Posts Tagged ‘Employer Incentives’

Republican Party Platform Guts Obesity Policies

August 30th, 2012

Among the provisions in the Republican Party Platform adopted this week in Tampa, Florida are these affecting obesity:

Food stamps and other nutrition programs be sent in block grants to the states.

On Medicare and Medicaid, the platform states,  “The problem (with these programs) goes beyond finances. Poor quality healthcare is the most expensive type of care because it prolongs afflictions and leads to ever more complications. Even expensive prevention is preferable to more costly treatment later on. When approximately 80 percent of healthcare costs are related to lifestyle – smoking, obesity, substance abuse – far greater emphasis has to be put upon personal responsibility for health maintenance. Our goal for both Medicare and Medicaid must be to assure that every participant receives the amount of care they need at the time they need it, whether for the expectant mother and her baby or for someone in the last moments of life.”

Editor’s note: This paragraph is rather hard to discern. On the one hand, it seems to be an blank check for prevention programs which are, overwhelmingly, governmental programs. Yet, then it shifts to personal responsibility. Then, a neck-whipsawing shift to Medicare and Medicaid participants getting every service they need when they need it. So, what exactly does this mean? Do you get bariatric surgery, for example, when you need it? Or is it denied because you did not take “personal responsibility?”

Regarding Medicare, the platform calls for making the program into a “premium support” program for those age 55 and younger. For these individuals, Medicare would provide a voucher to go out and purchase private health insurance coverage. Currently, Medicare covers bariatric surgery and intensive behavioral counseling for both those over age 65 and those disabled and receiving Social Security disability. Frankly, I am skeptical that private insurance companies (which did not insure elderly persons before Medicare was enacted) would cover such persons and such services without prohibitively high premiums.

For Medicaid, the platform proposes “alternatives to hospitalization for chronic health problems. Patients should be rewarded for participating in disease prevention activities. Excessive mandates on coverage should be eliminated. Patients with long-term care needs might fare better in a separately designed program.”

Editor’s note: The platform does not describe what an “alternative to hospitalization” would be. The reference to “patients with long-term care needs” refers to millions of elderly Americans whose nursing home costs are paid for by Medicaid, after their own assets are exhausted. It has been a politically charged issue to make the spouse’s assets at risk for the patient’s nursing home costs. This was proposed in the Ryan Budget. What a “separately-designed” program would be was not specified.

Of course, the platform calls for  the repeal Obamacare or the Affordable Care Act “in its entirety.” This would include free intensive behavioral  counseling for adults with obesity under plans which were not grandfathered, grants for healthier communities, access to breastfeeding sites at work, access to health insurance by persons whose obesity has prevented them from getting insurance due to a “pre-existing condition, and greater rights for individuals to fight denials of claims.

Of course, also repealed would be the regressive provisions for “workplace wellness” programs which penalize overweight workers for not meeting weight targets set by their employers.

In 2008, The Republican Party Platform, adopted in St. Paul, Minnesota, provided:

“Prevent Disease and End the “Sick Care” System. Chronic diseases – in many cases, preventable conditions – are driving health care costs, consuming three of every four health care dollars. We can reduce demand for medical care by fostering personal responsibility within a culture of wellness, while increasing access to preventive services, including improved nutrition and breakthrough medications that keep people healthy and out of the hospital.  To reduce the incidence of diabetes, cancer, heart disease and stroke we call for a national grassroots campaign against obesity, especially among children”.

 

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”

War on the Obese – More Employers To Impose Penalties

November 17th, 2011

Reed Abelson of the New York Times reports that that higher penalties for employees who are obese are coming. He writes, “Policies that impose financial penalties on employees have doubled in the last two years to 19 percent of 248 major American employers recently surveyed. Next year, Towers Watson, the benefits consultant that conducted the survey, said the practice – among employers with at least 1,000 workers – was expected to double again. “ Smokers Penalized With Health Insurance Premiums – NYTimes.com The article looks closely at penalties imposed by  Wal-Mart on smokers.

The enhanced penalties are the result of the Affordable Care Act. Led by Steve Burd, CEO of Safeway Inc. a broad business coalition pushed a  provision (of course called a “wellness” provision in Washington-speak) to allow employers to charge overweight employees higher health insurance premiums than those meeting the employer’s weight standard. President Barack Obama applauded incorporating this “Republican idea” into his health care reform legislation Republican Ideas Included in the President’s Proposal | The White House.

Archives

September 27th, 2009

APRIL 2009

April 24, 2009

After planting garden, Michelle Obama skips out to Five Guys for a burger.

First lady says she sneaks off to fun restaurants – washingtonpost.com

MARCH 2009

March 31, 2009

Kansas Governor Kathleen Sebelius lead off her testimony to the Senate Health, Education, Labor, and Pensions Committee stating, “Yet, at the beginning of the 21st century, we face new and equally daunting challenges.

We face an obesity epidemic that threatens to make our children the first generation of Americanchildren to face life expectancies shorter than our own.”

March 30, 2009

Review of new drugs for obesity Obesity Drug by Arena Has an Effect, but a Limited One – NYTimes.com

March 27, 2009

New York Times reports on walking school buses in Italy fighting obesity and climate change

Students Give Up Wheels for Their Own Two Feet – NYTimes.com

March 18, 2009

Another study shows obesity increases risk of death

Obesity Takes Years Off Your Life – Forbes.com

March 13, 2009

Mississippi to cover state workers’ bariatric surgery

Surgery: Long-term care is more expensive | clarionledger.com | The Clarion-Ledger

March 9, 2009

Obama sets out Administration policy on use of science The White House – Press Office – Memorandum for the Heads of Executive Departments and Agencies 3-9-09

March 6, 2009

Abdominal obesity adversely affects lung function Belly Fat Bad for Your Lungs?

March 6, 2009

New study finds dietician students prejudiced against persons with obesity Bias Against Obesity Is Found Among Future Dietitians – Forbes.com

March 1, 2009

Obesity increases worker’s comp. Obesity supersizing workers comp costs – Financial Week

March 1, 2009

South Carolina Senator criticized for trying to dump bicycle paths from stimulus bill. DC Bicycle Transportation Examiner: Sen. DeMint’s pro-obesity legislation was the real pork in the stimulus debate

FEBRUARY 2009

February 27, 2009

Obama budget to cut farm subsidies; improve child nutrition Obama wants to cut subsidies to farmers | DesMoinesRegister.com | The Des Moines Register

February 27, 2009

Drug maker buries data on diabetes drug causing weight gain AstraZeneca Documents Released in Seroquel Suit – NYTimes.com

February 20, 2009

North Carolina looks to penalize persons with obesity: Smoking, obesity may cost state employees | CharlotteObserver.com

February 19, 2009

Robert Wood Johnson Foundation announces national effort on childhood obesity Leading Research Funders Launch Collaborative To Accelerate Nation’s Progress in Reducing Childhood Obesity – RWJF

February 19, 2009

Clinton Foundation announces alliance on childhood obesity Alliance for a Healthier Generation Expands Efforts to Combat Childhood Obesity with Launch of Landmark Healthcare Initiative

February 18, 2009

Court of Appeals upholds NYC Calorie Disclosure Ordinance

http://www.citizen.org/documents/NYSRAOpinion.pdf

Court Upholds the City’s Rule Requiring Some Restaurants to Post Calorie Counts – NYTimes.com

CDC: Young Invincibles are obese CDC: ‘Young invincibles’ have significant health concerns – CNN.com

February 16, 2009:

Home recipes increase in calories: ‘Joy of Cooking’ or ‘Joy of Obesity’? – Los Angeles Times

February 12, 2009

CMS Issues decision on using bariatric surgery to treat Type 2 Diabetes; notes effectiveness of bariatric surgery in resolving Type 2 Diabetes. Centers for Medicare & Medicaid Services

Obesity linked to Birth Defects

Obesity During Pregnancy Linked to Infant Birth Defects – NYTimes.com

JAMA paper on birth defect risks with mothers with obesity. JAMA — Maternal Overweight and Obesity and the Risk of Congenital Anomalies: A Systematic Review and Meta-analysis, February 11, 2009, Stothard et al. 301 (6): 636

February 19, 2009

Fast food restaurants predict strokes

More Fast-Food Joints in Neighborhoods Mean More Strokes – US News and World Report

February 12, 2009

How evolution lead to modern obesity

AAAS: Modern obesity epidemic can be traced back two million years – Telegraph

NEJM — Expanding Coverage for Children — The Democrats’ Power and SCHIP Reauthorization

JANUARY 2009

January 24, 2009

Childhood obesity influenced by genetic variations

Science Centric | News | Childhood obesity risk increased by newly-discovered genetic mutations

January 21, 2009

Obesity imperils health care reform

FEATURE-U.S. obesity epidemic shows perils to health reform – Forbes.com

January 20, 2009

Employers try incentives for healthier workforce Firms offer bigger incentives for healthy living – USATODAY.com

January 13, 2009

NIH launches study of how genes and environment affect children’s development National Children’s Study Begins Recruiting Volunteers, January 13, 2009 News Release – National Institutes of Health (NIH)

January 9, 2009

Physical Activity May not be Key to Obesity After All

Physical Activity May Not Be Key To Obesity Epidemic

January 6, 2009

Obesity and Ovarian Cancer Linked

Obesity Linked To Elevated Risk Of Ovarian Cancer

DECEMBER 2008

December 22, 2008

A little overweight and inactive hurts too

Even a Little Overweight, Inactivity Hurts the Heart – washingtonpost.com

December 19, 2008

Limiting snacks in schools can increase fruit, veggie consumption

Limiting School Snacks Boosts Fruit, Veggie Consumption – US News and World Report

December 18, 2008

Childhood Obesity may affect thyroid

Childhood Obesity May Cause Thyroid Problems – washingtonpost.com

December 16, 2008

New York Debates Tax on Soft Drinks

A Tax on Many Soft Drinks Sets Off a Spirited Debate – NYTimes.com

December 12, 2008

Study looks at relationship between obesity, breast cancer and frequency of mammography

Daily Cancer News – CancerConsultants.com

December 3, 2008

Visceral obesity linked to depression in elderly

Depression Linked to Increase in Abdominal Fat – US News and World Report