiveness of Interventions to Promote Fruit and Vegetable Consumption

Article

Full-text available

Nov 2010
PLOS ONE

Fruits and vegetables are an essential part of the human diet, but many people do not consume the recommended serves to prevent cardiovascular disease and cancer. In this research, we evaluate the cost-effectiveness of interventions to promote fruit and vegetable consumption to determine which interventions are good value for money, and by how much current strategies can reduce the population disease burden. In a review of published literature, we identified 23 interventions for promoting fruit and vegetable intake in the healthy adult population that have sufficient evidence for cost-effectiveness analysis. For each intervention, we model the health impacts in disability-adjusted life years (DALYs), the costs of intervention and the potential cost-savings from averting disease treatment, to determine cost-effectiveness of each intervention over the lifetime of the population, from an Australian health sector perspective. Interventions that rely on dietary counselling, telephone contact, worksite promotion or other methods to encourage change in dietary behaviour are not highly effective or cost-effective. Only five out of 23 interventions are less than an A$50,000 per disability-adjusted life year cost-effectiveness threshold, and even the most effective intervention can avert only 5% of the disease burden attributed to insufficient fruit and vegetable intake. We recommend more investment in evaluating interventions that address the whole population, such as changing policies influencing price or availability of fruits and vegetables, to see if these approaches can provide more effective and cost-effective incentives for improving fruit and vegetable intake.

Coverage of Obesity Treatment: A State-by-State Analysis of Medicaid and State Insurance Laws

Article

Jul 2010

We determined whether state Medicaid programs cover recommended treatments for adult and pediatric obesity and to what extent states regulate the treatment and coverage of obesity by private insurers. We conducted a state-by-state document review of Medicaid manuals and private insurance laws and regulations. Eight state Medicaid programs appear to cover all recommended obesity treatment modalities for adults. Only 10 states appear to reimburse for obesity-related treatment in children. In the small-group insurance market, 35 states expressly allow obesity to be used for rate adjustments, while 10 states do so in the individual market. Two states expressly allow obesity to be used in eligibility decisions in the individual market. Five states provide for coverage of one or more treatments for obesity in both small-group and individual markets. Very few states ensure coverage of recommended treatments for adult and pediatric obesity through Medicaid or private insurance. Most states allow obesity to be used to adjust rates in the small-group and individual markets and to deny coverage in the individual market.

Article

Full-text available

Jun 2010
J Med Econ

To assess the return on investment (ROI) and economic impact of providing insurance coverage for the laparoscopic adjustable gastric banding (LAGB) procedure in classes II and III obese members of the Texas Employees Retirement System (ERS) and their dependents from payer, employer, and societal perspectives. Classes II and III obese employee members and their adult dependents were identified in a Texas ERS database using self-reported health risk assessment (HRA) data. Direct health costs and related absenteeism and mortality losses were estimated using data from previous research. A dynamic input-output model was then used to calculate overall economic effects by incorporating direct, indirect, and induced impacts. Direct health costs were inflation-adjusted to 2008 US dollars using the Consumer Price Index for Medical Care and other spending categories were similarly adjusted using relevant consumer and industrial indices. The future cost savings and other monetary benefits were discounted to present value using a real rate of 4.00%. From the payer perspective (ERS), the payback period for direct health costs associated with the LAGB procedure was 23-24 months and the annual return (over 5 years) was 28.8%. From the employer perspective (State of Texas), the costs associated with the LAGB procedure were recouped within 17-19 months (in terms of direct, indirect, and induced gains as they translated into State revenue) and the annual return (over 5 years) was 45.5%. From a societal perspective, the impact on total business activity for Texas (over 5 years) included gains of $195.3 million in total expenditures, $93.8 million in gross product, and 1354 person-years of employment. The analysis was limited by the following: reliance on other studies for methodology and use of a control sample; restriction of cost savings to 2.5 years which required out-of-sample forecasting; conservative assumptions related to the cost of the procedure; exclusion of presenteeism; and no sensitivity analyses performed. This analysis indicates that providing benefits for the LAGB procedure to eligible members of the Texas ERS and their dependents is worthy of support from payer, employer, and societal perspectives.

Difference of Body Compositional Changes According to the Presence of Weight Cycling in a Community-based Weight Control Program

Article

Full-text available

Jan 2010
J KOREAN MED SCI

Many obese people who try to control body weight experience weight cycling (WC). The present study evaluated the importance of WC in a community-based obesity intervention program. We analyzed the data of 109 Korean participants (86% women) among 177 subjects who had completed a 12-week intervention program at two public health centers in Korea from April to December, 2007. Completion of a self-administrated questionnaire at baseline was used to obtain anthropometric measurements, and laboratory testing was done before and after the program. Differences in body composition change and obesity-related life style between the two groups were compared with respect to WC and non-weight cycling (NWC). After 12 weeks, both groups showed reductions in weight, waist circumference, and body mass index. The group differences were not significant. However, significant differences were evident for the WC group compared to the NWC group in fat percent mass (WC vs. NWC, -3.49+/-2.31% vs. -4.65+/-2.59%, P=0.01), fat free mass (WC vs. NWC, -0.95+/-1.37 kg vs. -0.38+/-1.05 kg, P=0.01), and total cholesterol (WC vs. NWC, -3.32+/-14.63 vs. -16.54+/-32.39, P=0.005). In conducting a community-based weight control program that predominantly targets women, changes of body composition and total cholesterol may be less effective in weight cyclers than in non-weight cyclers.

Economic evaluation of prevention; further evidence

Article

Full-text available

This report is the third in a series of reports that aim to identify cost-effective preventive interventions that have not yet been diffused into the Dutch health care system or into a public health setting. In the first part of this report, five new interventions are presented and at the same time, renew the information on cost-effectiveness and implementation issues for six interventions that were described in less detail in our first report. For all eleven interventions, brief information on the magnitude and character of the health problem is presented, along with information on the intervention, its cost-effectiveness, and issues related to the transferability of foreign study results to the Dutch situation and possible future implementation of the intervention in the Netherlands. There is strong evidence for cost-effectiveness for (1) screening for neonatal group beta streptococcal infections, (2) fluoridation of drinking water, (3) mandatory folic acid fortification of staple foods, (4) vaccination against varicella zoster virus and (5) stop smoking interventions. Evidence on cost-effectiveness is moderate for (6) influenza vaccination of healthy working adults, (7) rotavirus vaccination of newborns, (8) universal hepatitis B vaccination, (9) pertussis vaccination of adolescents, (10) human papilomavirus vaccination of adolescents, and (11) pneumococcal vaccination of elderly persons. However, for all interventions, we conclude that the transferability of the results to the Dutch situation is poor and more research is needed to investigate cost-effectiveness in the Dutch context. With respect to implementation opportunities, it is anticipated that screening for neonatal group beta streptococcal infections, pertussis vaccination of adolescents, influenza vaccination of healthy working adults and pneumococcal vaccination of elderly persons is feasible. In the second part of this report, the cost-effectiveness was modelled for two interventions that were shown to be cost-effective in an international context and had no major barriers for implementation in the Netherlands. The two interventions were the prevention of recurrent depression by maintenance cognitive behavioural therapy (mCBT), and the prevention of chronic diseases by pharmacologic treatment of obesity. The analyses showed that mCBT is more cost-effective than usual care, which is prescription of anti-depressive medication. Compared to usual care, mCBT has a cost-effectiveness ratio of 15,000 per QALY. The cost-effectiveness of providing pharmacologic treatment (Orlistat) in combination with a diet is relatively high. Costs per QALY gained are 62,000 for Orlistat plus diet compared to diet alone. The modelling study underlines the importance of performing Dutch specific cost-effectiveness analyses and confirms the low transferability of foreign studies to the Dutch situation as was shown in the first part of the report. Dit rapport is de derde in een serie van rapporten over de doelmatigheid van preventieve interventies die nog niet systematisch in Nederland in de (openbare) gezondheidzorg zijn ingevoerd. In het eerste deel van dit rapport worden vijf nieuwe preventieve interventies gepresenteerd en wordt tevens de kennis ten aanzien van zes eerder beschreven interventies up-to-date gemaakt. Per interventie wordt achtereenvolgens het gezondheidsprobleem waar de interventie op gericht is, de interventie zelf, de doelmatigheid (kosteneffectiviteit) op basis van buitenlandse studies, de kansrijkheid van invoering en de vertaalbaarheid van de resultaten naar de Nederlandse situatie beschreven. Het onderzoek toont aan dat er sterke bewijslast voor kosteneffectiviteit is voor de volgende interventies: (1) screening op neonatale groep bhta streptokokkeninfecties, (2) fluoridering van het drinkwater, (3) verplicht verrijken van graanproducten met foliumzuur, (4) varicella zoster (waterpokken), virusvaccinatie en (5) stoppen-met-roken interventies via de huisarts. De bewijslast voor kosteneffectiviteit is matig voor (6) griepvaccinatie bij gezonde werknemers, (7) rotavirus- vaccinatie bij pasgeborenen, (8) universele hepatitis B-vaccinatie, (9) pertussis (kinkhoest) vaccinatie bij adolescenten, (10) humane papiloma virus vaccinatie bij adolescenten en (11) pneumokokkenvaccinatie bij ouderen. Echter, bij alle interventies is de vertaalbaarheid van buitenlandse onderzoeksresultaten naar de Nederlandse situatie beperkt en is meer onderzoek nodig om de doelmatigheid in de Nederlandse context te bestuderen. Met betrekking tot de haalbaarheid van invoering wordt screening op neonatale groep beta streptokokken infecties, pertussis vaccinatie bij adolescenten, griepvaccinatie bij gezonde werknemers en pneumokokken vaccinatie bij ouderen kansrijk geacht. In het tweede deel van het rapport wordt de doelmatigheid van twee interventies berekend, die in het buitenland kosteneffectief zijn gebleken en waarbij geen belangrijke barrieres bij de implementatie te verwachten zijn. Dit zijn terugvalpreventie van depressie door regelmatige cognitieve gedragstherapie (mCBT) en preventie van chronische ziekten door farmacologische behandeling van obesitas. Uit de economische evaluatie bleek dat mCBT doelmatiger is dan de huidige behandeling, die bestaat uit het voorschrijven van anti-depressiva. De kosteneffectiviteitsratio van mCBT is 15.000 per QALY. De doelmatigheid van het verstrekken van farmacologische behandeling (Orlistat) in combinatie met een dieet is relatief hoog. De kosten per gewonnen QALY zijn 62.000 voor Orlistat in combinatie met een dieet ten opzichte van dieet alleen. De modelleerstudie onderstreept het belang van de uitvoering van economische evaluaties in de Nederlandse context en bevestigt de slechte vertaalbaarheid van buitenlandse studies naar de Nederlandse situatie.

Pharmacoeconomic evaluation of anti-obesity drugs for chronic weight management: a systematic review of literature

Article

Full-text available

Nov 2023

Introduction Pharmacological therapy is recommended as a second-line alternative to reverse obesity. Currently, five anti-obesity drugs (AODs) have been approved by the U.S. Food and Drug Administration (FDA) for chronic weight management. The aim of this paper is to investigate the pharmacoeconomic evaluation of AODs through a systematic review with a special focus on methodological considerations. Methods We searched the general and specific databases to identify the primary pharmacoeconomic evaluation of AODs. Results A total of 18 full-text articles and three conference abstracts were included in this review. Most of the economic assessments were still about Orlistat. And the observations we could make were consistent with the previous systematic review. A few studies were on the combined therapies (i.e. PHEN/TPM ER and NB ER) compared to different comparators, which could hardly lead to a generalized summary of the cost-effectiveness. Most recently, pharmacoeconomic evidence on the newest GLP 1 RA approved for the indication of obesity or obesity with at least one comorbidity emerged gradually. Modelling-based cost-utility analysis is the major type of assessment method. In the modelling studies, a manageable number of the key health states and the state transitions were structured to capture the disease progression. In particular, the principal structure of the decision model adopted in the three studies on the newly approved drug was nearly the same, which enables more in-depth comparisons and generalizations of the findings. Conclusion This study provided an up-to-date overview of the strengths and areas for improvement in the methodological design of the pharmacoeconomic evaluation of the licensed drugs for chronic weight management. Future modelling evaluations would benefit from a better understanding of the long-term weight loss effects of the current therapeutic options and the weight rebound process after the discontinuation of treatment. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022302648 , identifier CRD42022302648.

Outcomes from a Whole-Systems Ayurvedic Medicine and Yoga Therapy Treatment for Obesity Pilot Study

Article

Mar 2019

Objectives: To determine the feasibility and acceptability of an Ayurveda/Yoga intervention for weight loss, using dual-diagnosis inclusion criteria, dual-paradigm outcomes, and a semistandardized protocol with tailoring according to the Ayurvedic constitution/imbalance profile of each participant. Design: Seventeen participants enrolled in a weekly intervention for 3 months. Outcome measurements were performed at baseline, postintervention, and 3 and 6 months follow-up. Setting: The intervention was conducted through the University of Arizona, Department of Family and Community Medicine from April through December 2012. Subjects: Participants included 2 men and 15 women recruited from the community of Tucson, AZ using flyers and hospital message boards. Seventeen enrolled and 12 participants provided complete follow-up data. Intervention: Participants met with an Ayurvedic practitioner twice monthly (six times) and followed semistandardized dietary guidelines with individual tailoring to address relevant psychophysiological imbalances obstructing weight loss and a standardized protocol of therapeutic yoga classes three times weekly with recommended home practice of two to four additional sessions. Outcome measures: Primary outcome was weight loss. Other biomedical outcomes included body mass index, body fat percentage, waist and hip circumference, waist to hip ratio, and blood pressure. Unique instruments were designed to collect data on outcomes associated with the Ayurvedic medical paradigm, including dietary changes by food qualities, mood/affect, relationships, and changes in Ayurvedic imbalance profiles. Results: Participants lost an average of 3.5 kg during the 3-month intervention. Weight loss at 3 and 6 months postintervention increased to an average of 5.6 kg and 5.9 kg, respectively. Participants who lost 3% of their body weight during the 12 week intervention, lost on average an additional 3% during the follow-up period. Psychosocial outcomes also improved. No additional services were provided to participants during the follow-up period. Conclusions: A whole-systems Ayurvedic medicine and Yoga therapy approach provides a feasible promising noninvasive low-cost alternative to traditional weight loss interventions with potential added benefits associated with sustainable holistic lifestyle modification and positive psychosocial changes.

Author's manuscript

Data

Full-text available

Aug 2018

Role of Endoscopy in the Treatment of Bariatric and Metabolic Disease

Article

Full-text available

Jun 2018

Kyung Uk Jung

Behaviour Change Update: Stage 3. BCT analysis of behaviour change interventions reported in studies of cost effectiveness

Article

Full-text available

Apr 2013

Using a search strategy of studies with economic analyses by Bazian, 251 interventions targeting smoking cessation, diet, physical activity, sexual health, alcohol and multiple health-related behaviours were identified. Of these, 102 provided cost-utility (CUA) estimates and 85.3% were considered to be cost-effective based on a conservative NICE threshold. Overall, smoking cessation interventions provided lower CUA values and were more likely to be cost-effective than interventions for multiple health-related behaviours. Across all interventions, those targeting the general population had lower CUA results and were more likely to be costeffective than those aimed at vulnerable populations. In addition, interventions featuring behaviour change techniques (BCTs) related to “Reduce negative emotions” had higher CUA values and those featuring the BCT “Monitoring outcome(s) of behaviour by others without feedback” were less likely to be cost-effective. When looking at health-related behaviours separately, diet interventions that provided medication only had higher CUA outcomes than other types of diet interventions. Moreover, diet interventions including BCTs related to “Comparison of outcomes” and interventions for multiple health-related behaviours that used electronic supporting material were less likely to be cost-effective than interventions that did not. Cost-effective interventions included in this report had CUA estimates broadly similar to interventions already appraised as cost-effective by NICE (reported in Stage 1). However, a higher proportion of interventions in this report focused on multiple health-related behaviours, were set in primary care, aimed at vulnerable populations, involved training and included BCTs pertaining to practical and social support and to discussing body changes. By contrast, fewer interventions than in Stage 1 focused on alcohol, were set in the work place, delivered at population level, used self-help material or incentives, and featured ‘choice architecture’ (CA). In general, interventions in this report served fewer functions, covered fewer BCT clusters and included fewer individual BCTs compared with Stage 1 interventions. Based on the present analysis, there is no consistent and little association between the presence of an individual BCT or BCT cluster and an intervention being considered cost-effective. These findings need to be interpreted cautiously given 1) different search strategies for this and the Stage 1 report, 2) reliance on incomplete information in published papers, 3) heterogeneity in economic analyses, 4) lack of consensus for a definition of CA and 5) bias in reporting of study findings.

Cost-effectiveness of a lifestyle modification program in long-term survivors of hemopoietic stem cell transplantation

Article

Jul 2017
CLIN TRANSPLANT

To evaluate the cost-effectiveness of a lifestyle modification program targeting long-term survivors of haematological malignancy treated with haemopoietic stem cell transplantation, a multi-state life table Markov model was used to calculate health outcomes for both the intervention and no intervention. Cost per health-adjusted life year (HALY) saved was reported for four scenarios: all participants with/without standard weight regain, participants who at baseline were overweight with/without standard weight regain. The program recruited 53 participants and was associated with reductions in body weight of 2.2 kg and BMI 0.8 units on intervention completion (12 months) at a cost of $1233/participant. These adipose reductions were sustained and remained significant at 24 months. The incremental cost-effectiveness ratios varied from $118,418 per HALY to dominant, depending on the weight regain assumption. The program may be cost-effective in transplant survivors, with the results most sensitive to the weight regain assumption and intervention cost. This article is protected by copyright. All rights reserved.

Current and Future Medical Treatment of Obesity

Article

Apr 2017

Obesity is a major health crisis resulting in comorbidities such as hypertension, type 2 diabetes, and obstructive sleep apnea. The need for safe and efficacious drugs to help assist with weight loss and reduce cardiometabolic risk factors is great. With several FDA-approved drugs on the market, there is still a great need to develop long-term obesity treatments or noninvasive oral agents to help assist individuals with obesity when used in conjunction with lifestyle modifications.

Effectiveness of Weight Loss Intervention in Highly-Motivated People

Article

Oct 2016

Mariétou H. Ouayogodé

A variety of approaches have been implemented to address the rising obesity epidemic, with limited success. I consider the success of weight loss efforts among a group of highly motivated people: those required to lose weight in order to qualify for a life-saving kidney transplantation. Out of 246 transplantation centers, I identified 156 (63%) with explicit body mass index (BMI) requirements for transplantation, ranging from 30 to 50kg/m2. Using the United States national registry of transplant candidates, I examine outcomes for 29,608 obese deceased-donor transplant recipients between 1990 and 2010. I use value-added models to deal with potential endogeneity of center choice, in addition to correcting for sample selection bias arising from focusing on transplant recipients. Outcome variables measure BMI level and weight change (in BMI) between initial listing and transplantation. I hypothesize that those requiring weight loss to qualify for kidney transplantation will be most likely to lose weight. I find that the probability of severe and morbid obesity (BMI≥35kg/m2) decreases by 4 percentage points and the probability of patients achieving any weight loss increases by 22 percentage points at centers with explicit BMI eligibility criteria. Patients are also 13 percentage points more likely to accomplish clinically relevant weight loss of at least 5% of baseline BMI by transplantation at these centers. Nonetheless, I estimate an average decrease in BMI of only 1.7kg/m2 for those registered at centers with BMI requirements. Further analyses suggest stronger intervention effects for patients whose BMI at listing exceeds thresholds as the distance from their BMI to the thresholds increases. Even under circumstances with great potential returns for weight loss, transplant candidates exhibit modest weight-loss. This suggests that, even in high-stakes environments, weight loss remains a challenge for the obese, and altering individual incentives may not be sufficient.

Cost- Effectiveness of Anti-Obesity Interventions

Article

Jan 2012

L. Roux

This chapter emphasizes key methodologic features of cost-effectiveness analysis (CEA), its potential to inform policy and direct future research, and the current state of the CEA literature in obesity. The comparative performance of alternate interventions is summarized by a cost-effectiveness ratio, which is defined as the additional cost of a specific intervention divided by its additional clinical benefit, compared with a relevant alternative. Although diet, physical activity, behavior modification, and pharmacotherapy are considered first-line treatments for obesity, non-surgical therapy for severe obesity has shown limited success. There are a number of surgical procedures available to treat severe obesity. As data gaps are filled and methodological challenges are addressed by increasingly sophisticated techniques and increasingly diverse research teams, the rigor and scope of CEAs will expand. CEAs will help policy makers prioritize public health decisions in both high-and low-resource settings.

The cost-effectiveness of primary care referral to a UK commercial weight loss programme

Article

Dec 2014

Primary care referral to commercial weight loss programmes that follow best practice is included in current UK guidance on the management of adult obesity. This study investigated whether such a programme was cost-effective compared with usual care. A decision-analytical Markov model was developed to estimate the lifetime costs and benefits of the referral programme compared with usual care and enable a cost-utility analysis. The model cohort transited between body mass index classifications and type 2 diabetes, stroke and myocardial infarction (MI) with risk, cost and effect parameter values taken from published literature. The cost per incremental quality-adjusted life year (QALY) was calculated. Extensive deterministic and scenario sensitivity analyses and probabilistic sensitivity analyses (PSA) were conducted. At 12 months, the incremental cost-effectiveness ratio was £6906, indicating that programme referral was cost-effective. Over a lifetime, referral to the commercial programme was dominant as it led to a cost saving of £924 and conferred incremental benefit (0.22 QALY) over usual care. Model simulations estimated lower lifetime rates of type 2 diabetes, stroke and MI as a result of the weight loss achieved. The results were robust to extensive sensitivity analyses. The PSA indicated that programme referral had a 68% chance of being cost-effective at a willingness to pay per incremental QALY threshold of £20 000. Referral to the programme dominated usual care, being both cheaper and more effective. These results compare favourably with economic evaluations of other obesity interventions and add to a growing evidence base on the cost-effectiveness of commercial weight loss providers and practices. © 2014 World Obesity.

Screening for and Management of Obesity and Overweight in Adults Investigators

Article

Full-text available

This report is based on research conducted by the Oregon Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. HHSA-290-2007-10057-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment. This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied. This document is in the public domain and may be used and reprinted without permission, except those copyrighted materials noted for which further reproduction is prohibited without the specific permission of copyright holders.

Meta- and Cost-Effectiveness Analysis of Commercial Weight Loss Strategies

Article

Sep 2014
OBESITY

Objective To estimate the incremental cost-effectiveness of clinically proven nonsurgical commercial weight loss strategies for those with BMIs between 25 and 40.Methods We performed a systematic literature review to identify randomized controlled trials of commercially available weight loss studies of at least 1 year in duration. Using the results of these trials and publicly available cost data, we quantified the incremental cost per kilogram of weight loss and per quality adjusted life year (QALY) gained. We then use probabilistic sensitivity analyses to quantify uncertainty in our results.ResultsBased on the literature review, two lifestyle programs (Weight Watchers and Vtrim), one meal replacement program (Jenny Craig), and three pharmaceutical products (Qsymia, Lorcaserin, and Orlistat) were included in the analysis. Average cost per kilogram of weight lost ranged from $155 (95% CI: $110-$218) for Weight Watchers to $546 (95% CI: $390-$736) for Orlistat. The incremental cost per QALY gained for Weight Watchers and Qsymia was $34,630 and $54,130, respectively. All other interventions were prohibitively expensive or inferior in that weight loss could be achieved at a lower cost through one or a combination of the other strategies.Conclusions Results suggest that, in the absence of other considerations and at current market prices, Weight Watchers and Qsymia represent the two most cost-effective strategies for nonsurgical weight loss.

Modelling the Economics of Type 2 Diabetes Mellitus Prevention: A Literature Review of Methods

Article

Mar 2014
Appl Health Econ Health Pol

Our objective was to review modelling methods for type 2 diabetes mellitus prevention cost-effectiveness studies. The review was conducted to inform the design of a policy analysis model capable of assisting resource allocation decisions across a spectrum of prevention strategies. We identified recent systematic reviews of economic evaluations in diabetes prevention and management of obesity. We extracted studies from two existing systematic reviews of economic evaluations for the prevention of diabetes. We extracted studies evaluating interventions in a non-diabetic population with type 2 diabetes as a modelled outcome, from two systematic reviews of obesity intervention economic evaluations. Databases were searched for studies published between 2008 and 2013. For each study, we reviewed details of the model type, structure, and methods for predicting diabetes and cardiovascular disease. Our review identified 46 articles and found variation in modelling approaches for cost-effectiveness evaluations for the prevention of type 2 diabetes. Investigation of the variables used to estimate the risk of type 2 diabetes suggested that impaired glucose regulation, and body mass index were used as the primary risk factors for type 2 diabetes. A minority of cost-effectiveness models for diabetes prevention accounted for the multivariate impacts of interventions on risk factors for type 2 diabetes. Twenty-eight cost-effectiveness models included cardiovascular events in addition to type 2 diabetes. Few cost-effectiveness models have flexibility to evaluate different intervention types. We conclude that to compare a range of prevention interventions it is necessary to incorporate multiple risk factors for diabetes, diabetes-related complications and obesity-related co-morbidity outcomes.

Supporting self-management

Article

Full-text available

Jan 2008
FLORA

The Role of Cost-Effectiveness Analysis in Developing Nutrition Policy

Article

Apr 2013
ANNU REV NUTR

Concern about the overconsumption of unhealthy foods is growing worldwide. With high global rates of noncommunicable diseases related to poor nutrition and projections of more rapid increases of rates in low- and middle-income countries, it is vital to identify effective but low-cost interventions. Cost-effectiveness studies show that individually targeted dietary interventions can be effective and cost-effective, but a growing number of modeling studies suggest that population-wide approaches may bring larger and more sustained benefits for population health at a lower cost to society. Mandatory regulation of salt in processed foods, in particular, is highly recommended. Future research should focus on lacunae in the current evidence base: effectiveness of interventions addressing the marketing, availability, and price of healthy and unhealthy foods; modeling health impacts of complex dietary changes and multi-intervention strategies; and modeling health implications in diverse subpopulations to identify interventions that will most efficiently and effectively reduce health inequalities. Expected final online publication date for the Annual Review of Nutrition Volume 33 is July 17, 2013. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates.

Food Acquisition Practices Used by Food-Insecure Individuals When They Are Concerned About Having Sufficient Food for Themselves and Their Households

Article

Jan 2011

Food-insecure individuals' food acquisition practices can result in inadequate nutrition, consumption of unsafe foods, and risky behaviors. A survey instrument was developed to collect sociodemographic information and frequency of engagement in different practices. After expert review, cognitive interviewing and pretesting, data were collected from 10 individuals/site at 50 emergency food providers. Descriptive analysis was performed and prevalence of each practice was ascertained for 3 time periods. Participants confirmed use of 78 practices with 50% using 19. Sixty-three percent posed a potential risk, including eating road kill, going to prison to obtain meals, and diluting foods (like baby formula) to extend them. Prevalence and riskiness of practices used by the food-insecure can inform policy and public health decisions regarding issues of food insecurity.

A Systematic Review and Critical Assessment of Health State Utilities Weight Change and Type 2 Diabetes Mellitus

Article

Oct 2012
PHARMACOECONOMICS

Objective: The study aimed to conduct a systematic literature search to identify health state utilities for weight change in type 2 diabetes mellitus (T2DM) and to review those values for appropriateness for inclusion in a submission to the National Institute for Health and Clinical Excellence (NICE). Methods: The search was conducted using keywords and Medical Subject Heading (MeSH) terms designed to exhaustively capture health state utility values across a variety of known economic, health technology assessment and peer-reviewed publication databases. The values were then critically reviewed from the perspective of the NICE reference case (2008 methods guide). Results: The search resulted in a large number of repeat references across databases suggesting good sensitivity. Thirty-three articles were selected for inclusion and subjected to a critical review including their methodological quality, symmetry with the NICE reference case, sample size and country source. This critical review led to a shortlist of nine utility studies, all of which had potential for inclusion in cost-utility models or a meta-analysis. Conclusions: A relatively large number of utilities have been collected in weight change and T2DM. Many of these utility values are not suitable for inclusion in a NICE submission. A better way of reviewing the methodological quality of utilities is needed.

Medicaid Coverage for Weight Loss Counseling May Make 'Cents'

Article

Full-text available

Sep 2012
J GEN INTERN MED

Preventing Childhood Obesity: Evidence Policy and Practice

Chapter

Full-text available

May 2010

Summary and recommendations for researchIntroductionWhy involve economics?Describing and projecting the cost burden of obesityEvaluating interventions to prevent obesityThe challenges in producing quality economic evaluationsMoving beyond economic evaluation of single interventions to priority settingConclusions References

Cost-effectiveness of diet and exercise interventions to reduce overweight and obesity

Article

Full-text available

Jan 2011
INT J OBESITY

To analyze whether two dietary weight loss interventions--the dietary approaches to stop hypertension (DASH) program and a low-fat diet program--would be cost-effective in Australia, and to assess their potential to reduce the disease burden related to excess body weight. We constructed a multi-state life-table-based Markov model in which the distribution of body weight influences the incidence of stroke, ischemic heart disease, hypertensive heart disease, diabetes mellitus, osteoarthritis, post-menopausal breast cancer, colon cancer, endometrial cancer and kidney cancer. The target population was the overweight and obese adult population in Australia in 2003. We used a lifetime horizon for health effects and costs, and a health sector perspective for costs. We populated the model with data identified from Medline and Cochrane searches, Australian Bureau of Statistics published catalogues, Australian Institute of Health and Welfare, and Department of Health and Ageing. Disability adjusted life years (DALYs) averted, incremental cost-effectiveness ratios (ICERs) and proportions of disease burden avoided. ICERs under AUS$50,000 per DALY are considered cost-effective. The DASH and low-fat diet programs have ICERs of AUS$12,000 per DALY (95% uncertainty range: Cost-saving- 68,000) and AUS$13,000 per DALY (Cost-saving--130,000), respectively. Neither intervention reduced the body weight-related disease burden at population level by more than 0.1%. The sensitivity analysis showed that when participants' costs for time and travel are included, the ICERs increase to AUS$75,000 per DALY for DASH and AUS$49,000 per DALY for the low-fat diet. Modest weight loss during the interventions, post-intervention weight regain and low participation limit the health benefits. Diet and exercise interventions to reduce obesity are potentially cost-effective but have a negligible impact on the total body weight-related disease burden.

Cost-effectiveness of Weight Watchers and the Lighten Up to a Healthy Lifestyle program

Article

Jun 2010
AUST NZ J PUBL HEAL

Intensive weight loss programs that incorporate dietary counselling and exercise advice are popular and are supported by evidence of immediate weight loss benefits. We evaluate the cost-effectiveness of two weight loss programs, Lighten Up to a Healthy Lifestyle and Weight Watchers. Health gains from prevention of chronic disease are modelled over the lifetime of the Australian population. These results are combined with estimates of intervention costs and cost offsets (due to reduced rates of lifestyle-related diseases) to determine the dollars per disability-adjusted life year (DALY) averted by each intervention program, from an Australian health sector perspective. Both weight loss programs produced small improvements in population health compared to current practice. The time and travel associated with attending group-counselling sessions, however, was costly for patients, and overall the cost-effectiveness ratios for Lighten Up ($130,000/DALY) and Weight Watchers ($140,000/DALY) were high. Based on current evidence, these intensive behavioural counselling interventions are not very cost-effective strategies for reducing obesity, and the potential benefits for population health are small. It will be critical to consider other strategies (e.g. changing the 'obesogenic' environment) or explore alternative methods of intervention delivery (e.g. Internet) to see if they offer a more cost-effective approach by effectively reaching a high number of people at a low cost.

A Question of Balance: A Qualitative Study of Mothers' Interpretations of Dietary Recommendations

Article

Full-text available

Jan 2010
ANN FAM MED

Poor nutrition is an increasing problem for economically deprived families, and mothers play a key role in establishing children's diets. We explored mothers' understanding of health-promotion recommendations for healthy eating. We conducted qualitative semistructured interviews of 46 mothers within a relatively socioeconomically deprived community. Data were subject to framework analysis. The basic slogans of health promotion were known by mothers and had been adopted into everyday language. Television was the main source of information on dietary advice. Barriers to making changes were due to practical constraints (time, money, family preferences) and a desire to enhance quality of life through enjoyment of food. Although the headline messages of the importance of a healthy diet and what constitutes a healthy diet had reached mothers, misunderstandings were common and led to inappropriate actions. Many descriptions of what mothers reported as a balanced diet would not satisfy official definitions. Some women willfully adapted their understanding of advice to suit their preferences and the reality of their lives and family circumstances. To provide effective advice and guidance, health professionals need a deeper understanding of how families interpret messages about healthy eating. In addition, they should provide advice based on more individual understandings of diet and take into account patient preferences and life circumstances.

Obesity: Responding to the Global Epidemic

Article

Full-text available

Jun 2002

Obesity has reached epidemic proportions in the United States and other developed nations. In the United States, 27% of adults are obese and an additional 34% are overweight. Research in the past decade has shown that genetic influences clearly predispose some individuals to obesity. The marked increase in prevalence, however, appears to be attributable to a toxic environment that implicitly discourages physical activity while explicitly encouraging the consumption of supersized portions of high-fat, high-sugar foods. Management of the obesity epidemic will require a two-pronged approach. First, better treatments, including behavioral, pharmacologic, and surgical interventions, are needed for individuals who are already obese. The second and potentially more promising approach is to prevent the development of obesity by tackling the toxic environment. This will require bold public policy initiatives such as regulating food advertising directed at children. The authors call not for the adoption of a specific policy initiative, but instead propose that policy research, based on viewing obesity as a public health problem, become a central focus of research.

Prevalence and Trends in Obesity Among US Adults, 1999-2000

Article

Full-text available

Oct 2002

Katherine Mayhew Flegal

Context The prevalence of obesity and overweight increased in the United States between 1978 and 1991. More recent reports have suggested continued increases but are based on self-reported data.Objective To examine trends and prevalences of overweight (body mass index [BMI] ≥25) and obesity (BMI ≥30), using measured height and weight data.Design, Setting, and Participants Survey of 4115 adult men and women conducted in 1999 and 2000 as part of the National Health and Nutrition Examination Survey (NHANES), a nationally representative sample of the US population.Main Outcome Measure Age-adjusted prevalence of overweight, obesity, and extreme obesity compared with prior surveys, and sex-, age-, and race/ethnicity–specific estimates.Results The age-adjusted prevalence of obesity was 30.5% in 1999-2000 compared with 22.9% in NHANES III (1988-1994; P<.001). The prevalence of overweight also increased during this period from 55.9% to 64.5% (P<.001). Extreme obesity (BMI ≥40) also increased significantly in the population, from 2.9% to 4.7% (P = .002). Although not all changes were statistically significant, increases occurred for both men and women in all age groups and for non-Hispanic whites, non-Hispanic blacks, and Mexican Americans. Racial/ethnic groups did not differ significantly in the prevalence of obesity or overweight for men. Among women, obesity and overweight prevalences were highest among non-Hispanic black women. More than half of non-Hispanic black women aged 40 years or older were obese and more than 80% were overweight.Conclusions The increases in the prevalences of obesity and overweight previously observed continued in 1999-2000. The potential health benefits from reduction in overweight and obesity are of considerable public health importance.

Exercise and the Maintenance of Weight Loss: 1Year Follow-Up of a Controlled Clinical Trial

Article

Full-text available

Apr 1998

This study reports results 1 year after treatment for 77 obese women who had been treated for 48 weeks by diet combined with supervised (a) aerobic exercise, (b) strength training, (c) aerobic plus strength training combined, or (d) no exercise. Mean (± SD) end-of-treatment weight losses for the 4 conditions ranged from 13.5 ± 9.1 kg to 17.3 ± 10.3 kg, but there were no statistically significant differences among groups. Participants in all 4 conditions regained approximately 35% to 55% of their weight loss in the year after treatment; again, there were no significant differences among groups. Participants, however, who reported exercising regularly in the 4 months preceding the follow-up assessment regained significantly less weight than did nonexercisers.

Weight Control and Risk Factor Reduction in Obese Subjects Treated for 2 Years With OrlistatA Randomized Controlled Trial

Article

Full-text available

Jan 1999

Orlistat, a gastrointestinal lipase inhibitor that reduces dietary fat absorption by approximately 30%, may promote weight loss and reduce cardiovascular risk factors. To test the hypothesis that orlistat combined with dietary intervention is more effective than placebo plus diet for weight loss and maintenance over 2 years. Randomized, double-blind, placebo-controlled study conducted from October 1992 to October 1995. Obese adults (body mass index [weight in kilograms divided by the square of height in meters], 30-43 kg/m2) evaluated at 18 US research centers. Subjects received placebo plus a controlled-energy diet during a 4-week lead-in. On study day 1, the diet was continued and subjects were randomized to receive placebo 3 times a day or orlistat, 120 mg 3 times a day, for 52 weeks. After 52 weeks, subjects began a weight-maintenance diet, and the placebo group (n = 133) continued to receive placebo and orlistat-treated subjects were rerandomized to receive placebo 3 times a day (n = 138), orlistat, 60 mg (n = 152) or 120 mg (n = 153) 3 times a day, for an additional 52 weeks. Body weight change and changes in blood pressure and serum lipid, glucose, and insulin levels. A total of 1187 subjects entered the protocol, and 892 were randomly assigned on day 1 to double-blind treatment. For intent-to-treat analysis, 223 placebo-treated subjects and 657 orlistat-treated subjects were evaluated. During the first year orlistat-treated subjects lost more weight (mean +/- SEM, 8.76+/-0.37 kg) than placebo-treated subjects (5.81+/-0.67 kg) (P<.001). Subjects treated with orlistat, 120 mg 3 times a day, during year 1 and year 2 regained less weight during year 2 (3.2+/-0.45 kg; 35.2% regain) than those who received orlistat, 60 mg (4.26+/-0.57 kg; 51.3% regain), or placebo (5.63+/-0.42 kg; 63.4% regain) in year 2 (P<.001). Treatment with orlistat, 120 mg 3 times a day, was associated with improvements in fasting low-density lipoprotein cholesterol and insulin levels. Two-year treatment with orlistat plus diet significantly promotes weight loss, lessens weight regain, and improves some obesity-related disease risk factors.

The continuing epidemics of obesity and diabetes in the United States. Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP

Article

Full-text available

Sep 2001

Context Recent reports show that obesity and diabetes have increased in the United States in the past decade.Objective To estimate the prevalence of obesity, diabetes, and use of weight control strategies among US adults in 2000.Design, Setting, and Participants The Behavioral Risk Factor Surveillance System, a random-digit telephone survey conducted in all states in 2000, with 184 450 adults aged 18 years or older.Main Outcome Measures Body mass index (BMI), calculated from self-reported weight and height; self-reported diabetes; prevalence of weight loss or maintenance attempts; and weight control strategies used.Results In 2000, the prevalence of obesity (BMI ≥30 kg/m2) was 19.8%, the prevalence of diabetes was 7.3%, and the prevalence of both combined was 2.9%. Mississippi had the highest rates of obesity (24.3%) and of diabetes (8.8%); Colorado had the lowest rate of obesity (13.8%); and Alaska had the lowest rate of diabetes (4.4%). Twenty-seven percent of US adults did not engage in any physical activity, and another 28.2% were not regularly active. Only 24.4% of US adults consumed fruits and vegetables 5 or more times daily. Among obese participants who had had a routine checkup during the past year, 42.8% had been advised by a health care professional to lose weight. Among participants trying to lose or maintain weight, 17.5% were following recommendations to eat fewer calories and increase physical activity to more than 150 min/wk.Conclusions The prevalence of obesity and diabetes continues to increase among US adults. Interventions are needed to improve physical activity and diet in communities nationwide.

Lifestyle Intervention in Overweight Individuals With a Family History of Diabetes

Article

Full-text available

Mar 1998
DIABETES CARE

To assess the effect of lifestyle intervention over 2 years on changes in weight, coronary heart disease (CHD) risk factors, and incidence of diabetes in overweight individuals with a parental history of diabetes. Participants (n = 154), who were 30-100% over ideal body weight, had one or both parents with diabetes, and were currently nondiabetic, were randomly assigned to 2-year treatments focused on diet (decreasing calories and fat intake), exercise (goal of 1,500 kcal/week of moderate activity), or the combination of diet plus exercise or to a no-treatment control group. Subjects were reassessed at 6 months, 1 year, and 2 years. At 6 months, the groups differed significantly on measures of eating, exercise, and fitness; weight losses in the diet and diet-plus-exercise groups were significantly greater than in the exercise and control conditions. Weight losses were associated with positive changes in CHD risk factors. After 6 months, there was gradual deterioration of behavioral and physiological changes, so that at 2 years, almost no between-group differences were maintained. Differences between groups in risk of developing diabetes were of borderline significance (P = 0.08). Strongest predictors were impaired glucose tolerance at baseline, which was positively related to risk of developing diabetes, and weight loss from baseline to 2 years, which was negatively related; in all treatment groups, a modest weight loss of 4.5 kg reduced the risk of type 2 diabetes by approximately 30% compared with no weight loss. Although initially successful, the interventions studied here were not effective in producing long-term changes in behavior, weight, or physiological parameters. However, weight loss from 0 to 2 years reduced the risk of developing type 2 diabetes. Since modest weight loss significantly reduced risk of type 2 diabetes, further research is needed to determine how best to increase the percentage of subjects achieving at least a modest weight loss.

Impact of Overweight on the Risk of Developing Common Chronic Diseases During a 10-Year Period

Article

Full-text available

Jul 2001
ARCH INTERN MED

Background Overweight adults are at an increased risk of developing numerous chronic diseases. Methods Ten-year follow-up (1986-1996) of middle-aged women in the Nurses' Health Study and men in the Health Professionals Follow-up Study to assess the health risks associated with overweight. Results The risk of developing diabetes, gallstones, hypertension, heart disease, and stroke increased with severity of overweight among both women and men. Compared with their same-sex peers with a body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) between 18.5 and 24.9, those with BMI of 35.0 or more were approximately 20 times more likely to develop diabetes (relative risk [RR], 17.0; 95% confidence interval [CI], 14.2-20.5 for women; RR, 23.4; 95% CI, 19.4-33.2 for men). Women who were overweight but not obese (ie, BMI between 25.0 and 29.9) were also significantly more likely than their leaner peers to develop gallstones (RR, 1.9), hypertension (RR, 1.7), high cholesterol level (RR, 1.1), and heart disease (RR, 1.4). The results were similar in men. Conclusions During 10 years of follow-up, the incidence of diabetes, gallstones, hypertension, heart disease, colon cancer, and stroke (men only) increased with degree of overweight in both men and women. Adults who were overweight but not obese (ie, 25.0≤BMI≤29.9) were at significantly increased risk of developing numerous health conditions. Moreover, the dose-response relationship between BMI and the risk of developing chronic diseases was evident even among adults in the upper half of the healthy weight range (ie, BMI of 22.0-24.9), suggesting that adults should try to maintain a BMI between 18.5 and 21.9 to minimize their risk of disease.

Weight as a risk factor for clinical diabetes in women

Article

Full-text available

Oct 1990
AM J EPIDEMIOL

To determine the relation of body mass index (weight/height2) with the risk of clinical non-insulin-dependent diabetes, the authors analyzed data from a cohort of 113,861 US women aged 30-55 years in 1976. During 8 years of follow-up (826,010 person-years), 873 definite cases were identified among women initially free from diagnosed diabetes. Among women of average body mass index, 23-23.9 kg/m2, the relative risk was 3.6 times that of women having a body mass index less than 22 kg/m2. The risk continued to increase above this level of body mass index. The authors observed a much weaker positive association with weight at age 18, and this association was eliminated after adjustment for current body mass index. Thus, weight gain after age 18 was a major determinant of risk. For an increase of 20-35 kg, the relative risk was 11.3, and for an increase of more than 35 kg, the relative risk was 17.3. Adjusting for family history did not appreciably alter the strong relation observed among women at average levels of body mass index. These data indicate that, at even average weight, women are at increased risk of clinical non-insulin-dependent diabetes and that the relation between body mass index and risk of diabetes is continuous.

Weight loss and changes in serum lipids and lipoproteins in obese women

Article

Full-text available

Sep 1995

Several reports have suggested that modest weight losses, as little as 10% of initial weight, are sufficient to control many of the health complications of obesity. This study examined the relation between changes in weight and those in serum lipids and lipoproteins in obese women who participated in a 48-wk weight-reduction study. Subjects were 66 obese women who were prescribed a 3870-kJ (925-kcal)/d diet for the first 16 wk and a balanced-deficit diet of 5029-6279 kJ (1200-1500 kcal)/d thereafter. Anthropometric measures were assessed at baseline and weeks 8, 24, and 48, as were serum triacylglycerols (triglycerides), total cholesterol, and low-density-lipoprotein- and high-density-lipoprotein-cholesterol concentrations. Weight decreased 11.1% during the first 8 wk, during which time triacylglycerols and total cholesterol fell 22.7% and 15.7%, respectively. Subjects lost an additional 4.7 kg (equal to a total reduction of 16.4%) between weeks 8 and 24 but triacylglycerols and total and low-density-lipoprotein cholesterol increased by 5.2%, 4.2%, and 4.5%, respectively during this time. Multiple-regression analyses showed that at no time did weight loss account for > 6% of the variance in the reductions in triacylglycerol and cholesterol concentrations. These findings indicate that modest weight losses are associated with significant improvements in serum lipids, but that factors including the energy and macronutrient content of the diet prescribed contribute significantly to the improvements observed.

Cost-Effectiveness in Health and Medicine

Article

Jul 1996

This is a unique, in-depth discussion of the uses and conduct of cost-effectiveness analyses (CEA) as decision-making aids in the health and medical fields. The product of over two years of deiberation by a multi-disciplinary Public Health Service appointed panel that included economists, ethicists, psychometricians, and clinicians, it explores cost-effectiveness in the context of societal decision-making for resource allocation purposes. It proposes that analysts include a “reference-case” analysis in all CEA’s designed to inform resource allocation and puts forth the most expicit set of guidelines (together with their rationale) ever outlined of the conduct of CEAs. Important theoretical and practical issues encountered in measuring costs and effectiveness, valuing outcomes, discounting, and dealing with uncertainty are examined in separate chapters. These discussions are complemented by additional chapters on framing and reporting of CEAs that aim to clarify the purpose of the analysis and the effective communication of its findings. Primarily intended for analysts in medicine and public health who wish to improve practice and comparability of CEAs, this book will also be of interest to decision-makers in government, managed care, and industry who wish to consider the roles and limitations of CEA and become familiar with criteria for evaluating these studies.

Patient-Specific Decisions About Hormone Replacement Therapy in Postmenopausal Women

Article

Oct 1997

Prevalence of overweight, obesity,and extreme obesity among adults: United States, trends 1960-1962through 2007

Article

Behavioral Counseling in primary care to promote physical activity: Recommendation and rationale

Article

Apr 2003
AM J NURS

This statement summarizes the U.S. Preventive Services Task Force (USPSTF) recommendations on counseling by primary care physicians to promote physical activity and the supporting scientific evidence, and it updates the 1996 recommendations contained in the Guide to Clinical Preventive Services, second edition, The complete USPSTF recommendations and rationale statement on this topic, which includes a brief review of the supporting evidence, is available through the USPSTF Web site (www.preventiveservices.ahrq.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 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.

Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults

Book

Jan 1998

Lung National Heart

American Heart Association Guidelines for Weight Management Programs for Healthy Adults

Article

Jan 1994

Actual causes of death in the United States

Article

Jan 2004

Ali Mokdad

Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World. Health

Article

Jan 2000

Success and failure in the treatment of obesity: Where do we go from here?

Article

Jan 1995

An updated coronary risk profile. A statement for health professionals, AHA medical/scientific statement science advisory

Article

Jan 1991

[Randomized placebo-controlled trial of orlistat for weight loss and prevention of weight regain in obese patients]

Article

Oct 2000

Background: We undertook a randomised controlled trial to assess the efficacy and tolerance of orlistat, a gastrointestinal lipase inhibitor, in promoting weight loss and preventing weight regain in obese patients over a 2-year period. Methods: 743 patients (body-mass index 28-47 kg/m2), recruited at 15 European centres, entered a 4-week, single-blind, placebo lead-in period on a slightly hypocaloric diet (600 kcal/day deficit). 688 patients who completed the lead-in were assigned double-blind treatment with orlistat 120 mg (three times a day) or placebo for 1 year in conjunction with the hypocaloric diet. In a second 52-week double-blind period patients were reassigned orlistat or placebo with a weight maintenance (eucaloric) diet. Findings: From the start of lead-in to the end of year 1, the orlistat group lost, on average, more bodyweight than the placebo group (10.2% [10.3 kg] vs 6.1% [6.1 kg]; LSM difference 3.9 kg [p < 0.001] from randomisation to the end of year 1). During year 2, patients who continued with orlistat regained, on average, half as much weight as those patients switched to placebo (p < 0.001). Patients switched from placebo to orlistat lost an additional 0.9 kg during year 2, compared with a mean regain of 2.5 kg in patients who continued on placebo (p < 0.001). Total cholesterol, low-density lipoprotein (LDL) cholesterol, LDL/high-density lipoprotein ratio, and concentrations of glucose and insulin decreased more in the orlistat group than in the placebo group. Gastrointestinal adverse events were more common in the orlistat group. Other adverse symptoms occurred at a similar frequency during both treatments. Interpretation: Orlistat taken with an appropriate diet promotes clinically significant weight loss and reduces weight regain in obese patients over a 2-year period. The use of orlistat beyond 2 years needs careful monitoring with respect to efficacy and adverse events.

Risk factor correlates of body mass index

Article

Jan 1997

Objective: To examine the association of obesity, as reflected by body mass index, with other cardiovascular risk factors specifically blood pressure, smoking, physical inactivity, plasma lipid levels and diabetes mellitus. Design: Population-based, cross-sectional surveys. Setting: Ten Canadian provinces between 1986 and 1992. Participants: A probability sample of 29,855 men and women aged 18 to 74 years was selected from the health insurance registration files of each province and invited to participate. Anthropometry was performed on 19,841 (66%) of these adults. Outcome measures: Body mass index (BMI, kg/m2), systolic and diastolic blood pressure, smoking status, level of leisure-time physical activity, self-reported diabetes, levels of plasma total cholesterol, high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL) and triglycerides (TRIG). Results: The prevalence of high blood pressure increased with increasing BMI. The gradient of increase was steepest for younger (18-34 years) men and women compared with older (55-74 years) groups. The prevalence of physical inactivity in women tended to increase with increasing BMI except in the lowest BMI category. The J-shaped relationship, although weaker, was also seen in men. The prevalence of self-reported diabetes mellitus was greater with higher BMI categories at all ages and for both sexes except for the youngest group of men. The prevalence of dyslipidemia was related to BMI, as LDL and TRIG levels were higher and HDL levels lower in those with higher BMI. BMI was strongly related to blood pressure, diabetes mellitus and lipid abnormalities. Conclusion: These data suggest a central role for obesity in cardiovascular risk and the potential importance of intervention strategies aimed at reducing population obesity in the management of other cardiovascular risk factors.

Cost-Effectiveness of Diagnostic Strategies for Patients with Chest Pain

Article

May 1999

Karen M. Kuntz

Background: Many noninvasive tests exist to determine whether patients should undergo coronary angiography. The routine use of coronary angiography without previous noninvasive testing is typically not advocated. Objective: To determine the cost-effectiveness of diagnostic strategies for patients with chest pain. Design: Cost-effectiveness analysis, Data Sources: Published data. Target Population: Patients who present with chest pain, have no history of myocardial infarction, and are able to perform an exercise stress test. Time Horizon: Lifetime. Perspective: Societal. Interventions: No testing, exercise electrocardiography, exercise echocardiography, exercise single-photon emission computed tomography (SPECT), and coronary angiography alone. Outcome Measures: quality-adjusted life expectancy, lifetime cost, and incremental cost-effectiveness. Results of Base-Case Analysis: The incremental cost-effectiveness ratio of routine coronary angiography compared with exercise echocardiography was $36 400 per quality-adjusted life-year (QALY) saved for 55-year-old men with typical angina. For 55-year-old men with atypical angina, exercise echocardiography compared with exercise electrocardiography cost $41 900 per QALY saved. If adequate exercise echocardiography was not available, exercise SPECT cost $54 800 per QALY saved compared with exercise electrocardiography for these patients. For 55-year-old men with nonspecific chest pain, the incremental cost-effectiveness ratio of exercise electrocardiography compared with no testing was $57 700 per QALY saved. Results of Sensitivity Analysis: On the basis of a probabilistic sensitivity analysis, there is a 75% chance that exercise echocardiography costs less than $50 900 per QALY saved for 55-year-old men with atypical angina. Conclusions: Exercise electrocardiography or exercise echocardiography resulted in reasonable cost-effectiveness ratios for patients at mild to moderate risk for coronary artery disease in terms of age, sex, and type of chest pain. Coronary angiography without previous noninvasive testing resulted in reasonable cost-effectiveness ratios for patients with a high pretest probability of coronary artery disease.

Effects of weight loss and sodium reduction intervention on blood pressure and hypertension incidence in overweight people with high-normal blood pressure - The trials of hypertension prevention, phase II

Article

Mar 1997
ARCH INTERN MED

Objective: To provide a firmer basis for preventing high blood pressure (BP), we tested interventions to promote weight loss, dietary sodium reduction, and their combination for lowering diastolic BP, systolic BP, and the incidence of hypertension during a 3- to 4-year period. Methods: We conducted a randomized, 2x2 factorial, clinical trial, with BP levels measured by blinded observers. Nine academic medical centers recruited 2382 men and women (age range, 30-54 years) not taking antihypertensive drugs, with a diastolic BP of 83 to 89 mm Hg, a systolic BP lower than 140 mm Hg, and a body mass index (the weight in kilograms divided by the square of the height in meters) representing 110% to 165% of desirable body weight. Counseling aimed at helping participants achieve their desirable weight or a 4.5-kg or more weight reduction (in the weight loss and combined groups) and/or sodium intake of 80 mmol/d (in the sodium reduction and combined groups) was provided. Results: From baseline, participants' weight decreased by 4.3 to 4.5 kg at 6 months and by approximately 2 kg at 36 months in the weight loss and combined groups compared with weight changes in the usual care group (all groups, P<.001). Sodium excretion decreased 50 and 40 mmol/d at 6 and 36 months, respectively, in the sodium reduction group and about 15 mmol/d less at each time point in the combined group compared with the usual care group (all groups, P<.01). Compared with the usual care group, BP decreased 3.7/2.7 mm Hg in the weight loss group, 2.9/1.6 mm Hg in the sodium reduction group, and 4.0/2.8 mm Hg in the combined group at 6 months (all groups, P<.001). At 36 months, BP decreases remained greater in the active intervention groups than in the usual care group (weight loss group, 1.3/0.9 mm Hg; sodium reduction group, 1.2/0.7 mm Hg; combined group, 1.1/0.6 mm Hg). Differences were statistically significant for systolic and diastolic BP in the weight loss group and for systolic BP in the sodium reduction group. Through 48 months, the incidence of hypertension (BP greater than or equal to 140 mm Hg systolic or greater than or equal to 90 mm Hg diastolic or the use of antihypertensive drugs) was significantly less in each active intervention group than the usual care group (average relative risks, 0.78-0.82). Conclusions: In overweight adults with high-normal BP, weight loss and reduction in sodium intake, individually and in combination, were effective in lowering systolic and diastolic BP, especially in the short-term (6 months). Although the effects on average BP declined over time, reductions in hypertension incidence were achieved.

Weight, weight change, and coronary heart disease in women. Risk within the 'normal' weight range

Article

Feb 1995

W. C. Willett

Weight, Weight Change, and Coronary Heart Disease in Women

Article

Feb 1995

Walter C. Willett

Objective. —To assess the validity of the 1990 US weight guidelines for women that support a substantial gain in weight at approximately 35 years of age and recommend a range of body mass index (BMI) (defined as weight in kilograms divided by the square of height in meters) from 21 to 27 kg/m2, in terms of coronary heart disease (CHD) risk in women.Design. —Prospective cohort study.Setting. —Female registered nurses in the United States.Participants. —A total of 115 818 women aged 30 to 55 years in 1976 and without a history of previous CHD.Main Outcome Measure. —Incidence of CHD defined as nonfatal myocardial infarction or fatal CHD.Results. —During 14 years of follow-up, 1292 cases of CHD were ascertained. After controlling for age, smoking, menopausal status, postmenopausal hormone use, and parental history of CHD and using as a reference women with a BMI of less than 21 kg/m2, relative risks (RRs) and 95% confidence intervals (CIs) for CHD were 1.19 (0.97 to 1.44) for a BMI of 21 to 22.9 kg/m2, 1.46 (1.20 to 1.77) for a BMI of 23 to 24.9 kg/m2,2.06 (1.72 to 2.48) for a BMI of 25 to 28.9 kg/m2, and 3.56 (2.96 to 4.29) for a BMI of 29 kg/m2 or more. Women who gained weight from 18 years of age were compared with those with stable weight (±5 kg) in analyses that controlled for the same variables as well as BMI at 18 years of age. The RRs and CIs were 1.25 (1.01 to 1.55) for a 5- to 7.9-kg gain, 1.64 (1.33 to 2.04) for an 8- to 10.9-kg gain, 1.92 (1.61 to 2.29) for an 11-to 19-kg gain, and 2.65 (2.17 to 3.22) for a gain of 20 kg or more. Among women within the BMI range of 18 to 25 kg/m2, weight gain after 18 years of age remained a strong predictor of CHD risk.Conclusions. —Higher levels of body weight within the "normal" range, as well as modest weight gains after 18 years of age, appear to increase risks of CHD in middle-aged women. These data provide evidence that current US weight guidelines may be falsely reassuring to the large proportion of women older than 35 years who are within the current guidelines but have potentially avoidable risks of CHD.(JAMA. 1995;273:461-465)

Patient-Specific Decisions About Hormone Replacement Therapy in Postmenopausal Women

Article

Apr 1997

Nananda F Col

Objective. —To examine the effect of hormone replacement therapy on life expectancy in postmenopausal women with different risk profiles for heart disease, breast cancer, and hip fracture.Design. —Decision analysis using a Markov model. Published regression models were used to link risk factors to disease incidence and to estimate the lifetime risks of developing coronary heart disease (CHD), breast cancer, hip fracture, and endometrial cancer. The impact of hormone therapy on disease incidence was estimated from published epidemiologic studies.Setting. —Mathematical model applicable to primary care.Interventions. —Treatment with hormone replacement therapy or no hormone replacement therapy.Main Outcome Measure. —Life expectancy.Results. —Hormone replacement therapy should increase life expectancy for nearly all postmenopausal women, with some gains exceeding 3 years, depending mainly on an individual's risk factors for CHD and breast cancer. For women with at least 1 risk factor for CHD, hormone therapy should extend life expectancy, even for women having first-degree relatives with breast cancer. Women without any risk factors for CHD or hip fracture, but who have 2 first-degree relatives with breast cancer, however, should not receive hormone therapy.Conclusions. —The benefit of hormone replacement therapy in reducing the likelihood of developing CHD appears to outweigh the risk of breast cancer for nearly all women in whom this treatment might be considered. Our analysis supports the broader use of hormone replacement therapy.

Diet, Behavior Modification, and Exercise

Article

Dec 1991

Daniel J. Safer

An Annotated Cost Questionnaire for Completion by Patients

Article

Jan 2001

Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults--The Evidence Report. National Institutes of Health NIH Obes Res 1998 6 Suppl 2 51S 209S 9813653

Article

Jan 1998

Effective

About 97 million adults in the United States are overweight or obese. Obesity and overweight substantially increase the risk of morbidity from hypertension; dyslipidemia; type 2 diabetes; coronary heart disease; stroke; gallbladder disease; osteoarthritis; sleep apnea and respiratory problems; and endometrial, breast, prostate, and colon cancers. Higher body weights are also associated with increases in all-cause mortality. The aim of this guideline is to provide useful advice on how to achieve weight reduction and maintenance of a lower body weight. It is also important to note that prevention of further weight gain can be a goal for some patients. Obesity is a chronic disease, and both the patient and the practitioner need to understand that successful treatment requires a life-long effort. Assessment of Weight and Body Fat Two measures important for assessing overweight and total body fat content are; determining body mass index (BMI) and measuring waist circumference. 1. Body Mass Index: The BMI, which describes relative weight for height, is significantly correlated with total body fat content. The BMI should be used to assess overweight and obesity and to monitor changes in body weight. Measurements of body weight alone can be used to determine efficacy of weight loss therapy. BMI is calculated as weight (kg)/height squared (m 2). To estimate BMI using pounds and inches, use: [weight (pounds)/height (inches) 2 ] x 703. Weight classifications by BMI, selected for use in this report, are shown in the table below. • Pregnant women who, on the basis of their pre-pregnant weight, would be classified as obese may encounter certain obstetrical risks. However, the inappropriateness of weight reduction during pregnancy is well recognized (Thomas, 1995). Hence, this guideline specifically excludes pregnant women. Source (adapted from): Preventing and Managing the Global Epidemic of Obesity. Report of the World Health Organization Consultation of Obesity. WHO, Geneva, June 1997.

Current Literature: Body-Mass Index and Mortality in a Prospective Cohort of U.S. Adults

Article

Feb 2000

Background: Body-mass index (the weight in kilograms divided by the square of the height in meters) is known to be associated with overall mortality. We investigated the effects of age, race, sex, smoking status, and history of disease on the relation between body-mass index and mortality. Methods: In a prospective study of more than 1 million adults in the United States (457,785 men and 588,369 women), 201,622 deaths occurred during 14 years of follow-up. We examined the relation between body-mass index and the risk of death from all causes in four subgroups categorized according to smoking status and history of disease. In healthy people who had never smoked, we further examined whether the relation varied according to race, cause of death, or age. The relative risk was used to assess the relation between mortality and body-mass index. Results: The association between body-mass index and the risk of death was substantially modified by smoking status and the presence of disease. In healthy people who had never smoked, the nadir of the curve for body-mass index and mortality was found at a body-mass index of 23.5 to 24.9 in men and 22.0 to 23.4 in women. Among subjects with the highest body-mass indexes, white men and women had a relative risk of death of 2.58 and 2.00, respectively, as compared with those with a body-mass index of 23.5 to 24.9. Black men and women with the highest body-mass indexes had much lower risks of death (1.35 and 1.21), which did not differ significantly from 1.00. A high body-mass index was most predictive of death from cardiovascular disease, especially in men (relative risk, 2.90; 95 percent confidence interval, 2.37 to 3.56). Heavier men and women in all age groups had an increased risk of death. Conclusions: The risk of death from all causes, cardiovascular disease, cancer or others disease increases throughout the range of moderate and severe overweight for both men and women in all age groups. The risk associated with a high body-mass index is greater for whites than for blacks. (N Engl J Med 341:1097–1105, 1999)

A prospective study of weight change and health-related quality of life in women

Article

Jul 2013

Getting a handle on obesity

Article

Jun 2002

The Lancet

The natural history of the development of obesity in a cohort of young U

Article

Effects of diet & exercise on cholesterol

Article

Nov 1998

The Cost-effectiveness of Screening for Type 2 Diabetes CDC Diabetes Cost-Effectiveness Study Group

Article

Nov 1998

Michael M Engelgau

Context: Type 2 diabetes mellitus is a common and serious disease in the United States, but one third of those affected are unaware they have it. Objective: To estimate the cost-effectiveness of early detection and treatment of type 2 diabetes. Design: A Monte Carlo computer simulation model was developed to estimate the lifetime costs and benefits of 1-time opportunistic screening (ie, performed during routine contact with the medical care system) for type 2 diabetes and to compare them with current clinical practice. Cost-effectiveness was estimated for all persons aged 25 years or older, for age-specific subgroups, and for African Americans. Data were obtained from clinical trials, epidemiologic studies, and population surveys, and a single-payer perspective was assumed. Costs and benefits are discounted at 3% and costs are expressed in 1995 US dollars. Setting: Single-payer health care system. Participants: Hypothetical cohort of 10000 persons with newly diagnosed diabetes from the general US population. Main outcome measures: Cost per additional life-year gained and cost per quality-adjusted life-year (QALY) gained. Results: The incremental cost of opportunistic screening among all persons aged 25 years or older is estimated at $236449 per life-year gained and $56649 per QALY gained. Screening is more cost-effective among younger people and among African Americans. The benefits of early detection and treatment accrue more from postponement of complications and the resulting improvement in quality of life than from additional life-years. Conclusions: Early diagnosis and treatment through opportunistic screening of type 2 diabetes may reduce the lifetime incidence of major microvascular complications and result in gains in both life-years and QALYs. Incremental increases in costs attributable to screening and earlier treatment are incurred but may well be in the range of acceptable cost-effectiveness for US health care systems, especially for younger adults and for some subpopulations (eg, minorities) who are at relatively high risk of developing the major complications of type 2 diabetes. Although current recommendations are that screening begin at age 45 years, these results suggest that screening is more cost-effective at younger ages. The selection of appropriate target populations for screening should consider factors in addition to the prevalence of diabetes.

Cost-effectiveness of Gemfibrozil for Coronary Heart Disease Patients With Low Levels of High-Density Lipoprotein Cholesterol

Article

Background: Although numerous clinical trials and eco- nomic analyses have established the efficacy and cost- effectiveness of lowering cholesterol for the prevention of coronary heart disease, there are few data on the role of raising high-density lipoprotein cholesterol (HDL-C) levels and lowering triglyceride levels. The US Depart- ment of Veterans Affairs (VA) Cooperative Studies Pro- gram HDL-C Intervention Trial (VA-HIT) was a multi- center, randomized trial of gemfibrozil, an agent that raised HDL-C levels and lowered triglyceride levels, yet had no effect on low-density lipoprotein cholesterol (LDL-C) lev- els. The study showed that gemfibrozil therapy signifi- cantly reduced major cardiovascular events (cardiovas- cular death, myocardial infarction, and stroke) in patients with coronary heart disease, low HDL-C levels, and low LDL-C levels. Objective: To report the results of a cost-effectiveness study based on the results of the VA-HIT. Methods: The cost per year of life gained with gemfib- rozil therapy was calculated. Hazard functions were es- timated, and the resulting probabilities were used in a Markov model simulation to estimate the effect of gem- fibrozil on life expectancy and costs over a simulated life- time. Sensitivity analyses were used to account for un- certainty. Results: Using the prices of gemfibrozil that were ne- gotiated by the VA, gemfibrozil was cost saving. Using drug prices found outside the VA, a quality-adjusted life- year saved by gemfibrozil therapy cost between $6300 and $17100.

The Role of Cost-Effectiveness Analysis in Health and Medicine

Article

Dec 1997
Surv Anesthesiol

The continuing epidemics of obesity and diabetes in the United States

Article

Sep 2001

Recent reports show that obesity and diabetes have increased in the United States in the past decade. To estimate the prevalence of obesity, diabetes, and use of weight control strategies among US adults in 2000. The Behavioral Risk Factor Surveillance System, a random-digit telephone survey conducted in all states in 2000, with 184 450 adults aged 18 years or older. Body mass index (BMI), calculated from self-reported weight and height; self-reported diabetes; prevalence of weight loss or maintenance attempts; and weight control strategies used. In 2000, the prevalence of obesity (BMI >/=30 kg/m(2)) was 19.8%, the prevalence of diabetes was 7.3%, and the prevalence of both combined was 2.9%. Mississippi had the highest rates of obesity (24.3%) and of diabetes (8.8%); Colorado had the lowest rate of obesity (13.8%); and Alaska had the lowest rate of diabetes (4.4%). Twenty-seven percent of US adults did not engage in any physical activity, and another 28.2% were not regularly active. Only 24.4% of US adults consumed fruits and vegetables 5 or more times daily. Among obese participants who had had a routine checkup during the past year, 42.8% had been advised by a health care professional to lose weight. Among participants trying to lose or maintain weight, 17.5% were following recommendations to eat fewer calories and increase physical activity to more than 150 min/wk. The prevalence of obesity and diabetes continues to increase among US adults. Interventions are needed to improve physical activity and diet in communities nationwide.

Long-Term Weight Maintenance after an Intensive Weight-Loss Program

Article

Dec 1999

This prospective study assessed long-term weight maintenance of patients completing an intensive very-low-calorie diet (VLCD) weight-loss program. Individuals who had completed the 12-week core education program and lost > or = 10 kg were recruited. Of 154 eligible subjects, follow-up weights were obtained at > or = 2 years in 112 subjects (72.7%, 72 women, 40 men). Subjects had an average initial body mass index of 37.3 kg/m2 and an average weight loss of 29.7 kg in five months. Six hundred and forty-five follow-up weights (median, five per subject) were obtained over two to seven years of follow-up from clinic visits (70%) and self-report by telephone or mail (30%). Subjects regained an average of 2.5% per month of their lost weight during the first two to three years of follow-up; however, their weight stabilized over the next four years. Subjects regained an average of 73.4% of their weight loss during the first three years. The average weight loss maintained for 112 subjects was 22.8% of initial weight loss after an average of 5.3 years of follow-up. When successful weight maintenance was defined as maintaining a weight loss of 5% or 10% of initial (pre-treatment) body weight, 40% were maintaining a 5% weight loss at five years and 25% were maintaining a weight loss of 10% at 7 years. Multiple regression analyses suggested that age had a significant (p=0.004) and positive effect on weight maintenance. This study suggests that weight maintenance after an intensive VLCD program is improving but still needs intensive efforts to enable most individuals to maintain a substantial percentage of their weight loss long-term.

The public health impact of obesity

Article

Nov 2000

Tommy Visscher

The prevalence of obesity (severe overweight) has been increasing in western societies during the last decades. Epidemiological studies to the public health impact of obesity are therefore warranted. This thesis aimed at describing the long-term and recent time trends of obesity in the Netherlands, and to explore the relations between obesity, mortality, morbidity, and disability.The prevalence of obesity, body mass index (BMI)≥30.0 kg/m <sup>2</SUP>, increased steadily in Dutch adults between 1974 and 1997. Between 1993 and 1997, the prevalence of obesity was estimated at 9% among men and at 10% among men aged 20-59 years, based on data from the Dutch MORGEN-project. Levels of waist circumference increased more over time and showed even greater seasonal variation than BMI.Obesity measured by BMI was related to increased all-cause mortality in men who never smoked, although relative risks seemed to decrease somewhat with ageing in European men from the Seven Countries Study. Levels of waist circumference identified more men over 55 years of age who never smoked with increased risk of mortality than levels of BMI in the Rotterdam Study.Obesity was related to hospitalisation for coronary heart disease and to medication for chronic conditions in Finnish men and women from the Social Insurance Institution's Mobile Clinic study. In the Mini-Finland Health Survey, obesity was associated with the presence of osteoarthritis, low back pain, shoulder joint impairment and neck pain. In addition, obesity was associated with work disability during a 15 years follow-up and to the presence of difficulties in daily life activities. Relative risks of obesity for morbidity and disability were highest in the youngest Finnish adults studied, and exceeded the relative risk for mortality.Prevention of weight gain (<0.5 kg/year) during a period of ten years, could prevent 26,000 new cases of knee osteoarthritis and 19,000 new cases of work disability in the Dutch working aged population.Although obesity was related to increased mortality, obese Finns had more unhealthy life years than Finns with normal weight. During a maximal follow-up period of 15 years until age 65 years, obese men had 0.5, 0.4 and 1.7 extra years of work disability, coronary heart disease and morbidity leading to chronic medication, respectively. Obese women suffered respectively 0.5, 0.4 and 1.3 extra years from these conditions.This thesis provides new evidence based on large epidemiological studies that weight gain prevention programs should get high priority on both the scientific and the political agenda.

Estimating Health-Related Quality of Life in Obese Individuals

Article

Feb 1998
DIS MANAG HEALTH OUT

Obesity has a significant impact on both morbidity and mortality, as well as an individual’s capacity to live a full and active life. Traditionally, outcome measures in obesity treatments have emphasised physiological variables such as amount of bodyweight lost and improvements in various health parameters. Increasingly, measures of health-related quality of life (HRQOL) are used to address the patient’s point of view on whether obesity treatment has adequately enhanced functioning and general well-being. Generic measures of HRQOL allow clinicians and researchers to compare the negative social, emotional and physical impact of obesity against other health conditions; specific measures offer insight into how treatment interventions may alter distinct dimensions of HRQOL in overweight individuals. Obesity has been shown to have a deleterious effect on level of functioning, mood, perceived health and self-concept. Further, many obese people also report clinically significant levels of pain which further impair HRQOL. Losing even small amounts of bodyweight appears to ameliorate many of these decrements in HRQOL. However, the long term effects of subsequent bodyweight regain or bodyweight cycling on HRQOL remain unknown. Thus, comprehensive treatment of overweight individuals must also address HRQOL. Given that long term bodyweight maintenance remains elusive for many, additional research on finding ways to enhance and sustain positive changes in HRQOL is clearly needed.

Beneficial effects of modest weight loss

Article

Jul 1992

D.J. Goldstein

The medical effects of modest weight reduction (approximately 10% or less) in patients with obesity-associated medical complications were reviewed. The National Library of Medicine MEDLINE database and the Derwent RINGDOC database were searched to identify English language studies that examined the effects of weight loss in obese patients with serious medical complications commonly associated with obesity (non-insulin dependent diabetes mellitus (NIDDM or type II), hypertension, hyperlipidemia, hypercholesterolemia, and cardiovascular disease). Studies in which patients experienced approximately 10% or less weight reduction were selected for review. Studies indicated that, for obese patients with NIDDM, hypertension or hyperlipidemia, modest weight reduction appeared to improve glycemic control, reduce blood pressure, and reduce cholesterol levels, respectively. Modest weight reduction also appeared to increase longevity in obese individuals. In conclusion, a large proportion of obese individuals with NIDDM, hypertension, and hyperlipidemia experienced positive health benefits with modest weight loss. For patients who are unable to attain and maintain substantial weight reduction, modest weight loss should be recommended; even a small amount of weight loss appears to benefit a substantial subset of obese patients.

Diet, behavior modification, and exercise: A review of obesity treatments from a long-term perspective

Article

Jan 1992

Daniel Safer

Reviewed herein are the long-term weight loss outcomes of three fairly recent major modifications of standard dietary therapy for obesity. Appraised separately and in combination, these therapeutic approaches are very low calorie diets (VLCD), behavior modification, and exercise. The weight loss results from VLCD are impressive for only the first 6 to 10 months. Adding behavioral procedures to VLCD increases the weight loss for the first year or two, but not in 3 to 5 years. Adding exercise further increases the weight loss at 1 to 2 years, and those who continue regular exercise achieve the best weight loss results 1 to 6 years later.

The Effects on Plasma Lipoproteins of a Prudent Weight-Reducing Diet, with or without Exercise, in Overweight Men and Women

Article

Sep 1991

The National Cholesterol Education Program (NCEP) recommends a low-saturated-fat, low-cholesterol diet, with weight loss if indicated, to correct elevated plasma cholesterol levels. Weight loss accomplished by simple caloric restriction or increased exercise typically increases the level of high-density lipoprotein (HDL) cholesterol. Little is known about the effects on plasma lipoproteins of a hypocaloric NCEP diet with or without exercise in overweight people. We tested the hypothesis that exercise (walking or jogging) will increase HDL cholesterol levels in moderately overweight, sedentary people who adopt a hypocaloric NCEP diet. We randomly assigned 132 men and 132 women 25 to 49 years old to one of three groups: control, hypocaloric NCEP diet, or hypocaloric NCEP diet with exercise. One hundred nineteen of the men and 112 of the women returned for testing after one year. After one year, the subjects in both intervention groups had reached or closely approached NCEP Step 1 dietary goals and reduced their mean body fat significantly (range of reduction in mean fat weight, 4.0 to 7.8 kg). Weight loss on the NCEP diet alone did not significantly change HDL cholesterol levels in either the men or the women as compared with the subjects in the control group. Plasma levels of HDL cholesterol increased significantly more in the men who exercised and dieted (mean [+/- SE] change, +13 +/- 3 percent) than in the men who only dieted (+2 +/- 3 percent, P less than 0.01) or the men who acted as controls (-4 +/- 2 percent, P less than 0.001). HDL cholesterol levels remained about the same in the women who exercised and dieted (+1 +/- 2 percent); they were higher than in the women who only dieted (-10 +/- 3 percent, P less than 0.01), but not higher than in the controls (-3 +/- 3 percent). Regular exercise in overweight men and women enhances the improvement in plasma lipoprotein levels that results from the adoption of a low-saturated-fat, low-cholesterol diet.

Anderson KM, Wilson PW, Odell PM, Kannel WB. An updated coronary risk profile. A statement for health professionals. Circulation 83, 356-362

Article

Feb 1991

Using a simple worksheet, a patient's 5- and 10-year CHD risks can be estimated. The components of the profile were selected because they are objective and strongly and independently related to CHD and because they can be measured through simple office procedures and laboratory results

A Cost-effectiveness analysis of exercise as a health promotion activity

Article

Dec 1988

We used cost-effectiveness analysis to estimate the health and economic implications of exercise in preventing coronary heart disease (CHD). We assumed that nonexercisers have a relative risk of 2.0 for a CHD event. Two hypothetical cohorts (one with exercise and the other without exercise) of 1,000 35-year-old men were followed for 30 years to observe differences in the number of CHD events, life expectancy, and quality-adjusted life expectancy. We used jogging as an example to calculate cost, injury rates, adherence, and the value of time spent. Both direct and indirect costs associated with exercise, injury, and treating CHD were considered. We estimate that exercising regularly results in 78.1 fewer CHD events and 1,138.3 Quality Adjusted Life Years (QALYs) gained over the 30-year study period. Under our base case assumptions, which include indirect costs such as time spent in exercise, exercise does not produce economic savings. However, the cost per QALY gained of $11,313 is favorable when compared with other preventive or therapeutic interventions for CHD. The value of time spent is a crucial factor, influencing whether exercise is a cost-saving activity. In an alternative model, where all members of the cohort exercise for one year, and then only those who like it or are neutral continue, exercise produces net economic savings as well as reducing morbidity.

Methodologic Standards for Controlled Clinical Trials of Early Contact and Maternal-Infant Behavior

Article

Apr 1984

To provide an objective evaluation of published studies on the effect of early contact on subsequent maternal-infant behavior, a set of 11 methodologic standards generally applicable to controlled clinical trials of perinatal care was developed. Sixteen reports of early contact trials were assessed and seven of the 11 standards were found to be satisfactorily fulfilled. The four "problem" standards were: adequate definition of subjects, randomization, subject bias, and treatment contamination (care giver) bias. Of the five best trials fulfilling eight or more of the standards, three reported a beneficial effect of early contact, while two demonstrated no effect. The evidence that early contact improves subsequent maternal-infant behavior thus remains inconclusive. It is urged that for future research in this domain more attention be given to adequate subject definition, strict randomization procedures, and safeguards against bias by the subjects or their care givers.

Plan and operation of the Second National Health and Nutrition Examination Survey, 1976-1980.

Article

Feb 1981
Vital Health Stat 1 Programs Collect Proced

Ewbank PP, Darga LL, Lucas CP. Physical activity as a predictor of weight maintenance in previously obese subjects. Obes Res.3(3):257-63

Article

May 1995

We examined the association between exercise and weight loss maintenance in a group of 45 previously obese subjects 2 years post very-low-calorie diet (VLCD) to suggest exercise goals for this population. At baseline, subjects weighed a mean 100 kg and had a mean total cholesterol (TC) of 5.8 mmol/L. With VLCD they lost an average 28 kg and decreased their TC by 1.6 mmol/L. Two years post-VLCD their weight and lipids were measured and they completed a physical activity survey (Paffenbarger). Subjects were grouped into tertiles by reported exercise levels: low active (< 850 kcals per week), moderate active (850–1575 kcals per week) and high active (> 1575 kcals per week). Walking accounted for the greatest calorie expenditure (65%). Analysis of variance showed that baseline characteristics and weight and blood lipid changes during the VLCD did not differ (P>0.05) among groups. At follow-up, high active patients maintained significantly greater weight loss, had a lower percent regain and a significantly greater decrease in total cholesterol (P < 0.05) than less active patients. Multiple regression analysis indicated that total exercise calories independently predicted overall weight loss and percent regain (r = 0.66 and r = 0.62, respectively). Exercise calories also predicted total cholesterol change (r=-0.37). The high active group walked more miles (16.2 per week) than the low and moderate active groups (4.8 and 9.1 per week, respectively) and exercised more days per week (5.3 vs. 1.9 and 3.7). The low and moderate active groups regained virtually equal amounts of weight, even though the moderate group expended twice as many kcals per week as the low active group. These data demonstrate that increased exercise levels enhance weight loss maintenance.

Body Weight and Mortality among Women

Article

Sep 1995

The relation between body weight and overall mortality remains controversial despite considerable investigation. We examined the association between body-mass index (defined as the weight in kilograms divided by the square of the height in meters) and both overall mortality and mortality from specific causes in a cohort of 115,195 U.S. women enrolled in the prospective Nurses' Health Study. These women were 30 to 55 years of age and free of known cardiovascular disease and cancer in 1976. During 16 years of follow-up, we documented 4726 deaths, of which 881 were from cardiovascular disease, 2586 from cancer, and 1259 from other causes. In analyses adjusted only for age, we observed a J-shaped relation between body-mass index and overall mortality. When women who had never smoked were examined separately, no increase in risk was observed among the leaner women, and a more direct relation between weight and mortality emerged (P for trend < 0.001). In multivariate analyses of women who had never smoked and had recently had stable weight, in which the first four years of follow-up were excluded, the relative risks of death from all causes for increasing categories of body-mass index were as follows: body-mass index < 19.0 (the reference category), relative risk = 1.0; 19.0 to 21.9, relative risk = 1.2; 22.0 to 24.9, relative risk = 1.2; 25.0 to 26.9, relative risk = 1.3; 27.0 to 28.9, relative risk = 1.6; 29.0 to 31.9, relative risk = 2.1; and > or = 32.0, relative risk = 2.2 (P for trend < 0.001). Among women with a body-mass index of 32.0 or higher who had never smoked, the relative risk of death from cardiovascular disease was 4.1 (95 percent confidence interval, 2.1 to 7.7), and that of death from cancer was 2.1 (95 percent confidence interval, 1.4 to 3.2), as compared with the risk among women with a body-mass index below 19.0. A weight gain of 10 kg (22 lb) or more since the age of 18 was associated with increased mortality in middle adulthood. Body weight and mortality from all causes were directly related among these middle-aged women. Lean women did not have excess mortality. The lowest mortality rate was observed among women who weighed at least 15 percent less than the U.S. average for women of similar age and among those whose weight had been stable since early adulthood.

Economic Evaluation of Weight Loss Interventions in Overweight and Obese Women*

Abstract

No full-text available

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