Asia
Pacific Journal of Clinical Nutrition
Volume 15, Supplement
(September 2006, on-line only)
Health Economics of weight management
A report for the Weight Management Code Administration
Council of Australia
Abstracts
& Full papers
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Epidemiology
and health impact of obesity: an Asia Pacific perspective
TIM GILL
This
paper compares body mass index, waist circumference, hip circumference,
and waist-hip ratio as risk factors for ischaemic heart disease and
stroke in Asia Pacific populations. We undertook a pooled analysis
involving six cohort studies (45 988 participants) and used Cox proportional
hazards regression to assess the associations of the four anthropometric
indices with stroke and ischaemic heart disease by age, sex and region.
During a mean follow-up of six years, 346 stroke and 601 ischaemic
heart disease events (fatal and non-fatal) were documented. Overall,
a one-standard deviation increase in index was associated with an
increase in risk of ischaemic heart disease of 17% (95% CI 7-27%)
for body mass index, 27% (95% CI 14-40%) for waist circumference,
10% (95% CI 1-20%) for hip circumference, and 36% (95% CI 21-52%)
for waist-hip ratio. There were no significant differences between
age groups, sex, and region. None of the four anthropometric indices
had a strong association with risk of stroke. These data indicate
that measures of central obesity such as waist circumference and waist-hip
ratio are strongly associated with risk of ischaemic heart disease
in this region. Therefore, we suggest that, along with calculation
of body mass index, measures of central obesity such as waist circumference
and waist-hip ratio should be undertaken routinely.
Key Words: abdominal obesity, waist circumference, waist hip ratio,
cardiovascular diseases, cohort studies, Asia
.
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Socio-economic
factors in obesity: a case of slim chance in a fat world?
KYLIE BALL AND DAVID CRAWFORD
The
global obesity pandemic has been well-documented and widely discussed
by the public, the media, health officials, the food industry and
academic researchers. While the problem is widely recognised, the
potential solutions are far less clear. There is only limited evidence
to guide decisions as to how best to manage obesity in individuals
and in populations. While widely viewed as a clinical and public health
problem in developed countries, it is now clear that many developing
countries also have to grapple with this problem or face the crippling
healthcare costs resulting from obesity-related morbidity. There is
also abundant evidence that obesity is socio-economically distributed.
In developed countries persons of lower socio-economic position are
more likely to be affected, while in developing countries, it is often
those of higher socio-economic position who are overweight or obese.
The aim of this paper is to briefly review the evidence that links
socio-economic position and obesity, to discuss what is known about
underlying mechanisms, and to consider the role of social, physical,
policy and cultural environments in explaining the relationships between
socio-economic position and obesity. We introduce the concept of 'resilience'
as a potential theoretical construct to guide research efforts aimed
at understanding how some socio-economically disadvantaged individuals
manage to avoid obesity. We conclude by considering an agenda to guide
future research and programs focused on understanding and reducing
obesity among those of low socio-economic position.
Key
Words: socio-economic factors, obesity, environment, social environment,
resilience
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.
Weight
management in transitional economies: the "double burden of disease"
dilemma
WIDJAJA
LUKITO AND MARK L WAHLQVIST
The
nature of nutritionally-related disease (NRD) in transitional economies
is such that deficiency can frequently co-exist with excess. This
is most usually represented by the combination of diets of low nutritional
quality (low and little food component density and diversity, FCDD)
and decreased levels of physical activity, predicated, in part, on
limited affordability of alternatives. Moreover, these changes are
not simply inter-generational, as the pace of socio-environmental
change is great enough for them to be intra-generational as well.
The most troublesome situation is that of maternal undernutrition,
with intra-uterine growth retardation, compromised lactation and infant
feeding, leading to stunting in early life and to abdominal obesity
and its consequences later in life. Weight management in these situations
requires pre-conceptional interventions, effective maternal-child
health programmes and life-long approaches to avoid inappropriate
gene programming and body compositional disorders. It is unlikely
that narrow strategies, located solely around energy balance, will
do more than attenuate this growing burden of disease for most of
the world's populations. The pluralistic approaches to health required
are likely to build on more effective lifestyle, behavioural and pharmacotherapeutic
strategies to weight management, and do so at all ages, from conception
to later life.
Key
Words: Nutritionally-Related Disease (NRD), deficiency disorders,
body compositional disorders (BCD), energy imbalance, food component
density and diversity (FCDD), poverty, affordability, maternal health,
child health, life stages
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State
of the science: behavioural treatment of obesity
LASHANDA R JONES AND THOMAS A WADDEN
Obesity
is a global and preventable epidemic with serious health consequences
for individuals worldwide, particularly for those in developed countries.
The World Health Organization estimates that at least 1 billion people
worldwide are overweight, and 300 million are obese. Research has
demonstrated that weight losses as small as 7-10% of initial weight
produce significant health benefits. These include reducing the risk
of heart disease, stroke, and some cancers. This paper describes behavioural
methods to modify maladaptive eating and activity habits to achieve
a healthy weight. It also examines the short- and long-term results
of behavioural treatment for obesity and methods to improve long-term
weight control.
Key Words:
behaviour therapy, obesity, lifestyle intervention, weight-loss, physical
activity
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State
of the science: a focus on physical activity
ANDREW P HILLS AND NUALA M BYRNE
Diet,
exercise, behavioural support and for some obese individuals, pharmacotherapy,
represent the set of lifestyle factors necessary for effective management
of obesity. An on-going challenge in the prevention, treatment and
management of obesity is to arm health professionals in particular,
with the necessary knowledge and understanding and time to engage
in meaningful weight management counseling. Despite the many barriers
to effective management such as lack of relevant education in nutrition
and physical activity, perceived patient non-compliance, perceived
inability to change patient behaviours, and the cost of specialist
behavioural support, there is increasing evidence of the value of
behaviour modification techniques to both dietary and exercise counseling,
particularly when focusing on current behaviour. Behavioural counseling
addresses the barriers to compliance with diet and physical activity
goals and also equips the individual with practical strategies and
motivation to be more self-responsible. Commonly employed behavioural
interventions include stimulus control, reinforcement techniques,
self-monitoring, behavioural contracting, and social support programs.
This paper addresses one of the key behavioural components in the
treatment and management of obesity - physical activity. Higher levels
of energy expenditure through increased physical activity are central
to successful weight loss and long-term weight maintenance. The specific
value derived from physical activity in the context of weight management
for the overweight and obese is in large part associated with an appreciation
of the role of both physical activity promotion and exercise prescription.
Key
Words: behavioural, exercise, obesity, overweight, lifestyle factors,
physical activity, prescription, promotion
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State
of the science: VLED (Very Low Energy Diet) for obesity
ELIZABETH DELBRIDGE AND JOSEPH PROIETTO
It
is often stated, "the faster you lose weight, the faster it is
regained". A review of existing literature does not support such
a statement - indeed if anything the reverse is true. The origins
of this erroneous view are the misconceptions that weight regain is
a simple matter of bad dietary and social habits and that it takes
time to change these, that physiological adaptations to rapid weight
loss are different to those of gradual weight loss and that weight
regain is simply due to a return to old habits. Indeed there are many
advantages to rapid weight loss achieved with the use of a modern
very low energy diet, including the fact that rapid weight loss is
a motivating factor, that the mild ketosis that occurs not only suppresses
hunger, but also slows protein loss and that adherence is easier with
a structured dietary regime. VLEDs are dietary preparations that provide
all nutritional requirements together with between 1845 and 3280 KJ
(450 and 800 Kcal) per day. An individual takes this meal replacement
three times daily as a substitute for breakfast, lunch and dinner.
In addition, a bowl of non-starchy vegetables once daily provides
some fibre and helps to satisfy the social aspect of eating. A teaspoon
of oil on the vegetables contracts the gall bladder to minimise the
risk of gall stone formation. Since weight loss, at whatever rate,
results in physiological adaptations leading to weight regain, careful
attention must be paid to the period after the VLED regime is completed.
Lifestyle modification, diet and exercise are instituted optimally
with behaviour modification. If, despite the subject's best efforts,
weight regain occurs, an appetite suppressant is advisable to help
control the drive to eat.
Key Words: weight loss, obesity, leptin, hunger, very low energy
diet, VLED, pharmacotherapy
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Emerging
pharmacotherapy for treating obesity and associated cardiometabolic
risk
IAN D CATERSON AND NICK FINER
The
global obesity epidemic is causing much concern among health professionals
due to the major health risks associated with obesity. Excess weight,
particularly abdominal obesity, elevates multiple cardiovascular and
metabolic risk factors, including Type 2 diabetes, hypertension, dyslipidaemia
and cardiovascular disease. Thus obesity management goals should encompass
health improvement and cardiometabolic risk reduction as well as weight
loss. While lifestyle and diet modification form the basis of all
effective strategies for weight reduction, some individuals may need
additional intervention. About one in four people with BMI >27
kg/m2 (those who have weight-related morbidity and who have been unsuccessful
losing weight in standard ways) may require adjunctive therapy such
as pharmacotherapy, very low energy diets/meal replacements, or bariatric
surgery. This review focuses on appropriate use of pharmacotherapy
for obesity and cardiometabolic risk. Sibutramine and orlistat are
currently available for use in Australia. Rimonabant has been approved
for use in the European Union, and is being considered for regulatory
approval in the USA and Australia. The efficacy and safety of these
three agents are examined. In addition, several novel pharmacotherapy
agents in development are discussed..
Key Words: obesity, pharmacotherapy, sibutramine, orlistat,
rimonabant .
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Combined
strategies in the management of obesity
JOHN B DIXON AND MAUREEN E DIXON
Obesity
is a chronic relapsing disease requiring a similar long term approach
to management as that of other chronic conditions. Management needs
to be multifaceted aiming to achieve sustainable behavioural changes
to physical activity and diet to alter the patient and family microenvironment
to one favouring better weight control. A range of therapies including
specific diets, calorie counting, meal replacements, very low calorie
diets, pharmacotherapy, intragastric balloons and surgery can provide
very useful additional benefit. Use of these should be guided by the
extent of weight loss required to reduce BMI to an acceptable level
with regard to the patient's ethnicity, risk and comorbid conditions.
Patients need to set goals that are optimistic, but realistic, and
understand the benefits of sustained modest weight loss and the likelihood
of weight regain requiring repeat episodes of weight loss. Practitioners
need to be informed about the efficacy of current therapies and their
combinations to enhance
choice of suitable methods for achieving the optimal weight loss required
by the patient. They will also need to anticipate trigger points for
renewed periods of weight loss in the event of weight regain, as relapse
is likely but not a reason for abandoning the battle. .
Key Words: chronic, weight loss, obesity, combined strategies,
lifestyle, health, comorbidity, quality of life
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The
Weight Management Code of Practice of Australia as a framework for
the commercial weight management sector
SYLVIA
RUTH RIDDELL
The
Weight Management Code of Practice Australia provides a framework
for the diversity of players in the weight management industry. In
the current worldwide epidemic of overweight and obesity, the potential
for the industry to 'do the right thing', comply with the Weight Management
Code of Practice Australia, and assist people with long-term weight
loss, is far reaching. The Weight Management Code of Practice in Australia
is managed by the Weight Management Council Australia Limited. There
are many players in the weight management industry, not all will be
eligible for membership of Council but there are many who could be
eligible. Ideally, all centres, programs and professionals in the
industry should have in place business practices and regimens that
comply with the Code. The more members of this industry who are willing
to modify their business practices and regimens to comply with the
Code, the more accountable the industry will be and the better the
products and services will be for consumers. The Code has the potential
to be implemented in other countries. The Australian Weight Management
Code of Practice can be a model for the rest of the world to establish
standards by which this huge industry can be governed..
Key Words: Weight Management Code of Practice, Weight Management Council
Australia Limited
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A
cost benefit analysis of weight management strategies
JODIE YATES AND CHRIS MURPHY
Over the past twenty years, obesity has become a major
topic of concern. In particular, this paper estimates that the number
of obese adults has risen from around 2.0 million in 1992/93 to about
3.1 million in 2005. With the prevalence of obesity on the rise, the
associated economic cost is also increasing significantly. The annual
cost of obesity in 1992-93 was estimated at around $840 million per
year. This paper shows that the annual cost of obesity in Australia
could now be as high as $1,721 million. With the cost of obesity rising,
the ability to assess and compare alternative programs for reducing
the current prevalence of obesity is very important. This involves
weighing up the costs and benefits of the different strategies. So,
in addition to providing an updated estimate of the potential cost
of obesity in Australia, this paper uses a weight management program
to illustrate the methodology used in assessing alternative intervention
programs. For illustration, the expected benefit per enrolment in
a weight loss program was calculated at $690. The associated cost
of the program was $202 per enrolment. It should be noted that the
estimate of the cost is more precise than the broad estimate of the
average benefit. Nevertheless, the average benefit outweighs the cost
by an overwhelming ratio of over three-to-one. So a more detailed
analysis is unlikely to overturn the general conclusion that the average
benefit clearly outweighs the cost, even if the precise ratio of benefits
to costs is likely to change..
Key
words: obesity, cost benefit, weight loss strategy, weight
reduction programs, health economics
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Last
Updated: September 2006
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Health
economics and weight management: evidence and cost