Within-Trial Cost-Effectiveness of a Structured Lifestyle Intervention in Adults With Overweight/Obesity and Type 2 Diabetes: Results From the Action for Health in Diabetes (Look AHEAD) Study.

OBJECTIVE: To assess the cost-effectiveness (CE) of an intensive lifestyle intervention (ILI) compared with standard diabetes support and education (DSE) in adults with overweight/obesity and type 2 diabetes, as implemented in the Action for Health in Diabetes study. RESEARCH DESIGN AND METHODS: Data were from 4,827 participants during their first 9 years of study participation from 2001 to 2012. Information on Health Utilities Index Mark 2 (HUI-2) and HUI-3, Short-Form 6D (SF-6D), and Feeling Thermometer (FT), cost of delivering the interventions, and health expenditures was collected during the study. CE was measured by incremental CE ratios (ICERs) in costs per quality-adjusted life year (QALY). Future costs and QALYs were discounted at 3% annually. Costs were in 2012 U.S. dollars. RESULTS: Over the 9 years studied, the mean cumulative intervention costs and mean cumulative health care expenditures were $11,275 and $64,453 per person for ILI and $887 and $68,174 for DSE. Thus, ILI cost $6,666 more per person than DSE. Additional QALYs gained by ILI were not statistically significant measured by the HUIs and were 0.07 and 0.15, respectively, measured by SF-6D and FT. The ICERs ranged from no health benefit with a higher cost based on HUIs to $96,458/QALY and $43,169/QALY, respectively, based on SF-6D and FT. CONCLUSIONS: Whether ILI was cost-effective over the 9-year period is unclear because different health utility measures led to different conclusions.

Physical Activity Energy Expenditure and Total Daily Energy Expenditure in Successful Weight Loss Maintainers.

OBJECTIVE: The objective of this study was to compare physical activity energy expenditure (PAEE) and total daily energy expenditure (TDEE) in successful weight loss maintainers (WLM) with normal weight controls (NC) and controls with overweight/obesity (OC). METHODS: Participants were recruited in three groups: WLM (n = 25, BMI 24.1 ± 2.3 kg/m2 ; maintaining ≥ 13.6-kg weight loss for ≥ 1 year), NC (n = 27, BMI 23.0 ± 2.0 kg/m2 ; similar to current BMI of WLM), and OC (n = 28, BMI 34.3 ± 4.8 kg/m2 ; similar to pre-weight loss BMI of WLM). TDEE was measured using the doubly labeled water method. Resting energy expenditure (REE) was measured using indirect calorimetry. PAEE was calculated as (TDEE - [0.1 × TDEE] - REE). RESULTS: PAEE in WLM (812 ± 268 kcal/d, mean ± SD) was significantly higher compared with that in both NC (621 ± 285 kcal/d, P < 0.01) and OC (637 ± 271 kcal/d, P = 0.02). As a result, TDEE in WLM (2,495 ± 366 kcal/d) was higher compared with that in NC (2,195 ± 521 kcal/d, P = 0.01) but was not significantly different from that in OC (2,573 ± 391 kcal/d). CONCLUSIONS: The high levels of PAEE and TDEE observed in individuals maintaining a substantial weight loss (-26.2 ± 9.8 kg maintained for 9.0 ± 10.2 years) suggest that this group relies on high levels of energy expended in physical activity to remain in energy balance (and avoid weight regain) at a reduced body weight.

No consistent evidence of a disproportionately low resting energy expenditure in long-term successful weight-loss maintainers.

Background: Evidence in humans is equivocal in regards to whether resting energy expenditure (REE) decreases to a greater extent than predicted for the loss of body mass with weight loss, and whether this disproportionate decrease in REE persists with weight-loss maintenance. Objectives: We aimed to1) determine if a lower-than-predicted REE is present in a sample of successful weight-loss maintainers (WLMs) and 2) determine if amount of weight loss or duration of weight-loss maintenance are correlated with a lower-than-predicted REE in WLMs. Design: Participants (18-65 y old) were recruited in 3 groups: WLMs (maintaining ≥13.6 kg weight loss for ≥1 y, n = 34), normal-weight controls [NCs, body mass index (BMI; in kg/m2) similar to current BMI of WLMs, n = 35], and controls with overweight/obesity (OCs, BMI similar to pre-weight-loss maximum BMI of WLMs, n = 33). REE was measured (REEm) with indirect calorimetry. Predicted REE (REEp) was determined via 1) a best-fit linear regression developed with the use of REEm, age, sex, fat-free mass, and fat mass from our control groups and 2) three standard predictive equations. Results: REEm in WLMs was accurately predicted by equations developed from NCs and OCs (±1%) and by 3 standard predictive equations (±3%). In WLMs, individual differences between REEm and REEp ranged from -257 to +163 kcal/d. A lower REEm compared with REEp was correlated with amount of weight lost (r = 0.36, P < 0.05) but was not correlated with duration of weight-loss maintenance (r = 0.04, P = 0.81). Conclusions: We found no consistent evidence of a significantly lower REE than predicted in a sample of long-term WLMs based on predictive equations developed from NCs and OCs as well as 3 standard predictive equations. Results suggest that sustained weight loss may not always result in a substantial, disproportionately low REE. This trial was registered at clinicaltrials.gov as NCT03422380.

Physical activity patterns using accelerometry in the National Weight Control Registry.

The National Weight Control Registry (NWCR) was established in 1993 to examine characteristics of successful weight-loss maintainers. This group consistently self-reports high levels of physical activity. The aims of this study were to obtain objective assessments of physical activity in NWCR subjects and compare this to physical activity in both normal-weight and overweight controls. Individuals from the NWCR (n = 26) were compared to a never obese normal-weight control group matched to the NWCR group's current BMI (n = 30), and an overweight control group matched to the NWCR group's self-reported pre-weight-loss BMI (n = 34). Objective assessment of physical activity was obtained for a 1-week period using a triaxial accelerometer. Bouts of moderate-to-vigorous physical activity (MVPA) ≥10 min in duration, as well as nonbout MVPA (bouts of MVPA 1-9 min in duration) were summed and characterized. NWCR subjects spent significantly (P = 0.004) more time per day in sustained bouts of MVPA than overweight controls (41.5 ± 35.1 min/day vs. 19.2 ± 18.6 min/day) and marginally (P = 0.080) more than normal controls (25.8 ± 23.4). There were no significant differences between the three groups in the amount of nonbout MVPA. These results provide further evidence that physical activity is important for long-term maintenance of weight loss and suggest that sustained volitional activity (i.e., ≥10 min in duration) may play an important role. Interventions targeting increases in structured exercise may be needed to improve long-term weight-loss maintenance.

Productivity costs associated with cardiometabolic risk factor clusters in the United States.

OBJECTIVE: Cardiometabolic risk factors such as overweight/obesity, hyperlipidemia, diabetes, and hypertension are prone to cluster together in the same individual and result in an elevated risk of cardiovascular disease and mortality. The purpose of this study was to examine and quantify the impact of cardiometabolic risk factor clusters independent of heart disease on productivity in a nationally representative sample of US adults. METHODS: The current study estimated the impact of cardiometabolic risk factor clusters on missed work days and bed days, controlling for sociodemographic characteristics, comorbidity, and smoking status in a nationally representative, pooled 2000 and 2002 Medical Expenditure Panel Survey sample. Cardiometabolic risk factor clusters included BMI >or= 25 and two of the following three: diabetes, hyperlipidemia, and/or hypertension. All estimates were expressedin $US 2005. Sensitivity analyses were conducted to examine the impact of varying assumptions on the results. RESULTS: After controlling for differences in sociodemographics, smoking and comorbidity, individuals with cardiometabolic risk factor clusters missed 179% more work days and spent 147% more days in bed (in addition to lost work days) than those without. Lost work days and bed days resulted in $17.3 billion annually in lost productivity attributable to cardiometabolic risk factor clusters in the United States. Sensitivity analyses resulted in a range of annual lost productivity costs from $3.2 to $23.1 billion. CONCLUSIONS: Common cardiometabolic risk factor clusters have a significant deleterious impact on the US economy, resulting in $17.3 billion in lost productivity.

The medical cost of cardiometabolic risk factor clusters in the United States.

OBJECTIVE: Diabetes, hypertension, hyperlipidemia, and overweight/obesity often cluster together. The prevalence of these cardiometabolic risk factor clusters (CMRFCs) is increasing significantly for all sociodemographic groups, but little is known about their economic impact. RESEARCH METHODS AND PROCEDURES: The nationally representative Medical Expenditure Panel Survey was used (2000 and 2002). The current study estimated the national cost of CMRFCs independent of the cost of cardiovascular disease in the U.S., as well as the cost for all major payers and the marginal cost per individual using a Heckman selection model with Smearing retransformation. CMRFCs included BMI >or= 25 and two of the following three: diabetes, hyperlipidemia, and/or hypertension. All amounts are expressed in 2005 U.S. dollars. RESULTS: National medical expenditures attributable to CMRFCs in the U.S. totaled 80 billion dollars, of which 27 billion dollars was spent on prescription drugs. Private insurance paid the largest amount of the national bill (28 billion dollars), followed by Medicare (11 billion dollars), Medicaid (6 billion dollars), and the Veterans Administration (4 billion dollars), whereas individuals paid 28 billion dollars out-of-pocket. For each individual with CMRFCs, 5477 dollars in medical expenditures was attributable to CMRFCs, of which 1832 dollars was for prescription drugs. On average, individuals with CMRFCs spent 1668 dollars out-of-pocket, of which 830 dollars was for prescription drugs. DISCUSSION: The results of this study show that CMRFCs result in significant medical cost in the U.S. independent of the cost of cardiovascular disease. Individuals, private insurers, Medicare, Medicaid, the Veterans Administration, and other payers all share this burden.

A Colorado statewide survey of walking and its relation to excessive weight.

INTRODUCTION: There is an urgent need to increase the physical activity in the population. Small-scale success has been achieved in programs like Colorado on the Move (COM), an obesity prevention program using electronic pedometers. METHODS: To provide baseline information for COM, this first-ever statewide survey of walking was conducted with 1098 individuals. The weighted mean BMI was 25.3 +/- 0.18 kg x m(-2), and mean age was 44 +/- 0.42 yr of age. Subjects participated in a short telephone interview and then were sent a pedometer to wear for four consecutive days. A total of 742 of the 1098 subjects completed the pedometer phase. RESULTS: The average adult in Colorado reported taking 6804 steps per day. About 33% reported taking fewer than 5000 steps per day, and only 16% reported taking 10,000 or more steps per day. Steps per day increased with other self-reported measures of physical activity (P = 0.0001) and decreased with self-reported inactivity (P = 0.0001). Significant determinants of steps per day included increasing age (negative, P = 0.001), marital status (positive for single status, P = 0.05), income (positive for incomes of dollar 25,000 to dollar 99,000, P = 0.003), and increasing BMI (negative for BMI > or = 30 kg x m(-2), P = 0.000). Obese individuals (BMI > or = 30 kg x m(-2)) walked about 2000 fewer steps per day than normal-weight individuals. These results provide the first population data on current walking levels, on how this relates to self-reported physical activity, and on determinants of walking. Results also provide a baseline level of walking for future evaluation of COM. CONCLUSION: Increasing steps per day appears to be a good target to use in interventions to increase physical activity. Even in Colorado, one of the leanest states, very low levels of physical activity are seen in much of the population.