THCB

Categories

Tag: Obesity

Unscience

• 1

By David Katz, MD

According to a widely circulated op-ed in the New York Times by Paul Campos, a law professor at the University of Colorado with whom I don’t believe I have ever managed to agree on anything, our “fear” of fat — namely, epidemic obesity — is, in a word, absurd. Prof. Campos is the author of a book entitled The Obesity Myth, and has established something of a cottage industry for some time contending that the fuss we make about epidemic obesity is all some government-manufactured conspiracy theory, or a confabulation serving the interests of the weight-loss-pharmaceutical complex.

In this instance, the op-ed was reacting to a meta-analysis, published last week in JAMA, and itself the subject of extensive media attention, indicating that mortality rates go up as obesity gets severe, but that mild obesity and overweight are actually associated with lower overall mortality than so-called “healthy” weight. This study — debunked for important deficiencies by many leading scientists around the country, and with important limitations acknowledged by its own authors — was treated by Prof. Campos as if a third tablet on the summit of Mount Sinai.

We’ll get into the details of the meta-anlysis shortly, but first I’d like to say: Treating science like a ping-pong ball is what’s absurd, and what scares the hell out of me. Treating any one study as if its findings annihilate the gradual, hard-earned accumulation of evidence over decades is absurd, and scares the hell out of me. Iconoclasts who get lots of attention just by refuting the conventional wisdom, and who are occasionally and importantly right, but far more often wrong — are often rather absurd, and scare the hell out of me.

And so does the obesity epidemic.

Continue reading…

The Pain Index

• 2

By PAUL LEVY

A recent report by the New York Times contained an excellent graphic showing the current percentage of uninsured people in each state.  The range is from a high of 24.6% in Texas to a low of 4.4% in Massachusetts.I have combined this rate with the most recently reported CDC rate of obesity in each state to create what I call The Pain Index.  It is a simple sum of the two numbers. 

The theory behind the total is that obesity is a rough guide for the level of unhealthiness in the population.  My hypothesis is that, when insurance is made available to people, they will use it, roughly in proportion to the degree they are unhealthy.

Yes, I know this is a crude metric, but I think it will be a relatively good predictor of the rate of increase in health care costs in each state over the coming years.  This will show up in the insurance premium rates offered in the health care exchanges and will also affect the need for state appropriations to pay for newly eligible Medicaid subscribers.

States with a Pain Index in the top decile are: Texas, South Carolina, Louisiana, Mississippi, and Arkansas.  Others with scores over 45 are Nevada, Florida, New Mexico, Georgia, Alaska, Oklahoma, North Carolina, Kentucky, Alabama, and West Virginia.

My advice to policy-makers:  Get ready!  My advice to health care CEOs:  This would be a really good time to focus on quality, safety, and front-line driven process improvement as the most effective way to reduce your costs and improve efficiency.

Continue reading…

The Only Way Out of the Health Care Wilderness

• 1

By William Bestermann, MD

The landmark 2001 document from the Institute of Medicine’s (IOM), Crossing the Quality Chasm, should have guided us out of the healthcare cost-quality crisis. It argued that the root cause of our difficulties has been a failure to meet the needs of patients with chronic disease. We have not solved this crisis because we have almost entirely ignored the recommendations for reform found in that document.

The claim that we have the best healthcare in the world is correct only if you have an acute condition. If you are having an event, such as a heart attack, our system can provide an emergency stent — for as much as $50,000 — that will open the blocked artery, immediately relieving the pain and saving your life. We are really good at rescue medicine-crisis medicine.

But acute conditions generate enormous costs only because we have not addressed the chronic condition earlier, interrupting the disease progression that produces the acute events. Since most healthcare cost growth over the past 2 decades has been related to patients with 4 or more chronic conditions, this should be recognized as the foremost issue in healthcare reform.

In fact, the IOM charged that, despite the central role of chronic disease in most pain, disability, death, and cost, care continues to be designed around the needs of providers and institutions, and most patients with chronic conditions do not receive the care they need. A 17-year lag in implementing new scientific findings results in highly variable care.

That cardiologists favor coronary stenting over optimal medical therapy — that is, managing vascular disease using $4 drugs and recommended lifestyle changes — provides a powerful case in point.

Continue reading…

Does America Really Want Change?

• 1

By LAWRENCE ROSEN, MD

Twenty years ago, in order to keep presidential candidate Bill Clinton’s campaign on message, James Carville hung a sign in their “war room” that read:

  1. Change vs. more of the same
  2. The economy, stupid
  3. Don’t forget health care

While point number two swiftly entered the national vernacular, the other two slogans have equally influenced the U.S. political landscape, especially since 2008. Four years ago, the country was on the precipice of transformation. Meaningful change was promised, and opportunities for significant, long-lasting reforms were abundant. Americans, particularly the millennial generation, turned out in record numbers to vote, and hope for the future was palpable. America, like a patient suffering from a debilitating chronic disease, seemed finally ready to put in the time and do the hard work to get healthy before that fatal heart attack occurred. After decades of procrastination, we heeded Carville and health care system overhaul became a top priority.

Pause: The State of America’s Health

Obesity prevalence increased 137 percent over 20 years, from 11.6 percent to 27.5 percent of the population. In 2008, more than one-third of children and adolescents were overweight or obese. The medical care costs of obesity in the U.S. totaled about $147 billion in 2008 dollars.

Diabetes has almost doubled in prevalence since 1996, rising from 4.4 percent to 8.7 percent of the adult population. For children, the prevalence of Type 2 diabetes increased 21 percent from 2001-2009, while Type 1 diabetes rose 23 percent. Estimated total diabetes costs in the U.S. were $174 billion in 2007.

Asthma diagnoses grew by 4.3 million from 2001 to 2009, and 9.4 percent of children currently have asthma. Asthma costs in the U.S. grew from about $53 billion in 2002 to about $56 billion in 2007.

Developmental Disabilities prevalence increased 17.1 percent over the last 12 years. The prevalence of autism increased 289.5 percent, and the prevalence of ADHD increased 33 percent. Autism alone is estimated to cost the U.S. $137 billion per year.

Continue reading…

Man versus Pizza

• 4

By Peter Ubel, MD

As a fan of free markets, I recognize that sometimes intelligent government regulations (not always an oxymoron!) can improve markets by requiring companies to provide consumers with information that will help them make better choices. Informed consumers, after all, are a central ingredient of a successful free market. That’s why even most libertarians support regulations that ban fraudulent advertising.

That’s also why, at first glance, the federal government seemed to be promoting better markets when it passed rules requiring chain restaurants to post calorie counts next to their menu items. Research has shown that many consumers are horribly uninformed about the number of calories in most menu options, often significantly underestimating the amount in their favorite meals. Calorie count information should help these consumers make more informed, and therefore better, decisions.

But recent push-back from groups like pizza companies raises important questions about the proper size and scope of such regulations. More importantly, this controversy should remind all of us that, when debating government regulations, we should be humble, because it is often difficult to set a proper balance between helping consumers while at the same time allowing businesses to prosper.

To understand the push-back, it helps to take a guess – your best shot – at estimating the number of calories in a large Little Caesars pizza.

Stumped? You should be. There is no right answer to this question, because there is no such thing as a generic large Little Caesars pizza. Instead, there are hundreds of possible large pizzas one could buy from this company – cheese pizzas, pepperoni and sausage pizzas, mushroom green pepper and extra sauce pizzas . . . you get the idea. The number of calories in a large Little Caesars pizza depends on how many toppings consumers choose to put on top of their pies. This variability makes it hard for Little Caesars to post calorie counts on its menu.

Continue reading…

The Return of Counter-Conventional Wisdom

• 8

By Dr. Wes

Diet and exercise: they were supposed to be the answer to all that ails America’s obesity and health care cost problem.

Signs of this Utopian vision are everywhere.  From entire government departments encouraging healthy lifestyles through fitness, sports and nutrition, government websites that encourage “healthy lifestyles,” and entire community efforts to partner with health care organizations to fight obesity with the hope of cutting health care costs.

What if, believe it or not, when it comes to people with Type II diabetes, diet and exercise don’t affect the incidence of heart attack, stroke, or hospital admission for angina or even the incidence of death?

Suddenly, all health care cost savings bets are off.  Suddenly, we have to re-tool, re-think our approach, understand and appreciate the limitation of lifestyle interventions to alter peoples’ medical destiny.  Suddenly we have to come to grips with a the reality that weight loss and exercise won’t affect outcomes in certain patients.  Suddenly, there is a sad reality that patients might note be able to affect their insurance premiums by enrolling in diet and exercise classes after all.

These thoughts are so disruptive to our most basic “healthy lifestyle” mantra that few can fathom such a situation.  Nor would any members of the ever-beauty-and-weight-conscious main stream media be likely to report such a finding if it came to pass.

And yet, that is exactly what has happened.

Continue reading…

The Health of Nations

• 2

By David Katz, MD

If all of us were simply to make better use of our feet, our forks, and our fingers — if we were to be physically active every day, eat a nearly optimal diet, and avoid tobacco — fully 80 percent of the chronic disease burden that plagues modern society could be eliminated. Really.

Better use of feet, forks, and fingers — and just that — could reduce our personal lifetime risk for heart disease, cancer, stroke, serious respiratory disease, or diabetes by roughly 80 percent. The same behaviors could slash both the human and financial costs of chronic disease, which are putting our children’s futures and the fate of our nation in jeopardy. Feet, forks, and fingers don’t just represent behaviors we have the means to control; they represent control we have the means to exert over the behavior of our genes themselves.

Feet, forks, and fingers could reshape our personal medical destinies, and modern public health, dramatically, for the better. We have known this for decades. So why doesn’t it happen?

Because a lot stands in the way. For starters, there’s 6 million years of evolutionary biology. Throughout all of human history and before, calories were relatively scarce and hard to get, and physical activity — in the form of survival — was unavoidable. Only in the modern era have we devised a world in which physical activity is scarce and hard to get and calories are unavoidable. We are adapted to the former, and have no native defenses against the latter.

Then, there’s roughly 12,000 years of human civilization. Since the dawn of agriculture, we have been applying our large Homo sapien brains and ingenuity to the challenges of making our food supply ever more bountiful, stable, and palatable; and the demands on our muscles ever less. With the advent of modern agricultural methods and labor-saving technologies of every conception, we have succeeded beyond our wildest imaginings.

So now, we are victims of our own success. Obesity and related chronic diseases might well be called “SExS” — the “syndrome of excessive successes.”

Continue reading…

The Ethics of Stupidity: Should a Good Doctor Refuse to Treat an Obese Patient?

• 27

By Dinosaur MD

Several folks have been kind enough to point out this story, and suggest that I may have an opinion on it:

[A woman from] Shrewsbury, Mass., claims that Dr. Helen Carter, a primary care physician at the UMass Memorial Medical Center in Worchester, refused to treat her because she is clinically obese…

It seems the good doctor has decided not to care for anyone (it is unclear if the prohibition applied to all patients or just to females) weighing over 200 lbs. Apparently there was a nearby specialty facility capable of caring for obese patients, so no one was being sent away with no resource to medical care.

There is nothing either illegal or unethical about this policy, according to the AMA and others. Much hullabaloo has ensued in the various comment trails, with many people stating that it should be (illegal. unethical, or both.) They are wrong. The only thing this physician has done is set her weight limit unreasonably low.

Here are the magic words: Scope of Practice. It means that doctors have not only the right but the ethical and legal responsibility to limit the care they provide based on their capabilities, their training and their experience, which together also translate to “comfort level”.

Continue reading…

KP’s Ray Baxter Talks Weighty Issues

• 2

By Matthew Holt

[viddler id=803f4ce0&w=490&h=275]

Kaiser Permanente is a different kind of health system, as we all know. It has been a major funder of the HBO Series Weight of the Nation — reviewed by Kristin Molven in a companion piece on THCB today. Matthew Holt interviewed Raymond Baxter who is Kaiser’s Senior Vice President of Community Benefit, Research and Health Policy about the role KP plays in community and policy issues, and what we know and what we should can and should do about obesity.

The Weight of the Nation

• 1

By Kristin Molven

Kristin Molven is a medical student at The University of Olso. She is currently a student in the Norwegian Entrepreneurship Programme at UiO and UC Berkeley, and is interning at Health 2.0.

HBO’s documentary series The Weight of the Nation made me sad. I was left with the feeling that the wealth my parents have provided and all prior generations’ good intentions to make it easier for us to gather food and survive, and the technologies they developed to make our lives easier now are destroying us. My generation is short-circuiting. When looking to satisfy our needs, we meet no obstacles, no resistance. Everything is readily available to us, and we are fast-forwarding towards the negative consequences of constant access. And the food industry makes a profit off our misfortune.

The Weight of the Nation campaign consists of four main films, a dozen of extra short films and an accompanying book and website. It was launched in May by HBO and the Institute of Medicine in association with the Centers for Disease Control and Prevention, the National Institutes of Health, Michael & Susan Dell Foundation and Kaiser Permanente.

The campaign abandons the idea that obesity is an individual shortcoming or to results from a lack of self-control. Instead the campaign holds society responsible for today’s weight problems. Come to think of it, this is not unreasonable as humans have the same mental capabilities as former generations that were not obese. What has changed is our behavior and surroundings. Physical activity has been engineered out of our daily routine, while unhealthy tempting food has become cheaper and more accessible. Let’s not pretend that our grandparents had higher moral standards by avoiding sugar and fat and took the stairs instead of the elevator. They surely would have made the same choices as us if they had the chance. Given that nobody intends to become overweight or obese, we have designed a society where it is just too hard for most of us to maintain a healthy weight.

Consequences and Choices, the two first films of The Weight of the Nation series, examine the physiology and pathology of weight gain and obesity.Continue reading…