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for at least $52 billion (9% of total medical expenditure), rising to $79 billion if nursinghome costs are included. Obesity alone accounted for $27 48 billion, half of which was borne by federally-funded Medicare and Medicaid programmes (Finkelstein, Fiebelkorn and Wang, 2004). These estimates were subsequently revised to $75 billion for obesity alone, of which $18 billion was borne by Medicare and 21 billion by Medicaid. None of these calculations includes indirect and societal costs (Finkelstein, Fiebelkorn and Wang, 2004). In other countries, the costs of obesity may be harder to calculate, and vary widely. In England, the National Audit Of ce (NAO) estimates that obesity accounted for 18 million sick days and 31 000 deaths each year, resulting in 40 000 lost years of working life; deaths associated with obesity shorten life by an average of 9 years. The NAO s conservative estimates of costs in 1998 were 2.6 billion (US $5.2 billion), predicted to rise to 3.6 billion (US $7.2 billion) by 2010. In Spain, the costs attributable to obesity are calculated at 2.5 billion (US $3.4 billion) per year. In 2002, and applying the methodology used by the UK s NAO, estimated costs across 15 EU countries were 33 billion (US $44 billion) (Fry and Finley, 2005). This has been extrapolated in 2005 to the expanded European Union (25 countries), where obesity was estimated to cost 41 billion per year and the combined cost with overweight reached 81 billion annually (Impact Assessment Report, 2007). The estimated costs of obesity per capita in selected Western countries are shown in Figure 2.13.





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Total energy expenditure comprises three main elements: basal metabolism, thermogenesis and physical activity (Figure 3.8). Various methods are available to measure or estimate these components and total energy expenditure, and are described below. Individual energy requirements and expenditure vary widely, mainly according to body size and composition, gender, age and physical activity levels. Special circumstances such as active growth, pregnancy and the catabolic response to trauma can also in uence energy expenditure. Body weight and composition are key determinants of total energy expenditure (TEE). Lean (fat-free) mass is broadly proportional to basal metabolic rate (BMR), which usually accounts for about two-thirds of TEE (Figure 3.8). As fat mass increases with obesity, lean mass also rises (although not as rapidly). Energy expenditure is therefore higher in obese subjects than in the lean, and as energy intake must equal output at steady rate, it follows that an obese person s intake must be higher than for a lean subject, in order to maintain the greater weight (Figure 3.9). Apart from profound hypothyroidism, there are no known exceptions to this rule an important practical point when explaining and managing the causes of obesity in a clinical setting. Average adult values for daily energy expenditure are generally 2000 2500 kcal; the lowest levels recorded (in terminally malnourished subjects) were 900 kcal/day. Energy is generated mainly by the oxidation of carbohydrate (which yields 4 kcal/g) and fat

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When you purchase a Media Center PC, it s a good time to review the progress you are making in moving to an all-digital entertainment system In fact, it is a great time to upgrade your current entertainment equipment and even get rid of some of it Whether the Media Center PC is in use in your living room, family room, or even your home of ce, it represents the opportunity to create an amazing digital home entertainment system At rst glance, a Windows XP Media Center PC looks just like a regular Windows PC because it is It is a high-end PC powered by Windows XP that has been expanded to excel at playing media using a special extension of the Windows XP operating system and high-performance components that are optimized for getting media content in and out of the PC.

Figure 10.9 Comparison of Heun s method (a second-order Runge Kutta method) with a fourth-order Runge Kutta method [Eqs. (10.80) and (10.81)]. This is for the differential equation in Example 10.8.

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