Obesity

Screen Shot 2014-12-12 at 2.27.00 PMI was enjoying drinks last week with Jody Holtzman (AARP)Terry Booker (IBC), and Doug Ghertner (change:healthcare) at a wonderful conference sponsored by Oliver Wyman. Jody was waxing eloquent about how every start-up needs a strategy for the senior population, when – after a few too many drinks – I emphatically told everyone at the table that I had the senior market cracked. I had experienced first hand the ills of the American health care system for seniors and had identified the perfect solutions.

My father-in-law grew up on a small, Kosher dairy farm outside of Pennsylvania (insert Jewish farmer joke here). He is 72 years old, he was about 40 pounds overweight, he has been widowed for about four years, and, about 30 minutes after my mother-in-law passed away, he started dating a woman that my wife never quite accepted, which is akin to saying that Russia is watching events unfold in the Ukraine from the sidelines (and to be clear, I don’t condone either position).

In January of this year, he was jumping from a backhoe onto a helicopter pad (don’t ask), fell 6 feet, and shattered his heel. The heel is a terrible bone to break in general (poor circulation) and, in particular, for someone who is older and a bit overweight (my goal is to not use the word “patient” once in this article because we aren’t patients, we’re people). Continue reading “Starvation: The Cure For the Obesity Epidemic. Or Will Esther Dyson Be My Next Mother-In-Law?”

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flying cadeuciiEating advice in the United States has taken leave of its senses. It is no wonder that Americans are perpetually on diets.

It is only in the last 20 years that eating, a task we do quite naturally, has become so complex that you apparently need professional spin from nutritionists and dietitians, or worse, from doctors, on how to do it.

Spend a little time on the web (and especially social media) and your head will spin from all the contradictory healthy eating advice: eat organic…no, wait, don’t waste your money; eat less salt…wait, too little salt might be worse for you than too much salt; don’t eat fat…oh, sorry, eating too little fat will actually make you fat because you’ll eat too many poor quality carbs; eat foods that have a low glycemic index…wait, we meant a low glycemic load, er, well maybe eat foods that are both; eat breakfast every day because it will help you control your body weight except when it doesn’t.

Continue reading “Eat Less. Eat Less Crap.”

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By ANDY ORAM

andy oramThe health care field is in the grip of a standard that drains resources while infusing little back in return. Stuck in a paradigm that was defined in 1893 and never revised with regard for the promise offered by modern information processing, ICD symbolizes many of the fetters that keep the health industries from acting more intelligently and efficiently.

We are not going to escape the morass of ICD any time soon. As the “I” indicates in the title, the standard is an international one and the pace of change moves too slowly to be clocked.

In a period when hospitals are gasping to keep their heads above the surface of the water and need to invest in such improvements as analytics and standardized data exchange, the government has weighed them down with costs reaching hundreds of thousands of dollars, even millions just to upgrade from version 9 to 10 of ICD. An absurd appeal to Congress pushed the deadline back another year, penalizing the many institutions that had faithfully made the investment. But the problems of ICD will not be fixed by version 10, nor by version 11–they are fundamental to the committee’s disregard for the information needs of health institutions.

Disease is a multi-faceted and somewhat subjective topic. Among the aspects the health care providers must consider are these:

  • Disease may take years to pin down. At each visit, a person may be entering the doctor’s office with multiple competing diagnoses. Furthermore, each encounter may shift the balance of probability toward some diagnoses and away from others.
  • Disease evolves, sometimes in predictable ways. For instance, Parkinson’s and multiple sclerosis lead to various motor and speech problems that change over the decades.
  • Diseases are interrelated. For instance, obesity may be a factor in such different complaints as Type 2 diabetes and knee pain.

All these things have subtle impacts on treatment and–in the pay-for-value systems we are trying to institute in health care–should affect reimbursements. For instance, if we could run a program that tracked the shifting and coalescing interpretations that eventually lead to a patient’s definitive diagnosis, we might make the process take place much faster for future patients. But all a doctor can do currently is list conditions in a form such as:

E66.0 – Obesity due to excess calories

E11 – Type 2 diabetes mellitus

M25.562 – Pain in left knee

The tragedy is that today’s data analytics allow so much more sophistication in representing the ins and outs of disease.Take the issues of interrelations, for instance.

These are easy to visualize as graphs, a subject I covered recently.

Continue reading “International Classification of Diseases Hampers the Use of Analytics to Improve Health Care”

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Among the American public and even some policymakers, it has become conventional wisdom that poverty, a dearth of supermarkets, reduced leisure time, and insufficient exercise are key forces behind the U.S. obesity epidemic.

Conventional wisdom is an unreliable guide, however, and in this case, much of it is wrong: The epidemic actually coincides with a falling share of income spent on food, wider availability of fruits and vegetables, increased leisure time, and more exercise among the general population.

Of course, there are differences between individuals, but we need to explain the change in obesity over time, not why people differ. Some differences in body mass index (BMI) are associated with genetic makeup. But genes haven’t changed in the past 50 years, so differences between individuals don’t explain trends.

Data from a new analysis of this issue indicates that the same argument applies to other characteristics, such as geography. Southern hospitality’s heavy food hasn’t caused the obesity epidemic any more than an active Colorado lifestyle has prevented it. There are differences at a given point in time, but the trend is the same, as shown in the figure below.

Percentage of Population with a BMI Over 25 in California, Colorado, and Mississippi

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SOURCE: Calculations based on Behavioral Risk Factor Surveillance Survey; smooth trend adjusted for 2010 demographics.

Increases in obesity have also been surprisingly similar by level of education and by racial/ethnic group, as the following figures show.

Increase in Average BMI Nationwide, by Highest Education Level Achieved

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SOURCE: Calculations based on Behavioral Risk Factor Surveillance Survey; smooth trend adjusted for 2010 demographics. Continue reading “What’s Behind the Obesity Epidemic? Easily Accessible Food, and Lots of It”

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cheeseburger

Consider that for the last year or so, we have been treated a deluge of entreaties to reduce our salt intake, with the American Heart Association going so far as to claim that daily sodium intake should not exceed 1,500 mg. This puts it at odds with the Institute of Medicine, and now European researchers whose data indicates that the healthy range for sodium intake appears to be much higher.

Our conversation about  sodium, much like advice about purportedly evil saturated fats and supposedly beneficial polyunsaturated fats, exemplifies a national obsession with believing eating more or less of a one or a small number of nutrients is the path to nutritional nirvana.

A few weeks back, an international team of scientists did their level best to feed this sensationalistic beast by producing what’s become known since then as the meat-and-cheese study, because it damned consumption of animal proteins.

Continue reading “Cheeseburger Please, and Make It a Double”

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companies health productivity
Al’s son once complained to Al’s Aunt Tillie about an overbearing supervisor.  Aunt Tillie suggested that he try to work under a different supervisor.  Tillie was one of those people – and we all know them – who could be counted on to inadvertently provide punchlines when needed.  Conversely, Al is one of those people – and we all know them – who can’t resist setting up those punchlines.  So I lamented that this suggestion may not work because, “Aunt Tillie, it’s a sobering fact that 50% of all supervisors are below average.”

Tillie replied, “I blame our educational system for that.”

Likewise, we may need to blame our educational system for Keas’ new poll on workplace stress.  To begin with, the lead paragraph from Keas — which like many other companies is “the market leader” in wellness – “reveals” that “4 in 10 employees experience above-average stress.”

SAN FRANCISCO, CA – (Apr 2, 2014) – Keas (www.keas.com), the market leader in employer health and engagement programs, today released new survey data, revealing four in ten employees experience above average levels of job-related stress. Keas is bringing attention to these findings to kick off Stress Awareness Month, and is also providing additional insight and tips to bring greater awareness to the role of stress in the workplace and its impact on employee health.

Wouldn’t that mean some other employees – mathematically, also 6 in 10 – must be experiencing average or below-average levels of stress?   It would seem like mathematically that would have to be the case.   However, the Keas poll also “reveals” that while some employees are average in stress, no employee is below-average – a true paradox.  Hence Keas’ selfless reasons for publishing this poll:  All employees being either average or above average in the stress department means we have a major stress epidemic on our hands.  This perhaps explains why Keas is “bringing attention to these findings.”

In a further paradox, Keas also uses the words “average” and “normal” as synonyms, even though they are often antonyms:  All of us want our children to be normal but who amongst us wants their children to be average?

Continue reading “Keas Poll on Workplace Stress and Disease Burden Provides an Education”

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Amid the rancorous debates over the Affordable Care Act, one provision deserves to be getting serious discussion.

It’s a provision that allows employers to increase the amount that they may fine their employees for “lifestyle” conditions, such as being overweight or having high blood pressure or high cholesterol.

Almost 37% of Americans are overweight or obese. The supposed goal is to use financial penalties to reduce obesity, the health costs of which exceed $200 billion per year. But this idea, while well intended, will not help Americans suffering from obesity, a medically defined disease and disability. In fact, it will likely make their situation worse.

For years, the country’s “wellness” industry has offered health-enhancement and obesity-reduction programs to corporations, from gym memberships to dietary counseling. For obesity, this approach has not worked. Research on these programs shows that they have not significantly reduced weight or cholesterol levels, or improved any other health outcomes.

Even the most successful programs, such as Weight Watchers, achieve an average two-year weight loss of only about 3% for their members— and even that tiny weight loss often returns later.

Continue reading “An Obamacare Fine on Overweight Americans: Discriminatory and Ineffective”

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With the exception of rare and particularly bleak days, I don’t tend to think of myself as a moron — nor, as far as I can tell, do those who know me well and love me. I will hazard a guess that neither you nor those who love you think of you as a moron, either.

So let’s be bold, proffer one another the mutual benefit of any disparate doubts, and declare: We are not morons!

I propose, then, that this be the year we stop ingesting as if we were. Still with me? Let’s find out.

On the matter of morons, I think they are very much the exception rather than the rule. I have met a lot of people over my years. I’ve taken care of many patients over decades and come to know their intimate thoughts as the privilege of doctoring uniquely allows and requires. So I know firsthand that most of us are endowed with our fair portion of both sense and sensitivity. Formal education, the color of a collar, degrees and credentials don’t distinguish us nearly as much as some might like to think. In most ways that matter, most people have that practical brand of folksy wisdom and intelligence that serve most handily on any given day.

And yet, as a matter of routine we are fed a steady diet of both food and food for thought as if we were abject morons. That’s how it’s served to us — but of course, only we get to decide whether or not to swallow such insalubrious slop. It’s a New Year, and time for new chances. Here’s our chance to stop the slop.

On the matter of common sense, I have been driven many times over the span of my career to lament the fact that it isn’t nearly common enough. But as just noted, I think it really is — in most areas. We apply it routinely to finances, home care, our careers and our families. We just turn it off when captivating promises about effortless weight loss, miraculous vitality, or age reversal waft our way. The result, of course, tends to be that even as we get fatter, sicker and older, we get poorer — spending our sensibly earned money on a senseless parade of false promises.

Continue reading “Please Don’t Feed the Morons!!”

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The ever-blurring line between the practice of medicine and the business of profiting from unhealthy lifestyles was crossed again Wednesday, as Aetna announced a collaboration with two pharmaceutical companies to pitch their prescription weight loss drugs to selected Aetna members.

This announcement crosses multiple lines, not just one. First, no insurer has ever announced that it would openly direct a specific class of members to use particular proprietary drugs. Disease management (DM) programs rarely recommend specific drugs, and certainly in the exceptionally rare instances when they do, the recommendations are not specific brand-name drugs (in this case, Arena’s Belviq and Vivus’s Qsymia).

Instead, DM focuses on improving compliance with existing drug regimens, and DM firms encourage members “talk to their doctor” about changing therapies. While DM companies shy away from directing patients to specific products, physicians and pharmacists have discretion to discuss the full range of covered generic and brand products with patients, in order to optimize therapy and close algorithm-identified care gaps.

Second, there are no generally accepted care algorithms (other than those created by the manufacturers of those products) for these two drugs in the treatment of obesity. So there is no “gap” to fill. If there were an accepted protocol, these drugs might be blockbusters but instead Belviq’s recent quarterly sales were an anemic $4.8-million, “well below even reduced Wall Street expectations,” while QSymia sales are “flailing” at $6.4-million for the same period.

Obese people and their physicians seem to be avoiding these drugs in droves. Regardless of what Aetna and the manufacturers believe about their effectiveness, or whatever promotional deal they’ve cut, market reaction is telling a different story, and unfortunately for Aetna, Vivus, and Arena we live in a market economy.

Continue reading “Dr. Aetna Will See You Now”

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Hi. I’m fat. I’m what most people call an in-betweenie—I have a heavy build, I wear plus sizes, my stomach poofs out, I have folds of fat along my back, I have chubby arms and legs. I can still buy clothes off the rack at a lot of stores, though.

Don’t rush to tell me I’m not ‘that kind’ of fattie or you’re ‘not talking about [me]‘ when you’re going on about how much you worry for fat people, though. We all know that you’re thinking of me, that when you think of fat people, my double chin comes to mind, my wobbling upper arms, my thighs broad in my jeans, my big ass. I’m fat. It’s okay. You can say it. I don’t have a problem with it.

I have a lot of issues with my body, but my size isn’t really one of them. It is what it is. The reasons I’m fat are complicated and not really your business. And yeah, I am unhealthy, and the reasons for that aren’t your business either, although I know you want to rush to assume that I’m unhealthy because I’m fat.

I don’t have an obligation to be healthy, actually, and I don’t have an obligation to rush to assure you that I’m a ‘good fatty’ with great cholesterol and good scores on other health indicators allegedly related to weight. I don’t have an obligation to tell you that fat isn’t correlated with health because I shouldn’t have to justify the existence of fat people by informing you that you don’t understand how fat bodies work, and you’re not familiar with the latest studies on fatness, morbidity and mortality, health indicators, and social trends.

Continue reading “Do You Care About My Health, Or Just Think I’m Gross? Be Honest.”

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