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Tag: Obesity

Dr. Aetna Will See You Now

• 14

By Al Lewis & Vik Khanna

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.

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

• 19

By S.E. Smith

 

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.

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Sorry. Saturated Fat is Bad For You. Or More Accurately — It’s Complicated. Let’s Review the Evidence…

• 8

By David Katz, MD

A commentary in the current issue of the British Medical Journal (BMJ) suggests that saturated fat is not really so bad after all. The article has the media buzzing, with headlines exonerating saturated fat sprouting like mushrooms throughout cyberspace and print media alike. My most recent Google search of “saturated fat” limited to news retrieved 20,000 sites.

Since the new paper is just a commentary — one doc’s opinion — and not a new study, and since this opinion has been asserted many times already, I’m not sure I really get the reaction. But hey, I just work here. Let’s deal with it.

Is it, in fact, time to absolve saturated fat? No, it’s not. But then again, it was never time to demonize it in the first place. I will lay out my case that we are ill-served to think of saturated fat as either scapegoat or martyred saint.

1) Ancel Keys was never really wrong.

The case against saturated fat, its implication in the development of atherosclerosis, inflammation, and chronic diseases, notably heart disease, involves a vast expanse of research over many years by thousands of researchers around the world. But dealing with all of that in this column would be a terrible bother, so let’s just blame it all on Ancel Keys. Keys was certainly among the first to emphasize the association between saturated fat intake and heart disease.

The temptation to absolve saturated fat comes along with a temptation to indict Dr. Keys of crimes against dinner. But, Ancel Keys, while perhaps not quite right, was never really wrong.

Keys looked at rates of disease around the world and correctly noted that heart disease was more common in societies that ate more meat and dairy. His mistake may have been to look past that dietary pattern for the “active ingredient” in it, which led to the convictions of dietary cholesterol, saturated fat, and to a lesser extent overall dietary fat.

There’s much that could be said about this. Whole columns could be written about dietary cholesterol, dietary fat, and saturated fat and ways we went wrong. In fact, I — along with innumerable others — have written just such columns. Simply click the inserted links.

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Obesity and the AMA, Part Two

• 11

By Vik Khanna & Al Lewis

A likely unanticipated consequence of the AMA’s decision to label obesity a disease, even though their own scientific council said not to, is that this might serve as the macguffin leading to furtherance of a protected class of people.  This has serious implications not only for employment discrimination, but also for wellness programs, which often hinge vastly overblown claims of being able to help the obese who they almost universally label as “high risk” people.

Well, what if people who are obese, who are no doubt tired of being condescended to, first by wellness companies, and now by the AMA, decide that they are going to seek medical approval to opt out of wellness programs?  A study recently published in the journal Translational Behavioral Medicine reports on a highly coercive, electronically monitored walking program for obese people: 17% opted not to participate and another 5% actually got their physician’s approval to opt out.  The physician approval to opt out is key to any resistance strategy.

Under the final wellness rules issued by the federal government earlier this year, physician certification that it is medically unadvisable for an employee to participate in a wellness program creates a burden for the employer and wellness vendor.  They must provide reasonable alternatives that do not disadvantage the employee in terms of either time or cost and that address the physician’s concerns.

Further, if the employee’s physician disagrees with offered alternative, the employer and wellness vendor must provide a second alternative.  The coup de grace is that “adverse benefit determinations based on whether a participant or beneficiary is entitled to a reasonable alternative standard for a reward under a wellness program are considered to involve medical judgment and therefore are eligible for Federal external review.”

Targeting people based on body mass index (BMI) is an intellectually, morally, scientifically, and mathematically bankrupt approach.  The AMA’s decision will actually help obese people and advocates for their dignified treatment in the workplace and society start to understand that they can refuse to opt in to these insulting programs and, simultaneously, be protected from penalties.  Clearly, this is the opposite of what unsuspecting employers expect when vendors (and their own brokers) sell them these programs: more useless doctor visits, less leverage with penalties…and more employee disgruntlement.  Not just the obese will be disgruntled, but also those who have to pay the penalties because their BMI is too high to get the reward but not high enough to get a doctor’s note.

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The Biggest Urban Legend in Health Economics–and How It Drives Up Our Spending

• 66

By Al Lewis & Vik Khanna

The wellness emphasis in the Affordable Care Act is built around the Centers for Disease Control and Prevention’s (CDC) 2009 call to action about chronic disease:  The Power to Prevent, the Call to Control.   On the summary page we learn some shocking statistics:

  • “Chronic diseases cause 7 in 10 deaths each year in the United States.”

  • “About 133 million Americans—nearly 1 in 2 adults—live with at least one chronic illness.”

  • “More than 75% of health care costs are due to chronic conditions.”

Shocking, that is, in how misleading or even false they are.  Take the statement that “chronic diseases cause 7 in 10 deaths,” for example.  We have to die of something.   Would it be better to die of accidents?  Suicides and homicides?  Mercury poisoning?   Infectious diseases?    As compared to the alternatives, it is much easier to make the argument that the first statistic is a good thing rather than a bad thing.

The second statistic is a head-scratcher.  Only 223 million Americans were old enough to drink in 2009, meaning that 60% of adults, not “nearly 1 in 2 adults,” live with at least one chronic illness — if their language is to be taken literally.   Our suspicion is that their “133-million Americans” figure includes children, and the CDC meant to say “133-millon Americans, including nearly 1 in 2 adults, live with at least one chronic illness.”   Sloppy wording is not uncommon at the CDC, as elsewhere they say almost 1 in 5 youth has a BMI  > the 95th percentile, which of course is mathematically impossible.

More importantly, the second statistic begs the question, how are they defining “chronic disease” so broadly that half of us have at least one?    Are they counting back pain?   Tooth decay?  Dandruff?   Ring around the collar?    “The facts,” as the CDC calls them, are only slightly less fatuous.   For instance, the CDC counts “stroke” as a chronic disease.   While likely preceded by chronic disease (such as hypertension or diabetes) and/or followed by a chronic ailment in its aftermath (such as hemiplegia or cardiac arrhythmias), a stroke itself is not a chronic disease no matter what the CDC says.  Indeed it is hard to imagine a more acute medical event.

They also count obesity, which was only designated as a chronic disease by the American Medical Association in June–and even then many people don’t accept that definition.   Cancer also receives this designation, even though most diagnosed cancers are anything but chronic – most diagnosed cancers either go into remission or cause death.    “Chronic disease” implies a need for and response to ongoing therapy and vigilance.  If cancer were a chronic disease, instead of sponsoring “races for the cure,” cancer advocacy groups would sponsor “races for the control and management.”  And you never hear anybody say, “I have lung cancer but my doctor says we’re staying on top of it.”

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What’s Science Got to Do With It?

• 53

By Jon Robison & Vik Khanna

Penn State University is now embroiled in a national controversy over the ham-handed launch of its coercive and intrusive wellness program, which can cost recalcitrant employees as much as $1,200 per year for not joining.  That ignominy of being the most distasteful and coercive program, however, belongs to Blue Care Network of Michigan, which recently published results from their “voluntary” walking program designed exclusively for their obese enrollees.  The invitation to join was extended to enrollees with a body mass index (BMI, which is an unscientific, mathematically bereft proxy for health – see Keith Devlin’s excellent article ) of 30 or greater.  The program was “voluntary” as long as you were okay with paying $2,000 in added insurance premiums if you did not volunteer.

Avoiding the $2,000 price tag came with its own cost in dignity and privacy.  Enrollees agreed to either: 1) wear an electronic pedometer and connect it to their computer daily to document completion of at least 5,000 steps or, 2) join Weight Watchers or some other approved “weight cycling” program.  This princely sum is not irrelevant to most families.  In fact, it is almost exactly equal to per capita spending on food eaten at home in the US and about four percent of median US household income in 2011.  So, in a household occupied by a single adult, this will almost buy your groceries for a year, meaning that is hard to refuse, and the less money you make the more likely that resistance will prove futile.

The BCN strategy legitimizes telling people who look a certain way that they should submit to online, electronic monitoring or pay more for their insurance than people who don’t look that way.  Why would an obese person submit to this when it is entirely possible that he or she is fitter and more metabolically healthy than an normal weight unfit person who would never be condescended to this way?

More disturbing is the prospect that this is only the leading edge of life-invading monitoring by the wellness industry.  It is easy to envision sleep monitoring because you have bags under your eyes.  Or, what about wrist-worn breathalyzers to make sure you don’t go over the one or two drink limit, or sneak cigarettes after lying on your health risk appraisal that you don’t smoke?  How much electronic surveillance would you be willing to undergo on the pure guesswork that it might save someone (i.e., your employer or your health plan) money?

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A Second Look at the Link Between Obesity and Mortality

• 24

By Lua Wilkinson

A controversial study published earlier this year in the Journal of the American Medical Association shows that overweight people have significantly lower mortality risk than normal weight individuals, and slightly obese people have the same mortality risk as normal weight individuals.


This meta-analysis, headed by statistician Katherine Flegal, Ph.D., at the National Center for Health Statistics, looked at almost 100 studies that included 3 million people and over 270,000 deaths. They concluded that while overweight and slightly obese appears protective against early mortality, those with a body mass index (BMI) over 35 have a clear increase in risk of early death. The conclusions of this meta-analysis are consistent with other observations of lower mortality among overweight and moderately obese patients.

Many public health practitioners are concerned with the ways these findings are being presented to the public. Virginia Hughes in Nature explains “some public-health experts fear…that people could take that message as a general endorsement of weight gain.” Health practitioners are understandably in disagreement how best to translate these findings into policy, bringing up the utility of BMI in assessing risk in the first place.

Walter Willett, chair of the nutrition department at the Harvard School of Public Health, told National Public Radio that “this study is really a pile of rubbish, and no one should waste their time reading it.” He argues that weight and BMI remain only one measure of health risk, and that practitioners need to look at the individual’s habits and lifestyle taken as a whole.

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Obesity and the AMA

• 25

By Vik Khanna

Last week’s announcement by the American Medical Association’s (AMA’s) council on science and public health cheered me. It said that the AMA should not designate obesity a disease, because doing so was unlikely to improve health outcomes and because the most widely utilized obesity metric — the body mass index or BMI — was simplistic and flawed. It’s a reasonable and principled stance, which should have been the first clue that it was doomed.

The AMA’s board and delegates proceeded to snatch defeat from the jaws of victory by ignoring their own scientific council and labeling obesity as a disease. To be clear, the decision is almost purely symbolic; it has no legal force or authority, but it does up the ante in the debate with insurers and employers over what care elements should be covered and reimbursed. In other words, this is about money. Obesity: the new ATM for the health care system.

I’m just curious about where physicians have been for the past, oh, thirty years. Since 1980, as Americans have morphed into the fattest culture in the history of Western civilization, physician supply per 100,000 population has increased about 50%. Per capita medical care spending has increased from roughly $1,100 to over $8,400. 1980 was also the last time that roughly half of US adults were normal weight. Now, only about a quarter of American adults have a normal BMI.

Were US physicians blindfolded as they encountered patients growing incrementally larger with each visit? Were they keeping their mouths shut about the obvious — gee, I really think you should get out for some walking and limit the snacks — because they were awaiting a chance to make more creative use of ICD and CPT codes?

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Is Obesity a Disease? I Vote No

• 41

By David Katz, MD

There is a certain irony in the nearly immediate juxtaposition of the rare introduction of a new FDA-approved drug for weight loss (Belviq) to the marketplace and the recognition of obesity as a “disease” by the AMA. A line from the movie Jerry Maguire comes to mind: “You complete me!” Drugs need diseases; diseases need drugs.

And that’s part of what has me completely worried. The notion that obesity is a disease will inevitably invite a reliance on pharmacotherapy and surgery to fix what is best addressed through improvements in the use of our feet and forks, and in our Farm Bill.

Why is the medicalization of obesity concerning? Cost is an obvious factor. If obesity is a disease, some 80 percent of adults in the U.S. have it or its precursor: overweight. Legions of kids have it as well. Do we all need pharmacotherapy, and if so, for life? We might be inclined to say no, but wouldn’t we then be leaving a “disease” untreated? Is that even ethical?

On the other hand, if we are thinking lifelong pharmacotherapy for all, is that really the solution to such problems as food deserts? We know that poverty and limited access to high quality food are associated with increased obesity rates. So do we skip right past concerns about access to produce and just make sure everyone has access to a pharmacy? Instead of helping people on SNAP find and afford broccoli, do we just pay for their Belviq and bariatric surgery?

If so, this, presumably, requires that everyone also have access to someone qualified to write a prescription or wield a scalpel in the first place, and insurance coverage to pay for it. We can’t expect people who can’t afford broccoli to buy their own Belviq, clearly.

There is, of course, some potential upside to the recognition of obesity as a disease. Diseases get respect in our society, unlike syndromes, which are all too readily blamed on the quirks of any given patient and other conditions attributed to aspects of character. Historically, obesity has been in that latter character, inviting castigation of willpower and personal responsibility and invocation of gluttony, sloth, or the combination. Respecting obesity as a disease is much better.

And, as a disease, obesity will warrant more consistent attention by health professionals, including doctors. This, in turn, may motivate more doctors to learn how to address this challenge constructively and compassionately.

But overall, I see more liabilities than benefits in designating obesity a disease. For starters, there is the simple fact that obesity, per se, isn’t a disease. Some people are healthy at almost any given BMI. BMI correlates with disease, certainly, but far from perfectly.

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Targeting Obesity With Health Care Reform

• 19

By TOMMY THOMPSON & KENNETH THORPE

The Medicare Board of Trustees just released its latest report on the program’s finances and the results are terrifying. Despite a decline in health care costs, the Medicare Trust Fund will be bankrupt in 2026.

For the program to survive for future generations, innovation will be essential. The old medical paradigm of diagnosing and treating diseases must give way to a more holistic approach aimed at eliminating risk factors that lead to disease. The best place to start is by addressing the growing problem of adult obesity.

In the past 30 years, the percentage of American adults who are obese has doubled, driving a sharp rise in such chronic conditions as diabetes, heart disease and hypertension.

The ramifications for health spending are significant. Annual health costs for obese individuals are more than $2,700 higher than for non-obese people. That adds up to about $190 billion every year. And many of these costs are borne by Medicare, which will spend a half-trillion dollars over the next decade on preventable hospital readmissions alone.

We cannot afford to wait until patients are on Medicare to fight obesity. Rather, we need to encourage weight control over the course of patients’ lives.

Fortunately, we now have an ideal opportunity to implement reforms. The new health insurance exchanges created under the Affordable Care Act can establish effective care coordination strategies to identify and treat chronic conditions earlier, addressing not just the immediate conditions but the underlying ones as well. Obesity is one of the most common. Medicare, in turn, can adopt these strategies, and the benefits for both patients and taxpayers will be substantial. Continue reading…

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