Body mass index and healthcare costs: a systematic literature review of individual participant data studies

The healthcare costs of increased body mass index-evidence from The Trøndelag Health Study

BACKGROUND

Earlier studies have estimated the impact of increased body mass index (BMI) on healthcare costs. Various methods have been used to avoid potential biases and inconsistencies. Each of these methods measure different local effects and have different strengths and weaknesses.

METHODS

In the current study we estimate the impact of increased BMI on healthcare costs using nine common methods from the literature: multivariable regression analyses (ordinary least squares, generalized linear models, and two-part models), and instrumental variable models (using previously measured BMI, offspring BMI, and three different weighted genetic risk scores as instruments for BMI). We stratified by sex, investigated the implications of confounder adjustment, and modelled both linear and non-linear associations.

RESULTS

There was a positive effect of increased BMI in both males and females in each approach. The cost of elevated BMI was higher in models that, to a greater extent, account for endogenous relations.

CONCLUSION

The study provides solid evidence that there is an association between BMI and healthcare costs, and demonstrates the importance of triangulation.

Calcium supplementation for people with overweight or obesity

BACKGROUND

Obesity is a major health problem worldwide as it can lead to high blood pressure, heart disease, stroke, diabetes, and insulin resistance. The prevalence of overweight and obesity is increasing worldwide across different age groups. There is evidence of an inverse relationship between calcium intake and body weight. The clinical relevance of a small reduction in body weight has been questioned. However, at a population level, a small effect could mitigate the observed global trends.

OBJECTIVES

To assess the effects of calcium supplementation on weight loss in individuals living with overweight or obesity.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS (Latin American and Caribbean Health Science Information database), and two clinical trials registries. The date of the last search of all databases (except Embase) was 10 May 2023. No language restrictions were applied.

SELECTION CRITERIA

We included randomised controlled trials evaluating the effect of calcium in participants with overweight or obesity of any age or gender. We excluded studies in participants with absorption problems. We included studies of any dose with a minimum duration of two months. We included the following comparisons: calcium supplementation versus placebo, calcium-fortified food or beverage versus placebo, or calcium-fortified food or beverage versus non-calcium-fortified food or beverage. We excluded studies that evaluated the effect of calcium and vitamin D or mixed minerals compared to placebo.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary outcomes were body weight, health-related quality of life, and adverse events. Our secondary outcomes were anthropometric measures other than body weight, all-cause mortality, and morbidity.

MAIN RESULTS

We found 18 studies that evaluated the effect of calcium compared to placebo or control, with a total of 1873 randomised participants (950 participants in the calcium supplementation groups and 923 in the control groups). All included studies gave oral calcium supplementation as the intervention. We did not find any studies evaluating calcium-fortified foods. We excluded 38 studies, identified four ongoing studies, and listed one study as 'awaiting classification'. Sixteen studies compared calcium supplementation to placebo; two studies compared different doses of calcium supplementation. Doses ranged from very low (0.162 g of calcium/day) to high (1.5 g of calcium/day). Most studies were performed in the USA and Iran, lasted less than six months, and included only women. Low-certainty evidence suggests that calcium supplementation compared to placebo or control may result in little to no difference in body weight (mean difference (MD) -0.15 kg, 95% confidence interval (CI) -0.55 to 0.24; P = 0.45, I2 = 46%; 17 studies, 1317 participants; low-certainty evidence). We downgraded the certainty of the evidence by two levels for risk of bias and heterogeneity. None of the included studies reported health-related quality of life, all-cause mortality, or morbidity/complications as outcomes. Only five studies assessed or reported adverse events. Low-certainty evidence suggests a low frequency of adverse events, with no clear difference between intervention and control groups. Moderate-certainty evidence shows that calcium supplementation compared to placebo or control probably results in a small reduction in body mass index (BMI) (MD -0.18 kg/m2,95% CI -0.22 to -0.13; P < 0.001, I2 = 0%; 9 studies, 731 participants) and waist circumference (MD -0.51 cm, 95% CI -0.72 to -0.29; P < 0.001, I2 = 0%; 6 studies, 273 participants). Low-certainty evidence suggests that calcium supplementation compared to placebo or control may result in a small reduction in body fat mass (MD -0.34 kg, 95% CI -0.73 to 0.05; P < 0.001, I2 = 97%; 12 studies, 812 participants).

AUTHORS' CONCLUSIONS

Calcium supplementation for eight weeks to 24 months may result in little to no difference in body weight in people with overweight or obesity. The current evidence is of low certainty, due to concerns regarding risk of bias and statistical heterogeneity. We found that the degree of heterogeneity might be partly explained by calcium dosage, the presence or absence of a co-intervention, and whether an intention-to-treat analysis was pursued. While our analyses suggest that calcium supplementation may result in a small reduction in BMI, waist circumference, and fat mass, this evidence is of low to moderate certainty. Future studies could investigate the effect of calcium supplementation on lean body mass to explore if there is a change in body composition.

Economic Evaluations of Anti-obesity Interventions in Obese Adults: An Umbrella Review

This umbrella review amalgamates the outcomes of economic evaluations pertaining to bariatric surgeries, pharmacotherapy, and gastric balloon for adult obesity treatment. Six databases were systematically searched. The inclusion criteria were established following the Patient/population Intervention Comparison and Outcomes (PICO) statement. Fifteen reviews met all the inclusion criteria. Eight studies focused on surgical interventions, four on pharmacotherapy, and three on both interventions. No systematic review of the economic evaluation of gastric balloons was identified. The majority of reviews advocated bariatric surgery as a cost-effective approach; however, there was discordance in the interpretation of pharmacological cost-effectiveness. Most of the economic evaluations were conducted from the payer and the healthcare system perspectives. We propose that future economic evaluations assessing weight loss interventions in adults adopt a societal perspective and longer-term time horizons.

Adherence to dietary guidelines associated with lower medical service utilization in preschoolers: a longitudinal study

OBJECTIVE

We aimed to evaluate the association between dietary guideline adherence and overall, outpatient, and emergency medical service utilization in Taiwanese preschoolers.

METHODS

We selected 614 preschoolers (2-6 years) who had one day of 24-h dietary recall data from the 2013-2016 Nutrition and Health Survey in Taiwan. The Taiwanese Children Healthy Eating Index (TCHEI) was developed on the basis of Taiwanese Food-Based Dietary Guidelines; it assesses dietary adequacy and eating behavior. Data on the participants' outpatient and emergency medical service utilization were obtained for 2013-2018 from the National Health Insurance Research Database. A multivariable generalized linear model was used to evaluate the association between the TCHEI and medical service utilization for all disease and respiratory diseases.

RESULTS

After adjustment for confounding factors, children aged 2-3 years in the Tertile (T) 2 and T3 groups of the TCHEI exhibited 25% (95% CI 0.69-0.83) and 16% (95% CI 0.77-0.92) lower overall medical visits, respectively. The same pattern was noted in the outpatient and emergency visits for all diseases and respiratory diseases. The children aged 4-6 years in the T2 group exhibited 15% (95% CI 0.80-0.91) and 11% (95% CI 0.82-0.97) lower overall visits and visits for respiratory diseases, respectively. Moreover, preschoolers in the T2 group exhibited lower overall medical expenditures than did those in the T1 group.

CONCLUSIONS

TCHEI score was positively correlated with better nutritional status. Optimal dietary intake associated with lower medical service utilization among Taiwan preschoolers.

First national analysis of severe obesity hospitalizations in Italy: insights from discharge card database

Background

Obesity is associated with numerous severe diseases necessitating intensive healthcare for diagnosis and treatment. Most patients with obesity, especially in its severe form, require at least one hospitalization. However, few studies in Italy have assessed the burden of obesity on the National Health System. This study aims to routinely estimate the 'disease burden' by analyzing hospital admissions related to severe obesity.

Subjects

We analyzed the medical records of the Italian national hospital discharge database, including all patients older than 18 years discharged with the diagnosis of 'severe obesity'.' We included patients who underwent bariatric surgery, even without an explicit obesity code, such as laparoscopic restrictive gastric procedures, other stomach operations, and high gastric bypass. Special focus was given to those who underwent abdominal reshaping surgery. The cross-sectional survey PASSI in Italy served as an additional data source to estimate. The phenomenon was described using appropriate indicators, including rates and ratios between rates. Linear regression was employed to analyze trends in standardized rates over time.

Results

Between 2014 and 2021, a total of 243,325 patients were discharged with a severe obesity code in Italy. Among these patients, 36.8% underwent at least one bariatric surgery procedure. We investigated the types of bariatric surgery procedures performed. The most frequent procedure was "other operations on the stomach," where sleeve gastrectomy is included which also appears to be steadily increasing during the study period together with the gastric bypass, while the gastric bondage is decreasing over time.

Conclusion

These findings underscore the significant burden of severe obesity on Italy's healthcare system, a burden that is progressively increasing. The growing utilization of bariatric surgery suggests an escalating trend toward adopting drastic solutions to combat this health issue.

Economic costs of obesity: a systematic review

INTRODUCTION

Obesity is a growing public health problem leading to substantial economic impact. This study aimed to summarize the economic impact of obesity and to critically analyze the methods used in the cost-of-illness (COI) studies on obesity.

METHODS

We conducted systematic search in PubMed and Scopus from September 1, 2016, to July 22, 2022. Original COI studies estimating the economic cost of obesity and/or overweight in at least one country, published in English were included. To facilitate the comparison of estimates across countries, we converted the cost estimates of different years to 2022 purchasing power parity (PPP) values using each country's consumer price index (CPI) and PPP conversion rate.

RESULTS

Nineteen studies were included. All studies employed a prevalence-based approach using Population Attributable Fraction (PAF) methodology. About half of the included studies (53%) were conducted in high-income countries while the others (47%) were conducted in middle-income countries. The economic burden of obesity ranged between PPP 15 million in Brazil to PPP 126 billion in the USA, in the year 2022. Direct medical costs accounted for 0.7% to 17.8% of the health system expenditure. Furthermore, the total costs of obesity ranged from 0.05% to 2.42% of the country's gross domestic product (GDP). Of the seven studies that estimated both direct and indirect costs, indirect costs accounted for the largest portion of five studies. Nevertheless, a variety in methodology across studies was identified. The number of co-morbidities included in the analysis varied across studies.

CONCLUSIONS

Although there was a variety of methodologies across studies, consistent evidence indicated that the economic burden of obesity was substantial. Obesity prevention and control should be a public health priority, especially among countries with high prevalence of obesity.

Association between weight loss and health care resource utilization in adults living with obesity: Evidence from a UK primary care database

AIMS

We investigated the impact of intentional weight loss on health care resource utilization (HCRU) and costs among people with obesity.

MATERIALS AND METHODS

This retrospective, observational cohort study used data from the Clinical Practice Research Datalink (CPRD) GOLD database. Adults >18 years at index date [first recorded body mass index (BMI) of 30-50 kg/m2 between 2006 and 2015 with a further BMI record 4 years later] were assigned to an intentional weight loss cohort (-25% to -10% BMI change) or a stable weight cohort (-3% to +3%), based on their BMI change during a 4-year baseline period from index date. Evidence of intention to lose weight during the baseline period was required. Linked Hospital Episode Statistics datasets captured HCRU and costs over an 8-year follow-up period. Mixed effects models adjusted for demographics, total costs during baseline and baseline comorbidities were used.

RESULTS

Baseline characteristics were similar between cohorts with weight loss (n = 8676) and stable weight (n = 44 519). Over follow-up, the weight loss cohort experienced a significantly lower mean annual increase in total costs [2.1% (95% confidence interval: 1.3-2.8)] than the stable weight cohort [4.3% (95% confidence interval: 4.0-4.6); p < .0001]. Weight loss was associated with a lower mean annual increase in multiple HCRU and cost components compared with maintaining a stable high weight.

CONCLUSIONS

Our findings suggest that intentional weight loss of 10-25% is associated with lower HCRU and costs in the long term among individuals living with obesity, relative to stable weight.

Real-world costs of obesity-related complications over eight years: a US retrospective cohort study in 28,500 individuals

BACKGROUND

Obesity-related complications (ORCs) are associated with high costs for healthcare systems. We assessed the relationship between comorbidity burden, represented by both number and type of 14 specific ORCs, and total healthcare costs over time in people with obesity in the USA.

METHODS

Adults (≥ 18 years old) identified from linked electronic medical records and administrative claims databases, with a body mass index measurement of 30-< 70 kg/m2 between 1 January 2007 and 31 March 2012 (earliest measurement: index date), and with continuous enrolment for ≥ 1 year pre index (baseline year) and ≥ 8 years post index, were included. Individuals were grouped by type and number of ORCs during the pre-index baseline year. The primary outcome was annual total adjusted direct per-person healthcare costs.

RESULTS

Of 28,583 included individuals, 12,686 had no ORCs, 7242 had one ORC, 4180 had two ORCs and 4475 had three or more ORCs in the baseline year. Annual adjusted direct healthcare costs increased with the number of ORCs and over the 8-year follow-up. Outpatient costs were the greatest contributor to baseline annual direct costs, irrespective of the number of ORCs. For specific ORCs, costs generally increased gradually over the follow-up; the largest percentage increases from year 1 to year 8 were observed for chronic kidney disease (+ 78.8%) and type 2 diabetes (+ 47.8%).

CONCLUSIONS

In a US real-world setting, the number of ORCs appears to be a cost driver in people with obesity, from the time of initial obesity classification and for at least the following 8 years.

The (cost) effectiveness of a very low-energy diet intervention with the use of eHealth in patients with type 2 diabetes and obesity: study protocol for a randomised controlled non-inferiority trial (E-diet trial)

BACKGROUND

Despite preventive measures, the number of people with type 2 diabetes and obesity is increasing. Obesity increases morbidity and mortality in people with type 2 diabetes, making weight loss a cornerstone of treatment. We previously developed a very low energy diet (VLED) intervention that effectively reduced weight in people with type 2 diabetes in the long term. However, this intervention requires considerable time and manpower, which reduces the number of people who can benefit from it. eHealth offers more efficient solutions but has proven to be less effective than face-to-face interventions. Therefore, we want to investigate whether a blended version of our VLED intervention (in which face-to-face contact is partly replaced by an eHealth (mobile) application (E-VLED)) would be more cost-effective than the current face-to-face intervention.

METHODS

We will conduct a randomised, controlled trial with non-inferiority design in patients with type 2 diabetes and obesity (BMI > 30 kg/m2), aged 18-75 years. The control group will receive the usual care VLED intervention, while the intervention group will receive the E-VLED intervention for 1 year, where face-to-face contact will be partly replaced by an eHealth (mobile) application. The main study endpoint is the difference in weight (% change) between the control and intervention group after 1 year, plus the difference between the total costs (euro) of the treatment in the control and intervention groups. The secondary aims are to investigate the effectiveness of the E-VLED diet intervention regarding cardiovascular risk factors, quality of life, patient satisfaction, compliance, and to study whether there is a difference in effectiveness in pre-specified subgroups. General linear models for repeated measurements will be applied for the statistical analysis of the data.

DISCUSSION

We hypothesise that the E-VLED intervention will be equally effective compared to the usual care VLED but lower in costs due to less time invested by the dietician. This will enable to help more people with type 2 diabetes and obesity to effectively lose weight and improve their health-related quality of life.

TRIAL REGISTRATION

Netherlands Trial Register, NL7832, registered on 26 June 2019.

Healthcare costs associated with overweight and obesity at an individual versus a population level - a HUNT study

BACKGROUND

The interpretation of research results is affected by how results are presented. We show the importance of presenting the association between body mass index (BMI) and healthcare costs from both the individual perspective and the population perspective.

MATERIAL AND METHOD

Using measurements of height and weight from the Nord-Trøndelag Health Study (HUNT Study) linked to register data on specialist healthcare costs and demographics, we estimated the association between BMI and specialist healthcare costs by means of regression analyses.

RESULTS

From an individual perspective, the association between BMI and specialist healthcare costs was strongest in people in obesity classes 2 and 3 (BMI ≥ 35 kg/m2). In contrast, from a population perspective, the association was strongest in the case of overweight (BMI ≥ 25 kg/m2) or obesity class 1 (BMI ≥ 30 kg/m2), as there are more people in this BMI range.

INTERPRETATION

The study emphasises the importance of including the population perspective in research studies and policy decision-making processes. People with severe obesity have a high individual risk, but their use of health services has less significance for the overall costs of health care since they are fewer people in this group.

Sleep duration, sleep quality and the risk of being obese: Evidence from the Australian panel survey

BACKGROUND

Sleep difficulty is an unmet public health concern affecting a vast proportion of the world's population. Poor sleep duration (short or long sleep length) and quality affect more than half of older people. Sleep difficulty is associated with negative health outcomes such as obesity and reduced longevity. We aimed to assess whether poor sleep duration and quality are significant risk factors for obesity in adults aged 15 and over in Australia by examining a nationally representative panel data.

METHODS

We used three waves (waves 13, 17, and 21) of the nationally representative Household, Income and Labour Dynamics in Australia (HILDA) survey data. The study applied generalized estimating equations (GEE) logistic regression model to assess the relationship between sleep duration and quality with obesity.

RESULTS

The study found that the odds of being obese was significantly higher amongst the study participants with poor sleep duration (adjusted odds ratio [aOR]: 1.24, 95% confidence interval [CI]: 1.16-1.32) and poor sleep quality (aOR: 1.29, 95% CI: 1.02-1.38) compared with their counterparts who had good sleep duration and quality, respectively.

CONCLUSION

Having short or long sleep at night and poor sleep quality are associated with an increased risk of obesity. Obesity poses a significant threat to the health of Australian adults. Enacting policies that raise public awareness of the significance of good sleep hygiene and encouraging healthy sleeping habits should be considered to address the alarming rise in the obesity rate.

Obesity and metabolic state are associated with increased healthcare resource and medication use and costs: a Finnish population-based study

AIM

To characterize healthcare resource (HCRU) and medication use and associated costs in individuals with obesity compared with individuals with normal weight or overweight in a population-based cohort of Finnish adults. The association between metabolic state and direct costs was also assessed.

METHODS

The study cohort included 5587 randomly selected individuals who participated in the national FinHealth 2017 health examination survey. Data on healthcare visits and hospital stays, including diagnoses (ICD-10), and purchases and costs of prescription medicines were collected from the nationwide registers by the Finnish Institute for Health and Welfare and Social Insurance Institution of Finland. The healthcare costs were calculated based on standard unit costs reported by the Finnish Institute for Health and Welfare.

RESULTS

The total annual direct costs were €2665 (SD €5673) and €1799 (SD €3874) per person with obesity and with normal weight or overweight, respectively. Obesity was associated with significantly increased total direct (age- and sex-adjusted cost rate ratio, RR, 1.356; p < 0.001), HCRU-related (1.273; p = 0.002), and medication (1.669; p < 0.001) costs. A vast majority (90%) of individuals with obesity were classified as metabolically unhealthy based on clinical measurements. The metabolically unhealthy state was associated with increased costs in individuals with obesity but not in individuals with normal weight or overweight.

CONCLUSION

Obesity is associated with a significant and complex direct cost burden to society, arising primarily from increased comorbidity. Metabolically healthy obesity is uncommon and obesity prevention and timely treatment should be of high priority to tackle the increasing burden of obesity.

Effects of a Web-Based Lifestyle Intervention on Weight Loss and Cardiometabolic Risk Factors in Adults With Overweight and Obesity: Randomized Controlled Clinical Trial

BACKGROUND

The high proportion of people with overweight and obesity has become a worldwide problem in recent decades, mainly due to health consequences, such as cardiovascular diseases, neoplasia, and type 2 diabetes mellitus. Regarding effective countermeasures, the digitization of health services offers numerous potentials, which, however, have not yet been sufficiently evaluated. Web-based health programs are becoming increasingly interactive and can provide individuals with effective long-term weight management support.

OBJECTIVE

The purpose of this randomized controlled clinical trial was to evaluate the effectiveness of an interactive web-based weight loss program on anthropometric, cardiometabolic, and behavioral variables and to compare it with a noninteractive web-based weight loss program.

METHODS

The randomized controlled trial included people who were aged between 18 and 65 years (mean 48.92, SD 11.17 years) and had a BMI of 27.5 to 34.9 kg/m² (mean 30.71, SD 2.13 kg/m²). Participants (n=153) were assigned to either (1) an interactive and fully automated web-based health program (intervention) or (2) a noninteractive web-based health program (control). The intervention program focused on dietary energy density and allowed for dietary documentation with appropriate feedback on energy density and nutrients. The control group only received information on weight loss and energy density, but the website did not contain interactive content. Examinations were performed at baseline (t0), at the end of the 12-week intervention (t1), and at 6 months (t2) and 12 months (t3) thereafter. The primary outcome was body weight. The secondary outcomes were cardiometabolic variables as well as dietary and physical activity behaviors. Robust linear mixed models were used to evaluate the primary and secondary outcomes.

RESULTS

The intervention group showed significant improvements in anthropometric variables, such as body weight (P=.004), waist circumference (P=.002), and fat mass (P=.02), compared with the control group over the course of the study. The mean weight loss after the 12-month follow-up was 4.18 kg (4.7%) in the intervention group versus 1.29 kg (1.5%) in the control group compared with the initial weight. The results of the nutritional analysis showed that the energy density concept was significantly better implemented in the intervention group. Significant differences in cardiometabolic variables were not detected between the 2 groups.

CONCLUSIONS

The interactive web-based health program was effective in reducing body weight and improving body composition in adults with overweight and obesity. However, these improvements were not associated with relevant changes in cardiometabolic variables, although it should be noted that the study population was predominantly metabolically healthy.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00020249; https://drks.de/search/en/trial/DRKS00020249.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.3390/ijerph19031393.

The association between obesity, health service use, and work productivity in Australia: a cross-sectional quantile regression analysis

The burden of disease attributable to obesity is rapidly increasing and becoming a public health challenge globally. Using a nationally representative sample in Australia, this study aims to examine the association of obesity with healthcare service use and work productivity across outcome distributions. We used Household, Income and Labour Dynamics Australia (HILDA) Wave 17 (2017-2018), including 11,211 participants aged between 20 and 65 years. Two-part models using multivariable logistic regressions and quantile regressions were employed to understand variations in the association between obesity levels and the outcomes. The prevalence of overweight and obesity was 35.0% and 27.6%, respectively. After adjusting for socio-demographic factors, low socioeconomic status was associated with a higher probability of overweight and obesity (Obese III: OR = 3.79; 95% CI 2.53-5.68) while high education group was associated with a lower likelihood of being high level of obesity (Obese III OR = 0.42, 95% CI 0.29-0.59). Higher levels of obesity were associated with higher probability of health service use (GP visit Obese, III: OR = 1.42 95% CI 1.04-1.93,) and work productivity loss (number of paid sick leave days, Obese III: OR = 2.40 95% CI 1.94-2.96), compared with normal weight. The impacts of obesity on health service use and work productivity were larger for those with higher percentiles compared to lower percentiles. Overweight and obesity are associated with greater healthcare utilisation, and loss in work productivity in Australia. Australia's healthcare system should prioritise interventions to prevent overweight and obesity to reduce the cost on individuals and improve labour market outcomes.

Overlooked and under-evidenced: Community health and long-term care service needs, utilization, and costs incurred by people with severe obesity

Numbers of people with severe obesity (BMI ≥ 40 kg/m² ), with need for community health and long-term care (LTC) services, are increasing, but documentation is lacking. We identified individuals with severe obesity known to community health and care professionals in a representative United Kingdom region and used an investigator-administered questionnaire to record needs and use of community health and LTC services. Data were verified against health and LTC records. Local and published sources informed detailed micro-costing. Twenty-five individuals (15 women) consented, aged 40-87 (mean = 62) years, BMI 40-77 (mean = 55) kg/m² : 20 participants (80%) were housebound. Twenty-two different cross-sector community health and LTC services were used, including community equipment service (n = 23), district nursing (n = 20), occupational therapy (n = 14), and LTC (n = 12). Twenty-four (96%) participants used three or more services, with longest care episode lasting over 14 years. Total annual service costs incurred by participants varied from £2053 to £82 792; mean £26 594 (lower estimate £80 064; mean £22 462/upper estimate £88 870; mean £30 726), with greatest costs being for LTC. Individual costs for equipment (currently provided) and home adaptations (ever provided) ranged widely, from zero to £35 946. Total mean annual costs increased by ascending BMI category, up to BMI 70 kg/m² . This study provides a framework with which to inform service provision and economic analysis of weight management interventions. People with severe obesity may need sustained care from multiple community care services.

Potential cost-effectiveness of e-health interventions for treating overweight and obesity in Australian adolescents

BACKGROUND

E-health, defined as the use of information and communication technologies to improve healthcare delivery and health outcomes, has been promoted as a cost-effective strategy to treat adolescent overweight and obesity. However, evidence supporting this claim is lacking.

OBJECTIVES

Assess the potential cost-effectiveness of a hypothetical e-health intervention for adolescents with overweight and obesity.

METHODS

The costs and effect size (BMI reduction) of the hypothetical intervention were sourced from recent systematic reviews. Using a micro-simulation model with a lifetime time horizon, we conducted a modelled cost-utility analysis of the intervention compared to a 'do-nothing' approach. To explore uncertainty, we conducted bootstrapping on individual-level costs and quality-adjusted life years (QALYs) and performed multiple one-way sensitivity analyses.

RESULTS

The incremental cost-effectiveness ratio (ICER) for the e-health intervention was dominant (cheaper and more effective), with a 96% probability of being cost-effective at a willingness-to-pay (WTP) of $50 000/QALY. The ICER remained dominant in all sensitivity analyses except when using the lower bounds of the hypothetical intervention effect size, which reduced the probability of cost-effectiveness at a WTP of $50 000/QALY to 51%.

CONCLUSION

E-health interventions for treatment of adolescent overweight and obesity demonstrate very good cost-effectiveness potential and should be considered by healthcare decision makers. However, further research on the efficacy of such interventions is warranted to strengthen the case for investment.

New proposal to address mediation analysis interrogations by using genetic variants as instrumental variables

The application of causal mediation analysis (CMA) considering the mediation effect of a third variable is increasing in epidemiological studies; however, this requires fitting strong assumptions on confounding bias. To address this limitation, we propose an extension of CMA combining it with Mendelian randomization (MRinCMA). We applied the new approach to analyse the causal effect of obesity and diabetes on pancreatic cancer, considering each factor as potential mediator. To check the performance of MRinCMA under several conditions/scenarios, we used it in different simulated data sets and compared it with structural equation models. For continuous variables, MRinCMA and structural equation models performed similarly, suggesting that both approaches are valid to obtain unbiased estimates. When noncontinuous variables were considered, MRinCMA presented, overall, lower bias than structural equation models. By applying MRinCMA, we did not find any evidence of causality of obesity or diabetes on pancreatic cancer. With this new methodology, researchers would be able to address CMA hypotheses by appropriately accounting for the confounding bias assumption regardless of the conditions used in their studies in different settings.

Weight regain after behavioural weight management programmes and its impact on quality of life and cost effectiveness: Evidence synthesis and health economic analyses

AIMS

We used data from a recent systematic review to investigate weight regain after behavioural weight management programmes (BWMPs, sometimes referred to as lifestyle modification programmes) and its impact on quality-of-life and cost-effectiveness.

MATERIALS AND METHODS

Trial registries, databases and forward-citation searching (latest search December 2019) were used to identify randomized trials of BWMPs in adults with overweight/obesity reporting outcomes at ≥12 months, and after programme end. Two independent reviewers screened records. One reviewer extracted data and a second checked them. The differences between intervention and control groups were synthesized using mixed-effect, meta-regression and time-to-event models. We examined associations between weight difference and difference in quality-of-life. Cost-effectiveness was estimated from a health sector perspective.

RESULTS

In total, 155 trials (n > 150 000) contributed to analyses. The longest follow-up was 23 years post-programme. At programme end, intervention groups achieved -2.8 kg (95%CI -3.2 to -2.4) greater weight loss than controls. Weight regain after programme end was 0.12-0.32 kg/year greater in intervention relative to control groups, with a between-group difference evident for at least 5 years. Quality-of-life increased in intervention groups relative to control at programme end and thereafter returned to control as the difference in weight between groups diminished. BWMPs with this initial weight loss and subsequent regain would be cost-effective if delivered for under £560 (£8.80-£3900) per person.

CONCLUSIONS

Modest rates of weight regain, with persistent benefits for several years, should encourage health care practitioners and policymakers to offer obesity treatments that cost less than our suggested thresholds as a cost-effective intervention to improve long-term weight management.

REGISTRATION

The review is registered on PROSPERO, CRD42018105744.

The association between body mass index groups and metabolic comorbidities with healthcare and medication costs: a nationwide biobank and registry study in Finland

BACKGROUND

The increasing prevalence of obesity imposes a significant cost burden on individuals and societies worldwide.

OBJECTIVE

In this nationally representative study, the association between body mass index (BMI) groups and the number of metabolic comorbidities (MetC) with total direct costs was investigated in the Finnish population.

STUDY DESIGN, SETTING, AND PARTICIPANTS

The study cohort included 5,587 adults with BMI ≥18.5 kg/m² who participated in the cross-sectional FinHealth 2017 health examination survey conducted by the Finnish Institute for Health and Welfare. Data on healthcare resource utilization (HCRU) and drug purchases were collected from national healthcare and drug registers.

MAIN OUTCOME MEASURE

The primary outcome was total direct costs (costs of primary and secondary HCRU and prescription medications).

RESULTS

Class I (BMI 30.0-34.9 kg/m²) and class II - III (BMI ≥35.0 kg/m²) obesity were associated with 43% and 40% higher age- and sex-adjusted direct costs, respectively, compared with normal weight, mainly driven by a steeply increased comorbidity in the higher BMI groups. In all BMI groups combined, individuals with ≥2 MetCs comprised 39% of the total study population and 60% of the total costs.

CONCLUSION

To manage the cost burden of obesity, treatment should be given equal consideration as other chronic diseases, and BMIs ≥30.0 kg/m² should be considered in treatment decisions.

Evaluation of an Interactive Web-Based Health Program for Weight Loss-A Randomized Controlled Trial

Personal behavior patterns, such as unhealthy diet and lack of physical activity, lead to the development of overweight and obesity. These are associated with other comorbidities, reduced quality of life, premature frailty and increased mortality. Personalized web-based interventions are promising in inducing behavioral change leading to effective reductions in body weight at relatively low costs. However, the long-term effects have not been thoroughly investigated. This work evaluates the effectiveness of web-based interactive weight loss coaching and compares it to a non-interactive web-based health program. Therefore, a randomized controlled trial (RCT) was implemented, measuring primary and secondary outcomes at four time points (program start; end of the 12-week-program; 6 months after program end, 12 months after program end). The net sample covered 1499 subjects in the intervention group and 1492 in the control group. On average, the IG was 43 years old (±13.6), 80.1% male, and had 86.4 kg body weight (±16.1) at baseline. The CG was 42.7 years old (±13.9), 79.5% male and had a mean body weight of 86.1 (±15.7). Multilevel analyses with fixed effects were carried out both from the perspective of an intention-to-treat (ITT) and a complete cases approach (CCA). In sum, our adjusted models suggest a weight loss of 0.4 kg per time point. At the end of the program, significant differences in weight loss in % to baseline (delta M = 1.8 in the CCA) were observed in favor of the intervention group. From a long-term perspective, no superiority of the intervention group in comparison to the control group could be found. More intensive use of the program was not statistically associated with higher weight loss.

Obesity as a risk factor for cardiac arrhythmias

Obesity is global health problem with an estimated three billion people worldwide being classified as overweight or obese. In addition to being associated with a range of adverse health outcomes, obesity is linked to higher risks of atrial and ventricular arrhythmias, as well as sudden cardiac death. Obesity is a multifactorial disease that often co-exists with hypertension, diabetes, and sleep apnoea, which are also independent risk factors for cardiac arrhythmias. Nevertheless, compelling evidence suggests that increasing adiposity is an independent proarrhythmic risk factor and that weight loss can be a mitigating and preventative intervention to reduce arrhythmia incidence. This review briefly outlines the economic and social burden of obesity and summarises evidence for the direct and indirect effects of increasing adiposity on risk of atrial and ventricular arrhythmias. The paper also summarises the evidence for electrocardiographic changes indicative of obesity-related atrial and ventricular remodelling and how weight reduction and management of comorbidity might reduce arrhythmic burden.

Association of Body Mass Index with Risk of Household Catastrophic Health Expenditure in China: A Population-Based Cohort Study

Catastrophic health expenditure (CHE) is a major obstacle to achieving universal health coverage, and body mass index (BMI) is linked to both health and economy. We aimed to explore the association of BMI with the risk of CHE to provide advice for reducing CHE. We used national cohort data from the China Family Panel Studies, which comprised 33,598 individuals (14,607 households) from 25 provinces between 2010 to 2018. We used multivariate Cox proportional hazard models to estimate adjusted hazard ratios (aHRs) and 95% confident interval (CI) for CHE in participants at underweight, overweight, and obesity, compared with those at normal weight. Restricted cubic splines were employed to model the association of continuous BMI scale with risk of CHE. We found that families with female household heads at underweight had a 42% higher risk of CHE (aHR = 1.42, 95%CI: 1.16–1.75), and those at overweight had a 26% increased risk of CHE (aHR = 1.26, 95%CI: 1.09–1.47), compared with those at normal weight. A weak U-shaped curve for the association of continuous BMI with risk of CHE in female-headed households (p for non-linear = 0.0008) was observed, which was not significant in male-headed households (p for non-linear = 0.8725). In female-headed households, underweight and overweight BMI are connected with a higher risk of CHE. Concerted efforts should be made to keep a normal BMI to prevent CHE.

Health care costs and lost productivity costs related to excess weight in Belgium

Background

This study aimed to estimate annual health care and lost productivity costs associated with excess weight among the adult population in Belgium, using national health data.

Methods

Health care costs and costs of absenteeism were estimated using data from the Belgian national health interview survey (BHIS) 2013 linked with individual health insurance data (2013–2017). Average yearly health care costs and costs of absenteeism were assessed by body mass index (BMI) categories – i.e., underweight (BMI < 18.5 kg/m²), normal weight (18.5 ≤ BMI < 25 kg/m²), overweight (25 ≤ BMI < 30 kg/m²) and obesity (BMI ≥ 30 kg/m²). Health care costs were also analysed by type of cost (i.e. ambulatory, hospital, reimbursed medication). The cost attributable to excess weight and the contribution of various other chronic conditions to the incremental cost of excess weight were estimated using the method of recycled prediction (a.k.a. standardisation).

Results

According to BHIS 2013, 34.7% and 13.9% of the Belgian adult population were respectively affected by overweight or obesity. They were mostly concentrated in the age-group 35–65 years and had significantly more chronic conditions compared to the normal weight population. Average total healthcare expenses for people with overweight and obesity were significantly higher than those observed in the normal weight population.

The adjusted incremental annual health care cost of excess weight in Belgium was estimated at €3,329,206,657 (€651 [95% CI: €144-€1,084] and €1,015 [95% CI: €343–€1,697] per capita for individuals with overweight and obesity respectively). The comorbidities identified to be the main drivers for these incremental health care costs were hypertension, high cholesterol, serious gloom and depression. Mean annual incremental cost of absenteeism for overweight accounted for €242 per capita but was not statistically significant, people with obesity showed a significantly higher cost (p < 0.001) compared to the normal weight population: €2,015 [95% CI: €179–€4,336] per capita. The annual total incremental costs due to absenteeism of the population affected by overweight and obesity was estimated at €1,209,552,137. Arthritis, including rheumatoid arthritis and osteoarthritis, was the most important driver of the incremental cost of absenteeism in individuals with overweight and obesity, followed by hypertension and low back pain.

Conclusions

The mean annual incremental cost of excess weight in Belgium is of concern and stresses the need for policy actions aiming to reduce excess body weight. This study can be used as a baseline to evaluate the potential savings and health benefits of obesity prevention interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14105-9.

Improved Prediction of Body Mass Index in Real-World Administrative Healthcare Claims Databases

INTRODUCTION

To continue closing the gap between the predictive modeling and its real-world application, we report a new data-to-prediction pipeline that advanced the state-of-the-art predictive performance of body mass index (BMI) classifications by integrating siloed claims databases via a common data model.

METHODS

This study adapted the ensemble-based methodology of the baseline prediction model and focused on removing the silos in the claims databases. We applied the Super Learner machine learning algorithm (SLA) to learn a combined dataset consisting of 50% data from the Optum Date of Death database and 50% data from the IBM MarketScan Commercial Claims and Encounters (CCAE), and omitted the commonly used one-hot-encoding step and used multi-categorical variables directly in the feature engineering process. These developments were then optimized via a standard cross-validation scheme and the performance was evaluated on a holdout test set.

RESULTS

Sociodemographic and clinical characteristics were used with (denoted as SLA₁) and without (denoted as SLA₂) baseline BMI values to predict BMI classifications (≥ 30, ≥ 35, and ≥ 40 kg/m²). Although the newly implemented SLA₁ performed similarly to the previous model, with the area under the receiver operating characteristic curve (ROC AUC) being approximately 88% for all BMI classifications, specificity ranging from 90% to 96%, and accuracy ranging from 88% to 93%. The new SLA₂ achieved consistently better performance on all metrics across all BMI classes. In particular, the new SLA₂ achieved 77-79% in ROC AUC, increasing from the previously reported level (73%). Its specificity improved to the range of 76-90% from 71-86%. Its accuracy improved to the range of 77-86% from 73-80%. Its recall (i.e., sensitivity) improved to the range of 64-78% from 60-76%.

CONCLUSIONS

This study demonstrates dramatic improvements in the prediction of BMI across classifications using integrated databases in a common data model for the generation of real-world evidence.

Healthcare Service Interventions to Improve the Healthcare Outcomes of Hospitalised Patients with Extreme Obesity: Protocol for an Evidence and Gap Map

Hospitalised patients with extreme obesity have poorer healthcare outcomes compared to normal weight patients. How hospital services are coordinated and delivered to meet the care needs of patients with extreme obesity is not well understood. The aim of the proposed evidence gap map (EGM) is to identify and assess the available evidence on healthcare interventions to improve healthcare outcomes for hospitalised patients with extreme obesity. This research will use standardised evidence gap map methods to undertake a five-stage process to develop an intervention–outcome framework; identify the current evidence; critically appraise the quality of the evidence, extract, code, and summarise the data in relation to the EGM objectives; and create a visualisation map to present findings. This EGM will provide a means of determining the nature and quality of health service initiatives available, identify the components of the services delivered and the outcome measures used for evaluation, and will identify areas where there is a lack of research that validates the funding of new research studies.

A Systematic Review of the Impact of the First Year of COVID-19 on Obesity Risk Factors: A Pandemic Fueling a Pandemic?

Obesity is increasingly prevalent worldwide. Associated risk factors, including depression, socioeconomic stress, poor diet, and lack of physical activity, have all been impacted by the coronavirus disease 2019 (COVID-19) pandemic. This systematic review aims to explore the indirect effects of the first year of COVID-19 on obesity and its risk factors. A literature search of PubMed and EMBASE was performed from 1 January 2020 to 31 December 2020 to identify relevant studies pertaining to the first year of the COVID-19 pandemic (PROSPERO; CRD42020219433). All English-language studies on weight change and key obesity risk factors (psychosocial and socioeconomic health) during the COVID-19 pandemic were considered for inclusion. Of 805 full-text articles that were reviewed, 87 were included for analysis. The included studies observed increased food and alcohol consumption, increased sedentary time, worsening depressive symptoms, and increased financial stress. Overall, these results suggest that COVID-19 has exacerbated the current risk factors for obesity and is likely to worsen obesity rates in the near future. Future studies, and policy makers, will need to carefully consider their interdependency to develop effective interventions able to mitigate the obesity pandemic.

Body mass index and healthcare costs: using genetic variants from the HUNT study as instrumental variables

Background

Past studies have found associations between obesity and healthcare costs, however, these studies have suffered from bias due to omitted variables, reverse causality, and measurement error.

Methods

We used genetic variants related to body mass index (BMI) as instruments for BMI; thereby exploiting the natural randomization of genetic variants that occurs at conception. We used data on measured height and weight, genetic information, and sociodemographic factors from the Nord-Trøndelag Health Studies (HUNT), and individual-level registry data on healthcare costs, educational level, registration status, and biological relatives. We studied associations between BMI and general practitioner (GP)-, specialist-, and total healthcare costs in the Norwegian setting using instrumental variable (IV) regressions, and compared our findings with effect estimates from ordinary least squares (OLS) regressions. The sensitivity of our findings to underlying IV-assumptions was explored using two-sample Mendelian randomization methods, non-linear analyses, sex-, healthcare provider-, and age-specific analyses, within-family analyses, and outlier removal. We also conducted power calculations to assess the likelihood of detecting an effect given our sample 60,786 individuals.

Results

We found that increased BMI resulted in significantly higher GP costs; however, the IV-based effect estimate was smaller than the OLS-based estimate. We found no evidence of an association between BMI and specialist or total healthcare costs.

Conclusions

Elevated BMI leads to higher GP costs, and more studies are needed to understand the causal mechanisms between BMI and specialist costs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07597-z.

The Effect of Corn Dextrin on the Rheological, Tribological, and Aroma Release Properties of a Reduced-Fat Model of Processed Cheese Spread

Low-calorie and low-fat foods have been introduced to the market to fight the increasing incidence of overweightness and obesity. New approaches and high-quality fat replacers may overcome the poor organoleptic properties of such products. A model of processed cheese spread (PCS) was produced as a full-fat version and with three levels of fat reduction (30%, 50%, and 70%). Fat was replaced by water or by corn dextrin (CD), a dietary fiber. Additionally, in the 50% reduced-fat spreads, fat was replaced by various ratios of CD and lactose (100:0, 75:25, 50:50, 25:75, and 0:100). The effect of each formulation was determined by measuring the textural (firmness, stickiness, and spreadability), rheological (flow behavior and oscillating rheology), tribological, and microstructural (cryo-SEM) properties of the samples, as well as the dynamic aroma release of six aroma compounds typically found in cheese. Winter’s critical gel theory was a good approach to characterizing PCS with less instrumental effort and costs: the gel strength and interaction factors correlated very well with the spreadability and lubrication properties of the spreads. CD and fat exhibited similar interaction capacities with the aroma compounds, resulting in a similar release pattern. Overall, the properties of the sample with 50% fat replaced by CD were most similar to those of the full-fat sample. Thus, CD is a promising fat replacer in PCS and, most likely, in other dairy-based emulsions.

Estimation and Prediction of Hospitalization and Medical Care Costs Using Regression in Machine Learning

Medical costs are one of the most common recurring expenses in a person’s life. Based on different research studies, BMI, ageing, smoking, and other factors are all related to greater personal medical care costs. The estimates of the expenditures of health care related to obesity are needed to help create cost-effective obesity prevention strategies. Obesity prevention at a young age is a top concern in global health, clinical practice, and public health. To avoid these restrictions, genetic variants are employed as instrumental variables in this research. Using statistics from public huge datasets, the impact of body mass index (BMI) on overall healthcare expenses is predicted. A multiview learning architecture can be used to leverage BMI information in records, including diagnostic texts, diagnostic IDs, and patient traits. A hierarchy perception structure was suggested to choose significant words, health checks, and diagnoses for training phase informative data representations, because various words, diagnoses, and previous health care have varying significance for expense calculation. In this system model, linear regression analysis, naive Bayes classifier, and random forest algorithms were compared using a business analytic method that applied statistical and machine-learning approaches. According to the results of our forecasting method, linear regression has the maximum accuracy of 97.89 percent in forecasting overall healthcare costs. In terms of financial statistics, our methodology provides a predictive method.

Health care use by adults with obesity: A French cohort study

OBJECTIVE

Studies on obesity costs have focused on global costs of people with obesity but scarcely investigated their precise use of health care. The aim of this study is to document real-life health care use across obesity classes.

METHODS

Data of participants with obesity and enrolled in the CONSTANCES cohort were analyzed. Health care use was defined as ≥1 visit to general practitioners, specialists, emergency departments, and inpatient hospital admissions versus none over a 3-year period prior to enrollment and was obtained from the Universal Health Insurance database. Multivariate regression models were conducted and adjusted for comorbidities and social deprivation markers with medical visits as the outcome variables and compared people with class II and III obesity versus class I obesity.

RESULTS

Out of the 10,774 participants with obesity, 613 (5.7%) had class III obesity, and 2,076 (19.3%) had class II obesity. Compared with participants with class I obesity, class III obesity participants had higher odds of visiting emergency departments (OR = 1.31; 95% CI: 1.07-1.61) and various specialist physicians (pneumologists, endocrinologists, cardiologists) but lower odds of visiting gynecologists (OR = 0.69; 95% CI 0.55-0.87). Participants with class II obesity had lower odds of visiting general practitioners, dentists, and psychiatrists. There was no difference with regard to hospital admissions.

CONCLUSION

Health care use by people with obesity differs across classes.

Reach of a Fully Digital Diabetes Prevention Program in Health Professional Shortage Areas

The National Diabetes Prevention Program (NDPP) offers lifestyle change education to adults at risk for diabetes across the United States, but its reach is curbed due, in part, to limitations of traditional in-person programs. Diabetes Prevention Programs (DPPs) that are fully digital may increase reach by overcoming these barriers. The aim of this research was to examine the reach of Lark's DPP, a fully digital artificial-intelligence-powered DPP. This study assessed geographic features and demographic characteristics of a sample of Lark DPP commercial health plan members with complete data (N = 16,327) and compared several demographic features with a large composite sample of members from DPPs across the nation (NDPP; N = 143,489) and a National Health Interview Survey (NHIS) sample of prediabetic adults in the United States (NHIS; N = 2118). Examination of the Lark DPP sample revealed that 24.4% of members lived in rural areas, 30.8% lived in whole county health professional shortage areas, and only 7.6% of members lived in a zip code with an in-person DPP. When comparing the Lark sample with the NDPP and NHIS samples, Lark DPP enrollees tended to be younger and have a higher body mass index (BMI) (p's < 0.001). Lark provides convenient access to a DPP for individuals living in hard-to-reach areas who may face barriers to participating in in-person or telephonic DPPs or who prefer a digital program. Compared with the NDPP sample, Lark is also reaching younger and higher BMI users, who are traditionally difficult to enroll and have a high need for intervention.

Weaker connectivity in resting state networks is associated with disinhibited eating in older adults

Background/objectives

Obesity affects more than forty percent of adults over the age of sixty. Aberrant eating styles such as disinhibition have been associated with the engagement of brain networks underlying executive functioning, attentional control, and interoception. However, these effects have been exclusively studied in young samples overlooking those most at risk of obesity related harm.

Methods

Here we assessed associations between resting-state functional connectivity and disinhibited eating (using the Three Factor Eating Questionnaire) in twenty-one younger (aged 19–34 years, BMI range: 18–31) and twenty older (aged 60–73 years, BMI range: 19–32) adults matched for BMI. The Alternative Healthy Eating Index was used to quantify diet quality.

Results

Older, compared to younger, individuals reported lower levels of disinhibited eating, consumed a healthier diet, and had weaker connectivity in the frontoparietal (FPN) and default mode (DMN) networks. In addition, associations between functional connectivity and eating behaviour differed between the two age groups. In older adults, disinhibited eating was associated with weaker connectivity in the FPN and DMN––effects that were absent in the younger sample. Importantly, these effects could not be explained by differences in habitual diet.

Conclusions

These findings point to a change in interoceptive signalling as part of the ageing process, which may contribute to behavioural changes in energy intake, and highlight the importance of studying this under researched population.

Mendelian randomization analysis of the causal impact of body mass index and waist-hip ratio on rates of hospital admission

We analyze how measures of adiposity - body mass index (BMI) and waist hip ratio (WHR) - causally influence rates of hospital admission. Conventional analyses of this relationship are susceptible to omitted variable bias from variables that jointly influence both hospital admission and adipose status. We implement a novel quasi-Poisson instrumental variable model in a Mendelian randomization framework, identifying causal effects from random perturbations to germline genetic variation. We estimate the individual and joint effects of BMI, WHR, and WHR adjusted for BMI. We also implement multivariable instrumental variable methods in which the causal effect of one exposure is estimated conditionally on the causal effect of another exposure. Data on 310,471 participants and over 550,000 inpatient admissions in the UK Biobank were used to perform one-sample and two-sample Mendelian randomization analyses. The results supported a causal role of adiposity on hospital admissions, with consistency across all estimates and sensitivity analyses. Point estimates were generally larger than estimates from comparable observational specifications. We observed an attenuation of the BMI effect when adjusting for WHR in the multivariable Mendelian randomization analyses, suggesting that an adverse fat distribution, rather than a higher BMI itself, may drive the relationship between adiposity and risk of hospital admission.

The Predictive Value of Adipokines and Metabolic Risk Factors for Dropouts and Treatment Outcomes in Children With Obesity Treated in a Pediatric Rehabilitation Center

BACKGROUND

Inpatient pediatric obesity treatments are highly effective, although dropouts and weight regain threaten long-term results. Preliminary data indicate that leptin, adiponectin, and cardiometabolic comorbidities might predict treatment outcomes. Previous studies have mainly focused on the individual role of adipokines and comorbidities, which is counterintuitive, as these risk factors tend to cluster. This study aimed to predict the dropouts and treatment outcomes by pre-treatment patient characteristics extended with cardiometabolic comorbidities (individually and in total), leptin, and adiponectin.

METHODS

Children aged 8-18 years were assessed before, immediately after and 6 months after a 12-month inpatient obesity treatment. Anthropometric data were collected at each visit. Pre-treatment lipid profiles; glucose, insulin, leptin, and adiponectin levels; and blood pressure were measured. The treatment outcome was evaluated by the change in body mass index (BMI) standard deviation score (SDS) corrected for age and sex.

RESULTS

We recruited 144 children with a mean age of 14.3 ± 2.2 years and a mean BMI of 36.7 ± 6.2 kg/m² corresponding to 2.7 ± 0.4 BMI SDS. The 57 patients who dropped out during treatment and the 44 patients who dropped out during aftercare had a higher pre-treatment BMI compared to the patients who completed the treatment (mean BMI, 38.3 ± 6.8 kg/m² vs 35.7 ± 5.5 kg/m²) and those who completed aftercare (mean BMI, 34.6 ± 5.3 kg/m² vs 37.7 ± 6.3 kg/m²) (all p<0.05). Additionally, aftercare attenders were younger than non-attenders (mean age, 13.4 ± 2.3 years vs 14.9 ± 2.0, p<0.05).Patients lost on average 1.0 ± 0.4 SDS during treatment and regained 0.4 ± 0.3 SDS post-treatment corresponding to regain of 43 ± 27% (calculated as the increase in BMI SDS post-treatment over the BMI SDS lost during treatment). A higher BMI and more comorbidities inversely predicted BMI SDS reduction in linear regression (all p<0.05).The absolute BMI SDS increase after returning home was predicted by pre-treatment leptin and systolic blood pressure, whereas the post-treatment BMI SDS regain was predicted by pre-treatment age, leptin, and adiponectin levels (all p<0.05) in multivariate linear regressions.

CONCLUSION

Patients who need treatment the most are at increased risk for dropouts and weight regain, emphasizing the urgent need for interventions to reduce dropout and support inpatients after discharge. Furthermore, this study is the first to report that pre-treatment leptin and adiponectin levels predict post-treatment BMI SDS regain, requiring further research.

COMPARISON OF BONE PARAMETERS BY BODY REGION IN UNIVERSITY ATHLETES: SYSTEMATIC REVIEW

ABSTRACT Introduction: Bone mineral density (BMD) and bone mineral content (BMC) vary depending on the type of sport practiced and the body region, and their measurement can be an effective way to predict health risks throughout an athlete’s life. Objective: To describe the methodological aspects (measurement of bone parameters, body regions, precision errors and covariates) and to compare BMD and BMC by body region (total body, upper limbs, lower limbs and trunk) among university athletes practicing different sports. Methods: A search was performed on the databases PubMed, Web of Science, Scopus, ScienceDirect, EBSCOhost, SportDiscus, LILACS and SciELO. Studies were selected that: (1) compared BMD and BMC of athletes practicing at least two different sports (2) used dual-energy X-ray absorptiometry (DXA) to assess bone parameters (3) focused on university athletes. The extracted data were: place of study, participant selection, participants’ sex, sport practiced, type of study, bone parameters, DXA model, software used, scan and body regions, precision error, precision protocol, covariates and comparison of bone parameters between different sports by body region. Results: The main results were: 1) BMD is the most investigated bone parameter; 2) total body, lumbar spine and proximal femur (mainly femoral neck) are the most studied body regions; 3) although not recommended, the coefficient of variation is the main indicator of precision error; 4) total body mass and height are the most commonly used covariates; 5) swimmers and runners have lower BMD and BMC values; and 6) it is speculated that basketball players and gymnasts have greater osteogenic potential. Conclusions: Swimmers and runners should include weight-bearing exercises in their training routines. In addition to body mass and height, other covariates are important. The results of this review can help guide intervention strategies focused on preventing diseases and health problems during and after the athletic career. Level of evidence II; Systematic Review.

Double Burden of Malnutrition and Inequalities in the Nutritional Status of Adults: A Population-Based Study in Brazil, 2019

Objective: To describe the inequalities in the double burden of malnutrition (DBM) in the adult population.

Methods: Study carried out with data from the VIGITEL study, conducted in 2019 in all Brazilian capitals. Underweight and excess weight were evaluated on the basis of years of schooling and age. Multi-level analysis was performed including Human Development Index of each capital and individual-level variables. The inequality slope index was used to assess the magnitude of the inequalities found. All analyses considered the svy command owing to the complexity of the sampling process.

Results: 47.119 individuals were studied. Men with no education had 6 percentage points more underweight compared to those with higher education. Higher prevalence of excess weight was found among men with higher education and women with no education. In women, the difference was 18 percentage points between extreme categories. Elderly people with no education had 10 percentage points more excess weight than those with higher education.

Conclusions: The findings suggest the need for intersectoral actions that can cope with the social inequalities and help confronting with the DBM in Brazil.

Impact of metabolic surgery on cost and long-term health outcome: a cost-effectiveness approach

BACKGROUND

The increase in obesity has become a major public health concern. Morbid obesity is associated with co-morbidities, reduced quality-of-life, and death. Metabolic surgery (MS) is the most effective treatment for obesity.

OBJECTIVES

The aim of this study was to evaluate the costs and outcomes of MS compared with no surgery in patients with a body mass index ≥30 kg/m².

SETTING

Health care system, Austria METHODS: A total of 177 patients who underwent MS were documented retrospectively, based on the hospital records of 2 specialized centers in Austria, over a 1-year period. At baseline 26.0% of patients exhibited type 2 diabetes (T2D), 52.5% cardiovascular disease (CVD), 23.2% hyperlipidemia, and 23.7% depression. Following the observation period, a Markov chain simulation model was developed to analyze the long-term consequences of T2D, including diabetic complications, CVD, hyperlipidemia, depression, non-alcoholic steatohepatitis (NASH), myocardial infarction, and stroke, over a total of 20 years. Direct medical costs were expressed in 2017 euros from the payer's perspective. Quality-adjusted life years (QALYs), life years (LYs), and costs were discounted.

RESULTS

MS led to costs of €40,427 and 9.58 QALYs (15.58 LYs) per patient over 20 years. No MS was associated with €64,819 and 6.33 QALYs (13.92 LYs). Total cost-savings amounted to €24,392, which offset the cost of the procedure including re-operations. Over 20 years MS saved -6.7 patient-years per patient with T2D, -5.8 patient-years with CVD, -1.5 patient-years with hyperlipidemia, -1.8 patient-years with depression, and -3.8 patient-years with NASH.

CONCLUSION

MS is associated with substantial savings in long-term costs, expected health benefits, and reduced onset of complications. MS significantly increases quality of life.

Does bariatric surgery reduce future hospital costs? A propensity score-matched analysis using UK Biobank Study data

OBJECTIVES

To estimate the hospital costs among persons with obesity undergoing bariatric surgery compared with those without bariatric surgery.

METHODS

We analysed the UK Biobank Cohort study linked to Hospital Episode Statistics, for all adults with obesity undergoing bariatric surgery at National Health Service hospitals in England, Scotland, or Wales from 2006 to 2017. Surgery patients were matched with controls who did not have bariatric surgery using propensity scores approach with a ratio of up to 1-to-5 by year. Inverse probability of censoring weighting was used to correct for potential informative censoring. Annual and cumulative hospital costs were assessed for the surgery and control groups.

RESULTS

We identified 348 surgical patients (198 gastric bypass, 73 sleeve gastrectomy, 77 gastric banding) during the study period. In total, 324 surgical patients and 1506 matched control participants were included after propensity score matching. Mean 5-year cumulative hospital costs were €11,659 for 348 surgical patients. Compared with controls, surgical patients (n = 324) had significantly higher inpatient expenditures in the surgery year (€7289 vs. €2635, P < 0.001), but lower costs in the subsequent 4 years. The 5-year cumulative costs were €11,176 for surgical patients and €8759 for controls (P = 0.001).

CONCLUSIONS

Bariatric surgery significantly increased the inpatient costs in the surgery year, but was associated with decreased costs in the subsequent 4 years. However, any cost savings made up to 4 years were not enough to compensate for the initial surgical expenditure.

Mendelian randomization: estimation of inpatient hospital costs attributable to obesity

BACKGROUND

Mendelian Randomization is a type of instrumental variable (IV) analysis that uses inherited genetic variants as instruments to estimate causal effects attributable to genetic factors. This study aims to estimate the impact of obesity on annual inpatient healthcare costs in the UK using linked data from the UK Biobank and Hospital Episode Statistics (HES).

METHODS

UK Biobank data for 482,127 subjects was linked with HES inpatient admission records, and costs were assigned to episodes of care. A two-stage least squares (TSLS) IV model and a TSLS two-part cost model were compared to a naïve regression of inpatient healthcare costs on body mass index (BMI).

RESULTS

The naïve analysis of annual cost on continuous BMI predicted an annual cost of £21.61 [95% CI £20.33 - £22.89] greater cost per unit increase in BMI. The TSLS IV model predicted an annual cost of £14.36 [95% CI £0.31 - £28.42] greater cost per unit increase in BMI. Modelled with a binary obesity variable, the naïve analysis predicted that obese subjects incurred £205.53 [95% CI £191.45 - £219.60] greater costs than non-obese subjects. The TSLS model predicted a cost £201.58 [95% CI £4.32 - £398.84] greater for obese subjects compared to non-obese subjects.

CONCLUSIONS

The IV models provide evidence for a causal relationship between obesity and higher inpatient healthcare costs. Compared to the naïve models, the binary IV model found a slightly smaller marginal effect of obesity, and the continuous IV model found a slightly smaller marginal effect of a single unit increase in BMI.

A systematic review of randomized controlled trials examining workplace wellness interventions

BACKGROUND

One of the influencing factors associated with weight gain is overeating as a maladaptive coping strategy to process or avoid the emotional impact of psychological stress. Psychological stress is chronically and pervasively associated with stress stemming from the workplace environment. Workplace wellness interventions have a unique opportunity to change environmental factors impacting psychological stress, which can improve individual food choice and weight management efforts.

AIM

To synthesize evidence from randomized controlled trials on workplace wellness interventions that impact employee psychological stress and food choice or weight management.

METHODS

A systematic review was completed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Selected studies were limited to English-language articles exploring randomized interventions at workplaces among adult employees and included measurements of psychometric stress and food choice (qualitative or quantitative) or biometric weight management. From the search, 10 studies were included in the final review.

RESULTS

Results were inconsistent across studies. There was no observable association between psychological stress reduction and food choice or weight management. Mid-length interventions (ranging from 6 to 9 months) had more consistent associations between intervention program implementation, reduced psychological stress, and improved food choice or weight management.

CONCLUSIONS

The studies examining employee food choices and weight management efforts remained very heterogeneous, indicating that more research is needed in this specific area of employee wellness program planning and measurement. Consistent research methodology and assessment tools are needed to measure dietary intake.

Attributable societal costs of first-incident obesity-related cardiovascular comorbidities in Denmark

Background: Obesity is associated with increased societal costs, primarily due to its comorbidities. The objective of this study was to estimate the 3-year attributable societal costs of the first event of cardiovascular comorbidities among people with obesity.Methods: We used an incidence-based cohort study based on Danish national registries. Attributable costs of each event were calculated as the difference between costs of individuals with an event and costs incurred by matched controls.Results: We identified 58,597 individuals with a diagnosis of obesity. On average, 2,038 individuals were diagnosed annually with one or more than ten cardiovascular comorbidities between 2007 and 2013. The 3-year attributable societal costs (health-care costs plus productivity loss) for patients of working age ranged from 8,164 EUR for other ischemic heart disease to 32,203 EUR for hemorrhagic stroke. In the incidence year, costs were mainly driven by health-care costs, while productivity loss and income transfer payments were the primary drivers in subsequent years.Conclusion: The onset of obesity-related cardiovascular comorbidities affected health-care costs and work ability to an extent where sick pay and disability pension were required. Our study demonstrates the need to intensify obesity and cardiovascular disease risk factor management to prevent costly and debilitating obesity-related comorbidities.

Association of body mass index with health care expenditures in the United States by age and sex

Background

Estimates of health care costs associated with excess weight are needed to inform the development of cost-effective obesity prevention efforts. However, commonly used cost estimates are not sensitive to changes in weight across the entire body mass index (BMI) distribution as they are often based on discrete BMI categories.

Methods

We estimated continuous BMI-related health care expenditures using data from the Medical Expenditure Panel Survey (MEPS) 2011–2016 for 175,726 respondents. We adjusted BMI for self-report bias using data from the National Health and Nutrition Examination Survey (NHANES) 2011–2016, and controlled for potential confounding between BMI and medical expenditures using a two-part model. Costs are reported in $US 2019.

Results

We found a J-shaped curve of medical expenditures by BMI, with higher costs for females and the lowest expenditures occurring at a BMI of 20.5 for adult females and 23.5 for adult males. Over 30 units of BMI, each one-unit BMI increase was associated with an additional cost of $253 (95% CI $167-$347) per person. Among adults, obesity was associated with $1,861 (95% CI $1,656-$2,053) excess annual medical costs per person, accounting for $172.74 billion (95% CI $153.70-$190.61) of annual expenditures. Severe obesity was associated with excess costs of $3,097 (95% CI $2,777-$3,413) per adult. Among children, obesity was associated with $116 (95% CI $14-$201) excess costs per person and $1.32 billion (95% CI $0.16-$2.29) of medical spending, with severe obesity associated with $310 (95% CI $124-$474) excess costs per child.

Conclusions

Higher health care costs are associated with excess body weight across a broad range of ages and BMI levels, and are especially high for people with severe obesity. These findings highlight the importance of promoting a healthy weight for the entire population while also targeting efforts to prevent extreme weight gain over the life course.

Effects of Gene-Environment Interaction on Obesity among Chinese Adults Born in the Early 1960s

The prevalence of obesity has been increasing sharply and has become a serious public health problem worldwide. Gene–environment interaction in obesity is a relatively new field, and little is known about it in Chinese adults. This study aimed to provide the effects of gene–environment interaction on obesity among Chinese adults. A stratified multistage cluster sampling method was conducted to recruit participants from 150 surveillance sites. Subjects born in 1960, 1961 and 1963 were selected. An exploratory factor analysis was used to classify the environmental factors. The interaction of single nucleotide polymorphisms (SNPs) and environmental factors on body mass index (BMI) and waist circumference were analyzed using a general linear model. A multiple logistic regression model combined with an additive model was performed to analyze the interaction between SNPs and environmental factors in obesity and central obesity. A total of 2216 subjects were included in the study (mean age, 49.7 years; male, 39.7%, female, 60.3%). Engaging in physical activity (PA) could reduce the effect of MC4R rs12970134 on BMI (β = −0.16kg/m², p = 0.030), and also reduce the effect of TRHR rs7832552 and BCL2 rs12454712 on waist circumference (WC). Sedentary behaviors increased the effects of SNPs on BMI and WC, and simultaneously increased the effects of FTO rs9939609 and FTO rs8050136 on obesity and central obesity. A higher socioeconomic status aggravated the influence of SNPs (including FTO rs9939609, BNDF rs11030104, etc.) on BMI and WC, and aggravated the influence of SEC16B rs574367 on central obesity. The MC4R rs12970134 association with BMI and the FTO rs8050136 association with central obesity appeared to be more pronounced with higher energy intake (β = 0.140 kg/m², p = 0.049; OR = 1.77, p = 0.004, respectively). Engaging in PA could reduce the effects of SNPs on BMI and WC; nevertheless, a higher socioeconomic status, higher dietary energy intake and sedentary behaviors accentuated the influences of SNPs on BMI, WC, obesity and central obesity. Preventative measures for obesity should consider addressing the gene–environment interaction.

Parental neglect of feeding in obese individuals. A review of scientific evidence and its application among Saudi population

Human beings encountered malnutrition during the twentieth century and obesity in the very next century. This is how the future will look when the present becomes a slice of history. Obesity is threatening the healthy being of many youngsters throughout the world. Environmental influences have indicated to effect even genetically safe subjects among which parental neglect seems to be most alarming. Two extensively and globally investigated variables, the feeding style and the physical activity, provide some hope in its prevention. Despite the high rise of obesity prevalence in Saudi Arabia, there is scant research on these topics. The purpose of this review is to present a comprehensive assessment of these 2-obesity associated parental variables. The composed literature could provide an insight to the dominant surge of obesity in the Arab nations and stimulate research on current parenting practices in the Kingdom.

Modeling Obesity in Norway (The MOON Study): A Decision-Analytic Approach-Prevalence, Costs, and Years of Life Lost

BACKGROUND

Limited knowledge exists on the expected long-term effects and cost-effectiveness of initiatives aiming to reduce the burden of obesity.

AIM

To develop a Norwegian obesity-focused disease-simulation model: the MOON model.

MATERIAL AND METHODS

We developed a Markov model and simulated a Norwegian birth cohort's movement between the health states "normal weight,""overweight,""obese 1,""obese 2," and "dead" using a lifetime perspective. Model input was estimated using longitudinal data from health surveys and real-world data (RWD) from local and national registers (N = 99,348). The model is deterministic and probabilistic and stratified by gender. Model validity was assessed by estimating the cohort's expected prevalence, health care costs, and mortality related to overweight and obesity.

RESULTS

Throughout the cohort's life, the prevalence of overweight increased steadily and stabilized at 45% at 45 y of age. The number of obese 1 and 2 individuals peaked at age 75 y, when 44% of women and 35% of men were obese. The incremental costs per person associated with obesity was highest in older ages and, when accumulated over the lifetime, higher among women (€12,118, €9,495-€15,047) than men (€6,646, €5,252-€10,900). On average, obesity shortened the life expectancy of women/men in the whole cohort by 1.31/1.08 y. The life expectancy for normal-weight women/men at age 30 was 83.31/80.31. The life expectancy was reduced by 1.05/0.65 y if the individual was overweight, obese (2.87/2.71 y), or obese 2 (4.06/4.83 y).

CONCLUSION

The high expected prevalence of obesity in the future will lead to substantial health care costs and large losses in life-years. This underscores the need to implement interventions to reduce the burden of obesity; the MOON model will enable economic evaluations for a wide range of interventions.

Cancer Research UK'S obesity campaign in 2018 and 2019: effective health promotion or perpetuating the stigmatisation of obesity?

In 2018 and 2019 Cancer Research UK (CRUK) launched a controversial advertising campaign to inform the British public of obesity being a preventable cause of cancer. On each occasion the advertisements used were emotive and provoked frustration among the British public which was widely vocalised on social media. As well serving to educate the public of this association, the advertisements also had the secondary effect of acting as health promotion through social marketing, a form of advertising designed to influence behavioural changes. As CRUK delivered a public health message through its campaign, the advertisements should be held according to the ethical principles which underpin healthcare in the UK. This article evaluates whether the advertisements used by CRUK in 2018 and 2019 fulfilled the ethical principles of beneficence, autonomy, non-maleficence and justice. It is found that while providing an important message, the oversimplification of obesity as being the result of personal decisions ignored the complex aetiology and served to stigmatise the target demographic, potentially disengaging them from the message. Additionally, posting cancer as the consequence of obesity invokes feelings of fear due to its connotations of suffering and premature death. Based on available evidence, the use of fear in social marketing does not create sustained behavioural change. This essay recommends that CRUK discontinue its use of such strategies in its future social marketing endeavours.

Health-care spending attributable to modifiable risk factors in the USA: an economic attribution analysis

BACKGROUND

There is a robust understanding of how specific behavioural, metabolic, and environmental risk factors increase the risk of health burden. However, there is less understanding of how these risks individually and jointly affect health-care spending. The objective of this study was to quantify health-care spending attributable to modifiable risk factors in the USA for 2016.

METHODS

We extracted estimates of US health-care spending by condition, age, and sex from the Institute for Health Metrics and Evaluation's Disease Expenditure Study 2016 and merged these estimates with population attributable fraction estimates for 84 modifiable risk factors from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 to produce estimates of spending by condition attributable to these risk factors. Because not all spending can be linked to health burden, we adjusted attributable spending estimates downwards, proportional to the association between health burden and health-care spending across time and age for each aggregate health condition. We propagated underlying uncertainty from the original data sources by randomly pairing the draws from the two studies and completing our analysis 1000 times independently.

FINDINGS

In 2016, US health-care spending attributable to modifiable risk factors was US$730·4 billion (95% uncertainty interval [UI] 694·6-768·5), corresponding to 27·0% (95% UI 25·7-28·4) of total health-care spending. Attributable spending was largely due to five risk factors: high body-mass index ($238·5 billion, 178·2-291·6), high systolic blood pressure ($179·9 billion, 164·5-196·0), high fasting plasma glucose ($171·9 billion, 154·8-191·9), dietary risks ($143·6 billion, 130·3-156·1), and tobacco smoke ($130·0 billion, 116·8-143·5). Spending attributable to risk factor varied by age and sex, with the fraction of attributable spending largest for those aged 65 years and older (45·5%, 44·2-46·8).

INTERPRETATION

This study shows high spending on health care attributable to modifiable risk factors and highlights the need for preventing and controlling risk exposure. These attributable spending estimates can contribute to informed development and implementation of programmes to reduce risk exposure, their health burden, and health-care cost.

FUNDING

Vitality Institute.

Individualizing pharmacogenomic test results in the context of the microbiome

The field of pharmacogenetic testing was hailed as one of the early successful clinical applications arising from the personalized (or precision) medicine revolution. Substantial progress has been made to identify genes and genetic variants involved in drug response and establish clinical implementation programs. Yet, drug response is a complex trait and recent work has highlighted the key role played by the gut microbiome. As the study of the gut microbiome and pharmacogenetics converge, it may be possible to generate more precise predictions of drug response and improve health outcomes to treatments. Substantial effort will be needed to understand the dynamic impact of the microbiome and the interplay with host genetics and how to implement expanded pharmacogenetic testing.

Effective SLOPE: EffectS of Lifestyle interventions in Older PEople with obesity: a systematic review and network meta-analysis protocol

INTRODUCTION

Obesity is highly prevalent in older adults aged 65 years or older. Different lifestyle interventions (diet, exercise, self-management) are available but benefits and harms have not been fully quantified comparing all available health promotion interventions. Special consideration must be given to functional outcomes and possible adverse effects (loss of muscle and bone mass, hypoglycaemia) of weight loss interventions in this age group. The objective of this study is to synthesise the evidence regarding the effects of different types and modalities of lifestyle interventions, or their combinations, on physical function and obesity-related outcomes such as body composition in older adults with obesity.

METHODS AND ANALYSES

Six databases (Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Psychinfo and Web of Science) and two trial registries (Clinicaltrials.gov and the WHO International Clinical Trials Registry Platform) will be searched for randomised controlled trials of lifestyle interventions in older adults with obesity. Screening (title/abstract and full-text) and data extraction of references as well as assessment of risk of bias and rating of the certainty of evidence (Grading of Recommendations, Assessment, Development and Evaluation for network meta-analyses) will be performed by two reviewers independently. Frequentist random-effects network meta-analyses will be conducted to determine the pooled effects from each intervention.

ETHICS AND DISSEMINATION

We will submit our findings to peer-reviewed journals and present at national and international conferences as well as in scientific medical societies. Patient-targeted dissemination will involve local and national advocate groups.

PROSPERO REGISTRATION NUMBER

CRD42019147286.