Background:The extent to which moderate overweight (body mass index [BMI], 25.0-29.9 [calculated as weight in kilograms divided by height in meters squared]) and obesity (BMI, Ն30.0) are associated with increased risk of coronary heart disease (CHD) through adverse effects on blood pressure and cholesterol levels is unclear, as is the risk of CHD that remains after these mediating effects are considered.Methods: Relative risks (RRs) of CHD associated with moderate overweight and obesity with and without adjustment for blood pressure and cholesterol concentrations were calculated by the members of a collaboration of prospective cohort studies of healthy, mainly white persons and pooled by means of random-effects models (RRs for categories of BMI in 14 cohorts and for continuous BMI in 21 cohorts; total N = 302 296).Results: A total of 18 000 CHD events occurred during follow-up. The age-, sex-, physical activity-, and smoking-adjusted RRs (95% confidence intervals) for moderate overweight and obesity compared with normal weight were 1.32 (1.24-1.40) and 1.81 (1.56-2.10), respectively. Additional adjustment for blood pressure and cholesterol levels reduced the RR to 1.17 (1.11-1.23) for moderate overweight and to 1.49 (1.32-1.67) for obesity. The RR associated with a 5-unit BMI increment was 1.29 (1.22-1.35) before and 1.16 (1.11-1.21) after adjustment for blood pressure and cholesterol levels.Conclusions: Adverse effects of overweight on blood pressure and cholesterol levels could account for about 45% of the increased risk of CHD. Even for moderate overweight, there is a significant increased risk of CHD independent of these traditional risk factors, although confounding (eg, by dietary factors) cannot be completely ruled out.
BackgroundObesity is a major cause of morbidity and mortality and is associated with high medical expenditures. It has been suggested that obesity prevention could result in cost savings. The objective of this study was to estimate the annual and lifetime medical costs attributable to obesity, to compare those to similar costs attributable to smoking, and to discuss the implications for prevention.Methods and FindingsWith a simulation model, lifetime health-care costs were estimated for a cohort of obese people aged 20 y at baseline. To assess the impact of obesity, comparisons were made with similar cohorts of smokers and “healthy-living” persons (defined as nonsmokers with a body mass index between 18.5 and 25). Except for relative risk values, all input parameters of the simulation model were based on data from The Netherlands. In sensitivity analyses the effects of epidemiologic parameters and cost definitions were assessed. Until age 56 y, annual health expenditure was highest for obese people. At older ages, smokers incurred higher costs. Because of differences in life expectancy, however, lifetime health expenditure was highest among healthy-living people and lowest for smokers. Obese individuals held an intermediate position. Alternative values of epidemiologic parameters and cost definitions did not alter these conclusions.ConclusionsAlthough effective obesity prevention leads to a decrease in costs of obesity-related diseases, this decrease is offset by cost increases due to diseases unrelated to obesity in life-years gained. Obesity prevention may be an important and cost-effective way of improving public health, but it is not a cure for increasing health expenditures.
Chronic obstructive pulmonary disease (COPD) causes extensive disability, primarily among the elderly. On the World Health Organization ranking list of disability-adjusted life years (DALYs), COPD rises from the twelfth to the fifth place from 1990 to 2020. The purpose of this study is to single out the impact of changes in demography and in smoking behavior on COPD morbidity, mortality, and health care costs. A dynamic multistate life table model was used to compute projections for the Netherlands. Changes in the size and composition of the population cause COPD prevalence to increase from 21/1,000 in 1994 to 33/1,000 in 2015 for men, and from 10/ 1,000 to 23/1,000 for women. Changes in smoking behavior reduce the projected prevalence to 29/1,000 for men, but increase it to 25/ 1,000 for women. Total life years lost increase more than 60%, and DALYs lost increase 75%. Costs rise 90%; smokers cause approximately 90% of these costs. The model demonstrates the unavoidable increase in the burden of COPD, an increase that is larger for women than for men. The major causes of this increase are past smoking behavior and the aging of the population; changes in smoking behavior will have only a small effect in the nearby future.
The aim of our study was to estimate the case fatality of a severe exacerbation from long-term survival data presented in the literature.A literature search identified studies reporting o1.5 yr survival after a severe chronic obstructive pulmonary disease (COPD) exacerbation resulting in hospitalisation. The survival curve of each study was divided into a critical and a stable period. Mortality during the stable period was then estimated by extrapolating the survival curve during the stable period back to the time of exacerbation onset. Case fatality was defined as the excess mortality that results from an exacerbation and was calculated as 1 minus the (backwardly) extrapolated survival during the stable period at the time of exacerbation onset. The 95% confidence intervals (CI) of the estimated case fatalities were obtained by bootstrapping. A random effect model was used to combine all estimates into a weighted average with 95% CI.The meta-analysis based on six studies that fulfilled the inclusion criteria resulted in a weighted average case-fatality rate of 15.6% (95% CI 10.9-20.3), ranging from 11.4% to 19.0% for the individual studies.A severe COPD exacerbation requiring hospitalisation not only results in higher mortality risks during hospitalisation, but also in the time-period after discharge and contributes substantially to total COPD mortality.
OBJECTIVE -In the current study we explore the long-term health benefits and costeffectiveness of both a community-based lifestyle program for the general population (community intervention) and an intensive lifestyle intervention for obese adults, implemented in a health care setting (health care intervention).RESEARCH DESIGN AND METHODS -Short-term intervention effects on BMI and physical activity were estimated from the international literature. The National Institute for Public Health and the Environment Chronic Diseases Model was used to project lifetime health effects and effects on health care costs for minimum and maximum estimates of short-term intervention effects. Cost-effectiveness was evaluated from a health care perspective and included intervention costs and related and unrelated medical costs. Effects and costs were discounted at 1.5 and 4.0% annually.RESULTS -One new case of diabetes per 20 years was prevented for every 7-30 participants in the health care intervention and for every 300 -1,500 adults in the community intervention. Intervention costs needed to prevent one new case of diabetes (per 20 years) were lower for the community intervention (€2,000 -9,000) than for the health care intervention (€5,000 -21,000). The cost-effectiveness ratios were €3,100 -3,900 per quality-adjusted life-year (QALY) for the community intervention and €3,900 -5,500 per QALY for the health care intervention.CONCLUSIONS -Health care interventions for high-risk groups and community-based lifestyle interventions targeted to the general population (low risk) are both cost-effective ways of curbing the growing burden of diabetes. Diabetes Care 30:128 -134, 2007R isk factors for developing type 2 diabetes include a high body weight, physical inactivity, and smoking, whereas moderate consumption of alcohol or coffee appears to be protective (1-9). The most serious of these factors is overweight. With every 1 unit increase in BMI, the risk of developing type 2 diabetes increases by ϳ10 -30% (10). There is substantial evidence that lifestyle interventions focused on diet and physical exercise can reduce diabetes incidence in individuals at high risk of developing diabetes (11)(12)(13)(14). Although the direct effect of lifestyle interventions on diabetes incidence in other target populations is relatively unknown, it is suggested that a relatively small shift of the entire general population toward more healthy behavior could lead to a reduction in the incidence of diabetes (15).Modeling can be used to assess the potential long-term impact of lifestyle programs on future health and health care costs. Such information is interesting to policy makers who have to decide on optimal allocation of limited budgets. Models have been used to demonstrate that intensive lifestyle modification programs are cost-effective for individuals at high risk of developing diabetes (16,17). However, the cost-effectiveness of such interventions for individuals at lower risk of developing diabetes is relatively unknown (15,16,18 -20). The inc...
All five smoking cessation interventions were cost-effective compared with current practice, and minimal GP counseling was even cost-saving.
Background The aim of this study was to estimate the long-term (cost-) effectiveness of smoking cessation interventions for patients with chronic obstructive pulmonary disease (COPD). Methods A systematic review was performed of randomised controlled trials on smoking cessation interventions in patients with COPD reporting 12-month biochemical validated abstinence rates. The different interventions were grouped into four categories: usual care, minimal counselling, intensive counselling and intensive counselling + pharmacotherapy ('pharmacotherapy'). For each category the average 12-month continuous abstinence rate and intervention costs were estimated. A dynamic population model for COPD was used to project the long-term (cost-) effectiveness (25 years) of 1-year implementation of the interventions for 50% of the patients with COPD who smoked compared with usual care. Uncertainty and one-way sensitivity analyses were performed for variations in the calculation of the abstinence rates, the type of projection, intervention costs and discount rates. Results Nine studies were selected. The average 12-month continuous abstinence rates were estimated to be 1.4% for usual care, 2.6% for minimal counselling, 6.0% for intensive counselling and 12.3% for pharmacotherapy. Compared with usual care, the costs per quality-adjusted life year (QALY) gained for minimal counselling, intensive counselling and pharmacotherapy were €16 900, €8200 and €2400, respectively. The results were most sensitive to variations in the estimation of the abstinence rates and discount rates. Conclusion Compared with usual care, intensive counselling and pharmacotherapy resulted in low costs per QALY gained with ratios comparable to results for smoking cessation in the general population. Compared with intensive counselling, pharmacotherapy was cost saving and dominated the other interventions.
Background This study estimated the lifetime cost-effectiveness and equity impacts associated with two lifestyle interventions in the Dutch primary school setting (targeting 4–12 year olds). Methods The Healthy Primary School of the Future (HPSF; a healthy school lunch and structured physical activity) and the Physical Activity School (PAS; structured physical activity) were compared to the regular Dutch curriculum (N = 1676). An adolescence model, calculating weight development, and the RIVM Chronic Disease Model, calculating overweight-related chronic diseases, were linked to estimate the lifetime impact on chronic diseases, quality adjusted life years (QALYs), healthcare, and productivity costs. Cost-effectiveness was expressed as the additional costs/QALY gained and we used €20,000 as threshold. Scenario analyses accounted for alternative effect maintenance scenarios and equity analyses examined cost-effectiveness in different socioeconomic status (SES) groups. Results HPSF resulted in a lifetime costs of €773 (societal perspective) and a lifetime QALY gain of 0.039 per child versus control schools. HPSF led to lower costs and more QALYs as compared to PAS. From a societal perspective, HPSF had a cost/QALY gained of €19,734 versus control schools, 50% probability of being cost-effective, and beneficial equity impact (0.02 QALYs gained/child for low versus high SES). The cost-effectiveness threshold was surpassed when intervention effects decayed over time. Conclusions HPSF may be a cost-effective and equitable strategy for combatting the lifetime burden of unhealthy lifestyles. The win-win situation will, however, only be realised if the intervention effect is sustained into adulthood for all SES groups. Trial registration Clinicaltrials.gov (NCT02800616). Registered 15 June 2016 – Retrospectively registered.
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