Measuring the full economic costs of diet, physical activity and obesity-related chronic diseases

Body weight changes and outpatient medical care utilisation: Results of the MONICA/KORA cohorts S3/F3 and S4/F4

Objectives: To test the effects of body weight maintenance, gain, and loss on health care utilisation in terms of outpatient visits to different kinds of physicians in the general adult population.

Methods: Self-reported utilisation data were collected within two population-based cohorts (baseline surveys: MONICA-S3 1994/95 and KORA-S4 1999/2001; follow-ups: KORA-F3 2004/05 and KORA-F4 2006/08) in the region of Augsburg, Germany, and were pooled for present purposes. N=5,147 adults (complete cases) aged 25 to 64 years at baseline participated. Number of visits to general practitioners (GPs), internists, and other specialists as well as the total number of physician visits at follow-up were compared across 10 groups defined by body mass index (BMI) category maintenance or change. Body weight and height were measured anthropometrically. Hierarchical generalized linear regression analyses with negative binomial distribution adjusted for sex, age, socioeconomic status (SES), survey, and the need factors incident diabetes and first cancer between baseline and follow-up were conducted.

Results: In fully adjusted models, compared to the group of participants that maintained normal weight from baseline to follow-up, the following groups had significantly higher GP utilisation rates: weight gain from normal weight (+36%), weight loss from preobesity (+39%), maintained preobesity (+34%), weight gain after preobesity (+43%), maintained moderate obesity (+48%), weight gain from moderate obesity (+107%), weight loss from severe obesity (+114%), and maintained severe obesity (+83%). Regarding internists, those maintaining moderate obesity reported +107% more visits; those with weight gain from moderate obesity reported +91%. The latter group also had +41% more consultations with other physicians. Across all physicians, mean number of visits were estimated at 7.8 per year for maintained normal weight, 9 for maintained preobesity, 11 for maintained moderate obesity, and 12 for maintained severe obesity. Among those with weight loss, the mean number of visits were 8.7, 10.6 and 10.8 for baseline preobesity, moderate obesity, and severe obesity, respectively. Finally, those with weight gain from normal weight and preobesity reported 9.4 and 9.3 visits, respectively, and those with baseline moderate and follow-up severe obesity reported 13.1 visits (the most overall). Women reported higher GP and other physician utilisation. While all utilisation rates increased with age, GP utilisation was lower in middle to high SES groups.

Conclusion: Compared to maintained normal weight over a 7- to 10-year period, maintained overweight, weight gain and weight loss are associated with higher outpatient physician utilisation in adults, especially after baseline obesity. These effects only partly became insignificant after inclusion of incident diabetes or first cancer into the model. Future research should further elucidate the associations between weight development and health care utilisation by BMI status and the mechanisms underlying these associations.

Obesity and overweight prevalence and its association with undiagnosed hypertension in Shanghai population, China: a cross-sectional population-based survey

The aim of this study was to determine the prevalence of overweight and obese subjects in the Shanghai population of China and its association with undiagnosed hypertension, by taking age, gender and place of residence (urban or suburban) into account. A cross-sectional population-based survey was conducted in 2007. The sample included 13,359 participants aged 15-69 years.Weight, height, and blood pressure were recorded, and information about gender, age and place of residence was obtained. Overweight and obesity prevalence were calculated by the body mass index (BMI) definition recommended by Working Group on Obesity in China (normal weight, 18.5-23.9 kg/m(2); overweight, 24-27.9 kg/m(2); obesity, ≥ 28 kg/m(2)). Undiagnosed hypertension was defined by China criteria in accord with that of WHO-ISH (subjects with systolic pressure ≥ 140 mmHg, and/or diastolic pressure ≥ 90 mmHg). Multiple logistic regression analyses were used to assess the association of overweight or obesity with undiagnosed hypertension by adjusting for age, gender and place of residence. The overall overweight, obesity, and undiagnosed hypertension prevalence were 27.6% (95% CI: 26.8-28.4), 6.6% (95% CI: 6.2-7.0), and 15.5% (95% CI: 14.9-16.1), respectively. Compared to normal weight subjects, the odds ratios (OR) for subjects who were overweight and had hypertension was 2.33 (95% CI: 2.10-2.59); that for obesity and hypertension was 4.27 (95% CI: 3.66-4.99). These data suggest that overweight and obesity prevalence and their association with undiagnosed hypertension are high in our study population.

Healthcare use and costs associated with obesity in Badalona, Spain: a study protocol

Introduction The objectives of the study are twofold. First, to calculate healthcare resource utilisation and costs for a cohort of adult overweight and obese patients observed in primary and hospital care centres during eight consecutive years (2003-2010) in an urban setting in Spain. An analysis of whether these costs vary by groups of individuals and types of disease, and of how they compare with the previous literature, is carried out in order to predict actions or policies for resource optimisation. The second objective is to estimate the impact of overweight and obesity on the consumption of resources and costs, accounting for a wide array of controls. Methods and analysis Observational and retrospective cohort data are used, consisting of medical records of patients followed up in outpatient and hospital care facilities during the years 2003-2010. Three cohorts of patients are analysed: normal weight (18.5≥ body mass index (BMI) <25), overweight (25≥ BMI <30) and obese (BMI ≥30); BMI is computed using clinical information. Individual-level data on comorbidity, resource utilisation and costs are available, and external information provided by the population census regarding socioeconomic status is used. Utilisation and associated costs across BMI groups are compared by computing ratios for overweight and obese individuals relative to those of normal weight. Count data regression models (hurdle and finite mixture models) are used, together with two-part model regression models and taking into account the panel structure of the data set to explore the impact of overweight and obesity on the increased utilisation of health services and costs, accounting for a wide set of controls.

Socioeconomic costs of overweight and obesity in Korean adults

This study was conducted to estimate the socioeconomic costs of overweight and obesity in a sample of Korean adults aged 20 yr and older in 2005. The socioeconomic costs of overweight and obesity include direct costs (inpatient care, outpatient care and medication) and indirect costs (loss of productivity due to premature deaths and inpatient care, time costs, traffic costs and nursing fees). Hypertension, diabetes mellitus, dyslipidemia, ischemic heart disease, stroke, colon cancer and osteoarthritis were selected as obesity-related diseases. The population attributable fraction (PAF) of obesity was calculated from national representative data of Korea such as the National Health Insurance Corporation (NHIC) cohort data and the 2005 Korea National Health and Nutrition Examination Survey (KNHANES) data. Direct costs of overweight and obesity were estimated at approximately U$1,081 million equivalent (men: U$497 million, women: U$584 million) and indirect costs were estimated at approximately U$706 million (men: U$527 million, women: U$178 million). The estimated total socioeconomic costs of overweight and obesity were approximately U$1,787 million (men: U$1,081 million, women: U$706 million). These total costs represented about 0.22% of the gross domestic product (GDP) and 3.7% of the national health care expenditures in 2005. We found the socioeconomic costs of overweight and obesity in Korean adults aged 20 yr and older are substantial. In order to control the socioeconomic burden attributable to overweight and obesity, effective national strategies for prevention and management of obesity should be established and implemented.

Is the obesity epidemic a national security issue around the globe?

PURPOSE OF REVIEW

To understand how obesity affects national security by focusing on three case study countries - the USA, China, and Mexico.

RECENT FINDINGS

Whereas in the USA and Mexico, over two-thirds of adults are overweight and obese compared to about 29% of Chinese, large increases in the prevalence of overweight and obesity have occurred in all three countries in the past two decades. National security affected in the USA ranges both from an economic perspective - increasing healthcare problems and costs to the point where our labor costs have reached uncompetitive cost levels, and from a military preparedness perspective, namely our overweight soldiers are unable to perform normal activities and functions required of soldiers. In both Mexico and China, it is the economic and health system costs that are dominant concerns, both the costs of obesity-related medical care and the productivity of the work force are creating potential long-term effects on economic competitiveness.

SUMMARY

Obesity is adversely affecting the welfare, economic, and in some cases military security of these three countries.

Obesity and injury-related absenteeism in a population-based firefighter cohort

A consistent relationship has been demonstrated between obesity and absenteeism in the workplace. However, most studies have focused on primarily sedentary occupational groups. Firefighting is a physically demanding profession that involves significant potential for exposure to dangerous situations and strenuous work. No studies to date have evaluated the impact of obesity on risk for absenteeism among firefighters. We examined the cross-sectional association between BMI and obesity and injury-related absenteeism. BMI, body fat percentage (BF%), waist circumference (WC), injury, and injury-related absenteeism were assessed in 478 career male firefighters. One hundred and fifteen firefighters reported an injury in the previous year and the number of days absent from work due to their injury. BMI was an independent predictor of absenteeism due to injury even after adjustment for confounding variables. Firefighters meeting the definition of class II and III obesity had nearly five times (odds ratio (OR) = 4.89; 95% confidence interval (CI) = 3.63-6.58) the number missed work days due to injury when compared to their normal weight counterparts and their elevated risk was greater than firefighters with class I obesity (OR = 2.71; 95% CI = 2.01-3.65) or those who were overweight (OR = 2.55; 95% CI = 1.90-3.41). The attributable per capita costs of class II and III obesity-related absenteeism over the last year were $1,682.90 per firefighter, $254.00 per firefighter for class I obesity, and $74.41 per firefighter for overweight. Our findings suggest that class II and III obesity were associated with substantial attributable costs to employers and our cost estimates probably underestimate the actual financial burden.

Health and economic burden of the projected obesity trends in the USA and the UK

Rising prevalence of obesity is a worldwide health concern because excess weight gain within populations forecasts an increased burden from several diseases, most notably cardiovascular diseases, diabetes, and cancers. In this report, we used a simulation model to project the probable health and economic consequences in the next two decades from a continued rise in obesity in two ageing populations--the USA and the UK. These trends project 65 million more obese adults in the USA and 11 million more obese adults in the UK by 2030, consequently accruing an additional 6-8·5 million cases of diabetes, 5·7-7·3 million cases of heart disease and stroke, 492,000-669,000 additional cases of cancer, and 26-55 million quality-adjusted life years forgone for USA and UK combined. The combined medical costs associated with treatment of these preventable diseases are estimated to increase by $48-66 billion/year in the USA and by £1·9-2 billion/year in the UK by 2030. Hence, effective policies to promote healthier weight also have economic benefits.

Obesity, metabolic syndrome, and adipocytes

Obesity and metabolic syndromes are examples whereby excess energy consumption and energy flux disruptions are causative agents of increased fatness. Because other, as yet elucidated, cellular factors may be involved and because potential treatments of these metabolic problems involve systemic agents that are not adipose depot-specific in their actions, should we be thinking of adipose depot-specific (cellular) treatments for these problems? For sure, whether treating obesity or metabolic syndrome, the characteristics of all adipose depot-specific adipocytes and stromal vascular cells should be considered. The focus of this paper is to begin to align metabolic dysfunctions with specific characteristics of adipocytes.

The cost of obesity and overweight in 2005: a case study of Alberta, Canada

OBJECTIVE

The aim of this paper is to highlight the potential impact of costs associated with overweight and obesity for provincial policy and prevention initiatives.

METHOD

Prevalence-based cost-of-illness methodology was used to estimate the direct costs (hospital care, drugs, physician care, institutional care, additional costs) and indirect costs (short- and long-term disability, premature mortality) associated with excess weight for 22 health conditions. Total costs for each health condition were estimated using the Public Health Agency of Canada's Economic Burden of Illness database. Population attributable fractions (PAF) were also estimated using 2004 and 2005 CCHS data and current literature reviews.

RESULTS

In 2005, the cost of excess weight in Alberta totaled $1.27 billion. The direct cost of excess weight was $630.1M (49.5%), the indirect cost $643.8M (50.5%). Excluding costs associated with premature mortality and caregiving, obesity accounted for 69.5% ($500.8M) of costs and overweight the remaining 30.5% ($220.2M). Among the 22 health conditions, coronary heart disease had the highest costs attributable to excess weight ($307.1 M), followed by osteoarthritis ($167.7M) and type 2 diabetes ($161.5M). The total cost of excess weight equated to 5.6% of the province's annual health care expenditures for 2005.

CONCLUSION

While obesity costing research often focuses on the direct health care costs, this study reveals that the indirect costs of excess weight are also significant and can account for over half of the total costs. Interventions to reduce excess weight among Canadians have the potential to improve the health of the population while reducing provincial and national health care costs.

Population-level effects of the national diabetes prevention programme (FIN-D2D) on the body weight, the waist circumference, and the prevalence of obesity

Background

The implementation project of the national diabetes prevention programme in Finland, FIN-D2D, was carried out in primary health care in the area of five hospital districts during 2003-2007.

Methods

The population strategy of FIN-D2D was primarily aimed at increasing the awareness of type 2 diabetes and preventing obesity. To investigate the effects of this strategy, we studied the changes in the prevalence of obesity, overweight, and central obesity among a random independent sample of individuals aged 45-74 years in the FIN-D2D area; and assessed whether they differed from a sample of individuals in the control area, which consisted of four geographical areas not participating in FIN-D2D (FINRISK study). Data was obtained for 5850/ 6406 (in the beginning/ in the end) individuals. The duration of the observation period varied from three to five years.

Results

The mean body weight decreased from 78.7 to 78.1 kg (p = 0.041) in the FIN-D2D area, and from 78.7 to 78.0 kg (p = NS) in the control area. The prevalence of obesity (BMI ≥30 kg/m²) decreased in the FIN-D2D area (26.5% vs. 24.4%, p = 0.015), and in the control area (28.4% vs. 25.2%, p = 0.005). The prevalence of morbid obesity (BMI ≥40 kg/m²) remained unchanged in the FIN-D2D area, but increased in the control area (1.2% vs. 2.3%, p = 0.007). The mean waist circumference remained unchanged in the FIN-D2D area, but increased in the control area (92.8 vs. 94.0 cm, p = 0.005).

Conclusions

The prevalence of obesity may be decreasing among 45-74 year old Finns. We still need a longer time perspective and future studies to see whether this favourable trend can be sustained in Finland. The actions of this implementation project can at least partly explain the differences in the mean waist circumference and the prevalence of morbid obesity between the intervention and control areas.

Simulation models of obesity: a review of the literature and implications for research and policy

Simulation models (SMs) combine information from a variety of sources to provide a useful tool for examining how the effects of obesity unfold over time and impact population health. SMs can aid in the understanding of the complex interaction of the drivers of diet and activity and their relation to health outcomes. As emphasized in a recently released report of the Institute or Medicine, SMs can be especially useful for considering the potential impact of an array of policies that will be required to tackle the obesity problem. The purpose of this paper is to present an overview of existing SMs for obesity. First, a background section introduces the different types of models, explains how models are constructed, shows the utility of SMs and discusses their strengths and weaknesses. Using these typologies, we then briefly review extant obesity SMs. We categorize these models according to their focus: health and economic outcomes, trends in obesity as a function of past trends, physiologically based behavioural models, environmental contributors to obesity and policy interventions. Finally, we suggest directions for future research.

The longitudinal effects of behavioral, health, and socio-demographic factors on body mass index among older Chinese adults

OBJECTIVES

To examine the effects of behavioral, health, and socio-demographic factors on being overweight or obese among older Chinese adults.

METHODS

This research uses panel data from the China Health and Nutrition Survey, which was designed to examine how social and economic transformation affected the health and nutritional status of residents. For these analyses, we used all available information on adults aged 60 years or older surveyed in 1997, 2000, 2004, and 2006 (N = 3,591). Body mass index (BMI) was dichotomized as normal (18.5-24.9 kg/m(2)) and overweight (25.0-29.9 kg/m(2))/obese (≥30 kg/m(2)). Generalized estimating equations were used to estimate population-averaged (marginal) effects.

RESULTS

The combined prevalence of overweight or obese was approximately 33%. Moderate or heavy non-leisure physical activities (OR = 0.39; 95% CI = 0.32-0.49) and smoking (OR = 0.69; 95% CI = 0.57-0.84) decreased the odds of being overweight or obese, while drinking alcohol (OR = 1.25; 95% CI = 1.05-1.50) increased the odds. For individuals in all income levels, the amount of non-leisure physical activity strongly affected the BMI among the older Chinese adults.

CONCLUSIONS

Active lifestyle interventions may help counter what could otherwise be a growing obesity epidemic in China.

Prevalence of obesity and factors associated with it in a worksite setting in Malaysia

Socio-economic status, lifestyle behaviors, and psychosocial factors have been implicated in the development of overweight and obesity. This study aims to observe the prevalence of overweight and obesity in an academic worksite and to examine the possible association between variables such as socio-economic characteristics, work factors, psychosocial factors, and weight control behaviors and obesity. In this study, the target population were full-time academic and non-academic staff. Body mass index (BMI) and waist circumference (WC) were computed to determine obesity. A pretested self-administered questionnaire was used to obtain information on socio-demographic factors, work related factors, psychosocial factors, and weight control behaviors. Data were obtained on 367 adults of whom 39.2% were males and 60.8% females. Overweight was seen in 31.9% of males and 26.5% of females while 16.1% of them were obese, irrespective of gender. Central obesity was noted in about 37% of males and 39% of females. The results showed that socio-demographic factors (age, gender, and education) and psychosocial factors (perceived health status, body weight perception, and weight-control goals) were significantly associated with BMI. Working hours were also significantly associated with BMI. However, weight control practices (diet-control practices and physical activity practices) were not significantly associated with BMI. In conclusion, this study found a higher prevalence of overweight and obesity among employees of a selected public university in comparison to the general population. Socio-demographic, psychosocial factors, and working hours were found to contribute to obesity in this sample of adults.

BMI and lifestyle changes as correlates to changes in self-reported diagnosis of hypertension among older Chinese adults

Nutrition transition theory attributes increased prevalence of high blood pressure to excess body weight associated with lifestyle changes in recent decades. We examined the association of changes in self-reported hypertension diagnoses with changes in body mass index (BMI), health-related behaviors, health status, and social risk factors among older Chinese adults from 1997 to 2006. Data from the longitudinal China Health and Nutrition Survey (CHNS) were analyzed for adults who were age 60 years and older, had a BMI exceeding 18.6 kg/m(2), and reported no diagnosis of hypertension at baseline (n = 1928). Logistic regression models identified factors contributing to staying nonhypertensive or developing hypertension over time. Approximately 17.8% (n = 324) of study participants developed self-reported hypertension, whereas 83.2% (n = 1604) remained without hypertension. Those who stayed overweight or obese or became overweight or obese were more likely to report a new hypertension diagnosis. Incident diagnoses were also observed among those who developed acute conditions, sustained memory loss, or increased their income, whereas remaining nonhypertensive was more likely among rural residents and those who became more physically active and quit drinking alcohol. Study findings provided partial support for the nutrition transition theory whereby changing demographics and lifestyle factors were associated with increases in incident hypertension.

Direct medical cost of overweight and obesity in the USA: a quantitative systematic review

To estimate per-person and aggregate direct medical costs of overweight and obesity and to examine the effect of study design factors. PubMed (1968-2009), EconLit (1969-2009) and Business Source Premier (1995-2009) were searched for original studies. Results were standardized to compute the incremental cost per overweight person and per obese person, and to compute the national aggregate cost. A total of 33 US studies met review criteria. Among the four highest-quality studies, the 2008 per-person direct medical cost of overweight was $266 and of obesity was $1723. The aggregate national cost of overweight and obesity combined was $113.9 billion. Study design factors that affected cost estimates included use of national samples vs. more selected populations, age groups examined, inclusion of all medical costs vs. obesity-related costs only, and body mass index cut-offs for defining overweight and obesity. Depending on the source of total national healthcare expenditures used, the direct medical cost of overweight and obesity combined is approximately 5.0% to 10% of US healthcare spending. Future studies should include nationally representative samples, evaluate adults of all ages, report all medical costs and use standard body mass index cut-offs.

The relationship between body weight (body mass index) and attachment history in young women

OBJECTIVE

This study investigated whether attachment history predicts unique variance in body mass index in young women.

METHOD

A cross-sectional design was employed. One hundred and forty five women completed self report measures of attachment history and psychological symptoms.

RESULTS

The findings indicated that negative parental discipline predicted significant variance in body mass index when common variance associated with demographic and psychological symptom measures was taken into account.

CONCLUSIONS

It is concluded that attachment history may contribute to overweight and obesity and may be an important factor to consider in the prevention and treatment of overweight in women.

Minimal changes in environmental temperature result in a significant increase in energy expenditure and changes in the hormonal homeostasis in healthy adults

OBJECTIVE

Resting energy expenditure (EE) is a major contributor to the total EE and thus plays an important role in body weight regulation. Adaptive thermogenesis is a major component of EE in rodents, but little is known on the effects of exposure of humans to mild and sustainable reduction in environmental temperature.

DESIGN

To characterize the dynamic changes in continuously measured resting EE, substrate utilization, and hormonal axes simultaneously in response to mild reduction in environmental temperature, we performed a cross-over intervention.

METHODS

Twenty-five volunteers underwent two 12-h recordings of EE in whole room indirect calorimeters at 24 and 19 °C with simultaneous measurement of spontaneous movements and hormonal axes.

RESULTS

Exposure to 19 °C resulted in an increase in plasma and urine norepinephrine levels (P<0.0001), and a 5.96% (P<0.001) increase in EE without significant changes in spontaneous physical activity. Exposure to the lower temperature resulted in a significant increase in free fatty acid levels (P<0.01), fasting insulin levels (P<0.05), and a marginal decrease in postprandial glucose levels. A small but significant (P<0.002) increase in serum free thyroxine and urinary free cortisol (P<0.05) was observed at 19 °C.

CONCLUSIONS

Our observations indicate that exposure to 19 °C, a mild and tolerable cold temperature, results in a predictable increase in EE driven by a sustained rise in catecholamine and the activation of counter-regulatory mechanisms.

Metabolomic analysis of livers and serum from high-fat diet induced obese mice

Liver and serum metabolites of obese and lean mice fed on high fat or normal diets were analyzed using ultraperformance liquid chromatography-quadrupole-time-of-flight mass spectrometry, gas chromatography-mass spectrometry, and partial least-squares-discriminant analysis (PLS-DA). Obese and lean groups were clearly discriminated from each other on PLS-DA score plot and major metabolites contributing to the discrimination were assigned as lipid metabolites (fatty acids, phosphatidylcholines (PCs), and lysophosphatidylcholines (lysoPCs)), lipid metabolism intermediates (betaine, carnitine, and acylcarnitines), amino acids, acidic compounds, monosaccharides, and serotonin. A high-fat diet increased lipid metabolites but decreased lipid metabolism intermediates and the NAD/NADH ratio, indicating that abnormal lipid and energy metabolism induced by a high-fat diet resulted in fat accumulation via decreased β-oxidation. In addition, this study revealed that the levels of many metabolites, including serotonin, betaine, pipecolic acid, and uric acid, were positively or negatively related to obesity-associated diseases. On the basis of these metabolites, we proposed a metabolic pathway related to high-fat diet-induced obesity. These metabolites can be used to better understand obesity and related diseases induced by a hyperlipidic diet. Furthermore, the level changes of these metabolites can be used to assess the risk of obesity and the therapeutic effect of obesity management.

Interleukin-15 contributes to the regulation of murine adipose tissue and human adipocytes

An alarming global rise in the prevalence of obesity and its contribution to the development of chronic diseases is a serious health concern. Recently, obesity has been described as a chronic low-grade inflammatory condition, influenced by both adipose tissue and immune cells suggesting proinflammatory cytokines may play a role in its etiology. Here we examined the effects of interleukin-15 (IL-15) on adipose tissue and its association with obesity. Over expression of IL-15 (IL-15tg) was associated with lean body condition whereas lack of IL-15 (IL-15(-/-)) results in significant increase in weight gain without altering appetite. Interestingly, there were no differences in proinflammatory cytokines such as IL-6 and tumor necrosis factor-alpha (TNF-alpha) in serum between the three strains of mice. In addition, there were significant numbers of natural killer (NK) cells in fat tissues from IL-15tg and B6 compared to IL-15(-/-) mice. IL-15 treatment results in significant weight loss in IL-15(-/-) knockout and diet-induced obese mice independent of food intake. Fat pad cross-sections show decreased pad size with over expression of IL-15 is due to adipocyte shrinkage. IL-15 induces weight loss without altering food consumption by affecting lipid deposition in adipocytes. Treatment of differentiated human adipocytes with recombinant human IL-15 protein resulted in decreased lipid deposition. In addition, obese patients had significantly lower serum IL-15 levels when compared to normal weight individuals. These results clearly suggest that IL-15 may be involved in adipose tissue regulation and linked to obesity.

The association between body mass index and incident hypertension in rural women in China

BACKGROUND/OBJECTIVES

To evaluate the association between body mass index (BMI) and incident hypertension in a cohort of rural women in the Chinese population.

SUBJECTS/METHODS

A population-based sample of 11,468 rural Chinese women aged >or=35 years and free from hypertension at baseline were followed-up from 2004-2006 to 2008. We calculated BMI from measured weight and height. Incident hypertension was defined as systolic blood pressure (BP) >or=140 mm Hg, diastolic BP>or=90 mm Hg or current use of antihypertensive medications.

RESULTS

During a median follow-up of 28 months, 2,666 participants developed hypertension. Higher baseline BMI, even within the 'normal' range, was consistently associated with an increased risk of hypertension. Compared with participants in the lowest BMI quintile (18.5-21.1 kg/m(2)), the multivariable-adjusted relative risks (95% confidence interval) of developing hypertension for women with a BMI of 21.2 to 22.4, 22.5 to 23.7, 23.8 to 25.4 and >or=25.4 kg/m(2) were 1.200 (1.058-1.361), 1.250 (1.100-1.419), 1.466 (1.291-1.666) and 1.785 (1.584-2.012), respectively (P for trend, <0.001). Further adjustment for baseline BP did not substantially alter these results. We found similar associations using other BMI categories and after excluding women with smoking history at baseline. The pattern of association also existed among old women (age >or=55 years).

CONCLUSIONS

In this large cohort, we found a strong gradient association between higher BMI and increased risk of hypertension, even among older women within the normal BMI range. Clinicians should emphasize the importance of weight management for the primary prevention of hypertension in rural women in the Chinese population.

Report on childhood obesity in China (8): effects and sustainability of physical activity intervention on body composition of Chinese youth

OBJECTIVES

To determine whether a large-scale physical activity intervention could affect body composition in primary school students in Beijing, China.

METHODS

The study design was one-year cluster randomized controlled trial of physical activity intervention (20 min of daily exercise in the classroom) with an additional year of follow-up among 4 700 students aged 8-11 years at baseline.

RESULTS

After the one-year intervention, BMI increased by 0.56 kg/m(2) (SD 1.15) in the intervention group and by 0.72 kg/m(2) (SD 1.20) in the control group, with a mean difference of -0.15 kg/m(2) (95% CI: -0.28 to -0.02). BMI z score decreased by -0.05 (SD 0.44) in the intervention group, but increased by 0.01 (SD 0.46) in the control group, with a mean difference of -0.07 (-0.13 to -0.01). After another year of follow up, compared to the control group, children in the intervention group had significantly lower BMI (-0.13, -0.25 to -0.01), BMI z score (-0.05, -0.10 to -0.01), fat mass (-0.27 kg, -0.53 to -0.02) and percent body fat (-0.53, -1.00 to -0.05). The intervention had a more pronounced effect on weight, height, BMI, BMI z score, and body composition among obese children than among normal weight or overweight children. Compared to the control group, the intervention group had a significantly higher percentage of children who maintained or reduced their BMI z score at year 1 (P=0.008) and year 2 (P=0.04).

CONCLUSIONS

These findings suggest that 20 min of daily moderate to vigorous physical activity during the school year is a feasible and effective way to prevent excessive gain of body weight, BMI, and body fatness in primary school students.

[Costs of health. Costs-effectiveness in case of lifestyle changes]

Economical burden for the individuals and for the national budgets of chronic cardio-vasculo-metabolic diseases is high and is rapidly increasing. Costs of treatments and prevention are very different in countries of diverse culture, ethnicity, social-economical situations, but prevention with healthy foods and with adequate physical activity are cheaper than medicines anywhere in the world. A great couple of studies approved cost-effectiveness of interventions directed to the change of life style factors. Cheaper is to influence the whole, yet healthy population, but interventions on people with high risk are more target-specific and usually more expensive. Enhanced physical activity (minimum 30 minutes five times per week with low-medium intensity, plus resistance exercises for maintain the muscle mass and force, plus stretching and calisthenics to maintain joints motility) can be promoted by few hundred-few ten hundred euros or dollars. Price of gain in Quality/Disability-Adjusted Life Years expressed as Incremental Cost Effectiveness/Utility Ratio is known, estimated or modelled, and offers a good value of money.

The nutrition-based comprehensive intervention study on childhood obesity in China (NISCOC): a randomised cluster controlled trial

BACKGROUND

Childhood obesity and its related metabolic and psychological abnormalities are becoming serious health problems in China. Effective, feasible and practical interventions should be developed in order to prevent the childhood obesity and its related early onset of clinical cardiovascular diseases. The objective of this paper is to describe the design of a multi-centred random controlled school-based clinical intervention for childhood obesity in China. The secondary objective is to compare the cost-effectiveness of the comprehensive intervention strategy with two other interventions, one only focuses on nutrition education, the other only focuses on physical activity.

METHODS/DESIGN

The study is designed as a multi-centred randomised controlled trial, which included 6 centres located in Beijing, Shanghai, Chongqing, Shandong province, Heilongjiang province and Guangdong province. Both nutrition education (special developed carton style nutrition education handbook) and physical activity intervention (Happy 10 program) will be applied in all intervention schools of 5 cities except Beijing. In Beijing, nutrition education intervention will be applied in 3 schools and physical activity intervention among another 3 schools. A total of 9750 primary students (grade 1 to grade 5, aged 7-13 years) will participate in baseline and intervention measurements, including weight, height, waist circumference, body composition (bioelectrical impendence device), physical fitness, 3 days dietary record, physical activity questionnaire, blood pressure, plasma glucose and plasma lipid profiles. Data concerning investments will be collected in our study, including costs in staff training, intervention materials, teachers and school input and supervising related expenditure.

DISCUSSION

Present study is the first and biggest multi-center comprehensive childhood obesity intervention study in China. Should the study produce comprehensive results, the intervention strategies would justify a national school-based program to prevent childhood obesity in China.

Improving physical activity and dietary behaviours with single or multiple health behaviour interventions? A synthesis of meta-analyses and reviews

Since multiple health behaviour interventions have gained popularity, it is important to investigate their effectiveness compared to single health behaviour interventions. This synthesis aims to determine whether single intervention (physical activity or dietary) or multiple interventions (physical activity and dietary) are more effective at increasing these behaviours by synthesizing reviews and meta-analyses. A sub-purpose also explored their impact on weight. Overall, reviews/meta-analyses showed that single health behaviour interventions were more effective at increasing the targeted behaviours, while multiple health behaviour interventions resulted in greater weight loss. This review may assist policies aiming at improving physical activity and nutrition and reversing the obesity epidemic.

Recent dynamics suggest selected countries catching up to US obesity

BACKGROUND

The United States has been the country with the highest body mass indexes (BMIs; in kg/m(2)) at higher centiles, but research that compares the United States with other nations is lacking.

OBJECTIVE

To present a picture of global obesity and examine the shifts in BMI in children, I examined BMI data for men and women at the upper ends of the BMI distributions in Australia, China, the United Kingdom, and the United States.

DESIGN

As representative data, I used directly measured weight and height for children aged 6-18 y and for men and women aged > or =19 y. Quantile regression analysis with BMI was used to determine the outcome, and the coefficients of age, age squared, and age cubed represented the explanatory variables plotted to determine mean BMI at the 95th centile for each age group. Overweight and obesity measures across all selected countries, with the use of nationally representative surveys and the 95th centile mean BMI, were determined.

RESULTS

Among women, much larger increases were found in mean BMI at the 95th percentile in Australia (+5.7 BMI units) and the United Kingdom (+3.7 BMI units) than in the United States (+2.7 BMI units) in one-half the time. In contrast, among children, younger Chinese children experienced the largest increase. For example, the mean BMI at the 95th centile for 6-y-old Chinese children is 24.8 (a 5.0 increase), which is 2.6 BMI units more than the BMI at the 95th centile for children in the United States.

CONCLUSIONS

Among children, BMIs for US children at the 95th centile are below those in China, whereas among women, Australian and UK women are rapidly approaching BMIs found in US women.

Agriculture Policy Is Health Policy

The Farm Bill is meant to supplement and secure farm incomes, ensure a stable food supply, and support the American farm economy. Over time, however, it has evolved into a system that creates substantial health impacts, both directly and indirectly. By generating more profit for food producers and less for family farmers; by effectively subsidizing the production of lower-cost fats, sugars, and oils that intensify the health-destroying obesity epidemic; by amplifying environmentally destructive agricultural practices that impact air, water, and other resources, the Farm Bill influences the health of Americans more than is immediately apparent. In this article, we outline three major public health issues influenced by American farm policy. These are (1) rising obesity; (2) food safety; and (3) environmental health impacts, especially exposure to toxic substances and pesticides.

The effectiveness of worksite nutrition and physical activity interventions for controlling employee overweight and obesity: a systematic review

This report presents the results of a systematic review of the effectiveness of worksite nutrition and physical activity programs to promote healthy weight among employees. These results form the basis for the recommendation by the Task Force on Community Preventive Services on the use of these interventions. Weight-related outcomes, including weight in pounds or kilograms, BMI, and percentage body fat were used to assess effectiveness of these programs. This review found that worksite nutrition and physical activity programs achieve modest improvements in employee weight status at the 6-12-month follow-up. A pooled effect estimate of -2.8 pounds (95% CI=-4.6, -1.0) was found based on nine RCTs, and a decrease in BMI of -0.5 (95% CI=-0.8, -0.2) was found based on six RCTs. The findings appear to be applicable to both male and female employees, across a range of worksite settings. Most of the studies combined informational and behavioral strategies to influence diet and physical activity; fewer studies modified the work environment (e.g., cafeteria, exercise facilities) to promote healthy choices. Information about other effects, barriers to implementation, cost and cost effectiveness of interventions, and research gaps are also presented in this article. The findings of this systematic review can help inform decisions of employers, planners, researchers, and other public health decision makers.

Prediction of hypertension by different anthropometric indices in adults: the change in estimate approach

OBJECTIVE

To examine the relative contribution for the prediction of hypertension by waist circumference (WC), waist:stature ratio (WSR) or waist:hip ratio (WHR) with that by BMI, to ascertain if WC, WSR or WHR enhances the prediction of hypertension by BMI.

DESIGN

Population-based, cross-sectional study. A change of >or=10 % in the prevalence ratio of BMI (PR) or the area under the receiver-operating characteristic curve (AUC) when WC, WSR or WHR was added to a model with BMI was used as the criterion for significant contribution to the prediction of hypertension by BMI. For greater contributions (>or=10 %) these waist measures were considered as better predictors.

SETTING

Nine provinces in China.

SUBJECTS

Chinese adults aged 18 to 65 years (n 7336) who participated in the 2004 China Health and Nutrition Survey.

RESULTS

The prevalence of hypertension (17 % and 23 % for women and men, respectively) was significantly related to increased BMI, WC, WSR and WHR (P for trend <0.001). Although there was a better model fit when WC, WSR or WHR was added to a model with BMI (P < 0.05; likelihood ratio test), the changes in PR and AUC were <10 % and <5 %, respectively. The sex-specific AUC for the prediction of hypertension by BMI (of 0.7-0.8) was similar to that by WC, WSR or WHR.

CONCLUSIONS

The waist indices do not perform better than BMI or markedly enhance the prediction of increased hypertension risk by BMI in Chinese adults.

Why have physical activity levels declined among Chinese adults? Findings from the 1991-2006 China Health and Nutrition Surveys

Between 1991 and 2006, average weekly physical activity among adults in China fell by 32%. This paper discusses why total and occupational physical activity levels have fallen, and models the association between the rapid decline and various dimensions of exogenous community urbanization. We hypothesize that a) physical activity levels are negatively associated with urbanization; b) urbanization domains that affect job functions and opportunities will contribute most to changes in physical activity levels; and c) these urbanization domains will be more strongly associated for men than for women because home activities account for a larger proportion of physical activity for women. To test these hypotheses, we used longitudinal data from individuals aged 18-55 in the 1991-2006 China Health and Nutrition Surveys. We find that physical activity declines were strongly associated with greater availability of higher educational institutions, housing infrastructure, sanitation improvements and the economic wellbeing of the community in which people function. These urbanization factors predict more than four-fifths of the decline in occupational physical activity over the 1991-2006 period for men and nearly two-thirds of the decline for women. They are also associated with 57% of the decline in total physical activity for men and 40% of the decline for women. Intervention strategies to promote physical activity in the workplace, at home, for transit and via exercise should be considered a major health priority in China.

Indirect costs of obesity: a review of the current literature

This study reviews the recent literature on the relationship between obesity and indirect (non-medical) costs. Medline and Web of Science searches were conducted to identify published studies from 1992 to present that report indirect costs by obesity status; 31 studies were included. The indirect costs were grouped into six categories: costs associated with absenteeism, disability, premature mortality, presenteeism, workers' compensation, and total indirect costs. Compared with non-obese workers, obese workers miss more workdays due to illness, injury, or disability. Costs of premature mortality vary substantially across countries. The results for presenteeism and workers' compensation were mixed. More research is needed to determine obesity's causal role in increasing indirect costs, especially for workers' compensation and presenteeism. Cohort and longitudinal study designs should be a priority.

Will China's nutrition transition overwhelm its health care system and slow economic growth?

Rapid social and economic change is transforming China, with enormous implications for its population and economy. More than a fifth of China's adult population is overweight, related to changing dietary and physical activity patterns. Overweight and poor diets are becoming a greater burden for the poor than for the rich, with subsequent large increases in hypertension, stroke, and adult-onset diabetes. The related economic costs represent 4-8 percent of the economy. Public investments are needed to head off a huge increase in the morbidity, disability, absenteeism, and medical care costs linked with this nutritional shift.

Optimal cutoff values for overweight: using body mass index to predict incidence of hypertension in 18- to 65-year-old Chinese adults

Studies aimed at identifying BMI cutoffs representing increased diseased risk for Asians are typically based on cross-sectional studies. This study determines an optimal BMI cutoff for overweight that represents elevated incidence of hypertension in Chinese adults with data from the China Health and Nutrition Survey 2000-2004 prospective cohort. Cumulative incidence was calculated by dividing new cases of hypertension over the study period by the total at-risk population, aged 18-65 y, in 2000. Sex-specific receiver operating characteristic curves were used to assess the sensitivity and specificity of BMI as a predictor of hypertension incidence. Four-year cumulative incidences of hypertension (13% for women and 19% for men) were related (P < 0.005) to the increase in BMI. The crude area under the curves (AUC) were 0.62 (95% CI: 0.59-0.65) and 0.62 (95% CI: 0.58-0.65) for men and women, respectively; the age-adjusted AUC were 0.68 (95% CI: 0.65-0.70) and 0.71 (95% CI: 0.68-0.74) for men and women, respectively. A BMI of 23.5 kg/m(2) for women and 22.5 kg/m(2) for men provided the highest sensitivity and specificity (60%). The finding was consistent in different age groups. A BMI level of 25 kg/m(2) provided lower sensitivities (36% for women and 29% for men) with higher specificities (80% for women and 85% for men). Our study supported the hypothesis that the BMI cutoff to define overweight should be lower in Chinese than that in Western populations.

Sphingolipids, insulin resistance, and metabolic disease: new insights from in vivo manipulation of sphingolipid metabolism

Obesity and dyslipidemia are risk factors for metabolic disorders including diabetes and cardiovascular disease. Sphingolipids such as ceramide and glucosylceramides, while being a relatively minor component of the lipid milieu in most tissues, may be among the most pathogenic lipids in the onset of the sequelae associated with excess adiposity. Circulating factors associated with obesity (e.g., saturated fatty acids, inflammatory cytokines) selectively induce enzymes that promote sphingolipid synthesis, and lipidomic profiling reveals relationships between tissue sphingolipid levels and certain metabolic diseases. Moreover, studies in cultured cells and isolated tissues implicate sphingolipids in certain cellular events associated with diabetes and cardiovascular disease, including insulin resistance, pancreatic beta-cell failure, cardiomyopathy, and vascular dysfunction. However, definitive evidence that sphingolipids contribute to insulin resistance, diabetes, and atherosclerosis has come only recently, as researchers have found that pharmacological inhibition or genetic ablation of enzymes controlling sphingolipid synthesis in rodents ameliorates each of these conditions. Herein we will review the role of ceramide and other sphingolipid metabolites in insulin resistance, beta-cell failure, cardiomyopathy, and vascular dysfunction, focusing on these in vivo studies that identify enzymes controlling sphingolipid metabolism as therapeutic targets for combating metabolic disease.

Health-economic burden of obesity in Europe

Although overweight and obesity have long been recognised as major risk factors for a number of chronic diseases, lifestyle developments have led to substantial increases in bodyweight worldwide. In addition to their negative effects on health and quality of life, obesity and associated comorbidities may have a considerable impact on healthcare expenditures. The aim of this systematic review was to summarise cost estimates and compare costs attributable to obesity across different European countries. A structured search in MEDLINE, EMBASE, and all EBM Reviews was conducted to identify relevant literature. Two researchers independently assessed publications according to pre-defined inclusion criteria and with regard to study methodology. Costs attributable to obesity were extracted from the included studies and calculated relative to country-specific gross domestic income. Out of 797 publications that met our search criteria, 13 studies investigating 10 Western European countries were determined to be relevant and included in our review. Obesity-related healthcare burdens of up to 10.4 billion euros were found. Reported relative economic burdens ranged from 0.09% to 0.61% of each country's gross domestic product (GDP). Obesity appears to be responsible for a substantial economic burden in many European countries, and the costs identified in the available studies presumably reflect conservative estimates. There remains a great need for prospective and standardised studies to provide more accurate estimates of costs for all European countries.