Posts Tagged ‘weight’

How the AMA got it Wrong

September 27th, 2009

June 18, 2009 :: By Morgan Downey

The Associated Press reported on June 17, 2009 that the American Medical Association has adopted a new policy to oppose defining obesity as a disability. According to the report, “Doctors fear using that definition makes them vulnerable under disability laws to lawsuits from obese patients who don’t want their doctors to discuss their weight.”

What’s wrong with this? Well, nearly everything.

First, doctors do not discuss weight with their patients now. A new study confirms previous papers on physician visits found that BMI and obesity status could not be computed in half of office visits because of missing height or weight data. 70% of persons with obesity did not receive a diagnosis of obesity from the physician and 63% of those with obesity received no counseling for diet, exercise or weight reduction. Rates were even low for obesity patients with related co morbid conditions.1

Second, disability statutes don’t just list diseases and call them disabilities. Disability status is decided on a case by case basis depending on a combination of the medical factors and the applicant’s ability to carry on their normal work activities. At the federal level, the Social Security Administration has extensive procedures which basically require morbid or severe obesity and cardiovascular, respiratory or musculoskeletal problems. 2 Few would assert that obesity as a Body Mass Index level of 30 in itself is a disability. But higher BMI levels, with accompanying functional limitations, certainly do or should qualify.

Third, when I look at a statement like the AMA’s I find a quick test helpful: When I see “obesity”, substitute another disease such as “cancer,” “diabetes,” “arthritis,” or “sexually transmitted diseases” and see how it reads. It is impossible to imagine the AMA, which after all submitted an amicus brief to the Supreme Court in a 1998 to uphold the Americans with Disabilities Act against a dentist who would not treat a patient with HIV-positive patient3, as making such a statement about any other disease or condition.

All the AMA policy will do is to likely turn more physicians away from counseling patients with obesity, adding to the stigmatizing views of persons with obesity not only as ‘lacking self control’ but, now, ‘litigious’. It will support administrative judges deciding cases of who qualifies for disability in making negative decisions about an obese persons disability, cutting them off from perhaps their last economic support.

Too bad. On the gravest health issue of our time the AMA is AWOL. Whatever happended to ‘first, do no harm?’

1. Ma J et al Adult Obesity and office-based quality of care in the United States Obesity 2009, 17; 1077-1085

2. Social Security Administration policy on obesity as a disability http://www.socialsecurity.gov/OP_Home/rulings/di/01/SSR2002-01-di-01.html

3. http://www.ama-assn.org/ama/no-index/physician-resources/18680.shtml

Time for Obesity in Health Care Reform

September 27th, 2009

January 30, 2009 :: By Morgan Downey

These are exciting times for health care reformers. We seem to have a President who is truly committed to reform of the health care system with the political strength to get his program enacted, at least a good part of it. What is the President’s program and how does or can, obesity be part of it?

First, some parts have already been enacted in the American Recovery and Reinvestment Act (ARRA), aka the Stimulus Bill. Millions of federal dollars are starting to flow into (a) expanded Health Care Information Technology, (b) comparative-effectiveness research and (c) expanded research at the National Institutes of Health. In addition, President Obama and several of his key aides, such as Melody Barnes, Director of Domestic Policy Council, and Peter Orszag, director of Office of Management and Budget have both addressed obesity and its important role in reducing health care costs and increasing the nation’s health.

Second, a major component to be worked on this summer is providing health insurance to millions of Americans without health insurance.

How might these plans affect obesity?

Healthcare Information Technology (HIT) may provide some interesting opportunities. In a few places, extensive clinical databases are already in use which track patients receiving bariatric surgery. The Surgical Review Corporation, for one, has 100,000 surgical patients which are being tracked for long-term outcomes. The Geisinger Medical Center in central Pennsylvania also has extensive database on patients in surgical and medical treatment. Such clinical registries can provide a vast improvement in understanding obesity and its co-morbidities as well as tracking long-term improvements. Doing this in real time with real-world patients can add tremendous information to clinical trials, which, by their nature, have more restrictive populations and end-points. Last year, the National Committee on Quality Assurance (NCQA) expanded the widely used HEDIS system which measures quality in managed care plans to capture Body Mass Index (BMI) for adults and children. The Administration’s emphasis on electronic medical records (EMR) in primary care practice, by requiring capture of BMIs, along with other clinical indicators, such as blood pressure, cholesterol levels and lipids, can provide a tremendous database for researchers and has the potential to greatly improve patient care. But there is a third level as well. Private entities, such as Google and Microsoft, are developing Personal Health Records (PHR) for individuals to track their own information, which might include nutritional and exercise patterns. One can almost envision a system whereby food and exercise diaries, clinical indicators, pharmaceutical and surgical information is available for patients, health care professionals and researchers.

Of course, such systems take a lot of effort. Common terminology must be agreed to. Data has to be able to be verified. Systems have to interface and patient privacy has to be protected. Who owns this information is a critical issue.

Comparative effectiveness research has already received a great deal of funding under ARRA. The Institute of Medicine has a panel recommending research priorities and, given the discussion at a public meeting on March 20, 2009, there is good reason to anticipate that obesity will be one of the priorities. But the question should not be just what is the best way to lose weight. The research should look at weight loss by various interventions against standard treatments for a number of the co-morbid conditions associated with obesity. And, while there is good data on the efficacy of weight loss for resolution of type 2 diabetes and cardiovascular disease, less is know about its efficacy in mobility problems, such as knee and hip replacements, asthma or breast cancer.

Finally, the Obama Administration has an enormous opportunity in the coverage of the uninsured to make a real change for persons with obesity. First, the Administration should oppose using overweight or obesity as a pre-existing exclusion. While we do not know what percent of the uninsured population is overweight or obese, it is unlikely that the rate is any lower than the national averages. To exclude 30-60% of the uninsured population because of their weight would be poor policy indeed. Next, the Administration should provide a full range of interventions from counseling on nutrition and physical activity to pharmaceutical and surgical interventions. Not only would this directly address the source of many of the uninsured population’s health care problems, it could break the logjam of resistance to coverage of obesity prevention and treatment. While these two steps will be costly, we have seen the rising rates of health care costs and obesity go hand-in-hand. Economists today see obesity as a major contributor to chronic illness and its costs. Finally, coverage should be tied into electronic records which can track long term outcomes.

In the April 15, 2009 issue of the Journal of the American Medical Association, Johathan Q. Purnell and David R. Flum estimate that gastric bypass surgery could save 14, 310 diabetes-related deaths over five years. The evidence on the power of weight loss to prevent and improve chronic disease is there, if not yet perfect. The Administration has an opportunity to make a major leap forward in addressing obesity. It should not miss this chance.

A Diet for the New Administration

September 27th, 2009

December 30, 2008

By Morgan Downey

At this time of year, millions of Americans are hoping the new Administration will solve our seemingly intractable problems at home and abroad. Millions are also hoping to lose weight in the New Year. The two are not unrelated.

Over the past three decades, obesity has increased among all segments of the population, in the United States and abroad. Obesity is now recognized as the fuel behind many major health problems from cancer to diabetes to heart disease, and a significant cause of increasing health care utilization and health care costs.

While this recognition has increased among both Republicans and Democrats (for the first time, both parties recognized obesity in their 2008 party platforms), changing public policy has not caught up with the problem. Under President George W. Bush, Medicare did undo its policy that obesity was not a disease and did expand coverage of surgery for the treatment of obesity. There have been modest increases in the research and prevention budgets at the National Institutes of Health and the Centers for Disease Control and Prevention. But by and large, the efforts of the last eight years have been largely educational: tell people they should lose weight, eat more nutritiously, and exercise more.

Duh! We get it. And it doesn’t work. Frankly, other than bariatric surgery, nothing works very well to lose significant amounts for a long period of time. There simply is not one ‘fix’ that will reverse this disturbing trend.

So here is some advice to the incoming Administration. It should be noted that many appointees named so far have a solid exposure to obesity from a public policy perspective, including former Senator Tom Daschle, nominee for Secretary of Health and Human Services, Peter Orszag, named to head the Office of Management and Budget, Governor Bill Richardson, nominated for Secretary of Commerce, and Melody Barnes, incoming chief of domestic policy at the White House.

Universal health insurance is often put forward as the panacea for all ills. However, Democrats may have to learn that expanding health insurance coverage alone does not translate to a healthier population, especially if obesity continues to increase among children and adolescents. Truth be told, we do not have adequate medical interventions to affect the rates of obesity and its effects. So, if we do not know how to truly prevent obesity or create a long term treatment, what should a new Administration do? Basically, it should focus on how to create the conditions where it is more likely than not that we will find effective strategies for prevention and treatment in the future.

  1. Being a role model is not enough. It’s been noted that George Bush and Barack Obama share a passion for physical activity. Unfortunately, the habits of the chief executive do not translate to population changes. And then there is the smoking thing. Being a role model is not an excuse for inadequate policies.
  2. Make someone responsible for obesity policy development. Right now there is no one tasked at the upper levels of the U.S. Government with dealing with obesity. True, periodically the heads of different agencies give a speech, start a new website or create a new task force but little happens because so many do so little with scant coordination.
  3. Prepare to spend some money. For one of the most significant health problems in the country, the federal government spends vastly less than on obesity than other conditions. Research, prevention and treatment costs for diabetes and heart disease, to name but two, swamp comparable figures for obesity. The federal government is spending more on getting TV converters boxes in US homes than the entire NIH research budget on obesity.
  4. Do not just focus on childhood obesity. While childhood obesity is critical, remember that the population between 7 and 16 spans only 9 years out of a lifetime. Look at obesity over the lifetime and look for relevant interventions. Support childhood prevention programs but require that they have a competent evaluation method so we will know what is working and what is not.
  5. Do focus on research. Perhaps 90% of what we know about obesity has been learned since the discovery of leptin in 1994. Too many people believe that we know everything we need to know about obesity and do not need any more research. That’s not true. A great deal is known but there are many more questions than answers. Scientific credibility on issues around body weight is sorely needed. Every hour on television another weight loss program or product is hyped as being based on doctor’s advice or scientific study. What can help on both fronts is for the Administration to create a National Institute of Obesity Research at the National Institutes of Health. A new entity like this can reenergize researchers on obesity, can more closely coordinate the many disparate programs across NIH, provide leadership to other federal agencies, states and local governments and provide much needed focus on the social and economic impacts of obesity. Furthermore, a director who is articulate can help lead policymakers and the public away from harmful and dangerous products and keep a focus on developing effective interventions. The NIH bureaucracy will oppose “disease specific” research but their interests should not trump the public health needs and the best use of taxpayer dollars.
  6. As part of your health care reform package, remove the bias against drugs for weight loss in the Medicaid statute and change the exclusion of these drugs under Medicare Part D. Then have the Food and Drug Administration revisit its risk/benefit views of drugs to treat obesity. There are few fans of pharmaceutical companies in a Democratic Congress and Administration and there are even fewer who favor drugs to treat obesity. Nonetheless, there is a huge treatment gap. We have more and more effective surgical options, one over-the-counter FDA approved pill, a couple of tried medicines, commercial plans and self-help. What we do not have are the drug treatment options we have for high cholesterol, hypertension or diabetes. Recently, major pharmaceutical companies such as Merck, Pfizer, Solvay and Sanofi-Aventis have dropped or cut back on their programs to develop drugs for obesity. There are two reasons. First, insurance companies will not reimburse for most obesity treatments, including counseling, drugs and surgery. For the pharmaceutical industry, it just did not make economic sense to invest in drugs which were not going to be reimbursed. This is where leadership by Medicaid and Medicare is critical. If these programs support obesity products, private insurance may follow. This is in the government’s long term interest because insurers can avoid treating or preventing obesity knowing that the big effects, like diabetes and heart disease will not be seen until later in life, when Medicare will become the payor. Second, many involved in obesity drug development feel, rightly or wrongly, that the Food and Drug Administration is so risk-averse that they simply cannot afford the long and expensive trials necessary to meet the rising bar of safety. A National Institute of Obesity Research can help shape clinical trials needed by the FDA and speed the process along.
  7. Look to multiply your opportunities. For example, you can use the public works part of the economic stimulus package to construct new gyms in schools, sidewalks, playgrounds, green spaces and biking/walking trails to encourage more physical activity.
  8. Let the states experiment with taxes and proposals like displaying caloric content in restaurants. Vending machines, non-diet soft drinks, high-fat foods have all come under fire in recent years for contributing to the obesity epidemic. The problem is that these products still only contribute a fraction to an individual’s total caloric intake. But no one is sure that they won’t be replaced by other calories. Likewise, there will be voices to restrict food advertising to children through the federal government’s regulatory powers. Use your National Institute of Obesity Research to design evaluation studies so that there is an objective review to see if these policies will work.
  9. Take some leadership internationally. The United States has a long history of involvement in global health issues, such as HIV/AIDs. However, very little is done on the federal level to learn from other countries’ experiences and to help shape global patterns of eating and physical activity.
  10. Avoid the single fix ideas. The obesity field is full of good advice and scant evidence. Focusing on a single fix, such a TV advertising, agricultural subsidies or sweetened beverage may consume a great amount of political resources without producing the outcome you seek.

The obesity epidemic is more likely than not to continue to grow over the next four to eight years. However, the new Administration can position the United States for meaningful change if it takes its time and devotes attention to organizing the effort. With any luck, we can make future New Year’s resolutions more likely to be successful.