Archive for November, 2011

NPR Coverage of Medicare Decision

November 30th, 2011

Read NPR’s take on the Medicare decision to cover intensive counseling of obesity in adults (includes my interview).  http://www.npr.org/blogs/health/2011/11/30/142972241/medicare-offers-expanded-coverage-to-battle-expanding-waistlines

Medicare Covers Intensive Counseling For Obesity

November 30th, 2011

The Centers for Medicare and Medicaid Services has announced that it will begin paying for intensive behavioral counseling of adults with obesity. “This is a major step forward,” said Morgan Downey, “in addressing obesity in a particularly important demographic group. Hopefully, it will lead Medicaid programs and private payors to follow. This is the culimination of an effort that began in 2004 when Medicare removed a restriction declaring that obesity was not a disease. Medicare Changes Policy on Obesity (washingtonpost.com)  More immediately, it grew out of recommendations from the US Preventive Services Task Force.”

CMS Press Release: MEDICARE COVERS SCREENING AND COUNSELING FOR OBESITY

CMS Decision Memo: Decision Memo for Intensive Behavioral Therapy for Obesity (CAG-00423N)

Why Do Obese Employees Earn Less? Productivity or Bias?

November 29th, 2011

It has been well documented that obese workers are paid less than their co-workers for the same job. But is this because employers are deducting for lost productivity and higher health care costs or because of bias against persons with obesity. The best expert in the field lends his conclusion at The Obesity Wage Penalty – Room for Debate – NYTimes.com

Primum Non Nocere*

November 28th, 2011

Many media outlets are reporting on the removal of a 200 lb. 8 year old from his family in Cleveland. Cleveland is, of course, the home of Toby Cosgrove, MD, head of the Cleveland Clinic, who proclaimed his desire to not hire workers who were obese. This came a year or so after the American Medical Association took the official position that persons who are obese are not entitled to compensation for being disabled for being unable to work. 

The intellectual justification for the forced removal of the child from his family is that provided by Dr. David Ludwig of Harvard Medical School.  State Intervention in Life-Threatening Childhood Obesity, July 13, 2011, Murtagh and Ludwig 306 (2): 206 — JAMA In the Commentary in July in the Dr. Ludwig had indicated that the forced removal by the state of children who were obese was justified. 

On what basis, you might ask? Well, there were several and they were all, in my opinion, intellectually bankrupt.

First, Dr. Ludwig and his co-author Lindsey Murtagh, J.D., assume “even mild parenting deficiencies such as having excessive junk food in the home or failing to model a physically active lifestyle, may contribute to a child’s weight problem.”

Excuse me? Before you go calling these “parental deficiencies,” how about defining: “excessive”, “junk food” or “failing to model a physically active lifestyle? Well, forget about it. They don’t define their terms.

What do they mean by “may contribute” to a child’s weight problem? If you are arguing that these “mild parental deficiencies” cause life-threatening conditions, is “may” good enough? What is the degree of evidence? If you are arguing that these conditions merit breaking up a family should not the evidence be like, beyond a reasonable doubt or a preponderance of the evidence? Is “may” good enough?

Second, they posit that severe obesity (a BMI at or beyond the 99th percentile) represents a fundamentally different situation than most overweight and obese children who have “the opportunity to ameliorate these risks through behavior change and weight loss as adults.” So, they say that severe obesity is fundamentally different “suggesting profoundly dysfunctional eating and activity habits”. Obesity of this magnitude can cause immediate and potentially irreversible consequences, most notably type 2 diabetes”.

Excuse me? Where is it written that persons with severe obesity as a child have a much smaller likelihood of reversing it as an adult than those with a lower level of obesity?

And what makes the BMI, which we know is a limited measure of body adiposity, at the 99th percentile different from the 97th percentile or the 95th percentile or the 92nd  percentile for that matter?

They argue that  severe obesity ‘suggests’ profoundly dysfuncitional eating and physical activity habits? ‘Suggests?’ They aren’t sure? If they are proposing breaking up a family maybe something more than ‘suggests’ is warranted. More importantly, could it not be that we are confusing cause and effect.  If there is anything to the increases in height and weight over the past 350 years, if there is anything to the contribution of genetic inheritance to obesity, if there is anything to the contribution of epigenetic factors to obesity, then, we must at least allow the suggestion that some children are born programmed to be overweight or obese. Upon achieving that status, one would assume they would overeat and underexercise compared to their normal weight peers. Would these be acquired ‘habits’ or the adaptions to their body habitus?

When they say that obesity of this magnitude can cause immediate and potentially irreversible consequences, most notably type 2 diabetes, what do they mean? Only a subset will develop type 2 diabetes immediately and for many, it will be manageable by lifestyle, drugs or surgery. Others, at a BMI lower than the 99th percentile and some who are merely overweight or normal weight will develop diabetes as well.

Third, (here’s the rub) the authors point with alarm that these patients may have to have bariatric surgery, whose long-term safety and effectiveness is not established. Therefore, they propose an alternative “therapeutic approach” i.e., placement of the severely obese child under state protective custody. The authors state, “Indeed, it may be unethical to subject such children to an invasive and irreversible procedure without first considering foster care.”

Doh? Did I get this right? Because at some point in the future, a child has continued to suffer with obesity and decides to have bariatric surgery, Ludwig and Murtagh propose the state comes in when the child is a juvenile and break up the only family the child has ever known?

Friends, I have worked for years with the professional jealousy of surgeons and internists and non-physician health care professionals. For the most part, they keep these often bitter inter-professional competitions to themselves. But this approach of Ludwig and Murtagh is nothing more than saying that breaking up a family, taking an obese child away from their mother and father and siblings, making them a ward of the state, having them raised by strangers who are paid for their care is better than even the potential that someday that person may want/be eligible for/can pay for bariatric surgery. 

The bias is demonstrated by the additional point raised by the authors that, “Although removal of the child from the home can cause families great emotional pain, this option lacks the physical risks of bariatric surgery. Moreover, family reunification can occur when conditions warrant, whereas the most common bariatric procedure (Roux-en-Y anastomosis [gastric bypass]) is generally irreversible.” Well, this is factually wrong. Roux-en-Y is not the most common bariatric procedure. The reversible laproscopic gastric banding is. Metabolic/bariatric surgery Worldwide 2008. [Obes Surg. 2009] – PubMed – NCBI  And  emotional pain may play a  particularly important role on the development of obesity. See this recent post.

And what does family reunion “when conditions warrant” mean? There are several options here which are starkly different and completely unaddressed by the authors. One option is that the obese child has returned to normal weight. The second option is that the obese child is still obese or has lost some weight but has improved eating or physical activity behaviors. The third option is that one parent or both have improved their ‘deficiencies’ by (a) removing only ‘excessive’ junk food in the home and/or (b) modeling a physically active lifestyle, independent of any change in the child. (Did I mention that the NIH guidelines for pediatricians on weight management did not find much support for physical activity?)

The fourth option is that that the foster care parents are both removing excessive junk food and modeling a physically active lifestyle and the child is continuing to gain weight. In some cases, there may be no “family reunification” but a succession of foster homes, all equally unable to affect the child’s excess adiposity. 

At the very end of their Commentary, Ludwig and Murtagh do a bit of a CYA, stating, “Nevertheless, state intervention would clearly not be desirable or practical, and probably not be legally justifiable, for most of the approximately 2 million children in the United States with a BMI at or beyond the 99th percentile. Moreover, the quality of foster care varies greatly; removal from the home does not guarantee improved physical health, and substantial psychosocial morbidity may ensure. Thus, the decision to pursue this option must be guided by carefully defined criteria such as those proposed by Varness et al with less intrusive methods used whenever possible.”

Now, dear reader, when one comes upon a statement like this, one assumes that Varness, et al, is in at least broad agreement with Ludwig and Murtagh. So it came as some surprise to actually read the cited Varness articles. See Childhood obesity and medical neglect. [Pediatrics. 2009] – PubMed – NCBI 

What Varness says is that, for a child to be removed from their home, all 3 of the following criteria have to be met: (1) a high likelihood that serious imminent harm will occur; (2) a reasonable likelihood that coercive state intervention will result in effective treatment and (3) the absence of alternative options for addressing the problem.

Regarding #1, a high likelihood that serious imminent harm will occur, Varness states, “The mere presence of childhood obesity does not predict serious imminent harm…Although childhood obesity is a risk factor for the development of multiple diseases as an adult, increased risk for adult diseases does not constitute serious imminent harm.” At the other end of the spectrum are current risks, such as severe obstructive sleep apena with cardiorespiratory compromise, uncontrolled type 2 diabetes and advanced fatty liver disease with chirrhosis. In some cases, like advanced hepatic fibrosis, the harm cannot be reversed in adulthood. Varness et al state, contrary to Ludwig and Murtagh, “There is no clear threshold level of childhood obesity (overweight, obese, or severely obese) that automatically predicts serious imminent harm….Although it is true that childhood obesity can lead to adult obesity, childhood obesity itself does not seem to lead to irreversible changes that are significant enough to mandate coercive state intervention.”

Regarding #2, a reasonable likelihood that coercive state intervention will result in effective treatment, Varness states, “In other words, is it truly reasonable to demand that families be able to achieve effective weight loss for their children? In addition, if it has been impossible for a family to reduce weight, what evidence is there to suggest that removal from the home would be more successful?” 

Regarding #3, the absence of alternative options for addressing the problem, Varness clearly does not share Ludwig and Murtagh’s antipathy for bariatric surgery. He states, “In summary, medications and surgery hold some promise but still have a questionable risk/benefit ratio, in both the short term and the long term. Although these may seem to be attractive options for some motivated adolescents with severe obesity, they are not options that are likely to be mandated for a child over the family’s objections. In contrast to the Ludwig-Murtagh paradigm of “mild parenting deficiencies,” Varness observes, “ In most cases of obesity, families make a good-faith effort to address the problem when they are made aware of the condition and the potential adverse health consequences. The development of a serious comorbidity can serve as a “wake-up call” for families, prompting full cooperation with intensified medical services.”

In sum, Varness makes the case that state intervention for obese children with no comorbidity is not justified; for those with a serious imminent harm, e.g. obstructive sleep apnea with cardiorespiratory compromise, intervention is probably justified. In between, only those risks known to be irreversible as an adult, such as hepatic fibrosis resulting from nonalcoholic fatty liver disease as opposed to cardiovascular disease, seems to be justified.

Finally, contrary to the misinformation about bariatric surgery, Varness notes that, “If a medical or surgical intervention that has a very high probability of decreasing weight with minimal adverse events is developed, then the availability of this effective treatment might result in a stronger intervention on behalf of children. For instance, gastric banding is a reversible procedure that involves the laparoscopic placement of an adjustable band around the proximal stomach. This procedure is not approved by the Food and Drug Administration for adolescents, and long-term data on its efficacy and complications are lacking. However, this procedure may hold some promise for extremely obese children, particularly as it is reversible.” In other words, coercive state action may be justified for bariatric surgery, rather than as an alternative to bariatric surgery, as desired by Ludwig and Murtagh. Not to belabor the point, but it seems Varness contradicts every major point Ludwig and Murtagh make. Curious, no?

My problem with the Ludwig-Murtagh commentary is not just on its intellectually bankruptcy and the harm it is bringing on persons who have enough pain it their lives. It is the question of what is Organized Medicine doing? So the position of Organized Medicine is this: Persons with obesity should be denied jobs (and, presumably, employer-provided health care), denied disability compensation when they cannot work, empathetic treatment by their physician and now the support of their own families in favor of unknown, paid-to-be-parents in foster care? Shouldn’t medicine be looking for better treatments? Maybe diagnosing their own patients? Maybe making appropriate referrals? Why don’t Dr. Ludwig and Attorney Murtagh call on pediatricians to develop better treatment protocols for children and adolescents with obesity? Why don’t they call on the American Academy of Pediatrics to lobby for dedicated funding for research on new treatments? Why don’ they criticize their fellow pediatricians who neglect to advise their patients on weight loss, in my opinion, unethically so. Pediatricians, in particular, have spent decades telling parents their children will ‘grow out of’ their weight problems. Now that obesity has become epidemic, they have done next to nothing to actually treat the disease, instead pointing to food companies’ marketing, television viewing, computers, vending machines, and parents as the culprits. Is it too much to ask them to develop treatments for their patients and quit blaming everyone else?

This blaming is only driving parents away from consulting with primary care providers, as discussed in Dr. Arya Sharma’s blog today. www.drsharma.ca.



If medicine, and especially, pediatrics, cannot help, at least stop making matters worse. 

See County places obese Cleveland Heights child in foster care | cleveland.com

Associated Press, MSNBC News: U.S. News – Ohio puts 200-pound third-grader in foster care

ABC News: Health » Obese Third Grader Taken From Mom, Placed in Foster Care Comments Feed

Background: Should parents lose custody of super obese kids? – Washington Times 

* Latin for “First, Do No Harm”

Eating-What-You-Want-When-You-Want

November 26th, 2011

USA Today reports on the decline of standard meals and the rise of the eat-what-I-want-when-I-want-it meals abetted by food marketers. Eating Nonstop Crap All Day ‘The New Normal’ USA Today Video

Obesity Rates in Europe Spiral Upwards

November 25th, 2011

Two reports from Europe show pervasive increases in obesity throughout Europe, even though rates of obesity vary significantly within the continent.

The European Union reports that rates varied between 8% and 23.9% for women and 7.6% and 24.7% for men. (The US rates are 26.8% for women and 27.6% for men.) The lowest rates for men and women were in Romania, Italy, Bulgaria and France. The highest rates for women were in the United Kingdom, Malta, Latvia and Estonia; for men, in Malta, the UK, Hungary and the Czech Republic. Rates of obesity increased with age and fell with higher educational levels. See, http://epp.eurostat.ec.europa.eu/cache/ITY_PUBLIC/3-24112011-BP/EN/3-24112011-BP-EN.PDF

In the second report, the Organization for the Economic Co-operation and  Development (OECD) looked at obesity among its 34 member countries worldwide.

Looking at their latest surveys, they found more than half of the adult population in the OECD report they are overweight or obese. Where height and weight were measured (as opposed to self-report) the rate was even grater, 55.8%. 19 of the 34 OECD countries had more than 50% of adults who were overweight or obese. Even in countries with low rates, e.g. Japan, Korea, France and Switzerland, rates were increasing. Throughout the OECD, 17% of adults were obese. The report notes, “The rise in obesity has affected all population groups, regardless of sex, age, race, income, or education level, but to varying extents.” http://www.oecd-ilibrary.org/docserver/download/fulltext/8111101ec018.pdf?expires=1322264846&id=id&accname=guest&checksum=8D94E5CC3B86E6675810DE2CCB25CA83 

Regarding childhood, the OECD notes “Rates of overweight among boys and girls are increasing across the OECD. In many developed countries, child obesity levels doubled between the 1960s and the 1980s, and have doubled since then. Even in emerging countries, the prevalence of obesity is rising, especially in urban areas where there is more sedentary behavior and a greater access to energy-dense food.” OECD iLibrary: Statistics / Health at a Glance / 2011 / Overweight and obesity among children

Obesity Explodes in Elementary School

November 25th, 2011

A new study of 4,240 white, 640 black and 1,070 Hispanic children in 1st, 3rd and 5th grades, finds 40% of children started kindergarten with a BMI in the top quartile of growth charts. This proportion increased significantly during the elementary school years and the largest gains were seen between 1st and 3rd grades but there was no further increase during middle school. Increases were greatest among Hispanic and black children. Changes in Body Mass During Elementary and Middle… [Pediatrics. 2011] – PubMed – NCBI

NIH Disses Physical Activity as Cure of Childhood Obesity

November 23rd, 2011

The National Heart, Lung and Blood Institute has issued guidelines endorsed by the American Academy of Pediatrics. They are directed to all primary pediatric care providers to address the known risk factors of cardiovascular disease, including obesity, blood pressure, cholesterol, tobacco and lipids.

The report notes that longitudinal data on non-white populations are lacking and that “Clinically important differences in prevalence of risk factors exist according to race and gender, particularly with regard to tobacco-use rates, obesity prevalence, hypertension, and dyslipidemia.”

The report notes, “Obesity tracks more strongly than any other risk factor, among many reports from studies that have demonstrated this fact…Tracking data on physical data is more limited.”

Regarding overweight and obesity, the report states,

“The dramatic increases in childhood overweight and obesity in the United States since 1980 are an important public health focus. Despite efforts over the last decade to prevent and control obesity, recent reports from the National Health and Nutrition Examination Survey show sustained high prevalence: 17% of children and adolescents have a BMI at the >95th percentile for age and gender. The presence of obesity in childhood in childhood and adolescence is associated with increased evidence of atherosclerosis at autopsy and of subclinical measures of atherosclerosis on vascular imaging. Because of its strong association with many of the other established risk factors for cardiovascular disease, obesity is even more powerfully correlated with atherosclerosis; this association has been shown for BP, dyslipidemia, and insulin resistance in each of the major pediatric epidemiologic studies. Of all of the risk factors, obesity tracks most strongly from childhood into adult life.”

Given that physical activity is a primary prescription for preventing childhood and adolescent obesity, it is interesting to read what the expert panel has to say about its utility:

“A moderate number of RCTs (randomized controlled clinical trials) have evaluated the effect of interventions that addressed only physical activity and/or sedentary behavior on prevention of overweight and obesity. In a small number of these studies, the intervention was effective. It should be noted that these successful interventions often addressed reduction in sedentary behavior rather than attempts to increase physical activity. In a majority of these studies there was no significant difference in body-size measures. Sample sizes were often small and follow-up was often short (frequently < 6 months). ..Overall, the expert panel concluded that on the basis of the evidence review, increasing activity in isolation is of little benefit in preventing obesity. By contrast, the review suggests that reducing sedentary behavior might be beneficial in preventing the development of obesity.”

The report identifies populations at special risk for obesity: children with a BMI between the 85 and 95th percentiles;children in whom there is a positive family history of obesity in 1 or both parents; early onset of increasing weight; excessive weight gain during adolescence; children who have been very active and become inactive. See Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents- NHLBI, NIH