Columbia College of Physicians and Surgeons own Dr.Oz: How good is his advice

December 17th, 2014 No comments »

Well, now we have some evidence. Researchers took a random sample of advice from Dr. Oz Show and The Doctors. They found (are you sitting down?) that half the advice was either had no scientific basis or was contrary to it. Now, you just have to figure out which half is right. You have to wonder if the standards of Columbia College of Physicians and Surgeons are that their students have to be right only half the time?

 

Employer Wellness Plans: Even HR doesn’t think they are effective but personal data is at risk

December 17th, 2014 No comments »

Contrary to White House Press Secretary Josh Earnest assertion that employer wellness plans, a majority of Chief Human Resource Officers surveyed by the Consero Group think otherwise. In the survey, 56% said that their wellness program had not achieved a significant reduction in health care costs; only 22% of respondents said their company had achieved a significant cost reduction. Forty-eight percent said that their wellness program was ineffective while only 40% said it was effective. The survey was among 42 Chief Human Resources Officers from Fortune 1000 companies so it cannot be said to be highly representative of this group.

A recent Wall St. Journal report states that 38% of firms now cover bariatric surgery, one-third offer weight reduction wellness program. A small number of companies are “warming” to newly approved weight-loss drugs. However, the report also notes that 71% of employers representing 600,000 workers said overcoming stigma and embarrassment represented the biggest hurdle to effective corporate weight-loss programs.

An article by Shannon Pettypiece in Bloomberg yesterday stressed the personal information asked by employers, including whether the employee (or spouse if covered by the employer paid health insurance) is sexually active, how much one drinks, etc. The article includes a number of assurances from providers of wellness programs that their data is secure. Baloney. If Sony and the National Security Agency cannot protect their secrets how good is security at your local wellness office? Health risk assessments may also inquire whether the employee owns guns, something sure to raise the hackles of the National Rifle Association.

To clear up one confusing aspect, namely, whether health information given to an employer directly or to an employer wellness program is protected by federal law. According to the website of the Department of Health and Human Services, Office of Civil Rights, health information provided to employers or as part of a wellness program is NOTprotected by the Health Insurance Portability and Accountability Act (HIPAA). Just because a program is covered by HIPAA this does not mean the information is protected. The Office of Civil Rights records numerous cases of data breaches. A Washington Post story by Jason Millman reported that over 30 million Americans have had their personal health care data breached.

 

The Impact of Obesity on Medical Imaging

December 17th, 2014 No comments »

Anyone going to a hospital recently knows that medical imaging, X-rays, PET scans, MRIs, etc, are a critical component of diagnostic medicine. So what happens when more and more patients have obesity or severe or morbid obesity? Raul N. Uppot and colleagues have described many of the problems faced by radiologists. The issues include: transporting the patient with severe obesity, fitting the patient on the imaging equipment, the diagnostic quality of such images, and, how is the imaging industry responding with equipment designed for the patients with obesity?

 

How Much Weight Loss is Needed to Reduce Costs?

December 16th, 2014 No comments »

The whole premise of weight-focused employer wellness programs is that a significant amount of weight can be lost (by voluntary or involuntary participants) sufficient to reduce obesity-associated co-morbidities and, hence, health care costs, excessive sick days, etc. Unfortunately there is little to no evidence to support this premise.

Let’s just examine one part of this premise, namely, what is a sufficient weight loss to reduce costs. We have a systematic evidence review from the US Preventive Services Task Force which explored  behavioral counseling to promote a healthy lifestyle for cardiovascular disease prevention and found, “In general, intensive interventions that combined lifestyle interventions did not reduce CVD (cardio-vascular disease) events or mortality with up to 10 years of follow-up.” The researchers found “substantial statistical heterogeneity for weight outcomes” which is science-speak for ‘we can’t make heads or tails of the data’.

Now come three important studies. The first, from Tom Wadden and colleagues, looked at randomized controlled clinical trials that recruited overweight and obese subjects for primary care intervention, were provided with behavioral counseling (on diet, physical activity and behavioral therapy) for at least 3 months with at least 6 months of follow-up. They found that mean 6 month weight changes ranged from a loss of 0.3kg to 6.6kg. In the control group, mean change ranged from a gain of 0.9kg to a loss of 2.0kg. Weight loss in both groups declined with longer follow-up.

The second study from researchers in Canada looked at the assumption that a weight reduction of 5% to 10% was ‘clinically important.’ This is important because the economic arguments of employer weight wellness programs focus on achieving 5-10% weight loss. However, the employers do not realize that the great majority of health care costs are incurred by persons who have severe or morbid obesity.  What these researchers found was that the amount of weight loss needed by persons with severe obesity was markedly higher than what conventional (i.e. behavioral) therapy can deliver. In other words, rather than a weight loss of 5-10%, persons with severe obesity need a weight loss closer to 20% for clinicallly important improvements. This amount of weight loss can only be obtained using bariatric surgery. In other words, the type of interventions usually seen in employer wellness programs are insufficient to impact the higher costs associated persons with severe obesity.

The third study is from John Cawley and colleagues. They looked at the medical cost savings that can be achieved from a given amount of weight loss by people at different BMI values. They found that the savings from a given percent reduction in BMI are greater the heavier the individual with obesity and are greater for those with diabetes than those without diabetes. In other words, savings from a given BMI will be greater the higher the starting BMI. So the savings of a given amount of weight loss is going to be greater among persons with Class 3 obesity (BMI>40) and decline through Class 2 and Class 1.

The implications of these studies for employer wellness programs focusing on weight control is that they should be focused on the heaviest individuals and bariatric surgery should be provided for in the employer’s insured benefits. Wellness programs, properly structured, may provide useful, ancillary support but cannot alone reduce the higher costs associated with higher levels of obesity.

 

A new finding on breastfeeding and obesity

December 16th, 2014 No comments »

Advocates of breastfeeding as a strategy to prevent the development of obesity persist in the absence of definitive data. So here is another study from Europe which found a ‘non-significant’ trend of breastfeeding toward a protective effect on adolescent abdominal obesity. Nevertheless, the title of the study, “Breastfeeding Shows a Protective Trend toward Adolescents with Higher Abdominal Adiposity,” is somewhat misleading.

 

Employer Wellness Fight Heats Up

December 16th, 2014 No comments »

The Equal Employment Opportunity Commission (EEOC) has announced that they will propose, in 2015, amendments to regulations implementing the Americans with Disabilities Act (ADA) “to address the interaction between title 1 of the ADA and financial inducements and/or penalties as part of wellness programs offered through health plans” as well as other aspects of wellness programs that may be subject to the ADA’s nondiscrimination provisions. A notice of proposed rulemaking is expected to be issued in February, 2015.

The fur will certainly be flying when the proposed regulations come out. Business groups have come out heavily against a case the EEOC has already brought against three employers. One case, against Orion Energy, EEOC challenged the company’s plan requirement that employees participate in a health risk assessment and provide a blood sample. Employees who declined to participate are required to bear the entire costs of their health plan plus an additional $50 month penalty for non-participation. The EEOC has stated that voluntary participation in wellness programs is permissible under the ADA. However, employers cannot penalize employees who refuse to participate. According to the EEOC, “penalizing” means imposing significant costs such as shifting large portions of health care expenses to the employees or depriving them of significant incentives allowed to employees who do participate.

The second case was brought against Honeywell International because of penalties imposed on employees and their spouses who did not participate in biometric testing. This time violations of the Genetic Information Nondiscrimination Act were also included along with claims of violation of the ADA. Under federal regulations, an employee’s family medical history is considered to fall within the definition of “genetic information.” The request by EEOC for a temporary restraining order was denied.

Honeywell employees could be penalized up to $4,000 for not participating.

The third case, against Flambeau, Inc., claimed that the company violated the ADA by requiring a medical history as well as biometric screening. The inquiries were not job-related or consistent with business necessity, in the eyes of the EEOC.

But the business community is fighting back. The Business Roundtable has told the White House that US CEOs were considering withdrawing their support for the Affordable Care Act based on these three cases brought by the EEOC. Politico has reported that President Obama press secretary Josh Earnest offered that the EEOC suits “could be inconsistent with what we know about wellness programs…we know that they are good for both employers and employees.” Really? A recent post in Health Affairs by Al Lewis and colleagues raises a host of questions on studies showing wellness programs help employees and lower costs.  Also, see this article in the Los Angeles Times about employer wellness scams.

Luckily, the EEOC is an independent agency and is more likely to stick up for persons with disabilities than is the Obama Administration.

Fat Bullying Can Kill

November 13th, 2014 No comments »

Want an example? The November 13, 2014 edition of the Washington Post carries a sad story of a talented young man who put on weight, was bullied at school and turned to marijuana to ease the pain of the taunting. The marijuana use brought him into contact with violent drug dealers who are suspected in his shooting. This case will no doubt be listed as a drug-related crime and the shooter or shooters will probably be found and prosecuted. But the bullies at his school, his teachers and administrators, and his classmates who did nothing…they will not shoulder any responsibility but their guilt will be just as great.

The Memory of Starvation

November 13th, 2014 No comments »

Movie buffs may remember the 1999 movie A Bridge Too Far and the book by Cornelius Ryan of the same title on which it was based. The book and movie told the tale of an Allied operation to liberate Holland and achieve a bridgehead over the Rhine and into Germany. It failed. The book and movie only dealt with the military aspects of Operation Market-Garden, as it was called. Left out was what happened afterward.

The Nazi regime was going to punish the Dutch for their support to the combined English-American invasion of Holland. So they cut off food supplies to Holland in the winter of 1944-5. Thousands starved. Subsequently, researchers found that women who were pregnant during this period had offspring who were more prone to obesity, diabetes and cardiovascular disease and who were also smaller than those who were not exposed to the “Hunger Winter.” But, they also found that the grandchildren of those women had similar health problems. This helped establish the field of epi-genetics, i.e., that there were inheritance factors other than genes which might respond to early environmental stimulus, or the lack thereof. Now, in perhaps a groundbreaking paper, Dr. Oded Rechavi and colleagues may have found the mechanism. By studying worms exposed to starvation conditions, they observed a mechanism they call, ‘small RNA inheritance’ that enables worms to pass on the memory of starvation to at least three generations, perhaps more. At the very least, the study demonstrates that we still have a lot to learn about the gene-environment interaction as it affects the development of obesity and that those who say obesity is not genetic  only show they don’t know much about genetics or obesity.