Sachin Kamal-Bahl

Indirect costs of obesity: a review of the current literature.

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

Prevalence and extent of dyslipidemia and recommended lipid levels in US adults with and without cardiovascular comorbidities: the National Health and Nutrition Examination Survey 2003-2004.

BACKGROUND Despite improvements in low-density lipoprotein cholesterol (LDL-C) levels, recent national data are limited regarding the proportion of adults at recommended lipid levels according to the presence of cardiovascular disease (CVD) and related comorbidities. We evaluated the proportion of US adults with and without these conditions at (and distance to) recommended levels of LDL-C, non-high-density lipoprotein cholesterol (non-HDL-C), HDL-C, and triglycerides. METHODS We analyzed data from adults aged > or =20 who had fasted for 8 or more hours (n = 2,883, weighted to a US population of 128.5 million) in the National Health and Nutrition Examination Survey 2003-2004, a nationally representative cross-sectional survey. The number of adults at National Cholesterol Education Program recommended levels for LDL-C, non-HDL-C, HDL-C, triglycerides, and combined lipids, stratified by sex, age group, ethnicity, and the presence of CVD comorbidities was determined. RESULTS Although 85% to 89% of persons without CVD or related comorbidities were at recommended levels for LDL-C, non-HDL-C, HDL-C, and triglycerides, only 36% to 37% of those with CVD or related comorbidities were at recommended levels for LDL-C and non-HDL-C, and only 17% were at recommended levels for all lipids. Treated persons compared with those untreated had significantly lower LDL-C (112.3 vs 156.7 mg/dL, P < .001) and non-HDL-C levels (145.9 vs 188.7 mg/dL, P < .001), but similar HDL-C (52.0 vs 50.1 mg/dL, P = .09) and triglyceride (160.1 vs 148.7 mg/dL, P = .20) levels. CONCLUSIONS Despite improved LDL-C levels, many adults, especially with CVD or related comorbidities, are not at recommended levels for all lipids. Improved treatment efforts to target the spectrum of dyslipidemia are needed.

The lifetime medical cost burden of overweight and obesity: implications for obesity prevention.

This study quantifies age‐specific and lifetime costs for overweight (BMI: 25–29.9), obese I (BMI: 30–34.9), and obese II/III (BMI: >35) adults separately by race/gender strata. We use these results to demonstrate why private sector firms are likely to underinvest in obesity prevention efforts. Not only does the existence of Medicare reduce the economic burden that obesity imposes on private payers, but, from the perspective of a 20‐year‐old obese adult, the short‐term costs of obesity are small. This suggests that legislation that subsidizes wellness programs and/or mandates coverage for obesity treatments might make all firms better off. Ironically, Medicare has a greater incentive to prevent obesity because when an obese 65 year old enters the program, his/her costs are immediate and higher than costs for normal weight individuals.

Abdominal obesity and the spectrum of global cardiometabolic risks in US adults

Objective:To compare the association of obesity and abdominal obesity with cardiometabolic risk factor burden and global estimated coronary heart disease (CHD) risk among multiethnic US adults.Design:Cross-sectional, survey study.Subjects:A total of 4456 participants (representing 194.9 million adults) aged 20–79 years in the 2003–2004 National Health and Nutrition Examination Survey (NHANES).Measurements:Body mass index (BMI) and waist circumference (WC) measures, CHD risk factors and a 10-year estimated CHD risk based on Framingham algorithms. Obesity was defined as a BMI ⩾30 kg/m2 and abdominal obesity as a WC >88 cm in women and >102 cm in men. High CHD risk status included diabetes, cardiovascular disease (CVD) or a 10-year Framingham risk score of >20%.Results:Overall, abdominal obesity was present in 42.3% of men and 62.5% of women and in 53.6% of whites, 56.9% of blacks and 50.5% of Hispanics (P<0.001 between gender and ethnicity). However, using International Diabetes Federation (IDF)-recommended WC cut points for Hispanics, the prevalence of abdominal obesity was 78.3%. Mean levels of low-density lipoprotein cholesterol (LDL-C), systolic and diastolic blood pressure, fasting glucose and C-reactive protein increased, and high-density lipoprotein cholesterol (HDL-C) decreased (P<0.001) according to BMI and WC categories, although these associations were attenuated in blacks for blood pressure, LDL-C, HDL-C and triglycerides. Of those with high WC, 25–35% had ⩾3 cardiometabolic risk factors. High CHD risk among those with high WC was most common in men (27.9%) and non-Hispanic whites (23.9%). Persons with a high vs normal WC, adjusted for age, gender, ethnicity and BMI were more likely to have ⩾3 cardiometabolic risk factors (odds ratio (OR)=5.1, 95% confidence interval (CI)=3.9–6.6) and were classified as high CHD risk (OR=1.5, 95% CI=1.1–2.0).Conclusion:The association of abdominal obesity with risk factors varies by ethnicity and is independently associated with high CHD risk status, further validating its clinical significance.

Obesity, disease burden, and prescription spending by community-dwelling Medicare beneficiaries

ABSTRACT Objectives: To assess drug utilization and cost patterns by body mass index (BMI) for Medicare beneficiaries including cohorts diagnosed with diseases resulting from, or aggravated by, obesity. Research design: We used data from the 2003 Medicare Current Beneficiary Survey to characterize the community-dwelling Medicare population by BMI class and to assess the following outcomes: (1) prevalence of drugs recommended in treating obesity-related chronic diseases, (2) annual spending on these medications by disease cohort, and (3) spending for all medications for the full study sample. Linear regression techniques were used to assess the conditional association of BMI class with drug spending controlling for sociodemographic characteristics, prescription drug coverage, health status, and comorbidities. Results: Annual drug spending in 2003 was significantly higher (p < 0.05) for obese class I (

The impact of physician attitudes and beliefs on treatment decisions: lipid therapy in high-risk patients.

2374) and class III (

Contemporary Analysis of Secondary Failure of Successful Sulfonylurea Therapy

2976) compared to normal-weight beneficiaries (

Dosage, titration, and gaps in treatment with extended release niacin in clinical practice

1764). Obese individuals also had higher utilization rates for selected medications used to treat diabetes, hypertension, ischemic heart disease, heart failure, hyperlipidemia, and osteoarthritis. Regression results indicate that chronic disease is the main reason why drug spending is higher among the obese, but prescription drug coverage is also a significant factor. Conclusions: Obesity is associated with significantly higher drug spending among Medicare beneficiaries. The combination of growing numbers of obese beneficiaries, high rates of chronic disease, and greater than average prescription spending per condition will all contribute to higher future Part D and overall Medicare program costs. Limitations of the study include: self-reported data on height, weight, and drug use/spending; small sample size; and pre-Part D data.

Challenges faced in transferring economic evaluations to middle income countries

Background:Despite clinical guidelines, many patients with hypercholesterolemia do not achieve treatment goals in clinical practice. Objectives:This study examined physician attitudes and beliefs about hyperlipidemia and whether they are associated with lipid treatment decisions. Methods:This was a cross-sectional study of 107 physicians who completed a validated survey of attitudes and beliefs about hyperlipidemia and provided treatment histories for 1187 statin-treated patients with coronary heart disease (CHD) or who were CHD risk-equivalent. Logistic regressions (using generalized estimating equation) estimated the impact of patient characteristics and physician attitudes and beliefs on whether a patient received increases in the statin dose. Results:Approximately 70% of the 843 patients who were not at low-density lipoprotein cholesterol goal (<100 mg/dL) with initial statin therapy received a dose increase, although only one-half attained goal. Controlling for patient characteristics, patients whose physicians believed “close enough to goal is good enough” had 47% lower odds of having a dose increase (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.34–0.82), whereas patients whose physicians believed “statins are effective” had almost twice the odds of having a dose increase (OR, 1.78; 95% CI, 1.05–3.00). Conclusions:Although the understanding of basic and clinical science remains fundamental, clinical guideline authors may want to consider the importance of physician attitudes and beliefs in determining translation of their guidelines into clinical practice.

Trends in lipid management among patients with diabetes

OBJECTIVE To revise older estimates of secondary failure that may no longer describe the contemporary pattern of sulfonylurea (SU) monotherapy and to identify predictors of such failure. METHODS We identified 4,091 patients who achieved hemoglobin A1c (A1C) <8% within 1 year after initiation of SU therapy as their first-ever antihyperglycemic drug after January 1, 1996. The study subjects underwent follow-up until they added or switched antihyperglycemic medication, had A1C > or =8%, or terminated health plan membership or until December 31, 2004. We defined secondary failure by using two separate but overlapping approaches: (1) the addition of or switch to another antihyperglycemic drug after 6 months of SU therapy or (2) the first A1C measurement > or =8.0%. RESULTS The level of A1C achieved within 1 year after initiation of SU treatment was the most powerful predictor of secondary SU failure. About 50% of patients whose best A1C was 7.0% to 7.9% added or switched antihyperglycemic drugs within 40 months, whereas it took nearly 60 months for those in the 6.0% to 6.9% A1C category and 74 months in the A1C <6.0% category to reach a 50% failure rate. Similarly, more than half of those patients whose best A1C was 7.0% to 7.9% had an A1C value > or =8% within 24 months, whereas it took nearly 60 months for study subjects in the 6.0% to 6.9% A1C category and 86 months for those in the <6.0% category to have SU failure. Younger age and weight gain were also predictive of failure. CONCLUSION Secondary failure of SU therapy is inversely associated with the level of A1C achieved within the first year of SU monotherapy. Clinicians should quickly consider therapeutic adjustments to lower the A1C level rapidly if initial success is not achieved.