Multiple Comorbid Diseases Research Articles

Explicit Criteria for Potentially Inappropriate Medications to Reduce the Risk of Adverse Drug Reactions in Elderly People

Balanced and safe prescribing is difficult to achieve in frail older adults with multiple comorbid diseases. For this reason, great efforts have been made in the search for interventions to improve efficacy, safety and appropriateness of prescriptions in this vulnerable population. Among these interventions, the avoidance of medications that are considered to be inappropriate, i.e. potentially inappropriate medications (PIMs), has been considered a valuable treatment option. The aim of the present review was to summarize evidence about the use of explicit criteria for PIMs to reduce the risk of adverse drug reactions (ADRs) in older people. A PIM is a drug in which the risk of an adverse event outweighs its clinical benefit, particularly when there is evidence in favour of a safer or more effective alternative therapy for the same condition. Explicit criteria have been developed to identify PIMs, and among these, the Beers criteria have been the most frequently applied until recently. However, evidence suggests that such criteria can not easily be applied in European countries: several drugs listed in the 2003 Beers criteria were rarely prescribed or were not available in Europe and 2003 Beers-listed PIMs were not associated with ADRs in some studies. In the past few years, START/STOPP criteria have been developed and applied in several different studies and populations showing a greater ability to predict ADRs with respect to Beers criteria and to prevent potentially inappropriate prescribing. In 2012, Beers criteria have been updated using an evidence-based approach and future studies will investigate the impact of these and other criteria coming from ongoing studies on clinical outcomes relevant to geriatric populations.

Monitoring for and preventing the long‐term sequelae of bariatric surgery

To present a case study of a patient with multiple comorbid diseases who undergoes bariatric surgery. Recent clinical and research articles, bariatric professional society guidelines, and government sources were culled to provide recommendations for the care of the person who chooses bariatric surgery as the treatment for the comorbid conditions of obesity, type 2 diabetes, obstructive sleep apnea, hypertension, and hyperlipidemia. As surgical management of obesity becomes more prevalent in an attempt to improve health-related quality of life, reduce mortality, and address the comorbidities that are prevalent in this population, nurse practitioners (NPs) need to understand what long-term management these patients will require. NPs are primary care providers for patients with chronic diseases. It is likely that they will make referrals for this surgery and follow the patient after the procedure at some point. Knowledge of what the procedures involve, what changes to expect in the comorbid conditions, and what long-term monitoring and treatment should take place in the care of these patients will provide these patients with optimal care.

A TYPICAL PRESENTATION WITH AN ATYPICAL DIAGNOSIS

To the Editor: A 74-year-old man presented to the emergency department with sudden-onset sharp pleuritic central chest discomfort radiating to his left shoulder that resolved spontaneously on admission to hospital. He had complained of similar intermittent chest discomfort occurring at rest over 6 weeks with associated breathlessness and poor exercise tolerance. Initial investigations revealed high white cell count (13 × 109/L; normal 4–11 × 109/L), high C-reactive protein (188 mg/L; normal 0–6 mg/L), moderately high corrected calcium (2.77 mmol/L; normal 2.1–2.5 mmol/L), high troponin-I (0.75 μg/L; normal 0–0.1 μg/L) and a normal electrocardiogram. There was also left lower lobe opacification on chest radiograph. He was treated for acute coronary syndrome in view of his history and high cardiac enzymes. Past medical history included total penectomy, perineal urethrostomy, and bilateral groin dissection for penile squamous cell carcinoma (SCC) 18 months before this admission. His annual follow-up computed tomography (CT) did not reveal any metastases. A CT pulmonary angiography (CTPA) was performed on admission because the possibility of the presence of pulmonary emboli was raised. The CTPA (Figure 1) and subsequent abdominal CT showed a solitary splenic tumor invading the left hemidiaphragm and the pericardial sac. A splenic biopsy and immunohistochemistry confirmed it to be metastatic SCC. Subsequent other relevant investigations included a bone scan, which excluded bony metastases, and a low parathyroid hormone (PTH) level (0.64 pmol/L; normal 1.48–7.63 pmol/L). It was not possible to measure PTH-related peptide (PTHrP) levels. Computed tomography images (anterior-posterior lateral views) show a sizable mass invading the left hemidiaphragm and pericardial sac, with a small pleural effusion. Moderate hypercalcemia was treated aggressively with intravenous fluids to marginal effect and required intravenous pamidronate. The case was discussed extensively with surgical and oncology colleagues, but their general consensus in view of his premorbid performance status was to manage the aggressive splenic metastasis conservatively. The patient was discharged to the care of community palliative care colleagues. The authors have not found any previous published cases of metastatic penile SCC presenting as a solitary splenic metastasis invading through the left hemidiaphragm and the pericardial sac. This case highlights the importance of careful evaluation of older adults presenting with a typical history of angina-like chest discomfort but a resultant unusual diagnosis. Physiological changes of aging and multiple comorbid diseases often complicate and obscure the presentation of older adults to the hospital.1 Penile cancers are rare in developed countries but can account for up to 10% of male cancers in developing regions. In the United Kingdom, the reported incidence is 0.6 cases per 100,000 per year.2 The prevalence increases with age after the age of 60 and reaches a peak incidence at the age of 70, with rates probably differing as a result of religious practices and socioeconomic status.3 Risk factors include poor penile hygiene, penile inflammation, phimosis, and number of sexual partners; almost half of patients have had previous exposure to the human papilloma virus.4 Splenic metastasis is a rare complication, arising in fewer than 1% of all metastases, and is associated with a poor prognosis.5,6 SCC accounts for 95% of all penile carcinomas and is a malignant tumor of keratinocytes. Keratinocytes secrete PTHrP, inducing bone osteoclastic resorption, and PTHrP is associated with hypercalcemia as a paraneoplastic complication.7 Hypercalcemia and leukocytosis have reported associations with penile SCC and, in one case report, both resolved after surgery.8 Although the current patient had leukocytosis, the association cannot be definitively determined because there was significant necrotic tissue in the splenic metastasis that could have contributed to leukocytosis. Hypercalcemia in older adults must always prompt urgent evaluation because age-related renal changes lead to fluid loss and may be a manifestation of malignancy as bony metastases or humoral hypercalcemia of malignancy.9 It may present in up to 30% of people with penile cancer with lymphadenopathy.10 The moderately high hypercalcemia was probably a result of the presence of PTHrP because it shares the same N-terminal binding to the type 1 PTH receptor in the body as PTH, increasing bone osteoclastic activity and renal distal tubular calcium reabsorption. Bisphosphonates have been the main treatment for PTHrP-induced hypercalcemia because they inhibit osteoclast formation and their function. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Melvin P.W. Chua and Joel Chin were responsible for the conception of the letter and jointly wrote the first draft. Chinga Chileshe and Surabhi Singh contributed significantly to subsequent critical revisions of the article. All authors were involved in the final approval of version submitted for publication. Sponsor's Role: The authors report no financial conflicts of interest with this article.

The Consultant Pharmacist Provides Consultation and Recommendations for a Medical Patient

This case focuses on a general medical patient who resides in a local senior community-housing center and who has multiple comorbid diseases that are commonly seen in practice. The patient's past medical history includes coronary artery disease, peptic ulcer disease, hypertension, and type 2 diabetes mellitus. The patient was recently hospitalized and treated with an intravenous antibiotic for an influenza-related pneumonia infection, then discharged with a prescription for a course of oral fluoroquinolone antibiotics. This case discusses and addresses each of the patient's conditions, various drug interactions, and issues pertaining to the patient. An interdisciplinary-team approach is important for the medical management of a patient with multiple comorbid diseases along with the contribution of a consultant pharmacist as pharmacotherapy expert.

Infectious diseases in the nursing home setting: challenges and opportunities for clinical investigation.

The global population is aging. With the high prevalence of dementia and functional decline in older Americans, many aging adults with disabilities reside in nursing homes in their final stage of life. Immunosenescence, multiple comorbid diseases, and grouped quarter living all coalesce in nursing home residents to increase the risk for infectious disease. The unique issues involved with diagnosis, prognosis, and management of infectious diseases in nursing home residents make research based in the nursing home setting both necessary and exciting for the physician investigator. This review discusses the opportunities and challenges involved with research of the evolving public health problem of infections among nursing home residents.

Syndrome coronaire aigu avec élévation du segment ST chez l’octogénaire

Coronary artery disease is the leading cause of death in developed countries and its incidence and severity is greater among older patients. So, because of the ageing of the population, clinicians will be increasingly confronted in daily practice with managing acute coronary syndrome in extreme old age and high-risk patients. Despite this demographic reality, several large randomized controlled trials evaluating the benefit–risk ratio of invasive versus conservative approach have systematically excluded elderly patients. The extrapolation of evidence-based medicine, initially focused on younger patients, is often contentious in this population and because of the lack of clear and specific recommendations in the elderly, the optimal management of STEMI in octogenarians remains a topic of debate. Elderly patients present unique issues related to the ageing process and multiple comorbid diseases making difficult the extrapolation of evidence obtained on younger demographics. Data from registries seem to support, nevertheless, the benefit of primary revascularization by PCI of the culprit lesion in “selected” octogenarians with a high technical success rate, few complications, acceptable short and long-term mortality rate and quality of life. Obviously, the “ideal octogenarian” doesn’t exist and all the old patients are not suitable for an invasive approach. Managing elderly patients requires not only cardiological skills but also geriatric acknowledges and the individualized geriatric assessment is the corner store of the decision process. The aim is to screen for the presence of comorbidities (cognitive disorders, functional decline, anemia, renal insufficiency…), social isolation and existence of an underlying frailty. To conclude, the optimal strategy for the management of STEMI in octogenarians is not univocal: the best approach is the one that offers the greater benefits regard considerations of general health.

Patient Safety and Quality of Care in Intensive Care Medicine

The phrase Primum non nocere is almost as old as the practice of medicine. Together with the principles of beneficence, autonomy and justice, keeping in mind the confidence and dignity of the patient, it should constitute the basis of our behaviour as physicians and nurses. Since diagnostic and therapeutic interventions have become more complex and their risk/benefit ratio more difficult to access, the importance of safety and quality of care becomes more and more important. Avoiding the infliction of harm on our patients has become a priority. Patient safety is even viewed as a priority by the Presidency of the European Union. Physicians in intensive care medicine mostly deal with the most fragile and dependent of human beings, frequently at the extremes of age, with multiple co-morbid diseases, and with physiological derangements close to the limits of survival. These patients are often reliant on numerous invasive technologies for their survival. Moreover, the almost universal need for multiple pharmacological interventions, frequently in bundles and associations never scientifically tested before, places the critically ill patients at a very high risk of harm from the physicians interventions. The book is a valuable and useful education tool for physicians and nurses in intensive care medicine. It will help to improve the safety and overall care for critically ill patients.

Potentially Inappropriate Medication in Elderly Hospitalized Patients

Balanced and safe prescribing is difficult to achieve in frail older adults with multiple comorbid diseases. This issue is of particular concern, especially in elderly hospitalized patients because hospitalization exposes such individuals to an increased risk of adverse drug reactions (ADRs). The avoidance of medications that are considered to be inappropriate is among the interventions for treatment options in elderly patients. A potentially inappropriate medication (PIM) is a drug in which the risk of an adverse event outweighs its clinical benefit, particularly when there is a safer or more effective alternative therapy for the same condition. Explicit criteria have been developed to identify PIMs and among these, Beers' criteria are the most frequently applied in the literature. However, evidence suggests that such criteria cannot easily be applied to elderly hospitalized people in European countries; approximately 20% of drugs listed in Beers' criteria are rarely prescribed or are not available in Europe, and Beers' listed PIMs are not associated with inhospital mortality, length of hospital stay and/or ADRs in Italian studies. On the contrary, ADRs can contribute to accelerated functional decline in elderly hospitalized patients independently of the use of Beers' listed PIMs. Therefore, we will review the evidence pertaining to the application of Beers' criteria in elderly hospitalized patients, while focusing on Italian studies that have investigated the role of PIMs as potential predictors of negative hospital outcomes. In addition, we will also review the available evidence regarding new European criteria on identifying PIMs, because clinical application in elderly hospitalized Europeans is still under investigation.

Transcatheter and Transapical Aortic Valve Replacement

Minimally invasive valve replacement is limited to bioprosthetic aortic and pulmonary valves for use in very specific populations of patients. Replacement via trans-catheter and transapical techniques should be used only in patients in whom traditional surgical replacement is deemed an unacceptable risk. Nursing management will focus heavily on care for comorbid conditions because of the high-risk nature of the patients in whom these valves will initially be implanted.

Can we Overcome the Predestined Poor Survival of Diabetic Patients? Perspectives from Pre- and Post-Dialysis

Although the survival of diabetic peritoneal dialysis (PD) patients has improved, it is still much worse than the survival of nondiabetic patients. Diabetes has its own risks for cardiovascular disease (CVD), such as increased levels of advanced glycation end-products, carbonyl and oxidative stress, and low-grade inflammation. An independent, graded association has been observed between a reduced glomerular filtration rate and the risk of CVD events in chronic kidney disease (CKD). Both CKD and diabetes synergistically lead to a high risk of CVD. It seems that the poor survival of diabetic PD patients is predestined at the initiation of dialysis because of multiple pre-existing risk factors and comorbid diseases, particularly CVD. Recently, several trials were successful in improving the survival of patients with diabetic CKD. Tight control of glucose, blood pressure management using angiotensin converting-enzyme inhibitors or angiotensin II receptor blockers, and use of statins, antioxidants, or peroxisome proliferator-activated receptor gamma agonists may improve the survival of diabetic PD patients. However, simple correction of a single CVD risk factor is not likely to be effective. New PD solutions such as those low in glucose degradation products or those with icodextrin may also be effective in reducing the risk of CVD in diabetic PD patients. Therefore, multifactorial interventions--including diet control, early referral, and choice of an optimal PD solution--may improve the survival of diabetic PD patients.

How Can We Ground the “Frequent Fliers”?

How Can We Ground the “Frequent Fliers”?

Anemia of Kidney Disease and Clinical Practice Guidelines

In the 15 yr since the Institute of Medicine defined clinical practice guidelines (CPG) as “systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances” (1), there has been an upsurge in their promulgation. The Agency for Healthcare Research and Quality lists more than 2000 active CPG. The factors that have driven the profusion of clinical practice guidelines are essentially the same that have driven a general increase in evidence-based decision-making and the field of outcomes research. Evidence strongly suggests that standardization of medical practice can provide cost-effective care that improves outcomes (2). Despite the seemingly compelling virtue of CPG, they are certainly not a panacea for all of the ills in health care delivery. CPG usually focus on improving the management of one particular disease, often neglecting to provide guidance on the integration of complex medical regimens for patients with multiple comorbid diseases (3,4). When CPG are linked to clinical performance measures, the result can be an increase in auditing and regulation without necessarily improving patient outcomes (5,6). Grading evidence for CPG remains complex, with multiple varying systems and approaches available (7,8). Different conclusions can arise when applying different grading systems to the same body of evidence …

Can Disease Management Target Patients Most Likely to Generate High Costs? The Impact of Comorbidity

ContextDisease management programs are increasingly used to manage costs of patients with chronic disease.ObjectiveWe sought to examine the clinical characteristics and measure the health care expenditures of patients most likely to be targeted by disease management programs.DesignRetrospective analysis of prospectively obtained data.SettingA general medicine practice with both faculty and residents at an urban academic medical center.ParticipantsFive thousand eight hundred sixty-one patients enrolled in the practice for at least 1 year.Main OutcomesAnnual cost of diseases targeted by disease management.MeasurementsPatients’ clinical and demographic information were collected from a computer system used to manage patients. Data included diagnostic information, medications, and resource usage over 1 year. We looked at 10 common diseases targeted by disease management programs.ResultsUnadjusted annual median costs for chronic diseases ranged between $1,100 and $1,500. Congestive heart failure ($1,500), stroke ($1,500), diabetes ($1,500), and cancer ($1,400) were the most expensive. As comorbidity increased, annual adjusted costs increased exponentially. Those with comorbidity scores of 2 or more accounted for 26% of the population but 50% of the overall costs.ConclusionsCosts for individual chronic conditions vary within a relatively narrow range. However, the costs for patients with multiple coexisting medical conditions increase rapidly. Reducing health care costs will require focusing on patients with multiple comorbid diseases, not just single diseases. The overwhelming impact of comorbidity on costs raises significant concerns about the potential ability of disease management programs to limit the costs of care.

The Bottom Line on Practice Guidelines

The Bottom Line on Practice Guidelines

The Lifestyle Challenge Program: A Multidisciplinary Approach to Weight Management

The increasing prevalence of overweight and obesity in the US has received widespread attention and is highlighted in recent government-issued health priorities. While there are many weight loss programs in different settings, few include pharmacist involvement in spite of pharmacists' recognized easy accessibility to the public. To provide insight into a successful, collaborative, multidisciplinary approach to weight management and to encourage pharmacists and other healthcare professionals to adopt a similar approach to patient management. Adult patients >18 years of age were recruited from an outpatient university-based setting to participate in a weight management program. The principles of the program included diet, exercise, and behavior modification. The program was conducted through weekly one-hour group sessions held over a 20-week period. Faculty involved in the program included an attending physician specializing in nutrition, a pharmacist, and a behavioral psychologist. All data are expressed as mean +/- SD unless otherwise specified. Ninety participants (74 female, mean age 48 +/- 10 y) entered the program between April 2001 and April 2004. Participants had multiple obesity-related comorbid diseases. The weight of completers (n = 59) decreased from 100.9 +/- 20 kg at baseline to 97.3 +/- 19.5 kg at 10 weeks and 95.9 +/- 20 kg at 20 weeks. Thirty-nine patients completed both baseline and final assessments, which showed improvement in health-related quality of life, binge-eating behavior, and depressive symptoms (p < 0.05). This program is a successful multidisciplinary model for the management of overweight and obese patients in an outpatient-based hospital setting.

Clinical Practice Guidelines and Quality of Care for Older Patients With Multiple Comorbid Diseases

Clinical practice guidelines (CPGs) have been developed to improve the quality of health care for many chronic conditions. Pay-for-performance initiatives assess physician adherence to interventions that may reflect CPG recommendations. To evaluate the applicability of CPGs to the care of older individuals with several comorbid diseases. The National Health Interview Survey and a nationally representative sample of Medicare beneficiaries (to identify the most prevalent chronic diseases in this population); the National Guideline Clearinghouse (for locating evidence-based CPGs for each chronic disease). Of the 15 most common chronic diseases, we selected hypertension, chronic heart failure, stable angina, atrial fibrillation, hypercholesterolemia, diabetes mellitus, osteoarthritis, chronic obstructive pulmonary disease, and osteoporosis, which are usually managed in primary care, choosing CPGs promulgated by national and international medical organizations for each. Two investigators independently assessed whether each CPG addressed older patients with multiple comorbid diseases, goals of treatment, interactions between recommendations, burden to patients and caregivers, patient preferences, life expectancy, and quality of life. Differences were resolved by consensus. For a hypothetical 79-year-old woman with chronic obstructive pulmonary disease, type 2 diabetes, osteoporosis, hypertension, and osteoarthritis, we aggregated the recommendations from the relevant CPGs. Most CPGs did not modify or discuss the applicability of their recommendations for older patients with multiple comorbidities. Most also did not comment on burden, short- and long-term goals, and the quality of the underlying scientific evidence, nor give guidance for incorporating patient preferences into treatment plans. If the relevant CPGs were followed, the hypothetical patient would be prescribed 12 medications (costing her 406 dollars per month) and a complicated nonpharmacological regimen. Adverse interactions between drugs and diseases could result. This review suggests that adhering to current CPGs in caring for an older person with several comorbidities may have undesirable effects. Basing standards for quality of care and pay for performance on existing CPGs could lead to inappropriate judgment of the care provided to older individuals with complex comorbidities and could create perverse incentives that emphasize the wrong aspects of care for this population and diminish the quality of their care. Developing measures of the quality of the care needed by older patients with complex comorbidities is critical to improving their care.

Medication Use Patterns after Gastric Bypass Surgery for Weight Management

Bariatric surgery, commonly gastric bypass, is an effective intervention in achieving sustained weight loss in patients with a body mass index (BMI) >40 kg/m(2). Currently, there are few data in the literature describing medication use after bariatric surgery. To document the change in medication use patterns over a 2-year period in patients who had gastric bypass surgery. Institutional review board approval was obtained for this ongoing, prospective longitudinal study. Adults (>18 y) scheduled for gastric bypass surgery were recruited. Clinical and demographic data, including age, gender, weight, height, BMI, number of obesity-related comorbidities, and number of medications and nutritional supplements, were obtained by medical chart review. One hundred fourteen patients (87 females) were recruited. The mean +/- SD age was 45 +/- 9 years. Patients had multiple obesity-related comorbid diseases for which they were receiving medication. Drug therapy for diabetes and hypertension was significantly reduced (p < 0.05). All patients were required to take additional nutritional supplements and medications associated with surgery postoperatively. Bariatric surgery has a positive benefit in terms of reduction intake of medication associated with obesity-related comorbid disease. However, there is limited reduction in the overall number of drugs and supplements being consumed by the patient, especially during the first year postoperatively.

Predictive factors for conversion of laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy has replaced open cholecystectomy for the treatment of gallbladder disease. However, certain cases still require conversion to open procedures. Identifying these patients at risk for conversion remains difficult. This study identifies risk factors that may predict conversion from a laparoscopic to an open procedure. Methods: From January 1996 to January 2000, a total of 1,347 laparoscopic cholecystectomies were performed at the Cleveland Clinic Foundation (CCF). A retrospective analysis of 34 parameters including patient demographics, clinical history, laboratory data, ultrasound results, and intraoperative details was performed. Stepwise, multivariate logistic regression was used to determine those variables predicting conversion of laparoscopic cholecystectomy. Results: Seventy-one (5.3%) laparoscopic cholecystectomies required conversion. Multivariate analysis revealed that for all cases, a white blood cell count >9 (2.9 greater odds ratio [OR] of conversion P = 0.006) and a gallbladder wall thickness >0.4 cm (7.2 OR, P <0.001) predicted conversion to open cholecystectomy. However, when patients with acute cholecystitis were evaluated only a body mass index >30 kg/m 2 (5.6 OR, P = 0.02) predicted conversion. For patients undergoing elective cholecystectomy, a body mass index >40 kg/m 2 (33.1 OR, P = 0.01) and a wall thickness >0.4 cm (24.7 OR, P <0.004) predicted conversion. Finally, an ASA >2 (5.3 OR, P = 0.01) predicted conversion in patients undergoing nonelective cholecystectomies. Conclusions: Obese patients with acute cholecystitis undergoing laparoscopic cholecystectomy have an increased chance of conversion. Likewise, patients with multiple comorbid diseases undergoing nonelective laparoscopic cholecystectomy are more likely to require conversion. Finally, in an elective laparoscopic cholecystectomy, morbidly obese patients with chronic cholecystitis and a thickened gallbladder wall are more likely to require conversion. These factors can help counsel patients undergoing laparoscopic cholecystectomy with regards to the probability of conversion to an open procedure.

Endovascular exclusion of abdominal aortic pathology in patients with concomitant malignancy.

The advent of endoluminal aortic repair has gained increasing popularity as an alternative to traditional open surgery in the setting of multiple comorbid disease states. This study analyzes a single center experience of excluding aortic disease in patients with concomitant malignancy. As part of a Federal Drug Administration FDA-approved trial, 318 patients underwent aortic stent-graft repair between June 1996 and February 2001. During that period five patients with advanced-stage neoplasia were treated. Endovascular management of symptomatic abdominal aortic aneurysms (AAA) with a mean diameter of 7.8 cm (range, 6-10 cm), was performed in four patients. In the fifth patient, a custom-made aortic prosthesis was utilized to exclude a paraanastamotic abdominal aneurysm (PAAA) from a previous open AAA repair. Malignancies included esophageal, lung, renal, prostate, and urinary bladder cancers. A mean follow-up of 10.1 months was available. Successful endoluminal repair was accomplished in all five patients with minimal in-hospital morbidity. Mean length of stay was 3.4 days. There were no device-related mortalities and no persistent endoleaks detected for the duration of follow-up. Aneurysm sac enlargement was not seen in any of the patients and complete resolution of the PAAA was noted at one year. Exclusion of AAA and other aortic pathology in patients with an associated malignancy can be performed with a relatively low procedure-related morbidity and mortality. In this population, stent-graft repair remains an individualized option with a multidisciplinary team necessary to explore this therapeutic approach.

Socioeconomic issues affecting the treatment of obesity in the new millennium.

The prevalence of obesity among the populations of most developed countries has increased to such an extent that the healthcare and social security/disability system will accumulate direct and indirect costs related to obesity that will be more substantial than those for any other primary disease within this generation. For the past decade, the Healthcare Financing Agency, which oversees the Medicare and Medicaid programmes, has required all physicians and healthcare agencies serving beneficiaries of these programmes to include diagnoses using codes established by the ninth revision of the World Health Organization's International Classification of Diseases. This coding system actually distorts data collection and undermines appropriate medical insurance reimbursement for the treatment of obesity. Societal prejudices, inability of governmental agencies to address future concerns and the business community's attempts to control healthcare costs without addressing the underlying issues contributing to these costs have led to confusion on how to confront this emerging epidemic. How will we develop the scientific knowledge and the political willpower to confront this epidemic? First, we need more accurate methods for classifying obesity and for measuring the cost of treatment. We can then determine if it is more cost effective to prevent or treat obesity early in its evolution or pay for its consequences in the form of treatment costs associated with its multiple comorbid diseases, such as hypertension, other cardiovascular disorders, diabetes mellitus, osteoarthritis and cancers, plus the lost productivity from absenteeism, premature retirement and death.