Lifetime health and economic consequences of obesity

Obesity and use of acute hospital services in participants of the Renfrew/Paisley study

BACKGROUND

Because overweight and obesity are associated with comorbidities, increasing levels of overweight and obesity may impact on hospital use.

METHODS

Body mass index (BMI) in middle age was related to acute hospital use in 7036 men and 8327 women from the Renfrew/Paisley prospective cohort study in Scotland. Participants in this general population study were examined between 1972 and 1976 when aged 45-64 years. Acute hospital admissions and bed days per 1000 person-years were calculated by the World Health Organization BMI categories in the follow-up period to 31 March 2004.

RESULTS

Underweight and normal weight men had lower-than-expected admission rates, and overweight and obese men had higher-than-expected admission rates. Obese men had higher-than-expected bed day rates. For women, there was a U-shaped relationship with admission rate, with normal weight women having the lowest admission rate and underweight and obese women having similar high rates. Underweight and obese women had higher-than-expected bed day rates.

CONCLUSIONS

Participants who were obese in midlife had more-than-expected acute hospital admissions and in particular more bed days. With levels of obesity increasing since this study was started in the 1970s, if these patterns persist, there may be increasing demand on health service resources.

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

Most studies that have focused on the costs of obesity have ignored the direct effects of obesity-related patterns of diet and physical activity. This study reviews the full effects of each component--poor dietary and physical activity patterns and obesity--on morbidity, mortality and productivity. The direct healthcare costs are based on a review of the effects of these factors on key diseases and the related medical care costs of each disease. The indirect costs on reduced disability, mortality and sickness during the period of active labour force participation prior to retirement are also examined. A case study is prepared for China to provide some guidance in the utilization of this review for economic analysis of obesity. The case study shows that the indirect costs are often far more important than the direct medical care costs. The Chinese case study found that the indirect effects of obesity and obesity-related dietary and physical activity patterns range between 3.58% and 8.73% of gross national product (GNP) in 2000 and 2025 respectively.

Perioperative management of the obese orthopaedic patient

With nearly a third of American adults considered be obese, it is increasingly important that orthopaedic surgeons be familiar with management issues pertinent to these patients. Preoperative examination must assess cardiopulmonary status and other comorbid conditions, most notably diabetes. Intraoperative considerations include requirements for special equipment, patient positioning, intravenous line placement, central monitoring lines, and anesthesia specific to the physiologic changes in obese patients. Postoperatively, obese patients have higher rates of deep vein thrombosis and wound sepsis than do nonobese patients, and they may differ from other patients in supplemental oxygen requirements, medication dosing, and outcomes in intensive care units. Obese patients can successfully undergo virtually all orthopaedic procedures; however, the procedures are frequently more technically challenging, and obese patients appear to have higher rates of prosthetic failure, infection, hardware failure, and fracture malunion, although many of these complications can be minimized by appropriate countermeasures.

Adult obesity and number of years lived with and without cardiovascular disease

OBJECTIVE

To determine the differences in number of years lived free of cardiovascular disease (CVD) and number of years lived with CVD between men and women who were obese, pre-obese, or normal weight at 45 years of age.

RESEARCH METHODS AND PROCEDURES

We constructed multistate life tables for CVD, myocardial infarction, and stroke, using data from 2551 enrollees (1130 men) in the Framingham Heart Study who were 45 years of age.

RESULTS

Obesity and pre-obesity were associated with fewer number of years free of CVD, myocardial infarction, and stroke and an increase in the number of years lived with these diseases. Forty-five-year-old obese men with no CVD survived 6.0 years [95% confidence interval (CI), 4.1; 8.1] fewer than their normal weight counterparts, whereas, for women, the difference between obese and normal weight subjects was 8.4 years (95% CI: 6.2; 10.8). Obese men and women lived with CVD 2.7 (95% CI: 1.0; 4.4) and 1.4 years (95% CI: -0.3; 3.2) longer, respectively, than normal weight individuals.

DISCUSSION

In addition to reducing life expectancy, obesity before middle age is associated with a reduction in the number of years lived free of CVD and an increase in the number of years lived with CVD. Such information is paramount for preventive and therapeutic decision-making by individuals and practitioners alike.

Economic evaluation of weight loss interventions in overweight and obese women

OBJECTIVE

To conduct a clinical and economic evaluation of outpatient weight loss strategies in overweight and obese adult U.S. women.

RESEARCH METHODS AND PROCEDURES

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.

RESULTS

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.

DISCUSSION

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.

Counting the costs of overweight and obesity: modeling clinical and cost outcomes

OBJECTIVE

To quantify changes in clinical and cost outcomes associated with increasing levels of body mass index (BMI) in a US setting.

RESEARCH METHODS AND PROCEDURES

A semi-Markov model was developed to project and compare life expectancy (LE), quality-adjusted life expectancy (QALE) and direct medical costs associated with distinct levels of BMI in simulated adult cohorts over a lifetime horizon. Cohort definitions included age (20-65 years), gender, race, and BMI (24-45 kg m(-2)). Cohorts were exclusively male or female and either Caucasian or African-American. Mortality rates were adjusted according to these factors using published data. BMI progression over time was modeled. BMI-dependent US direct medical costs were derived from published sources and inflated to year 2004 values. A third party reimbursement perspective was taken. QALE and costs were discounted at 3% per annum.

RESULTS

In young Caucasian cohorts LE decreased as BMI increased. However, in older Caucasian cohorts the BMI associated with greatest longevity was higher than 25 kg m(-2). A similar pattern was observed in young adult African-American cohorts. A survival paradox was projected in older African-American cohorts, with some BMI levels in the obese category associated with greatest longevity. QALE in all four race/gender cohorts followed similar patterns to LE. Sensitivity analyses demonstrated that simulating BMI progression over time had an important impact on results. Direct costs in all four cohorts increased with BMI, with a few exceptions.

CONCLUSIONS

Optimal BMI, in terms of longevity, varied between race/gender cohorts and within these cohorts, according to age, contributing to the debate over what BMI level or distribution should be considered ideal in terms of mortality risk. Simulating BMI progression over time had a substantial impact on health outcomes and should be modeled in future health economic analyses of overweight and obesity.

The Metabolic Syndrome: Recognition and Management

The National Cholesterol Education Program defines the metabolic syndrome as three or more of five abnormalities: waist circumference of >40 in (102 cm) for men or >35 in (88 cm) for women, triglyceride level of > or =150 mg/dL, high-density lipoprotein cholesterol of <40 mg/dL in men or <50 mg/dL in women, blood pressure of > or =130 or > or =85 mm Hg, and fasting glucose of > or =110 mg/dL. It is related to insulin resistance, but the two terms are not synonymous. Both are associated strongly with obesity. The metabolic syndrome is important as an indicator of increased risk of cardiovascular disease (CVD) in patients with and without clinical CVD. The CVD risk of the metabolic syndrome is greater than that conferred by any single CVD risk factor. Since risk factors tend to cluster, if one component of the metabolic syndrome is present, one should assess for other risk factors. The metabolic syndrome is also predictive of new-onset type 2 diabetes. Early diagnosis provides justification for measures that can improve components of the syndrome and reduce CVD risk. The management strategy for metabolic syndrome focuses on overall CVD risk rather than single risk factors; effective therapy includes priority for weight reduction and increased physical activity. Pharmacotherapy is typically needed for control of high blood pressure, hypercoagulability, and increased levels of blood glucose and triglycerides.

Expression of Endothelin-1 and Adrenomedullin Was Not Altered by Leptin or Resistin in Bovine Brain Microvascular Endothelial Cells

Hypertension frequently occurs in obese subjects. It has been reported that leptin and resistin induce endothelin-1 expression in vascular endothelial cells. Altered function of brain microvascular endothelial cells may be related to increased occurrences of stroke in hypertensive patients. In the present study, we therefore studied the effects of leptin and resistin on the expression of endothelin-1 and adrenomedullin in bovine brain microvascular endothelial cells. Northern blot analysis showed that leptin (10(-10)-10(-8) mol/l), resistin (10(-10)-10(-8) mol/l) or a combination of leptin and resistin (10(-8) mol/l for each) had no significant effects on the expression of endothelin-1 mRNA or adrenomedullin mRNA in cultured bovine brain microvascular endothelial cells. On the other hand, hypoxia induced, and tumor necrosis factor-alpha (10 ng/ml) decreased, the expression levels of endothelin-1 and adrenomedullin mRNAs, indicating that the bovine brain microvascular endothelial cells were able to respond to hypoxia and tumor necrosis factor-alpha. Consistent with the results of Northern blot analysis, immunoreactive endothelin and immunoreactive adrenomedullin concentrations in the medium were not significantly changed by the treatment with leptin, resistin, or a combination of leptin and resistin. The present study thus showed that neither leptin nor resistin affects the expression of endothelin-1 or adrenomedullin in bovine brain microvascular endothelial cells.

A long-term population-based clinical and morbidity review of Prader-Willi syndrome in Western Australia

BACKGROUND

An investigation of the clinical morbidity and genetic profiles of individuals with Prader-Willi syndrome (PWS) in Western Australia (WA) was undertaken as part of a wider study into the effects of intellectual disability (ID) on the life course of individuals.

METHODS

All persons with a diagnosis of PWS were identified from the records of the Disability Services Commission of WA (DSC). The DSC client files formed the main data source, and were supplemented by information from other state health data sets. The analysis was retrospective and quantitative in nature.

RESULTS

A total of 56 individuals were identified, 10 of whom exhibited normal methylation patterns and so were analysed separately (PWS-like). The ages of the PWS group ranged from 0.9 to 48.3 years, with six persons deceased. Most people with PWS (76%) had mild or moderate ID, and 70% lived in their family home. The birth prevalence of the disorder was 1 in 29 500 births. Respiratory disorders, dentistry and gastrointestinal disorders were common reasons for hospital admission, with epilepsy or convulsions also reported at moderate frequency. The PWS-like group shared many clinical features in common with PWS patients, the principal exceptions being hypotonia and feeding difficulties in infancy.

CONCLUSIONS

The estimated birth prevalence of PWS was lower than expected; however, the case ascertainment method may have excluded some individuals. Older people with PWS were generally living in sheltered accommodation. As the cohort ages, demand for places in similar accommodation will increase, adding to the existing burden on service providers. Substantial future increases in the use of medical services and hospital-based care also are predicted with the onset of age-associated disorders.

Cost-of-illness studies : a review of current methods

The number of cost-of-illness (COI) studies has expanded considerably over time. One outcome of this growth is that the reported COI estimates are inconsistent across studies, thereby raising concerns over the validity of the estimates and methods. Several factors have been identified in the literature as reasons for the observed variation in COI estimates. To date, the variation in the methods used to calculate costs has not been examined in great detail even though the variations in methods are a major driver of variation in COI estimates. The objective of this review was to document the variation in the methodologies employed in COI studies and to highlight the benefits and limitations of these methods. The review of COI studies was implemented following a four-step procedure: (i) a structured literature search of MEDLINE, JSTOR and EconLit; (ii) a review of abstracts using pre-defined inclusion and exclusion criteria; (iii) a full-text review using pre-defined inclusion and exclusion criteria; and (iv) classification of articles according to the methods used to calculate costs. This review identified four COI estimation methods (Sum_All Medical, Sum_Diagnosis Specific, Matched Control and Regression) that were used in categorising articles. Also, six components of direct medical costs and five components of indirect/non-medical costs were identified and used in categorising articles.365 full-length articles were reflected in the current review following the structured literature search. The top five cost components were emergency room/inpatient hospital costs, outpatient physician costs, drug costs, productivity losses and laboratory costs. The dominant method, Sum_Diagnosis Specific, was a total costing approach that restricted the summation of medical expenditures to those related to a diagnosis of the disease of interest. There was considerable variation in the methods used within disease subcategories. In several disease subcategories (e.g. asthma, dementia, diabetes mellitus), all four estimation methods were represented, and in other cases (e.g. HIV/AIDS, obesity, stroke, urinary incontinence, schizophrenia), three of the four estimation methods were represented. There was also evidence to suggest that the strengths and weaknesses of each method were considered when applying a method to a specific illness. Comparisons and assessments of COI estimates should consider the method used to estimate costs both as an important source of variation in the reported COI estimates and as a marker of the reliability of the COI estimate.

Obesity and weight control practices in 2000 among veterans using VA facilities

OBJECTIVE

To examine obesity prevalence and weight control practices among veterans who use Department of Veterans Affairs (VA) medical facilities (VA users).

RESEARCH METHODS AND PROCEDURES

Data from the 2000 Behavioral Risk Factor Surveillance System, a telephone survey of 184,450 adults, were analyzed. Outcome measures included BMI, weight control practices (the intent to manage weight, and diet and physical activity patterns), and receipt of professional weight control advice.

RESULTS

Of VA users, 44% were overweight and 25% were obese. After controlling for demographic factors, VA users were somewhat less likely to be overweight (odds ratio, 0.86; 95% confidence interval, 0.74 to 1.00) but equally likely to be obese (odds ratio, 1.08; 95% confidence interval, 0.92 to 1.27), compared with non-VA users. Among obese VA users, 75% reported trying to lose weight, and another 17% reported trying to maintain weight. Of these, only 40% decreased both calorie and fat intake. Only 27% of obese VA users who reported increasing exercise to lose weight followed recommendations for regular and sustained physical activity. Of obese VA users, 59% were inactive or irregularly active. Only 51% of obese VA users received professional advice to lose weight. Obese VA users were more likely than obese non-VA users to report trying to lose weight, modifying diet to lose weight by decreasing both calories and fat intake, and receiving professional weight control advice.

DISCUSSION

Interventions for weight management programs in VA facilities need to take into account the high prevalence of overweight/obesity among VA users and should emphasize effective weight control practices.

Body mass index and health among Union Army veterans: 1891-1905

This paper explores the relationship between BMI and several health conditions among Union Army veterans who had medical examinations between 1891 and 1905. We find that BMI, when used as a proxy of nutrition, helps to explain morbidity and mortality differentials among veterans. There is evidence suggesting that among Union Army veterans extremely low or high BMIs were both associated with poor health, as indicated by a higher level of disability rating, higher risk of developing certain diseases, and higher mortality risk than those associated with having normal weight. Compared to veterans with normal weight, underweight veterans were more likely to be diagnosed with cardiovascular, respiratory and gastrointestinal diseases, but were less likely to be diagnosed with rheumatic and musculo-skeletal conditions at the first examination. High BMI levels are also associated with a higher risk of developing cardiovascular and rheumatic diseases, and higher mortality in the 20 years after the first examination. We performed a longitudinal analysis to study the association between earlier BMI as well as weight change and later development of diseases. The results suggest that, as a predictor of diseases, the explanatory power of BMI becomes lower the farther into the future we try to predict. Compared with those who maintained the same weight, veterans who gained weight were associated with a lower risk of being diagnosed with gastrointestinal diseases at their second examination.

Experience with INR self-management: patient selection and complication rates

BACKGROUND

INR self-management can reduce the risk of complications for patients with indication of long-term oral anticoagulation therapy. However, little is known about early indicators of complication risk.

METHODS

In a prospective study on 330 consecutive patients all participants were informed about oral anticoagulation by a structured teaching program. The two groups were divided as to whether they received usual medical care provided by a family physician (n=220) or self-management (n=110) on a portable coagulation monitor (CoaguChek System). After a mean follow up of 13.3+/-4.4 months, the participants of the study were interviewed by a structured questionnaire to obtain information about hemorrhagic and thromboembolic complications as well as survival.

RESULTS

In comparison to patients under usual care, patients with INR selfmanagement were significantly younger (58 vs 64 years) and had fewer comorbidities (diabetes and hypertension) as well as a higher ejection fraction (53.6 vs 51.1%). Indication for anticoagulation, age and heart rhythm explained 58% of the differences between the management groups. There was no significant difference in the overall complication rates between the two groups (usual care vs selfmanagement): major bleeding 0.5 vs 0.9%, cerebral embolism (TIA or stroke) 1.9 vs 0.9%, hospital admission 2.3 vs 1.8%. A high BMI (OR=1.5; 95% CI 1.06-1.25; p=0.001) or a high therapeutic INR range (OR=2.42; 95% CI 1.16-5.1; p=0.019) is associated with a higher complication rate.

CONCLUSIONS

Complication rates for patients with long-term oral anticoagulant therapy did not differ significantly between usual care and self-management. Rather, the patient's body weight and the requirement of high anticoagulation intensity drive the complication risk under both management systems.

Obesity, survival, and hospital costs-findings from a screening project in Sweden

OBJECTIVE

Our aims were to estimate 1) the costs of hospital treatment and 2) the value of lost production due to early death associated with overweight and obese patients, and then to extrapolate the findings to national costs.

METHODS

We use regression models to analyze survival, expected number of days in hospital treatment for patients with different body mass index (BMI), and costs with data obtained from screening of 33,196 middle-aged subjects living in Malmö, Sweden, and collected during a 15-year follow-up period. We subsequently scale up costs to national aggregate level using the BMI prevalence data from the screening project to the national population.

RESULTS

The total excess hospital (somatic, psychiatric) care cost (Swedish krona or SEK) for the national health-care budget, excess as compared to normal weight patients for obese (BMI > 30) and overweight (25 < or = BMI < 30) was estimated to SEK2155 million per annum (269 million dollars, assuming 1 dollar = SEK8), or about 2.3% of total hospital care costs in Sweden. The corresponding indirect costs due to early death were estimated to SEK2935 million (367 million dollars). For males at age 55, the potential hospital costs saving, excluding costs of the intervention that could be gained by an intervention that successfully and safely could alter the weight of an obese individual to become normal weight, was estimated on average to SEK4434 (554 dollars) per annum.

CONCLUSION

Hospital treatment costs are found to be higher for obese and overweight patients than for normal weight patients indicating potential cost savings especially on indirect costs by effective, safe and low cost weight-loss intervention.

A comparison of body mass index and waist-to-hip ratio as indicators of hypertension risk in an urban Argentine population: a hospital-based study

BACKGROUND AND AIM

To examine the relationship between 24-h ambulatory blood pressure monitoring (ABPM) and three commonest anthropometric measurements for obesity [body mass index (BMI), waist circumference (WC) and waist-hip ratio (WHR)] in patients with essential hypertension never treated or after a 3 week placebo period, living in Buenos Aires.

METHODS AND RESULTS

Cross-sectional survey among outpatients at the Hypertension Program of Buenos Aires University Hospital de Clinicas. Three-hundred seventy-seven essential hypertensives, aged 18-86 years, of either sex, were consecutively recruited. All subjects underwent 24 h ABPM performed with a blood pressure (BP) device. The prevalence of overweight-obesity was 56.76% in women and 75.86% in men. High WHR prevalence in non-obese women was 4.5% and 4.1% in non-obese men while high values of WC were observed in 3.0% of non-obese women and in 0% of non-obese men. The two-way ANCOVA showed that in women with high values of WHR, 24 h DBP was higher in those with BMI<25 than in those with BMI> or =25. Those females with a BMI> or =25 had a higher prevalence of top tertile values of PP (> or =68 mmHg) (P<0.05) than non-obese females. Only in women was mean pulse pressure (PP) significantly correlated with age (r=0.38; P<0.0001), WC (r=0.22; P<0.005), WHR (r=0.21, P<0.008), and BMI (r=0.20; P<0.01) while in men there was no significant correlation between variables. Logistic regression showed that the odds of morning blood pressure surge (MBPS) increased with age, central obesity (represented by high WHR and dipper status), while the odds of higher mean PP increased with age and high WHR.

CONCLUSION

These results indicated a high prevalence of overweight-obesity (more than 56% of women and 75% of men) in our hospital-based sample of essential hypertension and that the WHR offers additional information beyond BMI and WC to predict the hypertension risk according to the ABPM.

Associations between BMI, social strata and the estimated energy content of foods

OBJECTIVE

Many studies have shown that the prevalence of obesity is greater in lower social classes. The reasons for this effect however are unclear. Since there is also a link between education and social class, and an association between education and prevalence of obesity, one hypothesis is that lack of education about energy contents of foods may contribute to the effects of social class on obesity.

SUBJECTS

We tested the hypothesis that knowledge of food energy contents is associated with differences in body mass index (BMI) in a sample of 346 people of both genders, aged between 18 and 45 y, of variable body mass index and drawn from different social strata.

RESULTS

Estimates of food energy contents were on average well correlated with the actual energy contents, but individual estimates were very poor in all subpopulations of this sample. We found that subjects of different BMIs did not differentially estimate the energy contents of foods high in carbohydrate, but low in fat and protein (fruit and bread). However, foods that contained high fat contents, independent of the other macronutrients present, were generally perceived to have significantly lower energy contents by obese people than nonobese subjects (although this was not observed for all high-fat foods). Overall, this difference interacted with social class, such that the difference between the BMI groups was exaggerated in the lower social stratum but abolished in the higher social class. Binary logistic regressions revealed that the probability of being obese (BMI>30 kg/m2) in the lower social class group was significantly negatively associated with the estimated food energy content of most high-fat foods. Such an association was not found in the higher social class group. In the lower social class group, overall food knowledge appeared superior in the leaner subject group (BMI<30 kg/m2), but obese subjects were actually better at estimating the energy contents of snacks and alcoholic beverages. The leaner group significantly overestimated the energy contents of these items.

CONCLUSION

Differences between individuals in estimates of food energy contents may contribute to the development of obesity in lower social strata. Whether this is driven by a protective effect in lean subjects of overestimating the energy contents of certain foods (snacks and alcoholic beverages) or a susceptibility in the obese because they underestimate the energy contents of other foods is not certain. Knowing which of these alternatives is true is important and may help design public health education programmes directed at these people to help alleviate the obesity epidemic.

Economic causes and consequences of obesity

Obesity is not only a health but also an economic phenomenon. This chapter (a) examines underlying economic causes, such as technological advancements, behind the obesity epidemic; (b) describes economic consequences of obesity, including increasing obesity-related medical expenditures; and (c) discusses the role of government in combating the obesity epidemic. Because of the high costs of obesity, and the fact that the majority of these costs are financed by taxpayers, there is a clear motivation for government to try to reduce these costs. However, because obesity may result from poor information and addictive behavior and/or as a result of living in an increasingly obesogenic environment, interventions will need to be multifaceted to ensure the best chance of success.

Effects of adipokines on expression of adrenomedullin and endothelin-1 in cultured vascular endothelial cells

Obesity is a major risk factor for the development of hypertension. Adipokines may cause hypertension by acting both centrally and directly on the vascular vessels. We wished to clarify whether three adipokines, leptin, resistin and tumor necrosis factor-alpha, affect expression of adrenomedullin and endothelin-1 in vascular endothelial cells. Human umbilical vein endothelial cells were cultured for 24 h with leptin (1-10 nmol/l), resistin (1-10 nmol/l) or tumor necrosis factor-alpha (1-10 ng/ml). Expression of adrenomedullin and endothelin-1 was examined by radioimmunoassay and northern blot analysis. Immunoreactive-adrenomedullin in the medium and adrenomedullin mRNA expression levels were decreased by treatment of tumor necrosis factor-alpha time- and dose-dependently, whereas endothelin-1 secretion was not significantly changed by it. Leptin or resistin had no significant effects on expression of adrenomedullin or endothelin-1 in human umbilical vein endothelial cells. Under hypoxic conditions (1% O2), expression of both adrenomedullin and endothelin-1 was induced in these cells. Immunoreactive-adrenomedullin levels in the medium were decreased by treatment of tumor necrosis factor-alpha under hypoxia. Leptin or resistin had no significant effects on adrenomedullin or endothelin-1 expression also in hypoxia. These findings have raised the possibility that decreased expression of adrenomedullin by tumor necrosis factor-alpha may be related to the increased risk of hypertension and other cardiovascular diseases in obese subjects.

COMPETING DIETARY CLAIMS FOR WEIGHT LOSS: Finding the Forest Through Truculent Trees

In response to an accelerating obesity pandemic, competing weight-loss diets have propagated; those touting carbohydrate restriction are currently most in vogue. Evidence that sustainable weight loss is enhanced by means other than caloric restriction, however, is lacking. Whereas short-term weight loss is consistently achieved by any dietary approach to the restriction of choice and thereby calories, lasting weight control is not. Competing dietary claims imply that fundamental knowledge of dietary pattern and human health is lacking; an extensive literature belies this notion. The same dietary and lifestyle pattern conducive to health promotion is consistently associated with weight control. A bird's eye view of the literature on diet and weight reveals a forest otherwise difficult to discern through the trees. Competing diet claims are diverting attention and resources from what is actually and urgently needed: a dedicated and concerted effort to make the basic dietary pattern known to support both health and weight control more accessible to all.

The cost of glucocorticoid-associated adverse events in rheumatoid arthritis

OBJECTIVE

To estimate the costs of glucocorticoid associated adverse events (GAEs) in patients with rheumatoid arthritis (RA).

METHODS

We conducted a literature review of studies reporting GAEs in RA patients, and developed a Markov model with the following GAEs: fractures (vertebral, hip, pelvic), hypertension, diabetes, gastrointestinal complications, pneumonia, urinary tract infection, cataract and, in an extended model, myocardial infarction (MI) and stroke. Two-year total costs were calculated using direct medical costs (2001 US dollars [USD]) and by running 10,000 Monte Carlo simulations with probability values randomly selected from the GAE literature.

RESULTS

On average, glucocorticoid users spent USD 445 more than non-users, or USD 0.46 for each dollar spent on purchasing the drug. When adding MI and stroke, users spent on average USD 430 more than non-users, or USD 0.44 for each dollar spent on purchasing the drug; this incremental cost ranged from USD 193 to USD 682 if MI and stroke were excluded, respectively. In 70% of the simulations there were more deaths among users than among non-users, in both the model with and without MI and stroke.

CONCLUSIONS

Although results varied depending on attributed GAEs, in general glucocorticoid users spent more than non-users on GAE treatment, and had higher mortality. Patients, providers and policy makers should consider these potential costs of GAEs when making treatment decisions.

Obesity as a risk factor for premenstrual syndrome

PURPOSE

To determine the association between obesity and Premenstrual Syndrome (PMS).

METHODS

A cross-sectional study was conducted using a random-digit dialing method. The sampling frame consisted of all possible area codes, exchanges, and 4-digit suffixes in Virginia. A total of 874 women between the ages of 18-44 residing in the state of Virginia between August 1 and September 15, 1994 were interviewed. Cases were defined as women who reported severe or extreme PMS symptom changes using the Shortened Premenstrual Assessment Form. The main exposure variable was obesity as measured by Body Mass Index.

RESULTS

The prevalence of PMS in Virginia was 10.3 percent. Obese women (BMI > or = 30) had nearly a three-fold increased risk for PMS than non-obese women OR = 2.8 (95% CI = 1.1, 7.2). PMS was more prevalent among whites, younger women, and smokers.

CONCLUSION

This data provided evidence that obesity is strongly associated with PMS. Since obesity is a modifiable risk factor, PMS management strategies should not only consider factors such as, high stress, and smoking but also obesity.

Influence of intense multidisciplinary follow-up and orlistat on weight reduction in a primary care setting

Background

Obesity is the most common health problem in developed countries. Recently, several physicians' organizations have issued recommendations for treating obesity to family physicians, including instructions in nutrition, physical activity and medications. The aim of this study was to examine if effective weight-reducing treatment can be given by a family physician. It compares regular treatment with intensive treatment that include close follow-up and orlistat treatment.

Methods

The study was conducted in three primary care clinics. 225 patients were divided into three groups according to their choice. Group A received a personal diet with fortnightly meetings with the family physician and dietitian and orlistat treatment. Group B received a general diet, monthly meetings with the family physician only and orlistat treatment. Group C received a personal diet, monthly meetings with the dietitian only and no drug treatment. The primary endpoint was reduction of at least 5% of the initial weight during the study period.

Results

A greater percentage of patients in group A achieved their weight reduction goals than in other groups (51%, 13% and 9% in groups A, B and C, respectively, p < 0.001). There was a significant reduction in triglycerides in all groups, a significant reduction of low density lipids (LDL) in groups A and B and no significant difference in high density lipids (HDL) in any group.

Conclusions

Significant weight reduction was obtained in a family physician setting. Further research is needed to evaluate if, by providing the family physician with the proper tools, similar success can be achieved in more clinics.

Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis

BACKGROUND

Fast-food consumption has increased greatly in the USA during the past three decades. However, the effect of fast food on risk of obesity and type 2 diabetes has received little attention. We aimed to investigate the association between reported fast-food habits and changes in bodyweight and insulin resistance over a 15-year period in the USA.

METHODS

Participants for the CARDIA study included 3031 young (age 18-30 years in 1985-86) black and white adults who were followed up with repeated dietary assessment. We used multiple linear regression models to investigate the association of frequency of fast-food restaurant visits (fast-food frequency) at baseline and follow-up with 15-year changes in bodyweight and the homoeostasis model (HOMA) for insulin resistance.

FINDINGS

Fast-food frequency was lowest for white women (about 1.3 times per week) compared with the other ethnic-sex groups (about twice a week). After adjustment for lifestyle factors, baseline fast-food frequency was directly associated with changes in bodyweight in both black (p=0.0050) and white people (p=0.0013). Change in fast-food frequency over 15 years was directly associated with changes in bodyweight in white individuals (p<0.0001), with a weaker association recorded in black people (p=0.1004). Changes were also directly associated with insulin resistance in both ethnic groups (p=0.0015 in black people, p<0.0001 in white people). By comparison with the average 15-year weight gain in participants with infrequent (less than once a week) fast-food restaurant use at baseline and follow-up (n=203), those with frequent (more than twice a week) visits to fast-food restaurants at baseline and follow-up (n=87) gained an extra 4.5 kg of bodyweight (p=0.0054) and had a two-fold greater increase in insulin resistance (p=0.0083).

INTERPRETATION

Fast-food consumption has strong positive associations with weight gain and insulin resistance, suggesting that fast food increases the risk of obesity and type 2 diabetes.

Social work's partnership in community-based stroke prevention for older adults: a collaborative model

Stroke prevention includes public education and community- based screenings to identify stroke risks. Even though more than half of all strokes are preventable, the incidence has increased in recent years and remains the leading cause of adult disability. Age is highly associated with stroke and twice as likely to occur with each decade after age 55. Risks fall into one of two categories. One category, such as obesity and high blood pressure, are controllable through behavior change and/or preventive medical care. The other category of risks, such as age or race, are not controllable. Stroke risks tend to occur in multiples that interact to heighten individual effects, thus, interdisciplinary methods to identify and reduce risk may be required. Social workers can play a key role in these partnerships. Social work's skills base in gerontology, psychosocial interventions, and empowerment through community organization are ideal for early intervention and behavior change. This article describes a collaborative community-based model for screening older adults for stroke risk and lessons learned from a three-month risk reduction follow-up.

Effects of weight gain on medical care costs

OBJECTIVE

To examine in middle-aged adults the effect of medical care costs of large, rapid weight gain compared to weight maintenance.

DESIGN

: Retrospective cohort study for a 3-y time period.

SETTING AND PARTICIPANTS

Population-based sample (N=15174) of men and women members of a large managed care organization, aged 35-65 y, with a body mass index (BMI) >25 kg/m(2) at baseline. Health-care utilization and costs were measured at baseline and over the 3-y follow-up period.

RESULTS

Mean age at baseline was 49.7 y and mean BMI was 31.5 kg/m(2). During the 3-y follow-up period, 40.8% were classified as weight maintainers (+/-4 pounds), 45.3% gained 5-19 pounds, and 13.9% gained >/=20 pounds. A weight gain of >/=20 pounds was significantly associated with increased total medical care costs in all subgroups evaluated. Among all subjects, for those who gained >/=20 pounds compared to those who maintained weight, the adjusted 3-y increase in costs was 561 dollars. Among the subgroup with baseline comorbidities, the adjusted 3-y change in total medical care costs was 711 dollars. Multivariate analyses showed no significant differences between those who gained 5-19 pounds and those who maintained weight. Baseline BMI and comorbidities were also significant predictors of change in medical care costs, independent of weight gain.

CONCLUSION

A large 3-y weight gain (>/=20 lb) in middle-aged overweight and obese adults is associated with a correspondingly larger increase in total medical care costs compared to weight maintainers. The prevention of large weight gains holds promise for significantly reducing future medical care costs. Future studies should examine the causes of rapid weight gain and evaluate approaches to prevent and reverse such weight gain.

The coming epidemic of obesity in elderly Americans

OBJECTIVES

To estimate the prevalence of obesity in elderly Americans in 2010 and to discuss the health and economic implications of these estimates.

DESIGN

Three methods of generating future point-prevalence estimates using data from consecutive cross-sectional studies.

SETTING

All regions of the United States.

PARTICIPANTS

Estimates were based on five nationally representative surveys of the adult population of the United States, conducted from 1960 to 2000, and population estimates from the U.S. Census Bureau.

MEASUREMENTS

Changes in obesity (body mass index (BMI) > or =30 kg/m(2)) and normal weight (BMI <25 kg/m(2)) prevalence for men and women by 10-year U.S. birth cohorts were examined. The prevalence of obesity and normal weight in the elderly in 2010 was estimated under three different scenarios of obesity prevalence change.

RESULTS

It was estimated that the prevalence of obesity in adults aged 60 and older will increase from 32.0% in 2000 to 37.4% in 2010 (range 33.6-39.6%). The number of obese adults aged 60 and older will increase from 14.6 to 20.9 million (range 18.8-22.2 million). Similarly, it was estimated that the prevalence of normal weight among adults aged 60 and older will decrease from 30.6% in 2000 to 26.7% in 2010 (range 31.0-24.7%).

CONCLUSION

The prevalence of obesity in elderly Americans will likely continue to increase, challenging healthcare delivery and financing systems in the United States.

Weight Loss Interventions for Adult Obesity: Evidence for Practice

BACKGROUND

One out of three adults is obese, making obesity the most common presenting chronic medical condition in the primary care setting. Obesity is associated with an increased risk of developing secondary illnesses resulting in a higher rate of morbidity. This chronic condition is a constant challenge facing international health care systems. A need for a systematic approach to treatment is essential to conquering obesity and improving patients' outcomes and quality of lives. Despite the existence of evidence-based guidelines, the proportion of primary care clinicians implementing weight loss counseling is low.

APPROACH

This article identifies, critiques, and synthesizes the established body of research evidence for weight loss interventions.

FINDINGS

The strategies that have been shown to be effective in the management and treatment of obesity are outlined.

IMPLICATIONS

Finally, the feasibility of applying these findings to practice and the practical implications of these findings are discussed.

Effects of intake of a mixture of thiamin, arginine, caffeine, and citric acid on adiposity in healthy subjects with high percent body fat

We assessed the effects of intake of thiamin, arginine, caffeine, and citric acid (TACC) on lipid metabolism in healthy subjects. Thirty-one subjects with high percent body fat (> or = 25.0%) were randomly assigned to a 12-wk intervention with daily intake of TACC-supplemented tea (1.1, 1240, 52, and 540 mg, respectively; n=16) or control tea (n=15). The percent body fat decreased significantly during the intervention in both groups, especially in the TACC group. A percentage decrease in triceps skinfold was significantly greater in the TACC group than in the control group. The decrease in abdominal visceral fat in obese subjects was significantly greater in the TACC group than in the control group. Serum triglyceride was significantly lower during intervention than that during the non-intervention period in the TACC group. These results suggest that TACC may be effective in reducing body fat in obese subjects.

Body Mass Index and Alcohol Use

BACKGROUND

Obesity, inactivity and being overweight are leading causes of morbidity and mortality in the United States. The relationship between eating, overeating, and addiction have been discussed, debated and more recently investigated. We have hypothesized that drugs of abuse compete with food for brain reward sites. Overeating and obesity may act as protective factors reducing drug reward and addiction.

METHODS

In the first part of this study, 374 charts of all active weight management patients in a 12-month period were examined. Demographic information, laboratory testing, psychiatric diagnostic interview, alcohol and drug history were reviewed. A detailed alcohol use, abuse, dependence history was present in 298 charts as part of the pre-bariatric evaluation. The relationship between BMI and alcohol use among female patients (n = 298) was then analyzed.

RESULTS

We found a significant (p <.05) inverse relationship between BMI and alcohol consumption. The more obese the patient was, the less alcohol they consumed. The percentage of women who consumed alcohol in the past year decreased as BMI level increased. These results confirmed our surgeons' perception that it is rare to find a morbidly obese patient excluded for bariatric surgery because of excessive alcohol consumption.

CONCLUSIONS

Obese patients have lower rates of alcohol use than found in the general population of women. As BMI increases, lower rates of alcohol consumption are found. Overeating may compete with alcohol for brain reward sites, making alcohol ingestion less reinforcing.

Obesity over the life course

Obesity in middle-aged humans is a risk factor for many age-related diseases and decreases life expectancy by about 7 years, which is roughly comparable to the combined effect of all cardiovascular disease and cancer on life span. The prevalence of obesity increases up until late middle age and decreases thereafter. Mechanisms that lead to increased obesity with age are not yet well understood, but current evidence implicates impairments in hypothalamic function, especially impairments in the ability of hypothalamic pro-opiomelanocortin neurons to sense nutritional signals. The rapid increase in the prevalence of obesity at all ages in the past decade suggests that, in the next two or three decades, diseases associated with obesity, especially diabetes, will begin to rise rapidly. Indeed, these trends suggest that for the first time in modern history, the life expectancy of people in developed societies will begin to decrease, unless the rapid increase in the prevalence of obesity can be reversed.

Is there a rationale for angiotensin blockade in the management of obesity hypertension?

Obesity, currently affecting >20% of the adult population in most Western countries, is a major risk factor for the development of hypertension. Hypertension in obese patients is, in the majority of instances, further complicated by the concomitant presence of dyslipidemia and insulin resistance. The latter is reflected by derangement of glucose homeostasis, ranging from hyperinsulinemia to frank type 2 diabetes. Hypertension in obese patients is also associated with an increased risk for left ventricular hypertrophy, endothelial dysfunction, renal hyperfiltration, microalbuminuria, and elevated markers of inflammation. Sodium retention, volume expansion, and increased cardiac output are common findings in obese individuals. These changes are largely attributable to increased activity of the sympathetic nervous system and insufficient suppression of the renin-angiotensin system. Recent data show increased expression of angiotensin II-forming enzymes in adipose tissue, and increased activity of the renin-angiotensin system has recently been implicated in the development of insulin resistance and type 2 diabetes. Accordingly, antihypertensive agents that block the renin-angiotensin system might be a beneficial strategy for treatment of obesity-related hypertension. Both angiotensin-converting enzyme inhibitors and angiotensin type-1 receptor blockers have been associated with favorable metabolic properties and end-organ protection in addition to their antihypertensive effects. Data from ongoing large trials will provide an indication of the protective and preventive effects of these treatment strategies while offering insights into the mechanisms linking obesity, hypertension, and other facets of the metabolic syndrome.

Feeding behaviors and weight loss outcomes over 64 months

Maintenance of reduced body weight following intentional weight loss is often unsuccessful. Identification of behaviors associated with sustained reductions should aid in dietary weight management. This survey assessed associations between an array of appetitive indices and weight loss outcomes in a sample of 80 adults participating in an open-labeled, unsupervised weight management program over a 64-month period. Participants were divided into maintainers (weight loss >5 kg at Year 1, sustained reduction >75% at Month 64), rebounders (weight loss >5 kg at Year 1, <75% reduction at Month 64), and nonresponders (weight loss <5 kg at Year 1). Nonresponders spent significantly more time shopping for food weekly, tended to have the highest total exposure time to food and to eat with fewer people than the other groups. Maintainers reported higher mean hunger over the course of a day, tended to spend more time preparing food and consumed less energy from fat and foods that they rated as predominantly bitter. Rebounders had significantly lower dietary restraint scores and tended to have less control over the purchase and preparation of foods in their diet. Individuals with different long-term weight loss outcomes possess distinct feeding-related attributes that may provide a basis for improved intervention strategies.

Body mass index and hospitalization in the elderly

OBJECTIVES

To explore the association between body mass index (BMI) and hospital usage in the elderly.

DESIGN

Retrospective cohort study.

SETTING

Medicare Current Beneficiary Survey (1992-94).

PARTICIPANTS

Eight thousand seven hundred fifty-four noninstitutionalized individuals aged 65 to 100 without cancer at baseline and with available data on height and weight.

MEASUREMENTS

BMI categorized by quintiles and by the 1998 National Heart Lung and Blood Institute (NHLBI) BMI classification. Poisson regression was used for multivariate analyses relating BMI to number of hospitalizations, adjusting for sex, age, smoking status, and heart disease.

RESULTS

During 20464 years of observation, 1199 individuals had 4096 hospitalizations and 34190 hospital days. Individuals in the lowest BMI quintile had a higher risk of hospitalization than those in the middle BMI quintile (RR=1.22; 95% confidence interval=1.1-1.4); stratified analyses by age revealed that this association remained for individuals aged 65 to 75. Using the NHLBI classification, underweight, overweight, mild obesity, and moderate to severe obesity were related to higher risk of hospitalizations than normal BMI in individuals aged 65 to 75. In individuals older than 75, underweight, overweight, and mild obesity were not related to a higher risk of hospitalizations. Moderate to severe obesity was related to a higher risk of hospitalization in individuals aged 75 to 89, which represented only 1.5% of the sample.

CONCLUSION

BMI is not a predictor of hospitalization for most individuals aged 75 and older.

Risks of obesity

Obesity is a chronic disease caused by an imbalance between the energy ingested in food and the energy expended. Enlarged fat cells produce the clinical problems associated with obesity either because of the weight or mass of the extra fat or because of the increased secretion of free fatty acids and numerous peptides from enlarged fat cells. The consequence of these two mechanisms is other diseases, such as diabetes mellitus, gallbladder disease, osteoarthritis, heart disease, and some forms of cancer. The spectrum of medical, social, and psychologic disabilities includes a range of medical and behavioral problems.

Measuring the relationship between employees' health risk factors and corporate pharmaceutical expenditures

This study demonstrates the relationship between self-reported health risk factors on a health risk appraisal and pharmaceutical expenditures for a large employer. A total of 3554 employees who were participants in a pharmacy benefit plan for the entire year of 2000 completed a health risk appraisal. As the number of self-reported health risk factors increased from zero to six or more, corporate pharmaceutical costs increased in a stepwise manner: US dollars 345, 443, 526, 567, 750, 754, and 1121 US dollars, respectively. After controlling for age, gender, and the number of self-reported diseases, each additional risk factor was associated with an average annual increase in pharmacy claims costs of 76 US dollars per employee. Specific health risks were associated with significantly higher expenditures. The results provide estimates of incremental expenditures associated with common, potentially modifiable risk factors. Pharmaceutical expenditures should be considered by corporations in their estimates of total health-related costs and in prioritizing disease management initiatives based on health risk appraisal data.

Does early physical activity predict body fat change throughout childhood?

BACKGROUND

Declining levels of physical activity in the population at large may be responsible in part for the rising rates of childhood obesity. Studies to date, however, have not consistently demonstrated such a protective effect. We used longitudinal data from the Framingham Children's Study (FCS) to address this important question.

METHODS

We used 8 years of activity monitoring (Caltrac electronic motion sensors) and repeated anthropometry measures for 103 children to examine the effect of activity on body fat change from preschool to early adolescence. Longitudinal data analysis methods were employed to account for the use of repeated measures on these children.

RESULTS

Children in the highest tertile of average daily activity from ages 4 to 11 years had consistently smaller gains in BMI, triceps, and sum of five skinfolds throughout childhood. By early adolescence (age 11), the sum of five skinfolds was 95.1, 94.5, and 74.1 for the low, middle, and high tertiles of activity, respectively (P for trend = 0.045). This protective effect of activity was evident for both girls and boys.

CONCLUSION

This longitudinal study adds strong support for the hypothesis that higher levels of physical activity during childhood lead to the acquisition of less body fat by the time of early adolescence.

Rapid weight gain during infancy and obesity in young adulthood in a cohort of African Americans

BACKGROUND

Obesity is increasing in the United States. Evidence-based prevention is a public health priority and should target well-defined risk factors and critical periods.

OBJECTIVE

We tested the hypothesis that rapid weight gain during early infancy is associated with obesity in African American young adults, a group at increased risk of obesity.

DESIGN

A cohort of 300 African Americans born at full term was followed from birth to 20 y of age. A pattern of rapid weight gain was defined as an increase in weight-for-age > or = 1 SD between birth and 4 mo.

RESULTS

About 29% of subjects had a pattern of rapid weight gain during infancy; 8% were obese [body mass index (in kg/m(2)) > or = 30] at age 20 y. One-third of the obesity at age 20 y could be attributed to rapid weight gain in the first 4 mo of life. After adjustment for confounding factors, subjects with rapid weight gain during early infancy were more likely to become obese at age 20 y (odds ratio = 5.22; 95% CI: 1.55, 17.6; P = 0.008). The results were confirmed by using a combination of body mass index and skinfold thickness (odds ratio = 6.72; 95% CI: 1.93, 23.4; P = 0.003).

CONCLUSIONS

The results of the present study provide evidence that a pattern of rapid weight gain during early infancy is associated with obesity not only in childhood but also in young adulthood. We propose that early infancy constitutes a critical period for the development of obesity. Mechanisms of action and prevention strategies require further investigation.

Risks of obesity

Obesity is a chronic disease in the same sense as hypertension and atherosclerosis. The cause of obesity is an imbalance between the energy ingested in food and the energy expended. The excess energy is stored in fat cells that enlarge or increase in number. This hyperplasia and hypertrophy of fat cells is the pathologic lesion of obesity. Enlarged fat cells produce the clinical problems that are associated with obesity, either because of the weight or mass of the extra fat or because of the increased secretion of free fatty acids and numerous peptides from enlarged fat cells. The consequence of these two mechanisms is other diseases, such as diabetes mellitus, gallbladder disease, osteoarthritis, heart disease, and some forms of cancer.

Diet, exercise, and the challenge of combating obesity in primary care

Obesity has reached epidemic proportions in the United States and in most industrialized nations. More than 60% of US adults are now overweight or obese, predisposing over 97 million Americans to a host of chronic lifestyle diseases, particularly cardiovascular disease. Despite the existence of explicit evidence-based consensus reports on the health risks of obesity and the health benefits of even moderate amounts of weight loss, many patients do not receive advice from their health care providers to lose weight or on how to do so effectively. Even modest physical activity and small incremental healthy dietary changes when incorporated into one's lifestyle have a positive effect on weight loss and promote the maintenance of favorable body weight and body composition changes with advancing age. This article describes elements of effective counseling and practical guidelines for developing a healthy lifestyle approach for overweight and obese individuals.

Long-term divergent selection on fatness in mice indicates a regulation system independent of leptin production and reception

Divergent selection in mice on fatness over 60 generations produced a fat (F) and a lean (L) line, having about 22% and 4% body fat, respectively. To elucidate the importance of the leptin regulatory feedback loop in the genetic changes produced by this selection, Lep(ob) and Lepr(db) mutations causing leptin production and leptin receptor deficiency, respectively, were introgressed individually into both lines by repeated backcrossing. The fat amount increased significantly in homozygotes for Lep(ob) or Lepr(db) in both lines, for example, in F and L males from 8.5 to 18.8 and 17.2 g (P<0.001) and from 1.25 to 18.0 and 12.7 g (P<0.001), respectively. Line differences were, however, mostly maintained after introgression. Concentrations of circulating leptin were relatively independent of the original lines but heavily dependent on the introgressed genotype. Introgression of leptin production and receptor deficiencies had separate effects from long-term selection, indicating that the genes responsible for the line divergence must act independently of the leptin regulatory system. Energy budget analysis indicated that the major line differences were in the level of energy expended on physical activity, and these differences were preserved following introgression, suggesting that multiple pathways regulate fatness, which may be independently responsive to intervention.

Cost of in-patient care over 7 years among surgically and conventionally treated obese patients

OBJECTIVE

Bariatric surgery improves cardiovascular risk factors and quality of life, but few studies have directly addressed the relation between obesity treatment and hospitalization costs. This prospective controlled study compares in-patient care between surgically and conventionally treated obese patients.

RESEARCH METHODS AND PROCEDURES

A total of 962 surgically and conventionally treated obese patients from the intervention study, Swedish Obese Subjects, were followed for 6 years. Changes in days of hospitalization and hospitalization costs were analyzed. Information on hospitalizations for each subject were obtained from the Swedish Hospital Discharge Register.

RESULTS

After 6 years, weight change was -16.7% in the surgical group and +0.9% in the control group (p < 0.0001). The cumulated hospital stay over 6 years was 23.4 days in the surgical group and 6.9 days in the control group (p < 0.0001). The average hospital cost for the surgical intervention was US$4300. Incremental costs that could be attributable to obesity surgery averaged US$1200 per year. After exclusion of hospitalizations for the surgical intervention and conditions common after bariatric surgery, there were no significant differences between the groups in number of hospital days or hospitalization costs.

DISCUSSION

Our experience from bariatric surgery indicates that average weight reductions of 16% will not reduce hospitalization costs over 6 years. Costs of bariatric surgery are limited and seem to be motivated given the marked improvements of cardiovascular risk factors, cardiac structure, and function and health-related quality of life.