Posts Tagged ‘comorbid conditions’

D is For Disease, Death and Disability

July 8th, 2013

Supposed you woke up and the TV news and newspapers revealed that scientists had discovered a global threat affecting all races, both genders, reducing lifespans and causing millions of cases of disabilities, likely to cost billions of dollars a year. There was no clear cause and no treatment which seemed available, except, in some cases, surgically removing part of the GI track seemed to work…for a while.

What would you say? “Who cares”? “It’s their own fault”? “How much is this going to cost me?”  Perhaps, you would call your Congressional representative and Senator and demand a crash research program to find a cure? Or you could quibble for, say, forty years or so, over who is to blame and whether this “threat” is a condition, syndrome, risk factor or (God forbid!) a disease? Well, the latter is pretty much what we have been doing about obesity. Three new papers show the impact of obesity on mortality, disability and disability-related health care costs, reminding us of the toll this disease takes on the human body.

First, regarding mortality, a great number of studies have been published and the public is still confused. Now, Chang and colleagues, have published a paper in which they are able to predict life years lost associated with obesity-related diseases for non-smoking US adults. They found that obesity-related comorbidities are associated with large decreases in life years and increases in mortality rates. Years of life lost is more marked for younger than older adults, for blacks more than whites, for males than females and for more obese than less obese. Their study confirmed that being obese or underweight increased the risk of mortality. Furthermore, an obesity-related disease, such as coronary heart disease, hypertension, diabetes and stroke, increased the chances of dying and decreased life years by 0.2 to 11.7 years, depending on gender, race, BMI and age.  Obesity-related diseases were expected to shorten lifespan of people in their 20s by more than 5 years, while people in their 60s were predicted to lose just under one year of life. See, Chang SH, Pollack LM, Colditz, Life Years Lost Associated with Obesity-Related Diseases for U.S. Non-Smoking Adults.

Obesity-related diseases are also only partially understood. Type 2 diabetes and heart disease are commonly associated with obesity but there are a host of other conditions which are less well-known and appreciated. Among these are the disabling conditions associated with obesity. Brian S. Armour, et al, have looked at disability prevalence among persons who are obese. Of the 25.4% of US adults who are obese (53.4 million), 41.7% reported a disability in contrast to 26.7% of those at a healthy weight and 28.5% of those who were overweight. Movement difficulty was the most common type of basic action difficulty, affecting 32.5% of the adults with obesity. Of course, movement difficulties can hinder physical activity for weight loss.

Work limitations affected 16.6% of the adults with obesity. Visual difficulty was the common sensory difficulty at 11.5%, probably attributable to type 2 diabetes.  20.5% of adults with obesity reported complex activity limitation, compared to 12% of those at a healthy weight. All estimates for disability were significantly higher for people who were obese compared to those with a healthy weight. The prevalence of cognitive difficulty, contrary to Hank Cardello’s implications, was low at 3.6% for persons with obesity. However, persons at a healthy weight had higher cognitive difficulty than those who are overweight, 2.9% v. 2.4%. Armour BS, Courtney—Long EA, Campbell VA, Wethington HR, Disability Prevalence among health weight, overweight, and obese adults. Obesity, 2013 Apr.21 (4); 852-5.

Wayne L. Anderson, Joshua M. Weiner and colleagues widen the picture of persons who are obese with disabilities in terms of health care costs. Their new study estimates the additional average health care expenditures for overweight and obese adults with and without disabilities. They found that people with disabilities who were obese had almost three times the additional average costs of obesity compared to people without disabilities, $2,459 v. $889. Prescription drug costs were 3 times higher and outpatient expenditures were 74% higher. People with disabilities in the 45-64 year age group had the highest obesity expenditures. Overweight people with and without disabilities had lower expenditures than normal-weight people with and without disabilities. The authors note, “A substantial portion of people with disabilities are obese. People with disabilities are at higher risk of obesity because some conditions such as arthritis and diabetes are characterized by high levels of functional impairment. Arthritis can readily limit mobility, which may result in substantial weight gain over time. For diabetes, weight gain can be a byproduct of insulin use if patients do not effectively manage their weight. The coexistence of disability, obesity, and serious chronic conditions may result in very high health care expenditures.” Anderson WL, Wiener JM, Khatutsky G, Armour, BS Obesity and People with Disabilities: The Implications for Health Care Expenditures. Obesity, 2013 June 26, (epub ahead of print).

So, obesity is a driver of mortality and morbidity but is not a disease? Eh?

 

Primary Care

September 27th, 2009

Primary care practice in medicine does a very poor job of treating obesity. In a 2009 paper, researchers analyzed 696 million physician office visits of adults over 18 years old. In only 50% of these were both height and weight taken (so Body Mass Index could be determined) This was usually due to not taking the height measurement. Where a BMI was determined 27% of patients had normal weight, 31% were overweight and 37% were obese. Of the patients with obesity, a diagnosis of obesity was made in only 1/3 of the visits. In the patients with obesity, only 37% received counseling for diet, exercise or weight reduction. This percentage went up to 55% in patients who received a diagnosis of obesity. The researchers found the same pattern even when the patient with obesity had co-morbid conditions related to obesity. Adult obesity and office-based quality of care in …[Obesity (Silver Spring). 2009] – PubMed Result

Physician attitudes toward patients with obesity appear to be influenced by competency to treat, specialty and years since postgraduate training. Studies have shown that doctors can have stigmatizing attitudes to patients with obesity, believing such patients to not being able to benefit from counseling and have reported less desire to help obese patients. Implicit fat-bias has been found among health professionals treating obese patients. (See Fact Sheet on Stigma ) In a survey of School of Medicine faculty members, internal medicine faculty reported having the highest rate of obesity in their patients. Overall, physicians felt “fairly” competent in providing obesity counseling and reported an average of 14% of patient lost weight. 45% of physicians agreed that they have a negative reaction to the appearance of obese individuals which did not differ among specialties. Only about half felt qualified to treat obese patients; psychiatrists had the lowest sense of competency. More than half did not feel successful at treating obese patients with no difference between specialty. Physician success/efficacy was most strongly related to competency and patient weight loss. Pediatricians had a high expectation of a positive outcome but poorest weight loss in practice. Younger physicians had better expectations and outcomes than older physicians. Physicians’ attitudes about obesity and their asso…[BMC Health Serv Res. 2009] – PubMed Result

A complex set of factors may influence the physician’s decision to provide counseling, including judging the patient’s receptiveness to counseling, a ‘teachable moment,’ other medical matters, time and how many other patients are waiting to be seen. The art and complexity of primary care clinicians’…[Ann Fam Med. 2006 Jul-Aug] – PubMed Result

Another factor may be intentional neglect. In 1998 the editors of the prestigious New England of Medicine wrote an editorial in which they argued that weight loss was futile and dangerous and more so that treating obesity. They wrote, “In our view, doctors should provide advice if an overweight patient asks for help in planning a weight-loss program and recommend weight loss if a patient is suggering from health problems that can be ameliorated by weight loss, such as hypertension, diabetes or osteoarthritis, or it a patient is so obese that he or she is clearly in jeopardy (for example, if the patient is virtually immobilized.) In other situations, doctors should be cautious about exhorting patients to lose weight, especially when they are only mildly obese.” Losing weight–an ill-fated New Year’s resolution. [N Engl J Med. 1998] – PubMed Result The editorial produced a storm of reaction. William H. Dietz, MD, of the Centers for Disease Control and Prevention wrote prophetically, “This passive approach will not prevent weight gain in those at risk, nor will it prevent further weight gain in those who are already overweight. Furthermore, the rapid increase in body-mass index in the U.S. population who are overweight will most likely continue unabated if this passive approach is used. Because health care providers represent a trusted source of information about nutrition, we believe they should counsel all patients who are overweight to avoid further weight gain, regardless of whether their patients raise the issue of weight. Abundant data confirm that weight loss reduces obesity-associated morbidity. Delaying counseling until such a condition has developed reflects ineffective attempts at prevention and increases the likelihood that patients will rely on inappropriate or unhealthy methods of weight control.” The obesity problem. [N Engl J Med. 1998] – PubMed Result George L. Blackburn responded for the Massachusetts Medical Society Committee on Nutrition. They took issue with another statement from Dr. Angell in a February 9, 1998 Wall St. Journal that some people “just like to eat – an in that case it’s (obesity) no more a disease than bank robbery is a disease.” More on the obesity problem. [N Engl J Med. 1998] – PubMed Result

Childhood obesity is also poorly treated in primary care practices in the United States. This study reviewed many studies and found primary care physicians had negative feelings about dealing with childhood obesity. Primary care physicians’ knowledge, attitudes, bel…[Obes Rev. 2009] – PubMed Result

The Centers for Medicare and Medicaid undertook a large trial to see whether general prevention visits by Medicare beneficiaries resulted in improvements in smoking, alcohol consumption and sedentary lifestyle. There was not effect on sedentary behavior over two years. Medicare Lifestyle demonstration – PubMed Results

For more information, see

Reducing overweight and obesity: closing the gap b…[Fam Pract. 2008] – PubMed Result

Suboptimal identification of obesity by family phy…[Am J Manag Care. 2009] – PubMed Result

Health care providers perception of role Health care providers’ perceived role in changing …[Pediatrics. 2009] – PubMed Result

AHRQ Guidelines for Screening obesity in Adults Navigating the Health Care System: Ready to Lose Weight in the New Year? Experts Offer Guidance for Adults and Children