Treat Those with Severe Obesity to Save Serious Money

July 31st, 2015 No comments »

Health economist John Cawley and colleagues have published what might be an extremely important contribution to establishing priorities for interventions in the adult obesity population. Their paper, “Savings in Medical Expenditures  Associated with Reductions in Body Mass Index Among US Adults with Obesity, by Diabetes status,” shows that additional  costs associated with increases in body weight are not shared equally but increase exponentially as BMI increases. Likewise, the greatest savings in medical expenditures arise in weight loss among  those with the highest BMI, i.e. persons with Class III  or severe obesity. They write,”The IV model indicates that obesity raises annual medical care costs by $US3,508 per obese individual per year, or $US315.8 billion for the USA as a whole (both measured in 2010 values). The results of IV models are also used to construct detailed tables of the estimated medical care expenditure savings given specific reductions in BMI from specific starting values of BMI; these tables indicate that the savings from a given percent reduction in BMI is greater the heavier the obese individual, and is greater for those with diabetes than for those without diabetes. These estimates of the change in medical care expenditures resulting from weight loss can be used to more accurately calculate the cost effectiveness of interventions to prevent and treat obesity, and can be used by health insurers, employers, and government agencies to determine the societal savings from, and business case for, interventions that generate a specific amount of weight loss.”

Dr. Arya Sharma observes in his post on this paper, “Thus, for e.g. the annual cost savings with a 5% reduction in body weight for someone with a BMI of 30 kg/m2 amounted to a mere $69 per year.

This figure, however, increased exponentially for people with higher BMIs, increasing to $528, $2,137, and $10,030 in an individual with a BMI of 35, 40, and 45 kg/m2, respectively (these figures were somewhat higher, when the individual also has diabetes).

Thus, while treating obesity to achieve a 5% reduction in body weight in someone with a BMI of 30 kg/m2 may never be “cost-effective”, the same amount of weight loss in someone with more extreme obesity, would likely pay for itself or even lead to significant savings.

Because the impact of obesity on mental and physical health, life-expectancy and quality of life is also greatest at higher levels of BMI, one could also make a strong ethical argument for singling out these individuals for priority treatment in the health care system.”

We could not agree more.

Conflict Alert:  I have a great respect for Dr. Cawley’s work on obesity and was pleased to be part of a Point-Counterpoint  debate with him on Employer Wellness programs published in 2014 in the Journal of Policy Analysis and Management.

Liraglutide and Weight Loss

July 31st, 2015 No comments »

MedPage of July 8, 2015 contains an interesting  opinion piece on liraglutide SCALE study by Dr. F. Perry Wilson of the Yale School of Medicine. Dr. Wilson makes some fair points about the study regarding weight loss but seems a bit shocked that, when the drug is discontinued, the weight returns. He also notes that bariatric surgery is probably a better option than taking a drug for life. Perhaps. But there is a group of patients who would rather avoid surgery at all costs, even if more effective. As to seeing the weight return after discontinuation of the drug, we should not be surprised. Most conditions only respond during intervention and return when the intervention stops. It may be more remarkable that the drug continues to be effective against the phenomenon of adaptive thermogenesis.


New Insights on the Intergenerational Transmission of Metabolic Disease

July 31st, 2015 No comments »

Dr. Arya Sharma has a very useful post on the transgenerational transmission of metabolic disease, including obesity. As Dr. Sharma points out, if anyone says that obesity is not genetic, they don’t know what they are talking about. The article cited by Dr. Sharma recalls an earlier post on a three-generation transmission of the memory of starvation. Just goes to show that there much to be learned.


Dietary Supplement Officials Beholding to Industry

July 31st, 2015 No comments »

Anahad O’Connor, writing in the New York Times, discloses an upsetting picture of the Food and Drug Administration inaction on policing an amphetamine-like substance in dietary supplements. The article describes how the leadership of the FDA division responsible for policing dietary supplements has been and is led by high level executives from the Natural Products Association, the trade association representing dietary supplement makers.


FDA Approves New Device for Treating Obesity

July 30th, 2015 No comments »

The Food and Drug Administration (FDA) has approved a new medical device for the treatment of obesity. This device, a minimally invasive dual balloon delivered via an endoscope , is designed to make the stomach feel full and, thus, reduce consumption. While hailed by some groups like the American Society for Bariatric and Metabolic  Surgery, the importance of this approval may lie not so much in the specific device but in the greater willingness of the FDA medical device regulators to be open to more devices meant to assist in weight management. See here for more information.

The Food and Drug Administration (FDA) has approved a new medical device for the treatment of obesity. This device, a minimally invasive delivered via endoscope , is designed to make the stomach feel full and, thus, reduce consumption. While hailed by some groups like the American Society for Bariatric and Metabolic  Surgery, the importance of this approval may lie not so much in the specific device but in the greater willingness of the FDA medical device regulators to be open to more devices meant to assist in weight management. See here for more information.

Jules Hirsch, Obesity Research Pioneer, Passes Away

July 30th, 2015 No comments »

The New York Times reported this morning on the passing of Dr.  Jules Hirsch, a pioneer in obesity research. Twenty years ago, Dr.Hirsch and  colleagues produced a ground-breaking study showing  that,  weight is lost, metabolism slows down. This causes weight to plateau without even greater reductions in caloric intake. At some point, a patient becomes frustrated with the lack of progress and/or succumbs to the brain’s demand to assuage the sensation of hunger.

Dr. Hirsch provided a wonderful summary of brain and behavior vis a vis obesity in this 2003 publication in Cerebrum,  in 2003, from the Dana Foundation, Obesity: Matter  Over Mind.

Dr. Hirsch will  surely be missed by the generations of researchers and clinicians he trained, by colleagues throughout the world in obesity research ,as well as by family and friends.

For many years, Dr. Hirsch was a member of the Food and Drug  Administration’s advisory panel reviewing drugs for the treatment of obesity. As a witness to most of these hearings since 1998, I can say that fear spread across the faces of presenters from the pharmaceutical  company when Dr. Hirsch’s time came to ask questions. His approval  or disapproval had a wide impact on other panelists. Likewise, one could hear a virtual sigh of relief among pharmaceutical company presenters were there news Dr. Hirsch would be absent. His testament to scientific integrity will be surely missed.


How Can the EEOC Guarantee Personal Data Will Stay Confidential

June 29th, 2015 No comments »

As I have mentioned before, the Equal Employment Opportunity Commission (EEOC) has bought the platitude that personal data acquired via a health risk assessment or during an employer wellness program will be protected from disclosure that could be adverse to the employee.  Seemingly blissfully ignorant about the pervasive disclosure of personal data, whether from the government itself or the private sector, the EEOC cannot guarantee that personal data can be protected from unauthorized disclosure. Today, an article in the New York Times reveals that websites and mobile phone apps most frequently used have ‘privacy’ policies which allow for the sale of personal data during mergers, bankruptcy, asset sale or other commercial transaction. The articles states, “Sites, apps, data brokers and marketing analytics firms are gathering more and more details about people’s personal lives – from their social connections and health concerns to the ways they toggle between their devices…Such data can also be used to make inferences about people’s financial status, addictions, politics or religion in ways they may not want or like.” One dating service tried to sell its database of 43 million members revealing their names, birth dates, sexual orientation, race, religion, criminal convictions, photos, videos and contact information.  It would be simple for a data broker to combine such data with health risk assessment answers and data from a ‘wellness’ program, including wearable devices.


EEOC is Clueless or Misleading about Protecting Individual Privacy

June 24th, 2015 No comments »

Perhaps the most dangerous assumption made by the EEOC is that personal information disclosed in employer wellness programs can be protected. Such security is an illusion.

The proposed regulation provides that a wellness program that is part of a group health plan will likely satisfy the ADA confidentiality requirements by complying with the HIPAA and subject to the HIPAA privacy, security and breach notification rules. Employers and wellness programs must take steps to protect the confidentiality of employee medical information that is received in connection with an employee health program. However, it is questionable whether HIPAA covers third-party vendors which are not health plans.

The EEOC is either oblivious to the realities of modern computer security problems or misleading in its assumption that personal medical and behavioral records will be safe. Namely, there is no possible way to assure anyone that their privacy is protected. Recently, we have seen major security breaches at the National Security Agency, the Internal Revenue Service, the Department of Health and Human Services and the federal Office of Personnel Management (OPM).

The OPM breach includes the records of between 4 to 14 million current and former federal workers, friends and family members. A second breach of OPM computers was reported involving not only federal employees but also their friends, family members and associates that could number millions more, according to a report in the New York Times, June 13, 2015. “Data includes a form for national security positions which can include medical data, including information on treatment or hospitalization for “an emotional or mental health condition,” according to the story. A story in Wired indicates that the information could include polygraph information in which employees are asked about law breaking and sexual history.

Breaches of health data are pervasive and include the Centers for Medicare and Medicaid services, and the federal health care exchange, Premera Blue Cross. Premera Blue Cross, in Seattle Washington, reported a cyberattack that exposed personal information of 11 million customers. A breach at Anthem Insurance involved the records of 80 million customers. Other private sector breaches have included Sony Pictures, Home Depot, Target, Ebacy, and JP Morgan Chase.

A report in Bloomberg News, notes that the recent hack of Sony Corporation included health information on more than three dozen employees. It quotes Geoff Hancock, chief executive officer at Advanced Cybersecurity Group “who works with employers to protect their health data and other sensitive information from hackers. He was speaking about the industry in general. “Now, it’s zeros and ones. So many more people have access and can take it and make money off it or manipulate it or use it to find out who you are and what you are about. It is one of the biggest hoples in the cybersecurity infrastructure.” And, “Since 2009, there have been 1,187 incidents where health information protected by HIPAA was hacked, improperly disclosing, lost or stolen involving more than 41 million individuals, according to reports to the US Department of Health and Human Services. Those cases only include instances where more than 500 records were involved. Matters involving fewer records don’t have to be reported.” “Hackers can get $50 for a medical chart on the black market, compare with just a few dollars for other pieces of personal information, said Hancock of Advanced Cybersecurity. He said he’s refused to share his health information with wellness programs at past employers because he isn’t convinced the data are safe.” “Despite the popularity of wellness programs among employers and assurances about their security and confidentiality, more than half of works said they are hesitant about sharing their health information, and a quarter said they wouldn’t share their data under any circumstances, according to a survey by the Economist Intelligence Unit. More than one-quarter of employees said they were concerned their personal information wouldn’t remain condifential. Companies, like Honeywell, take blood samples to test for nicotine, high cholesterol and irregular blood sugar, height and weight. CVS asked their employees whether they drink, and are sexually active. Johnson & Johnson’s wellness program ask about the employees mode, stress at work and home, eating and exercising habits. Some ask for the information from spouses, as well. “Sexually Active? How much do you drink? Your Workplace Health Records May Not be as Private as You Think by Shannon Pettypiece, Bloomberg News, Dec. 16, 2014

A Washington Post article, “Hackers increasingly target health records,” noted that, “Health care data seems to be increasingly targeted, accounting for 43% of major data breaches reported in 2013, according to the Identity Theft Resource Center.”

The EEOC must assume that privacy of personal records cannot be assured.