This review identified 36 studies on the relation between obesity status and sick leave. Pooling of effect estimates was not possible due to great heterogeneity between studies regarding definition of sick leave (short-term/long-term), measure of obesity (body mass index/waist circumference/percentage body fat), definition of obesity status (World Health Organization standards/other), study population (sex/age/occupation/country) and exposure and outcome ascertainment (self-reported/objectively assessed). Nevertheless, a clear trend towards greater sick leave among obese compared with normal weight workers could be discerned, especially for spells of longer duration. In studies from the USA, which consistently reported about five times lower number of sick leave days per person-year than European, obese workers had about 1-3 extra days of absence per person-year compared with their normal weight counterparts. In European studies, the corresponding difference was about 10 d. For overweight workers the data were conflicting, indicating either increased or neutral level of sick leave compared with normal weight. Regarding underweight, the studies were very few and concerns regarding direction of causality were greater. Finally, in all four interventional studies identified substantial weight loss in obese subjects resulted in reduced sick leave, at least temporarily. In conclusion, increasing obesity in children and adults is likely to negatively affect future productivity as obesity increases the risk of sick leave, disability pension and death.

Disability pensions incur huge societal costs in many countries. In Sweden, the three greatest drivers of such productivity losses are musculo-skeletal, circulatory and psychiatric disorders, all closely associated with weight status. We identified 16 studies investigating the body mass index (BMI)-disability pension relation. In cross-sectional studies, a significantly greater proportion of obese compared with normal weight subjects were disability pensioners. In longitudinal studies, a J-shaped relation with BMI was generally found in both men and women of various ages. Different definitions of obesity status complicated interpretation, as several studies mixed the underweight and normal weight, which appear to have different disability pension risks. In middle-aged men, relative risks were elevated for circulatory causes only for the overweight and obese, while associations for mental disorders were similar in the underweight and overweight but much higher in the obese. In both sexes, monotonic increases and decreases were seen for circulatory and respiratory causes respectively. In intervention studies, reduced disability pension incidence and increased gainful employment were reported after surgery. In summary, BMI was significantly associated with disability pension, but the direction of causality may vary with underlying cause. Interventions had positive productivity effects in the morbidly obese, but whether this holds for the overweight remains to be proven.

The objective of this article was to estimate the risk of discontinuation due to adverse events in trials of orlistat, sibutramine and rimonabant. Medline, EMBASE, the Cochrane controlled trials register and reference lists of identified articles were searched from 1990 to May 2008. All randomized placebo-controlled trials of 12-24 months of duration on adults using licensed doses were included. Studies/study arms were excluded if they evaluated weight maintenance after weight loss. Trials were identified, subjected to inclusion and exclusion criteria and reviewed. Data on participants, interventions and discontinuation were extracted and trials rated for quality based on established criteria. A random effects model was used to estimate pooled risk ratios, risk differences and number needed to harm (NNH). A total of 28 trials met the inclusion criteria (16 orlistat, 7 sibutramine and 5 rimonabant). The risk ratios for discontinuation due to adverse events were significantly elevated for rimonabant (2.00; 1.66-2.41) and orlistat (1.59; 1.21-2.08), but not sibutramine (0.98, 0.68-1.41). Compared with placebo, the risk difference was the largest for rimonabant (7%, 5-9%; NNH 14, 11-19), followed by orlistat (3%, 1-4%; NNH 39, 25-83), while no significant difference was seen for sibutramine (0.2%, -3 to 4%; NNH 500). The most common adverse events leading to withdrawal were gastrointestinal for orlistat (40%) and psychiatric for rimonabant (47%). Corresponding information was unavailable for sibutramine. In conclusion, available weight loss drugs differ markedly regarding risk of discontinuation due to adverse events, as well as in underlying causes of these events. Given the large number of patients eligible for treatment, the low NNH for rimonabant is a concern.

Obesity is associated with almost twice as high productivity losses to society as for normal weight over a lifetime. These costs are important to include in health economic analyses of obesity intervention programmes in order to ensure an effective allocation of resources from a societal perspective.