Lifetime health and economic consequences of obesity

Exploring Attachment Dimensions in Individuals with Overweight or Obesity

Introduction. Obesity is a complex condition associated not only with physical health risks but also with social discrimination and a reduced quality of life (QoL). Psychological factors, including attachment styles, may play a role in emotional regulation and eating behaviors. According to attachment theory, insecure attachment is linked to difficulties in managing emotions and an increased likelihood of engaging in dysfunctional eating patterns. This study aimed to investigate the relationship between past and present attachment styles, binge-eating behaviors, and QoL scores in individuals with overweight or obesity (BMI ≥ 25 kg/m2) compared to those with a BMI in the normal weight range (18.5-24.9 kg/m2). Methods. A cross-sectional study evaluated 96 women with overweight/obesity and 96 women with normal weight. Psychological measures included the Parental Bonding Instrument (PBI), the Attachment Style Questionnaire (ASQ), the Binge Eating Scale (BES), and the Obesity-Related Well-being questionnaire (ORWELL 97). Data analysis included between-group comparisons of attachment dimensions and hierarchical regression to examine associations with the QoL score. Results. Participants with overweight/obesity showed less secure attachment (U = 5508, p = 0.019) and more avoidant attachment styles (U = 3825, p = 0.042) compared to participants with normal weight. Conversely, no significant differences were observed in PBI scores. Regression analysis revealed that attachment anxiety (B = 0.83, p = 0.009) and binge-eating behaviors (B = 0.57, p = 0.003) were significantly associated with a lower QoL. Conclusions. Obesity is associated with avoidant attachment in adulthood, but no differences were found in parental attachment when compared to individuals with normal body weight. Anxious attachment in individuals with obesity is strongly linked to reduced QoL, underlying the role played by attachment-related factors in the psychosocial challenges individuals often have to face.

Lifetime costs of overweight and obesity in Italy

We use longitudinal electronic clinical data on a large representative sample of the Italian population to estimate the lifetime profile costs of different BMI classes - normal weight, overweight, and obese (I, II, and III) - in a primary care setting. Our research reveals that obese patients generate the highest cost differential throughout their lives compared to normal weight patients. Moreover, we show that overweight individuals spend less than those with normal weight, primarily due to reduced expenditures beginning in early middle age. Our estimates could serve as a vital benchmark for policymakers looking to prioritize public interventions that address the obesity pandemic while considering the increasing obesity rates projected by the OECD until 2030.

Examining Obesity and Its Association With Burn Injury: A Secondary Analysis of the Transfusion Requirement in Burn Care Evaluation Study

INTRODUCTION

Literature examining the connection between obesity and burn injuries is limited. This study is a secondary analysis of a multicenter trial data set to investigate the association between burn outcomes and obesity following severe burn injury.

MATERIALS AND METHODS

Body mass index (BMI) was used to stratify patients as normal weight (NW; BMI 18.5-25), all obese (AO; any BMI>30), obese I (OI; BMI 30-34.9), obese II (OII; BMI 35-39.9), or obese III (OIII; BMI>40). The primary outcome examined was mortality. Secondary outcomes included hospital length of stay (LOS), number of transfusions, injury scores, infection occurrences, number of operations, ventilator days, intensive care unit LOS, and days to wound healing.

RESULTS

Of 335 patients included for study, 130 were obese. Median total body surface area (TBSA) was 31%, 77 patients (23%) had inhalation injury and 41 patients died. Inhalation injury was higher in OIII than NW (42.1% versus 20%, P = 0.03). Blood stream infections (BSI) were higher in OI versus NW (0.72 versus 0.33, P = 0.03). Total operations, ventilator days, days to wound healing, multiorgan dysfunction score, Acute Physiology and Chronic Health Evaluationscore, hospital LOS, and intensive care unit LOS were not significantly affected by BMI classification. Mortality was not significantly different between obesity groups. Kaplan-Meier survival curves did not significantly differ between the groups (χ2 = 0.025, P = 0.87). Multiple logistic regression identified age, TBSA, and full thickness burn as significant independent predictors (P < 0.05) of mortality; however, BMI classification itself was not predictive of mortality.

CONCLUSIONS

No significant association between obesity and mortality was seen after burn injury. Age, TBSA, and percent full- thickness burn were independent predictors of mortality after burn injury, while BMI classification was not.

Changes in weight, body composition and metabolic parameters after switch to dolutegravir/lamivudine compared with continued treatment with dolutegravir/abacavir/lamivudine for virologically suppressed HIV infection (The AVERTAS trial): a randomised, open-label, superiority trial in Copenhagen, Denmark

INTRODUCTION

With longer life expectancy in people living with HIV (PLWH) on antiretroviral therapy, cardiovascular disease (CVD) has become a common cause of mortality among them. Abacavir has been associated with an increased risk of myocardial infarction, but the mechanism is unknown. Additionally, abacavir may be obesogenic which could mediate an additional risk factor of CVD. We aim to investigate if discontinuation of abacavir will have a favourable impact on body weight and cardiac parameters in PLWH.

METHODS AND ANALYSIS

Randomised, controlled, superiority trial of virologically suppressed PLWH on dolutegravir, abacavir and lamivudine (DTG/ABC/3TC) for ≥6 months. In total, 70 PLWH will be randomised 1:2 to either continue DTG/ABC/3TC or to switch to dolutegravir and lamivudine (DTG/3TC) providing the power of 80% at alpha 5% to detect a mean difference in weight change of 2 kg (Δ) given an SD of 2.7 kg. Follow-up will be 48 weeks. Data will be collected at baseline and week 48. Primary outcome will be change in mean body weight from baseline to week 24 and 48 evaluated in a linear mixed model. Secondary outcomes will be changes in cardiac, inflammatory and metabolic parameters, fat distribution, coagulation, endothelial, platelet function, quality of life and virological control from baseline to week 48. Measurements include CT of thorax and abdomen, external carotid artery ultrasound, liver elastography and dual energy X-ray absorptiometry and blood analysis. Plasma HIV RNA will be measured at baseline, week 4, 24 and 48. Forty participants (20 from each arm) will be included in a substudy involving cardiac MRI at baseline and week 48. Twenty non-HIV-infected controls will be included with a single scan to compare with baseline scan data.

ETHICS AND DISSEMINATION

Result from this study will lead to a better understanding of the association between antiretroviral therapy and the impact on weight and risk of CVD. Findings will be useful for both clinicians and PLWH in the guidance of a more individualised HIV treatment. Results from the main study and the substudies will be submitted for publication in a peer-reviewed journal(s). The AVERTAS study is approved by the Ethics Committee of the Capital Region, Denmark (H-20011433), Danish Medicines Agency (EudraCT no. 2019-004999-19) and Regional Data Protection Centre (P-2020-207).

TRIAL REGISTRATION NUMBER

Pre-results registration at ClinicalTrials.gov Identifier: NCT04904406, registered 27 May 2021.

PROTOCOL VERSION

Protocol version 9.0, 4 April 2023, approved 10-05-2023 by Ethics Committee of the Capital Region, Denmark (H-20011433). Danish Medicines Agency (EudraCT no. 2019-004999-19). Regional Data Protection Centre (P-2020-207) ClinicalTrials.gov.

Obesity and labour market outcomes in Italy: a dynamic panel data evidence with correlated random effects

This paper investigates the effects of obesity, socio-economic variables, and individual-specific factors on work productivity across Italian regions. A dynamic panel data with correlated random effects is used to jointly deal with incidental parameters, endogeneity issues, and functional forms of misspecification. Methodologically, a hierarchical semiparametric Bayesian approach is involved in shrinking high dimensional model classes, and then obtaining a subset of potential predictors affecting outcomes. Monte Carlo designs are addressed to construct exact posterior distributions and then perform accurate forecasts. Cross-sectional Heterogeneity is modelled nonparametrically allowing for correlation between heterogeneous parameters and initial conditions as well as individual-specific regressors. Prevention policies and strategies to handle health and labour market prospects are also discussed.

Supermarket Proximity and Risk of Hypertension, Diabetes, and CKD: A Retrospective Cohort Study

RATIONALE & OBJECTIVE

Living in environments with low access to food may increase the risk of chronic diseases. We investigated the association of household distance to the nearest supermarket (as a measure of food access) with the incidence of hypertension, diabetes, and chronic kidney disease (CKD) in a metropolitan area of the United States.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

777,994 individuals without hypertension, diabetes, or CKD at baseline within the HealthLNK Data Repository, which contains electronic health records from 7 health care institutions in Chicago, Illinois.

EXPOSURE

Zip code-level average distance between households and nearest supermarket.

OUTCOME

Incidence of hypertension, diabetes, and CKD based on presence of ICD-9 code and/or blood pressure≥140/90mm Hg, hemoglobin A1c≥6.5%, and eGFR<60mL/min/1.73m², respectively.

ANALYTICAL APPROACH

Average distance to nearest supermarket was aggregated from street-level metrics for 56 Chicagoland zip codes. The cumulative incidence of hypertension, diabetes, and CKD from 2007-2012 was calculated for each zip code in patients free of these diseases in 2006. Spatial analysis of food access and disease incidence was performed using bivariate local indicator of spatial association (BiLISA) maps and bivariate local Moran I statistics. The relationship between supermarket access and outcomes was analyzed using logistic regression.

RESULTS

Of 777,994 participants, 408,608 developed hypertension, 51,380 developed diabetes, and 56,365 developed CKD. There was significant spatial overlap between average distance to supermarket and incidence of hypertension and diabetes but not CKD. Zip codes with large average supermarket distances and high incidence of hypertension and diabetes were clustered in southern and western neighborhoods. Models adjusted only for neighborhood factors (zip code-level racial composition, access to vehicles, median income) revealed significant associations between zip code-level average distance to supermarket and chronic disease incidence. Relative to tertile 1 (shortest distance), ORs in tertiles 2 and 3, respectively, were 1.27 (95% CI, 1.23-1.30) and 1.38 (95% CI, 1.33-1.43) for diabetes, 1.03 (95% CI, 1.02-1.05) and 1.04 (95% CI, 1.02-1.06) for hypertension, and 1.18 (95% CI, 1.15-1.21) and 1.33 (95% CI, 1.29-1.37) for CKD. Models adjusted for demographic factors and health insurance showed significant and positive association with greater odds of incident diabetes (tertile 2: 1.29 [95% CI, 1.26-1.33]; tertile 3: 1.35 [95% CI, 1.31-1.39]) but lesser odds of hypertension (tertile 2: 0.95 [95% CI, 0.94-0.97]; tertile 3: 0.91 [95% CI, 0.89-0.92]) and CKD (tertile 2: 0.80 [95% CI, 0.78-0.82]; tertile 3: 0.73 [95% CI, 0.72-0.76]). After adjusting for both neighborhood and individual covariates, supermarket distance remained significantly associated with greater odds of diabetes and lesser odds of hypertension, but there was no significant association with CKD.

LIMITATIONS

Unmeasured neighborhood and social confounding variables, zip code-level analysis, and limited individual-level information.

CONCLUSIONS

There are significant disparities in supermarket proximity and incidence of hypertension, diabetes, and CKD in Chicago, Illinois. The relationship between supermarket access and chronic disease is largely explained by individual- and neighborhood-level factors.

Influence of personality traits, gender, and socio-economic factors in obesity in the English Longitudinal Study of Ageing

Obesity is a chronic disorder associated with high mortality rates and high morbidity. The risk of obesity is associated with certain personality traits (PTs). Some studies have found correlations among some PTs and gender. Additionally, obesity implies higher costs in daily living. The aim of this paper is to overcome this problem in the literature and estimate the association between PTs and obesity by taking into account the economic situation of the individual. This study employs data from the English Longitudinal Study of Ageing (ELSA). We focus on waves 5 and 6 of the ELSA with a sample of 6562 individuals. The results suggests that the traits of agreeableness ( β = 0.071 , se = 0.016 , p < 0.001 $$ \beta =0.071, se=0.016,\kern0.5em p<0.001 $$ ) and openness ( β = 0.028 , se : 0.014 , p < 0.001 $$ \beta =0.028, se:0.014,\kern0.5em p<0.001 $$ ) are positively and significantly associated with obesity. On the other hand, consciousness has a negative and statistically significant effect on obesity β = 0.072 , se : 0.017 , p < 0.001 $$ \left(\beta =0.072, se:0.017,\kern0.5em p<0.001\right) $$ . Results are robust to the inclusion/exclusion of different regressors.

A Novel Approach to Characterize State-level Food Environment and Predict Obesity Rate Using Social Media Data: Correlational Study

BACKGROUND

Community obesity outcomes can reflect the food environment to which the community belongs. Recent studies have suggested that the local food environment can be measured by the degree of food accessibility, and survey data are normally used to calculate food accessibility. However, compared with survey data, social media data are organic, continuously updated, and cheaper to collect.

OBJECTIVE

The objective of our study was to use publicly available social media data to learn the relationship between food environment and obesity rates at the state level.

METHODS

To characterize the caloric information of the local food environment, we used food categories from Yelp and collected caloric information from MyFitnessPal for each category based on their popular dishes. We then calculated the average calories for each category and created a weighted score for each state. We also calculated 2 other dimensions from the concept of access, acceptability and affordability, to build obesity prediction models.

RESULTS

The local food environment characterized using only publicly available social media data had a statistically significant correlation with the state obesity rate. We achieved a Pearson correlation of 0.796 between the predicted obesity rate and the reported obesity rate from the Behavioral Risk Factor Surveillance System across US states and the District of Columbia. The model with 3 generated feature sets achieved the best performance.

CONCLUSIONS

Our study proposed a method for characterizing state-level food environments only using continuously updated social media data. State-level food environments were accurately described using social media data, and the model also showed a disparity in the available food between states with different obesity rates. The proposed method should elastically apply to local food environments of different sizes and predict obesity rates effectively.

Prehypertension and its predictors among older adolescents: A cross-sectional study from eastern Nepal

Prehypertension is a state of transition between normal blood pressure and hypertension. Adolescent prehypertension is a strong predictor of hypertension in adults and is now considered for cardiovascular intervention or risk reduction. This study was conducted among adolescents to assess the burden of pre-hypertension and its predictors. A cross-sectional study was conducted among grade 11 and 12 students in three districts in eastern Nepal namely Jhapa, Morang and Sunsari. Sampling was done using a multistage stratified proportionate random method. A semi-structured questionnaire adapted from the WHO STEPwise approach to the non-communicable disease risk factor surveillance (STEPS) instrument was used as a study tool after modification and pre-testing in addition to the anthropometric and blood pressure measurements by the investigators. The prevalence of prehypertension was assessed along with the identification of its predictors through multivariable binary logistic regression modelling. A total of 806 participants aged 15 to 19 years, with 57.1% female, participated in the study. Prehypertension was found in 20.8% (24.6% in males and 18.0% in females) of the participants, while 7.1% of them were hypertensive (9.2% males and 5.4% females). Obesity and central obesity were seen among 6.3% and 17.7% of the respondents respectively. Age, sex, ethnicity and obesity were found to be significantly associated with prehypertension. A significant proportion of prehypertension was seen among the adolescent population along with a notable presence of risk factors such as smoking, alcohol consumption, obesity, and eating out. This warrants careful consideration and identification of relevant strategies to reduce the burden of prehypertension via school-based interventions to reduce the modifiable risk factors.

A parsimonious model to validate cost-effectiveness analyses on preventive health care

Background

The effect of preventive health care on health expenditures is ambiguous. On the one hand, prevention reduces the costs of future morbidity. On the other hand, prevention leads to costs of life extension. The purpose of this paper is to develop a parsimonious model that determines for a preventive measure of interest whether savings from preventing morbidity are more than offset by the costs of living longer, resulting in a net expenditure increase.

Methods

A theoretical model was built based on a Weibull survival function. It includes savings and life extension costs over the remaining lifetime. The model was applied to the example of obesity prevention.

Results

The model shows that the cost consequences of prevention are essentially driven by two factors: i) the relative reduction of morbidity-related costs, which determines the amount of savings from avoiding morbidity; and ii) the hazard ratio of death, which determines the amount of life extension costs. In the application example, the model is able to validate the results of a more complex cost-effectiveness model on obesity prevention.

Conclusions

This work provides new insight into the lifetime cost consequences of prevention. The model can be used both to check plausibility of the results of other models and to conduct an independent analysis.

A Spatial Analysis of Obesity: Interaction of Urban Food Environments and Racial Segregation in Chicago

The obesity rate in Chicago has increased up to more than 30% in the last two decades. Obesity is a major problem in Chicago, where 36% of the city's high school students and 61% of adults in the metropolitan area are overweight or obese. Simultaneously, Chicago remains highly segregated by race-a phenomenon that begs for spatial analysis of health. Extant work exploring associations between the food retail environment and obesity has provided mixed findings, and virtually, none of this work has been done with the effects of the interaction between racial segregation and the food retail environment on obesity, where obesity rates are among the highest in the segregation area for the city defined by racial segregation. This study explores whether being overweight or obese is associated with urban food environments, such as access to different types of food retail outlets, and how its associations interact with racial factors, at the community level. This study uses the 2016-2018 data from the Healthy Chicago Survey to investigate the spatial variations in obesity and their association with food environments in Chicago. Also, this study examines the moderating effects of racial segregation on associations between obesity and access to food retail outlets. Using spatial statistics and regression models with interaction terms, this study assesses how the urban food environment can interact with racial segregation to explain the spatial distribution of obesity. The results indicate that the obesity population is highly concentrated in the African American community. In Chicago, each additional convenience store in a community is associated with a 0.42% increase in the obesity rate. Fast food restaurant access is predictive of a greater obesity rate, and grocery store access is predictive of less obesity rate in a community with a higher percentage of African American population. Findings can be used to promote equitable access to food retail outlets, which may help reduce broader health inequities in Chicago.

Childhood adversity is linked to adult health among African Americans via adolescent weight gain and effects are genetically moderated

Identifying the mechanisms linking early experiences, genetic risk factors, and their interaction with later health consequences is central to the development of preventive interventions and identifying potential boundary conditions for their efficacy. In the current investigation of 412 African American adolescents followed across a 20-year period, we examined change in body mass index (BMI) across adolescence as one possible mechanism linking childhood adversity and adult health. We found associations of childhood adversity with objective indicators of young adult health, including a cardiometabolic risk index, a methylomic aging index, and a count of chronic health conditions. Childhood adversities were associated with objective indicators indirectly through their association with gains in BMI across adolescence and early adulthood. We also found evidence of an association of genetic risk with weight gain across adolescence and young adult health, as well as genetic moderation of childhood adversity's effect on gains in BMI, resulting in moderated mediation. These patterns indicated that genetic risk moderated the indirect pathways from childhood adversity to young adult health outcomes and childhood adversity moderated the indirect pathways from genetic risk to young adult health outcomes through effects on weight gain during adolescence and early adulthood.

Methodological Challenges in Estimating the Lifetime Medical Care Cost Externality of Obesity

There is a great deal of variability in estimates of the lifetime medical care cost externality of obesity, partly due to a lack of transparency in the methodology behind these cost models. Several important factors must be considered in producing the best possible estimate, including age-related weight gain, differential life expectancy, identifiability, and cost model selection. In particular, age-related weight gain represents an important new component to recent cost estimates. Without accounting for age-related weight gain, a study relies on the untenable assumption that people remain the same weight throughout their lives, leading to a fundamental misunderstanding of the evolution and development of the obesity crisis. This study seeks to inform future researchers on the best methods and data available both to estimate age-related weight gain and to accurately and consistently estimate obesity's lifetime external medical care costs. This should help both to create a more standardized approach to cost estimation as well as encourage more transparency between all parties interested in the question of obesity's lifetime cost and, ultimately, evaluating the benefits and costs of interventions targeting obesity at various points in the life course.

Awareness drives changes in reward value which predict eating behavior change: Probing reinforcement learning using experience sampling from mobile mindfulness training for maladaptive eating

BACKGROUND AND AIMS

Maladaptive eating habits are a major cause of obesity and weight-related illness. The development of empirically-based approaches, such as mindfulness training (MT) that target accurate mechanisms of action to address these behaviors is therefore critical. Two studies were conducted to examine the impact of MT on maladaptive eating and determine the involvement of reinforcement learning mechanisms underlying these effects.

METHODS

In Study1, maladaptive eating behaviors were assessed using self-report questionnaires at baseline and 8 weeks after an app-based MT intervention (n = 46). A novel mindful eating craving tool was embedded in our intervention to assess: eating behaviors (intake frequency/magnitude), and reward (contentment ratings) experienced after eating. Using a well-established reinforcement learning (Rescorla-Wagner) model, expected reward values (EV) were estimated as a function of contentment levels reported after eating. In Study2 (n = 1,119), craving tool assessments were examined in an independent sample using the app in a real-world naturalistic context.

RESULTS

Study 1's results revealed a significant decrease in EV and eating behaviors across craving tool uses. In addition, changes in reward values predicted decreases in eating behaviors. Finally, Study 1's results revealed significant pre-post intervention reductions in self-reported eating behaviors. In Study2, we observed a significant decrease in EV, but not in eating behaviors, across craving tool uses. Study 2 also revealed a predictive relationship between EV and eating behaviors.

DISCUSSION AND CONCLUSIONS

These results support the implementation of MT to prevent and treat maladaptive eating behaviors, which target reinforcement learning processes as mechanisms of action.

One Hundred Years of Insulin: Value Beyond Price in Type 2 Diabetes Mellitus

Type 2 diabetes mellitus is a chronic, progressive disease that frequently necessitates treatment with basal insulin to maintain adequate glycaemic control. In considering the value of different basal insulin therapies, although acquisition costs are of increasing importance to budget-constrained healthcare systems, value beyond simple price considerations should be taken into account. Whilst human basal insulins are of lower acquisition cost compared to long-acting insulin analogues, this difference in price has the potential to be offset in terms of total healthcare system value through the ultra-long duration of action and low variability in glucose-lowering activity which have been translated into real clinical benefits, in particular a reduced risk of hypoglycaemic events. The maintenance of glycaemic targets and avoidance of hypoglycaemia that have been associated with insulin analogues represent a significant value consideration, beyond price, for the use of basal insulin analogues to manage type 2 diabetes mellitus from the perspective of all stakeholders within the healthcare system, including payers, healthcare professionals, patients and society.

A Causal Estimate of Long-Term Health Care Spending Attributable to Body Mass Index Among Adults

While high body mass index (BMI) is believed to be a major driver of poor health, there is little evidence about whether it leads to higher health care spending. Understanding the causal contribution of BMI to health care spending is necessary to estimate the returns to investment in weight loss efforts. We exploit genetic variation in BMI across siblings as a natural experiment to estimate the impact of BMI on cumulative third party and out-of-pocket health care spending among adults using the Panel Study of Income Dynamics data from 1999 through 2011. We estimate a two-stage residual inclusion model with a generalized linear model. We find a $611.60 increase in cumulative insurer spending for each one-unit increase in BMI. This amounts to $130.49 in mean annual spending, and is two times higher than the non-causal estimate. We find no difference in out-of-pocket spending by BMI. These findings suggest that having a higher BMI in young/middle adulthood leads to significantly higher insurer health expenditures over the life course, which can help to inform public and private insurer policies on BMI reduction and control.

Does Physical Activity Predict Obesity-A Machine Learning and Statistical Method-Based Analysis

BACKGROUND

Obesity prevalence has become one of the most prominent issues in global public health. Physical activity has been recognized as a key player in the obesity epidemic.

OBJECTIVES

The objectives of this study are to (1) examine the relationship between physical activity and weight status and (2) assess the performance and predictive power of a set of popular machine learning and traditional statistical methods.

METHODS

National Health and Nutrition Examination Survey (NHANES, 2003 to 2006) data were used. A total of 7162 participants met our inclusion criteria (3682 males and 3480 females), with average age ranging from 48.6 (normal weight) to 52.1 years old (overweight). Eleven classifying algorithms-including logistic regression, naïve Bayes, Radial Basis Function (RBF), local k-nearest neighbors (k-NN), classification via regression (CVR), random subspace, decision table, multiobjective evolutionary fuzzy classifier, random tree, J48, and multilayer perceptron-were implemented and evaluated, and they were compared with traditional logistic regression model estimates.

RESULTS

With physical activity and basic demographic status, of all methods analyzed, the random subspace classifier algorithm achieved the highest overall accuracy and area under the receiver operating characteristic (ROC) curve (AUC). The duration of vigorous-intensity activity in one week and the duration of moderate-intensity activity in one week were important attributes. In general, most algorithms showed similar performance. Logistic regression was middle-ranking in terms of overall accuracy, sensitivity, specificity, and AUC among all methods.

CONCLUSIONS

Physical activity was an important factor in predicting weight status, with gender, age, and race/ethnicity being less but still essential factors associated with weight outcomes. Tailored intervention policies and programs should target the differences rooted in these demographic factors to curb the increase in the prevalence of obesity and reduce disparities among sub-demographic populations.

Factors Affecting Metabolic Outcomes Post Bariatric Surgery: Role of Adipose Tissue

Obesity is an ever-growing public health crisis, and bariatric surgery (BS) has become a valuable tool in ameliorating obesity, along with comorbid conditions such as diabetes, dyslipidemia and hypertension. BS techniques have come a long way, leading to impressive improvements in the health of the majority of patients. Unfortunately, not every patient responds optimally to BS and there is no method that is sufficient to pre-operatively predict who will receive maximum benefit from this surgical intervention. This review focuses on the adipose tissue characteristics and related parameters that may affect outcomes, as well as the potential influences of insulin resistance, BMI, age, psychologic and genetic factors. Understanding the role of these factors may help predict who will benefit the most from BS.

The Influence of Obesity on Treatment and Outcome of Severely Burned Patients

Obesity and the related medical, social, and economic impacts are relevant multifactorial and chronic conditions that also have a meaningful impact on outcomes following a severe injury, including burns. In addition to burn-specific difficulties, such as adequate hypermetabolic response, fluid resuscitation, and early wound coverage, obese patients also present with common comorbidities, such as arterial hypertension, diabetes mellitus, or nonalcoholic fatty liver disease. In addition, the pathophysiologic response to severe burns can be enhanced. Besides the increased morbidity and mortality compared to burn patients with normal weight, obese patients present a challenge in fluid resuscitation, perioperative management, and difficulties in wound healing. The present work is an in-depth review of the current understanding of the influence of obesity on the management and outcome of severe burns.

A Comparison of Maternal Health Status and Weight-Related Cognitions, Behaviors, and Home Environments by Race/Ethnicity

This cross-sectional study compared weight-related cognitions, behaviors, and home environments of 568 mothers of young children (ages 2 to <9 years) by racial/ethnic group. Maternal health status was good and did not differ by race/ethnicity. Mothers were somewhat confident in their ability to promote healthy physical activity and eating behaviors in their children, with White and Asian mothers having greater confidence than Hispanic mothers. Mothers had low physical activity, with Hispanic mothers getting more sedentary screentime than White and Asian mothers. Mothers' dietary intake did not differ. Modeling of healthful behaviors was more frequent in White than Hispanic mothers. Asian mothers tended to use non-recommended feeding patterns more than White, Hispanic, and Black mothers. Children's physical activity and screentime did not differ by race/ethnicity. Asian children tended to drink less sugar-sweetened beverages and more milk than counterparts. All reported frequent family meals, with Hispanic mothers reporting more family meals eaten in less healthful locations. Household food environments did not differ. However, White mothers reported greater access to physical activity space and supports than Hispanic mothers. Race/ethnicity may link with maternal weight-related cognitions, behaviors, and home environments and thus can help inform the development of interventions tailored by race/ethnicity.

Socioeconomics of Obesity

PURPOSE OF REVIEW

The purpose of this review is to evaluate and emphasize important findings in the recent literature regarding the socioeconomics of obesity. It is important to evaluate trends of this global epidemic and elucidate its impact on different demographic groups and across socioeconomic strata.

RECENT FINDINGS

Obesity rates continue to increase domestically and globally which is associated with a concomitant rise in medical and economic costs. There are disparities in obesity rates based on race/ethnicity, sex, gender and sexual identity, and socioeconomic status, yet these disparities are not explained fully by health behaviors, socioeconomic position, or cumulative stress alone-community and societal environmental factors have a significant role in the obesity epidemic. Socioeconomic factors contribute to obesity on an individual and community level, and any viable approach to sustainably addressing the obesity epidemic must take these factors into account.

The Unequal Effect of Income on Risk of Overweight/Obesity of Whites and Blacks with Knee Osteoarthritis: the Osteoarthritis Initiative

BACKGROUND

Although the protective effect of socioeconomic status (SES) against risk of overweight/obesity is well established, such effects may not be equal across diverse racial and ethnic groups, as suggested by the marginalization-related diminished returns (MDR) theory.

AIMS

Built on the MDR theory, this study explored racial variation in the protective effect of income against overweight/obesity of Whites and Blacks with knee osteoarthritis (OA).

METHODS

This cross-sectional study used baseline data of the OA Initiative, a national study of knee OA in the USA. This analysis included 4664 adults with knee OA, which was composed of 3790 White and 874 Black individuals. Annual income was the independent variable. Overweight/obesity status (body mass index more than 25 kg/m2) was the dependent variable. Race was the moderator. Logistic regressions were used for data analysis.

RESULTS

Overall, higher income was associated with lower odds of being overweight/obese. Race and income showed a statistically significant interaction on overweight/obesity status, indicating smaller protective effect of income for Blacks compared with Whites with knee OA. Race-stratified regression models revealed an inverse association between income and overweight/obesity for White but not Black patients.

CONCLUSIONS

While higher income protects Whites with knee OA against overweight/obesity, this effect is absent for Blacks with knee OA. Clinicians should not assume that the needs of high-income Whites and Blacks with knee OA are similar, as high-income Blacks may have greater unmet needs than high-income Whites. Racially tailored programs may help reduce the health disparities between Whites and Blacks with knee OA. The results are important given that elimination of racial disparities in obesity is a step toward eliminating racial gap in the burden of knee OA. This is particularly important given that overweight/obesity is not only a prognostic factor for OA but also a risk factor for cardiometabolic diseases and premature mortality.

The ENGAGE-2 study: Engaging self-regulation targets to understand the mechanisms of behavior change and improve mood and weight outcomes in a randomized controlled trial (Phase 2)

Despite evidence for effective integrated behavior therapy for treating comorbid obesity and depression, treatment response is highly variable and the underlying neurobiological mechanisms remain unknown. This hampers efforts to identify mechanistic targets in order to optimize treatment precision and potency. Funded within the NIH Science of Behavior Change (SOBC) Research Network, the 2-phased ENGAGE research project applies an experimental precision medicine approach to address this gap. The Phase 1 study focused on demonstrating technical feasibility, target engagement and potential neural mechanisms of responses to an integrated behavior therapy. This therapy combines a video-based behavioral weight loss program and problem-solving therapy for depression, with as-needed intensification of antidepressant medications, and its clinical effectiveness was demonstrated within a parent randomized clinical trial. Here, we describe the ENGAGE Phase 2 (ENGAGE-2) study protocol which builds on Phase 1 in 2 ways: (1) pilot testing of an motivational interviewing-enhanced, integrated behavior therapy in an independent, primarily minority patient sample, and (2) evaluation of a priori defined neural targets, specifically the negative affect (threat and sadness) circuits which demonstrated engagement and malleability in Phase 1, as mediators of therapeutic outcomes. Additionally, the Phase 2 study includes a conceptual and methodological extension to explore the role of microbiome-gut-brain and systemic immunological pathways in integrated behavioral treatment of obesity and depression. This protocol paper documents the conceptualization, design and the transdisciplinary methodologies in ENGAGE-2, which can inform future clinical and translational research in experimental precision medicine for behavior change and chronic disease management. Trial registration: ClinicalTrials.gov #NCT 03,841,682.

Early outcomes and complications of obese patients undergoing shoulder arthroplasty: A meta-analysis

OBJECTIVE

The prevalence of obesity and shoulder arthroplasty have both been increasing in the United States. Although lower extremity arthroplasty literature suggests higher complication rates in these patients, there is a paucity of studies evaluating the outcome of shoulder arthroplasty in obese patients. Our purpose was to perform a meta-analysis to determine clinical outcomes and complications of these patients.

METHODS

Following the PRISMA guidelines, the MEDLINE (PubMed), Embase, and Ovid libraries were used to perform a comprehensive literature review to compare complications and outcomes following shoulder arthroplasty between obese and non-obese patients. Our initial search returned 143 publications. Our inclusion criteria included full-text reports, minimum follow-up of 1 year, minimum of 10 patients, no cadaveric or biomechanical studies, only studies published in English, studies involving obese patients undergoing either anatomic or reverse shoulder arthroplasty. A total of 13 studies met the inclusion criteria. These studies were then evaluating using a methodological index for non-randomized studies (MINORS) score. Ultimately, 6 studies met our criteria and were included in the final analysis.

RESULTS

A total of 978 patients were identified from the 6 studies. Patients with a BMI <30 kg/m² had a complication rate of 9.7% and American Shoulder and Elbow Surgeons score (ASES) increased from 37.4 to 76.7. Patients with a BMI >30 kg/m² had a complications rate of 6.5% and ASES increased from 34.4 to 76.2. Patients with a BMI >40 kg/m² ASES increased from 29.5 to 68.6. The postoperative ASES score of 68.6 for patients with a BMI >40 kg/m² was significantly lower than the ASES score of 76.8 in patients with a BMI <40 kg/m² (p = 0.007). There were an insufficient number of patients and an insufficient number of complications to perform any meaningful statistical test on complication rates in patients with a BMI >40 kg/m².

CONCLUSION

No significant difference was observed in number of complications and follow-up ASES scores following shoulder arthroplasty between obese and non-obese patients. Morbidly obese patients (BMI > 40 kg/m²) have a significantly lower ASES follow-up score than non-morbidly obese patients; however, this difference may not be clinically significant. Future studies are needed to investigate outcomes and complications associated with morbidly obese patients undergoing shoulder arthroplasty.

Body mass index and lifetime healthcare utilization

BACKGROUND

Overweight and obesity is a major global public health challenge, and understanding the implications for healthcare systems is essential for policy planning. Past studies have typically found positive associations between obesity and healthcare utilization, but these studies have not taken into consideration that obesity is also associated with early mortality. We examined associations between body mass index (BMI, reported as kg/m2) and healthcare utilization with and without taking BMI-specific survival into consideration.

METHODS

We used nationally representative data on 33 882 adults collected between 2002 and 2015. We computed BMI- and age-specific primary and secondary care utilization and multiplied the estimated values with gender-, age-, and BMI-specific probabilities of surviving to each age. Then, we summed the average BMI-specific utilization between 18 and 85 years.

RESULTS

During a survival-adjusted lifetime, males with normal weight (BMI: 18.5-24.9) had, on average, 167 primary care, and 77 secondary care contacts. In comparison, males with overweight (BMI: 25.0-29.9), category I obesity (BMI: 30.0-34.9), and category II/III obesity (BMI ≥35.0) had 11%, 41%, and 102% more primary care, and 14%, 29%, and 78% more secondary care contacts, respectively. Females with normal weight had, on average, 210 primary care contacts and 91 secondary care contacts. Females with overweight, category I obesity, and category II/III obesity had 20%, 34%, and 81% more primary care contacts, and 26%, 16%, and 16% more secondary care contacts, respectively.

CONCLUSION

The positive association between BMI and healthcare utilization was reduced, but not offset, when BMI-specific survival was taken into consideration. Our findings underpin previous research and suggest that interventions to offset the increasing prevalence of overweight, and especially obesity, are warranted.

Investigation of Skull-Based Cerebrospinal Fluid Leak Repair: A Single-Institution Comprehensive Study of 116 Cases Over 10 Years

BACKGROUND

Cerebrospinal fluid (CSF) leaks have been historically difficult to diagnose and treat because their cause can widely vary. There are insufficient diagnostic predictors and no clinically accepted standards for their treatment. This large institutional study reports on the diagnosis, management, and outcomes of patients presenting with CSF leak over 10 years and aims to identify potential comorbidities and risk factors for primary and recurrent leaks.

METHODS

Patients diagnosed with CSF leak from 2007 to 2017 were analyzed retrospectively. The data included medical history, body mass index, surgical treatment, and postoperative outcomes.

RESULTS

A total of 116 cases were identified. The location of leaks was 91 CSF rhinorrhea and 28 CSF otorrhea (3 both). The average BMI for females was greater than that of males (P = 0.01). Causes of leak were 64 noniatrogenic, 47 iatrogenic, and 9 traumatic. A total of 108 patients underwent surgical treatment. Sixty-nine were treated by endoscopic approaches, 42 involved open approaches, and 83 involved the placement of a lumbar drain. Eighteen patients had a ventriculoperitoneal shunt and 6 had a lumbar-peritoneal shunt. A total of 78 patients (72.22%) had an associated encephalocele with the CSF leak. The average length of stay was 7.73 days (0.76). The average length of follow-up was 1.58 years (0.22). The primary repair rate was 80.17% (n = 93) and the overall repair outcome was 99.14% (n = 115).

CONCLUSIONS

The overall CSF repair outcome was 99.14% over 10 years at a single institution. Despite this high percentage, CSF leaks continue to be a complex problem and require vigorous multidisciplinary work with close follow-up and use of multiple imaging strategies.

To what extent does sex, age and BMI impact medical and pharmacy costs? A retrospective cohort study involving employees in a large school district in the USA

OBJECTIVE

To identify the extent that sex, age and body mass index (BMI) is associated with medical and pharmacy costs.

DESIGN

Retrospective cohort.

SETTING

A school district in the Western USA involving 2531 workers continuously employed during 2011-2014.

MAIN OUTCOME MEASURES

Medical and pharmacy costs and BMI.

RESULTS

Approximately 84% of employees participated in wellness screening. Participants were 1.03 (95% CI 1.01 to 1.06) times more likely to be women and younger (M=47.8 vs 49.8, p<0.001). Median medical and pharmacy costs were higher for women than men, increased with age, and were greater in morbidly obese individuals (p<0.001). Annual pharmacy claims were 18% more likely to be filed by women than men, 23% more likely filed by those aged ≥60 versus <40 years, and 6% more likely filed by morbidly obese individuals than of normal weight (p<0.001) individuals. Greater medical and pharmacy costs in older age were most pronounced in underweight and morbidly obese groups. Higher use of medication among women than men was primarily because of drugs involving birth control, osteoporosis, thyroid disease and urinary tract infection. Higher medication use in older age was primarily related to medications used to treat gastrointestinal problems. Medication use was positively associated with BMI weight classifications for most of the 33 drug types considered, with exceptions involving birth control, herpes and osteoporosis. A J-shape relationship was observed between BMI and medication use for acne, antibiotic, cold/influenza/allergy, eye infection, oedema, muscle spasms, pain and ulcers.

CONCLUSIONS

Medications associated with higher medical and pharmacy costs among women, older age and underweight or obese individuals are identified. Lowering medical and pharmacy costs requires weight management in older ages, particularly for underweight and obese. Higher pharmacy costs for certain drugs among underweight individuals may be associated with poorer nutrition.

Antenatal Synthetic Glucocorticoid Exposure at Human Therapeutic Equivalent Doses Predisposes Middle-Age Male Offspring Baboons to an Obese Phenotype That Emerges With Aging

INTRODUCTION

Women threatening premature delivery receive synthetic glucocorticoids (sGC) to accelerate fetal lung maturation, reducing neonatal mortality and morbidity. Few investigations have explored potential long-term offspring side effects. We previously reported increased pericardial fat and liver lipids in 10-year-old (human equivalent 40 years) male baboons exposed to 3 antenatal sGC courses. We hypothesized middle-aged sGC male offspring show obesity-related morphometric changes.

METHODS

Pregnant baboons received courses of 2 betamethasone injections (175 μg·kg-1·d-1 intramuscular) at 0.6, 0.64, and 0.68 gestation. At 10 to 12.5 years, we measured morphometrics and serum lipids in 5 sGC-exposed males and 10 age-matched controls. We determined whether morphometric parameters predicted amount of pericardial fat or lipids. Life-course serum lipids were measured in 25 males (7-23 years) providing normal regression formulas to compare sGC baboons' lipid biological and chronological age.

RESULTS

Birth weights were similar. When studied, sGC-exposed males showed a steeper weight increase from 8 to 12 years and had increased waist and hip circumferences, neck and triceps skinfolds, and total and low-density lipoprotein cholesterol. Triceps skinfold correlated with apical and midventricular pericardial fat thickness, hip and waist circumferences with insulin.

CONCLUSIONS

Triceps skinfold and waist and hip circumferences are useful biomarkers for identifying individuals at risk for obesity and metabolic dysregulation following fetal sGC exposure. Prenatal sGC exposure predisposes male offspring to internal adiposity, greater body size, and increased serum lipids. Results provide further evidence for developmental programming by fetal sGC exposure and call attention to potential emergence of adverse life-course effects.

A Patient-Centered PaTH to Address Diabetes: Protocol for a Study on the Impact of Obesity Counseling

BACKGROUND

Overweight and obesity are America's number one health concern. The prevalence of obesity in the United States is greater than 36%, a rate that has doubled since 1970. As the second most preventable cause of death, obesity is a risk factor for diabetes, cardiovascular disease, stroke, and cancer, all major causes of death. Primary care clinics may be an ideal setting for weight control interventions to help manage and prevent diabetes. For this reason, the Centers for Medicare and Medicaid Services (CMS) implemented a health care procedure coding system code for intensive behavioral therapy (IBT) for obesity within primary care in 2012 to facilitate payment for addressing obesity, which was followed by broader coverage by most insurers for IBT for adults in 2013. However, the impact of this coverage on patient-centered outcomes is largely unknown.

OBJECTIVE

The overarching goal of this study is to understand the comparative effectiveness of obesity counseling as covered by CMS and other insurers in improving weight loss for adults either with or at increased risk for type 2 diabetes.

METHODS

This study leverages the novel infrastructure of the Patient-Centered Outcomes Research Institute-funded PaTH Clinical Data Research Network. The PaTH network is comprised of Geisinger Health System, Johns Hopkins University, Johns Hopkins Health System, Lewis Katz School of Medicine at Temple University, Temple Health System, Penn State College of Medicine, Penn State Milton S Hershey Medical Center, University of Pittsburgh, UPMC and UPMC Health Plan, and the University of Utah. Electronic health record (EHR) data will originate from the 6 PaTH health systems. Specifically, we will (1) evaluate the impact of broader preventive service coverage for obesity screening and counseling on weight loss, diabetes incidence, and diabetes outcomes in patients with diabetes or at increased risk for diabetes (defined by body mass index [BMI] ≥25). We will determine how the annual probability of receiving obesity and/or nutritional counseling changed pre- and postpolicy across all insurers in a cohort of patients with diabetes and at high risk for diabetes. We will (2) compare patient weight loss and diabetes-related outcomes among those who receive obesity screening and counseling with those who do not, following implementation of preventive service coverage. We will examine postpolicy impact of obesity screening and counseling in a cohort of patients with diabetes and at increased risk for diabetes. Specific outcomes to be examined include weight loss, diabetes incidence, and diabetes outcomes. Exploratory outcomes will include patient-reported outcomes. Furthermore, we will determine patient characteristics, including demographics, and practice characteristics, including provider type.

RESULTS

Our PCORI-funded study is underway. To date, we have obtained our second data extraction from the PaTH CDRN and are performing data editing and cleaning. Next steps include analysis of early policy change.

CONCLUSIONS

Given patients who are overweight are at highest risk for diabetes, improved weight management services could prevent diabetes and its negative health outcomes. Comparing weight and diabetes outcomes in 3 states using EHRs and claims data before and after this policy was implemented using the PaTH Network will allow important insight into policy effectiveness.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/12054.

Phenotypic and genetic relationship between BMI and cigarette smoking in a sample of UK adults

In addition to the health hazards posed individually by cigarette smoking and obesity, the combination of these conditions poses a particular impairment to health. Genetic factors have been shown to influence both traits and, to understand the connection between these conditions, we examined both the observed and genetic relationship between adiposity (an electrical impedance measure of body mass index (BMI)) and cigarettes smoked per day (CPD) in a large sample of current, former, and never smokers in the United Kingdom. In former smokers, BMI was positively associated with cigarettes formerly smoked; further, the genetic factors related to a greater number of cigarettes smoked were also responsible for a higher BMI. In current smokers, there was a positive association between BMI and number of cigarettes smoked, though this relationship did not appear to be influenced by similar genetic factors. We found a positive genetic relationship between smoking in current/former smokers and BMI in never smokers (who would be unmarred by the effects of nicotine). In addition to CPD, in current smokers, we looked at two variables, time from waking to first cigarette and difficulty not smoking for a day, that may align better with cigarette and food 'craving.' However, these smoking measures provided mixed findings with respect to their relationship with BMI. Overall, the positive relationships between the genetic factors that influence CPD in smokers and the genetic factors that influence BMI in former and never smokers point to common biological influences behind smoking and obesity.

Perceived causes of obesity, emotions, and attitudes about Discrimination Policy

RATIONALE

Although obesity represents a potential public health crisis, our understanding of public perceptions of obesity, emotional responses to the obese, and related policy preferences is limited.

OBJECTIVE

We employed Weiner's attribution theory of controllability (Weiner, 1988, 2011) to examine perceived causes of obesity, emotional responses, and related policy implications. If the perceived cause is controllable (eating and lifestyle habits), we expected less sympathy and greater anger toward obese people and support for prejudicial hiring policies based on weight. If the cause is perceived as uncontrollable (genetic), sympathy is anticipated as well as opposition to such hiring policies.

METHOD

We conducted multivariate analyses with data from two nationally representative surveys of U.S. adults.

CONCLUSION

Our findings supported the hypotheses, showing that sympathy and lack of anger toward obese people are strongly determined by a genetic attribution for obesity. Moreover, sympathy and the genetic attribution are significant predictors of opposition to hiring policies that discriminate against obese people. Finally, in a second study, chief among several causal attributions for obesity-lack of will power, lack of exercise, marketing of foods, and genetics-we discovered biological attribution functions as the key predictor of perceptions that obese people are frequent targets of discrimination. We suggest governments and the food industry should be more attuned to the underlying beliefs of the public about the causes of obesity when formulating programs and policies to address the issue.

Overweight and obesity in type 1 diabetes equal those of the general population

BACKGROUND

The obesity epidemic might affect patients with type 1 diabetes (T1DM), historically described as lean and insulin-sensitive subjects. Insulin resistance in T1DM might increase diabetic complications, especially cardiovascular disease. Therefore, the body mass index (BMI) in T1DM patients was analyzed in comparison to the general population. Furthermore, the impact of increased BMI on glycemic control and metabolic alterations was assessed.

METHODS

Body mass index was compared overall and among four different age groups between adult T1DM (n = 186), treated in the outpatient clinic between 2014 and 2016, and 15,771 individuals from the general population who took part at an Austrian health survey. Furthermore, parameters of glycemic control, lipid state, blood pressure and additional medication were compared between T1DM with a BMI under or above 27.5 kg/m².

RESULTS

Patients with T1DM had significantly higher BMI values than general population (25.9 ± 4.2 kg/m² vs. 25.3 ± 4.5 kg/m²; p = 0.027), controlling for age group; however, prevalence of overweight (39.8% vs. 33.1%) and obesity (14% vs. 13.8%) was not significantly different. Within the 4 age groups only T1DM patients between 30 years and 49 years old had significantly higher BMI values compared to the general population (mean difference 1.9 kg/m²; 95% confidence interval, CI: 0.96-2.83 kg/m²). In T1DM, a BMI ≥27.5 kg/m² was associated with increased rates of hypertension, dyslipidemia, microalbuminuria, and increased insulin demand, whereas glycemic control was not affected.

CONCLUSIONS

In contrast to common descriptions T1DM patients have a higher BMI compared to the general population. Rates of overweight and obesity in T1DM equal those of the general population. Therefore, it is concluded that the obesity epidemic has reached T1DM patients and "double diabetes" might be an entity to consider.

Coverage for Obesity Prevention and Treatment Services: Analysis of Medicaid and State Employee Health Insurance Programs

OBJECTIVE

This study examined changes in coverage for adult obesity treatment services in Medicaid and state employee health insurance programs between 2009 and 2017.

METHODS

Administrative materials from Medicaid and state employee health insurance programs in all 50 states and the District of Columbia were reviewed for indications of coverage and payment policies specific to evidence-based treatment modalities for adults (≥ 21 years of age) with obesity, including nutritional counseling, pharmacotherapy, and bariatric surgery.

RESULTS

From 2009 to 2017, the proportion of state employee programs indicating coverage increased by 75% for nutritional counseling (from 24 to 42 states), 64% for pharmacotherapy (from 14 to 23 states), and 23% for bariatric surgery (from 35 to 43 states). The proportion of Medicaid programs indicating coverage increased by 133% for nutritional counseling (from 9 to 21 states) and 9% for bariatric surgery (from 45 to 49 states), with no net increase for pharmacotherapy (16 states in both plan years).

CONCLUSIONS

Coverage for adult obesity care improved substantially in Medicaid and state employee insurance programs since 2009. However, recommended treatment modalities are still not covered in many states. Where coverage has expanded, educating providers and beneficiaries on the availability and proper use of evidence-based obesity treatments may improve health outcomes.

An update on physical health and economic consequences of overweight and obesity

Overweight and obesity (OW and OB) have been on the increase globally and posed health risks to the world's population of all ages, including pre-born babies, children, adolescents, adults and elderly people, via their comorbid conditions. Excellent examples of comorbidities associated with obesity include cancer, cardiovascular diseases (CVD) and type 2 diabetes mellitus (T2DM). In this article, we aimed to review and update scientific evidence regarding the relationships between obesity and its common physical health consequences, including CVD, T2DM, hypertension, ischemic stroke, cancer, dyslipidemia and reproductive disorders. In addition, the economic burden of OW and OB will be discussed. Abundant evidence is found to support the associations between obesity and other diseases. In general, the odd ratios, risk ratios or hazard ratios are often higher in OW and OB people than in the normal-weight ones. However, the molecular mechanism of how OW and OB induce the development of other diseases has not been fully understood. Figures also showed that obesity and its-related disorders exert enormous pressure on the economy which is projected to increase. This review highlights the fact that obesity can lead to numerous lethal health problems; therefore, it requires a lot of economic resources to fight against this epidemic.

Morbid obesity and 1-year costs after elbow dislocation

Background

Morbid obesity has been linked with serious associated injuries following dislocations of the knee. While similar devastating injuries have been observed following elbow dislocations in the obese, no study to date has characterized the financial impact of elbow dislocations in the morbidly obese population.

Purpose

The purpose of this study is to determine the impact of morbid obesity on 1-year costs related to elbow dislocation.

Methods

A retrospective query of the Medicare Standard Analytic Files database was performed for patients sustaining elbow dislocation from 2005 to 2014. 1-year reimbursement costs from the initial open or closed reduction procedures were compared for morbidly obese (BMI ≥ 40 kg/m²) patients versus those without morbid obesity (BMI < 40 kg/m²). Cohorts were matched based on age and gender. Total reimbursement costs associated with a diagnosis of elbow dislocation and/or reduction were analyzed.

Results

We identified 182 morbidly obese patients and 422 patients without morbid obesity who underwent open or closed reduction for elbow dislocation. 102 patients with 1-year cost data remained in each cohort after matching. Mean 1-year reimbursement costs related to elbow dislocation were significantly greater in morbidly obese patients ($6227.43 vs $4225.71, p = 0.006).

Conclusion

1-year costs related to elbow dislocation are significantly higher in morbidly obese patients. The increased costs likely reflect the complexity of managing dislocations in the obese population. Difficulties maintaining closed reduction, longer and more challenging surgeries with a higher likelihood on intra- and post-operative complications, and a higher risk of peri-operative medical complications may all contribute to these increased costs.

Obesity in Elective Foot and Ankle Surgery

Obesity is a global health problem with significant economic and health consequences. There is very little literature in regards to obesity and its effect on foot and ankle surgery, and to the author's knowledge, there has been no consolidated review on this subject to date. The purpose of this article is to provide a comprehensive review as it pertains to foot and ankle surgery, with hopes of improving surgeon decision making, mitigating risk, and providing better outcomes for patients. A better understanding of the effects of obesity also allows for improved prognostic performance.

Family Income Reduces Risk of Obesity for White but Not Black Children

Background: Although the protective effects of socioeconomic status (SES) on obesity and cardiovascular disease are well established, these effects may differ across racial and ethnic groups. Aims: Using a national sample, this study investigated racial variation in the association between family income and childhood obesity in White and Black families. Methods: This cross-sectional study used data from the National Survey of Children’s Health (NSCH), 2003⁻2004, a nationally representative survey in the United States. This analysis included 76,705 children 2⁻17 years old who were either White (n = 67,610, 88.14%) or Black (n = 9095, 11.86%). Family income to needs ratio was the independent variable. Childhood obesity was the outcome. Race was the focal moderator. Logistic regression was used for data analysis. Results: Overall, higher income to needs ratio was protective against childhood obesity. Race, however, interacted with income to needs ratio on odds of childhood obesity, indicating smaller effects for Black compared to White families. Race stratified logistic regressions showed an association between family income and childhood obesity for White but not Black families. Conclusions: The protective effect of income against childhood obesity is smaller for Blacks than Whites. Merely equalizing population access to SES and economic resources would not be sufficient for elimination of racial disparities in obesity and related cardiovascular disease in the United States. Policies should go beyond access to SES and address structural barriers in the lives of Blacks which result in a diminished health return of very same SES resources for them. As the likely causes are multi-level barriers, multi-level interventions are needed to eliminate racial disparities in childhood obesity.

Good functional outcomes expected after shoulder arthroplasty irrespective of body mass index

BACKGROUND

This study evaluated how body mass index (BMI) factors into functional outcomes and complications after shoulder arthroplasty.

METHODS

A retrospective analysis was performed of age-matched patients with a minimum 2-year follow-up after total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RTSA), or hemiarthroplasty (HA). Patient-reported outcome (PRO) scores, range of motion (ROM), and complications were assessed. Forty-nine patients were classified into the following groups: normal (BMI <24.9 kg/m²), overweight (BMI 25-29.9 kg/m²), class I obese (BMI 30-34.9 kg/m2), class II obese (BMI 35-39.9 kg/m²), and class III morbid obese (BMI ≥40 kg/m²).

RESULTS

A total of 245 patients (134 women, 111 men; average age, 64 ± 8 years) were evaluated at an average follow-up of 48 ± 18 months. TSA was performed in 122 patients (50%), RTSA was performed in 103 (42%), and HA was performed in 20 (8%). No significant difference was found among the 5 BMI groups in arthroplasty type (P = .108) or in complications, including reoperations (P = .27). All groups had significant postoperative improvements in PROs and ROM (P < .001 for both). There were no significant differences among the BMI groups in postoperative ROM or PROs.

DISCUSSION

This study demonstrates that patients undergoing TSA, RTSA, and HA can expect good functional outcomes, with improvements in pain, function and outcome scores, irrespective of BMI.

Postoperative Complications of Total Joint Arthroplasty in Obese Patients Stratified by BMI

BACKGROUND

High body mass index (BMI) is associated with significant complications in patients undergoing total joint arthroplasty. Many studies have evaluated this trend, but few have looked at the rates of complications based on BMI as a continuous variable. The purpose of this study was to stratify obese patients into 3 BMI categories and evaluate their rates of complications and gauge whether transitioning from higher to lower BMI category lowers complication.

METHODS

Patients undergoing primary total joint arthroplasty were selected from the National Surgical Quality Improvement Program database from 2008-2015 and arranged into 3 groups based on BMI: O1 (BMI 30-34.9 kg/m²), O2 (BMI 35-39.9 kg/m²), and O3 (BMI >40 kg/m²). Thirty-day complications were recorded and evaluated utilizing univariate and multivariate analyses stratified by BMI.

RESULTS

A total of 268,663 patients were identified. Patients with a BMI >30 kg/m² had more infectious and medical complications compared with nonobese patients. Furthermore, there were increased complications as the BMI categories increased. Patients with a BMI >40 kg/m² (O3) had longer operating times, length of stay, higher rates of readmissions, reoperations, deep venous thrombosis, renal insufficiency, superficial infections, deep infections, and wound dehiscence. These trends were present when comparing the O2 with O1 category as well.

CONCLUSION

We have demonstrated increased rates of medical and surgical complications in obese patients. Furthermore, we demonstrated a stepwise increase in complication rates when transitioning to higher BMI groups. Based on our data, we believe that preoperative counseling and interventions to decrease BMI should be explored before offering elective surgery to obese patients.

Euglena extract suppresses adipocyte-differentiation in human adipose-derived stem cells

Euglena gracilis Z (Euglena) is a unicellular, photosynthesizing, microscopic green alga. It contains several nutrients such as vitamins, minerals, and unsaturated fatty acids. In this study, to verify the potential role of Euglena consumption on human health and obesity, we evaluated the effect of Euglena on human adipose-derived stem cells. We prepared a Euglena extract and evaluated its effect on cell growth and lipid accumulation, and found that cell growth was promoted by the addition of the Euglena extract. Interestingly, intracellular lipid accumulation was inhibited in a concentration-dependent manner. Quantitative real-time PCR analysis and western blotting analysis indicated that the Euglena extract suppressed adipocyte differentiation by inhibiting the gene expression of the master regulators peroxisome proliferator-activated receptor-γ (PPARγ) and one of three CCAAT-enhancer-binding proteins (C/EBPα). Further Oil Red O staining experiments indicated that the Euglena extract inhibited the early stage of adipocyte-differentiation. Consistent with these results, we observed that down-regulation of gene expression was involved in the early stage of adipogenesis represented by the sterol regulatory element binding protein 1 c (SREBP1c), two of three CCAAT-enhancer-binding proteins (C/EBPβ, C/EBPδ), and the cAMP regulatory element-binding protein (CREB). Taken together, these data suggest that Euglena extract is a promising candidate for the development of a new therapeutic treatment for obesity.

GLP-1/glucagon receptor co-agonism for treatment of obesity

Over a relatively short period, obesity and type 2 diabetes have come to represent a large medical and economic burden to global societies. The epidemic rise in the prevalence of obesity has metabolic consequences and is paralleled by an increased occurrence of other diseases, such as diabetes, cancer and cardiovascular complications. Together, obesity and type 2 diabetes constitute one of the more preventable causes of premature death and the identification of novel, safe and effective anti-obesity drugs is of utmost importance. Pharmacological attempts to treat obesity have had limited success, with notable adverse effects, rendering bariatric surgery as the only current therapy for substantially improving body weight. Novel unimolecular, multifunctional peptides have emerged as one of the most promising medicinal approaches to enhance metabolic efficacy and restore normal body weight. In this review, we will mainly focus on the discovery and translational relevance of dual agonists that pharmacologically function at the receptors for glucagon and glucagon-like peptide-1. Such peptides have advanced to clinical evaluation and inspired the pursuit of multiple related approaches to achieving polypharmacy within single molecules.

The Additional Costs and Health Effects of a Patient Having Overweight or Obesity: A Computational Model

OBJECTIVE

This paper estimates specific additional disease outcomes and costs that could be prevented by helping a patient go from an obesity or overweight category to a normal weight category at different ages. This information could help physicians, other health care workers, patients, and third-party payers determine how to prioritize weight reduction.

METHODS

A computational Markov model was developed that represented the BMI status, chronic health states, health outcomes, and associated costs (from various perspectives) for an adult at different age points throughout his or her lifetime.

RESULTS

Incremental costs were calculated for adult patients with obesity or overweight (vs. normal weight) at different starting ages. For example, for a metabolically healthy 20-year-old, having obesity (vs. normal weight) added lifetime third-party payer costs averaging $14,059 (95% range: $13,956-$14,163), productivity losses of $14,141 ($13,969-$14,312), and total societal costs of $28,020 ($27,751-$28,289); having overweight vs. normal weight added $5,055 ($4,967-$5,144), $5,358 ($5,199-$5,518), and $10,365 ($10,140-$10,590). For a metabolically healthy 50-year-old, having obesity added $15,925 ($15,831-$16,020), $20,120 ($19,887-$20,352), and $36,278 ($35,977-$36,579); having overweight added $5,866 ($5,779-$5,953), $10,205 ($9,980-$10,429), and $16,169 ($15,899-$16,438).

CONCLUSIONS

Incremental lifetime costs of a patient with obesity or overweight (vs. normal weight) increased with the patient's age, peaked at age 50, and decreased with older ages. However, weight reduction even in older adults still yielded incremental cost savings.

Increasing Body Mass Index Is Associated with Worse Outcomes After Shoulder Arthroplasty

BACKGROUND

Although obesity is associated with increased complication rates after lower-extremity arthroplasty, there is a relative paucity of studies examining the effect of body mass index (BMI) on shoulder arthroplasty. The purpose of this investigation was to evaluate the effect of BMI on implant survival and the rate of complications after shoulder arthroplasty.

METHODS

Using an institutional total joint registry, 4,567 consecutive shoulder arthroplasty cases from 1970 to 2013 were studied. The mean BMI was 29.7 kg/m (range, 14 to 66 kg/m), with 1,622 patients (36%) with a BMI of 30 to 40 kg/m and 297 patients (7%) with a BMI of >40 kg/m. There were 2,493 female patients (55%). BMI was dichotomized after examination of the smoothing spline curve. The associations of factors and complications were assessed using Cox proportional hazard regression analysis.

RESULTS

Increasing BMI was associated with an increased risk of a revision surgical procedure, reoperation, revision for mechanical failure, and superficial infection, and it was negatively associated with risk of a periprosthetic fracture. The risk of a revision surgical procedure increased in a linear fashion with increasing BMI (hazard ratio [HR], 1.05, or a 5% increased risk per 1 unit of BMI; p = 0.03). Increased BMI was also associated with an increased risk of revision for mechanical failure (HR, 1.05; p = 0.004). In a multivariate model, the association of BMI and risk of a revision for any reason, revision for mechanical failure, and reoperation maintained significance (p ≤ 0.02). The most marked association between increasing BMI and any complication in shoulder arthroplasty was its association with superficial wound infection (HR, 1.09; p = 0.03).

CONCLUSIONS

Increasing BMI is strongly associated with increased rates of revision surgical procedures and postoperative complications after shoulder arthroplasty. It is important to consider these findings when counseling patients, estimating risks, and estimating complication risks in policy decisions.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Long-term neighborhood poverty trajectories and obesity in a sample of california mothers

Neighborhoods (and people) are not static, and are instead shaped by dynamic long-term processes of change (and mobility). Using the Geographic Research on Wellbeing survey, a population-based sample of 2339 Californian mothers, we characterize then investigate how long-term latent neighborhood poverty trajectories predict the likelihood of obesity, taking into account short-term individual residential mobility. We find that, net of individual and neighborhood-level controls, living in or moving to tracts that experienced long-term low poverty was associated with lower odds of being obese relative to living in tracts characterized by long-term high poverty.

Correlates of health-related quality of life in young-old and old-old community-dwelling older adults

PURPOSE

This study aimed (1) to examine the role of potential correlates of HRQoL in a large representative sample of older adults, and (2) to investigate whether the relationships between HRQoL and potential factors differ as a function of HRQoL component (physical vs. mental) and/or age cohort (young-old vs. old-old).

METHODS

This cross-sectional study included 802 older adults aged 60-79 years old. HRQoL was assessed using the SF-36 questionnaire. Functional fitness was assessed using the Senior Fitness Test. Physical activity was measured via the Baecke questionnaire. Demographic information, mental and health features were obtained through questionnaires.

RESULTS

A multiple regression analysis showed that BMI (β = -0.15, p = 0.001), body strength (β = 0.21, p < 0.001), aerobic endurance (β = 0.29, p < 0.001), physical activity (β = 0.11, p = 0.007), depressive symptoms (β = -0.19, p < 0.001), falls (β = -0.19, p < 0.001), and living alone (β = -0.16, p < 0.001) were all significantly related to HRQoL-SF-36 total score. The positive relation with aerobic endurance was significantly higher for the physical component of HRQoL, while the negative relation with living alone was significantly higher for the mental component. The positive relation of HRQoL with physical activity was significantly higher in old-old compared to young-old adults.

CONCLUSION

This data suggest that body composition, functional fitness, psycho-social factors, and falls are important correlates of HRQoL in old age. There are HRQoL-component and age-cohort differences regarding these correlates, underlying the need for specific strategies at the community level to promote HRQoL in older adults.

(How) Does Obesity Harm Academic Performance? Stratification at the Intersection of Race, Sex, and Body Size in Elementary and High School

In this study I hypothesize a larger penalty of obesity on teacher-assessed academic performance for white girls in English, where femininity is privileged, than in math, where stereotypical femininity is perceived to be a detriment. This pattern of associations would be expected if obesity largely influences academic performance through social pathways such as discrimination and stigma. In the Fragile Families and Child Wellbeing Study (~age 9) and the National Longitudinal Study of Youth 1997 (~age 18), I find obesity to be associated with a penalty on academic performance among white girls in English but not in math, while no association is found in either subject for white boys or for black students net of controls. Findings suggest that the relationship between obesity and academic performance may result largely from how educational institutions interact with bodies of different sizes, rather than primarily via constraints on physical health.

The Socioeconomic Burden of Obesity

OBJECTIVE

To evaluate the socioeconomic impact of obesity by estimating the direct and indirect costs associated with obesity in Denmark, based on individual level data.

METHODS

Costs were assessed for different BMI groups, and the relative risks for change in direct and indirect costs per BMI point above 30 were estimated. A fourth analysis estimated the odds ratio for comorbidities per BMI point above 30. Individual data on income, social transfer payments, healthcare costs and diagnoses were retrieved from national registries.

RESULTS

One BMI point above 30 was associated with a 2% decrease in income, a 3% increase in social transfer payments, and a 4% increase in healthcare costs. In absolute numbers, income contributed to most of the total economic burden. One BMI point above 30 was also associated with increased comorbidity, which explains the increase in both direct and indirect costs.

CONCLUSION

Obesity is associated with increased comorbidity, giving rise to an increase in both direct and indirect costs. Especially income is affected, which emphasizes the importance of including both measures when evaluating the total socioeconomic burden of obesity. Our findings draw attention to the potential for saving public resources and preventing loss of income by preventing obesity.

Effect of Body Mass Index on Reoperation and Complications After Total Knee Arthroplasty

BACKGROUND

High body mass index (BMI) is associated with increased rates of complications after total knee arthroplasty. To date, to our knowledge, studies have examined risk as a dichotomous variable using specific BMI thresholds. The purpose of this investigation was to quantify implant survival and the risk of common complications after total knee arthroplasty using BMI as a continuous variable.

METHODS

Using prospectively collected data from our institutional total joint registry, we analyzed 22,289 consecutive knees, in 16,136 patients, treated with primary total knee arthroplasty from 1985 to 2012. The mean BMI of these patients at the time of the surgical procedure was 31.3 kg/m (range, 11 to 69 kg/m). The Kaplan-Meier survival method was used to estimate survivorship, reoperations, and common complications, with associations of outcomes assessed using a Cox regression model.

RESULTS

Utilizing smoothing spline parameterization, we found that reoperation (p < 0.001) and implant revision or removal rates (p < 0.001) increased with increasing BMI after total knee arthroplasty. Increasing BMI also was associated with increased rates of wound infection (hazard ratio [HR], 1.07; p < 0.001) and deep infection (HR, 1.08; p < 0.001) per unit of BMI over 35 kg/m. A BMI of 35 to 40 kg/m was associated with a higher rate of implant revision for aseptic loosening (p < 0.001) and for polyethylene wear (p < 0.001) compared with a BMI of 18 to 24.99 kg/m. There was no correlation between BMI and risk of venous thromboembolism, tibiofemoral instability, or need for knee manipulation.

CONCLUSIONS

The rates of reoperation, implant revision or removal, and many common complications after total knee arthroplasty were strongly associated with BMI.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.