Archive for February, 2013

New study indicates bariatric surgery improves pancreatic beta-cell function

February 28th, 2013

Philip Schauer and colleagues have found that gastric bypass surgery but not intensive medical care or sleeve gastrectomy significantly increased insulin sensitivity and pancreatic beta-cell function even though weight loss was similar. The study randomized 60 subjects and followed them for two years. Pancreatic beta cells store and release insulin and their loss of function is a key feature in the progression to type 2 diabetes. The study is published in the March edition of Diabetes Care.


New Insights into how sleep deprivation leads to obesity

February 28th, 2013

New research, published in the Proceedings of the National Academy of Science, is shedding light on the interaction of sleep and genes. Researchers at Surrey University took a small group of 26 subjects. Half slept for less than six hours a night; the other for 10. The sleep-deprived group was found to have altered functions in 711 genes, including some involved in metabolism, inflammation, and stress. The body’s normal circadian rhythms were also affected.

Getting fewer than six hours’ sleep per night deactivates genes which play a key role in the body’s constant process of self-repair and replenishment, according to a new study.

Genes produce proteins which are used to replace or repair damaged tissue, but after a week of sleep deprivation some of these ceased functioning.

The subjects’ bodies returned to normal after a period of regular sleep but prolonged deprivation could lead to major problems. The Center for Disease Control reports that 25% of Americans have occasional sleep problems and 10% have chronic sleep disorders.



Employer Wellness Plans Continue To Grow

February 28th, 2013

National Business Group on Health has released findings from a new survey showing increases in the use of employer mandated wellness programs. The press release states:

“According to a new employer survey conducted by Fidelity Investments® and the National Business Group on Health (Business Group), corporate employers plan to spend an average of $521 per employee on wellness-based incentives within corporate health care programs. This marks an increase of 13 percent from the average of $460 reported for 2011, and is double the per employee average of $260 reported in 2009.

The survey is the latest in a series of studies Fidelity and the Business Group have conducted since 2009 to analyze the growth of health-improvement programs, or “wellness” programs, in the workplace. These programs typically consist of condition-management services (e.g., managing insulin treatments), lifestyle-management services (e.g., weight loss advice), health-risk management services (e.g., on-site flu shots), and environmental enhancements (e.g., bike racks, walking paths).

In addition to an increase in the average amount employers plan to spend on wellness incentives, the survey found that the overall use of wellness-based incentives among corporate employers continues to increase. The study found that nearly nine-out-of ten employers surveyed indicated that they currently offer wellness-based incentives (86%), an increase from 73 percent from 2011 and 57 percent from 2009.

And while the percent of corporate employers offering wellness-based incentives has increased across all markets, the survey results illustrated significant growth in the mid-market, where 77 percent of employers plan to offer wellness-based incentives in 2013, and more than double the 38 percent of mid-market employers that offered wellness-based incentives in 2010. In addition, almost half of employers in the mid-market (45%) plan to offer average incentives of more than $500 per employee.

“As the cost of providing health care continues to increase, employers recognize one of the key ways to manage their company’s costs is to incent their workforce to lead a healthier lifestyle,” said Adam Stavisky, senior vice president of Fidelity’s Benefits Consulting business, which commissioned the study with the Business Group. “Employers of all sizes have embraced wellness-based incentives to help control costs, and companies are now looking at ways to design and optimize their programs to maximize their positive impact on health for both the organization and employees.”

Employers Tying Employee Eligibility to Completion of Risk Assessment or Biometric Testing

The study also showed that 15% of employers surveyed are requiring employees to complete some sort of health activity – such as an employer-sponsored biometric screening or health risk assessment (HRA) – in order to determine their eligibility for one or all of the company’s health plans in 2013. The survey results showed that 10 percent of employers will be requiring employees to complete an HRA or risk being defaulted into a less attractive subset of the company’s health plan, while 7 percent of employers indicated failure to complete a biometric screening would result in being defaulted into a less attractive subset of their company’s health plan. In addition, 3 percent of employers indicated that failure to complete an HRA or biometric screening would result in loss of benefits for 2013.

Companies Continue to Tailor Programs to Increase Participation, Reward Behavior

This year’s survey found that an increasing number of employers are actively managing and expanding their wellness programs and offering incentives designed to increase participation and encourage positive behavior. The most popular wellness-based incentives continue to be a decrease in premiums (61%), cash or gift cards (55%) or an employer-sponsored contribution to a health savings account or similar heath care-based savings vehicle (27%).

This year a majority of employers (54%) will expand their wellness-based incentives to include dependents, up from 45 percent in 2011. And almost half (49%) will now include spouses/dependents in communications about wellness programs.

Employers are also tying wellness-based incentives to an increasing number of health-improvement activities. These include popular activities such as smoking cessation programs and discounts for gym memberships, as well as new options such as employer-sponsored fitness challenges (increasing 10 percent in 2013), and discounts for health food options in the company’s cafeteria (increasing 9 percent in 2013).

The study also found that 41 percent of employers currently include, or plan to incorporate, outcomes-based metrics as part of their incentive program – this gives both employers and employees a measurable goal that can be used to reward behavior or results in certain health categories, such as lowering cholesterol (30%) or blood pressure (29%), or reducing waist measurement (11%).

“An increasing number of employers understand how wellness programs contribute to a healthy workforce,” said Helen Darling, president and chief executive officer of the National Business Group on Health. “And it’s encouraging to see employers take the necessary steps to tailor their wellness programs in a way that will incent and motivate their employees to engage in health-improvement activities and find ways to reward them for their progress.”


Data for the survey was collected online in October and November of 2012 by the National Business Group on Health in conjunction with Fidelity and is based on responses from a national sample of 120 companies from numerous industries including transportation, health care, technology, entertainment, consumer products, retail and energy. The sizes of the companies spanned a broad range, from less than 2,000 to more than 50,000 employees. The results of this survey may not be representative of all companies meeting the same criteria as those surveyed for this study.

Yahoo Finance notes concerns that this can decrease access to health care, which is exactly what the Affordable Care Act was meant to prevent.

Nevertheless, the Census Bureau reports a significant drop in employers who provide health insurance.



The Putative 82 Causes of Obesity

February 28th, 2013

I’ve been keeping track of the putative causes of obesity. I am now up to 82. I don’t allege they are all correct. But they do exist in the scientific or popular literature, usually both. The links will not take you to a definitive study but only to an example of the debate going on in that area. So, the questions are: 1. If a disease (condition) has 82 possible causes, can anyone say we know what THE CAUSE is? 2. Can all these putative causes be correct? In other words, can a diverse collection of events trigger a perturbation in the system to cause obesity? Alternatively, since each putative cause has some individuals with exposure who do not develop obesity, is there some kind of “master switch” which has to be tripped to cause excess adipose tissue accumulation? What possible prevention strategy could account for all these variables? Curious minds want to know.

1. agricultural policies

2. air conditioning,

3. air pollution,

4. antibiotic usage at early age

5. arcea nut chewing,

6. assortative mating,

7. being a single mother,

8. birth by C-section,

9. built environment,

10. chemical toxins,

11. child maltreatment,

12. competitive food sales in schools,

13. consumption of pastries and chocolate (in Burkina Faso),

14. decline in occupational physical activity,

15. delayed prenatal care,

16. delayed satiety,

17. depression

18. driving children to school

19. eating away from home

20. economic development

21. endocrine disruptors,

22. entering into a romantic relationship,

23. epigenetic factors,

24. family conflict,

25. first-born in family

26. food addiction

27. food deserts

28. food insecurity,

29. food marketing to  children

30. food overproduction

31. friends

32. genetics,

33. gestational diabetes,

34. global food system,

35. grilled foods

36. gut microbioata,

37. having children, for women,

38. heavy alcohol consumption,

39. home labor saving devices,

40. hunger-response to food cues,

41. international trade policies (globalization)

42. high fructose corn syrup,

43. lack of family meals,

44. lack of nutritional education,

45. lack of self-control,

46. large portion sizes,

47. living in the suburbs,

48. living in crime-prone areas,

49. low levels of physical activity,

50. low socioeconomic status,

51. market economy,

52. marrying in later life

53. maternal employment,

54. maternal obesity,

55. maternal over-nutrition during pregnancy,

56. maternal smoking,

57. meat consumption,

58. menopause,

59. mental disabilities,

60. no or short term breastfeeding,

61. non-parental childcare

62. overeating,

63. participation in Supplemental Nutrition Assistance Program (formerly Food Stamp Program)

64. perception of neighborhood safety,

65. physical disabilities,

66. prenatal  maternal exposure to natural disasters,

67. poor emotional coping

68. sleep deficits,

69. skipping breakfast,

70. snacking,

71. smoking cessation,

72. stair design

73. stress

74. sugar-sweetened beverages,

75. trans fats,

76. transportation policies,

77. television set in bedrooms

78. television viewing,

79. thyroid dysfunction

80. vending machines,

81. virus

82. weight gain inducing drugs.


Mission Accomplished: Michelle Obama Style

February 26th, 2013

Like President George W. Bush, First Lady Michelle Obama is declaring “Mission Accomplished” in her war on childhood obesity. Appearing on ABC News’ Good Morning America today, she told Robin Roberts, co-anchor, “Our kids are eating better at school. They’re moving more. And we’re starting…to see a change in trends. We’re starting to see rates of obesity coming down like never before.”

Really? Time for a little fact checking. But first, a note of caution. It seems whenever someone in the political spotlight, as First Lady Michelle Obama is, claims victory, they are taking a risk. You might recall that in 2003, a dynamic governor of Arkansas signed the nation’s first comprehensive childhood obesity legislation. The law garnered much national attention for its provision to sending parents a BMI report card, as well as limiting access to vending machines.   On August 17, 2006, Governor Mike Huckabee declared, “Arkansas has halted the progression of childhood obesity.  We have stopped the locomotive train of childhood obesity in its tracks, now it’s time to turn the train around and move full speed ahead to healthier living.” Medical News Today

How’s that going? Reports by the Arkansas Center for Health Improvement show little difference in obesity rates in children from 2005-6 to 2011-12. (Note: there was a change in categorizing childhood obesity during this period but it does not appear to be significant.)

Now, the statement, “We’re starting to see rates of obesity coming down like never before,” just isn’t accurate. What’s the source of the confusion? Well, it is like playing ‘Telephone.’

In January 2012 Cynthia Ogden and colleagues from the National Center for Health Statistics, part of the CDC, published a  paper in the Journal of the American Medical Association which indicated a leveling of obesity rates between 2007-8 and 2009-10. At the time, many pointed out that this was a very small time period – 4 years – to use in reaching an important conclusion. The paper did report a significantly greater prevalence in obesity in boys aged 2-19 over a 12 year period but not in females. There was also a significant increase in BMI among adolescent males 12-19 but not among any other age group or among females.

In May of 2012, Department of Health and Human Secretary Kathleen Sebelius told the attendees at the Weight of the Nation conference, “The good news is that in the last decade, we’ve seen the rise in obesity rates begin to stabilize in some areas. A recent study out of Massachusetts even showed a decline in obesity among children under 6 in parts of the state. That’s progress.”

In December of 2012, the Robert Wood Johnson Foundation issued a brief, “Declining childhood obesity rates-where are we seeing the most progress.”  The report was widely covered in the media.

The Robert Wood Johnson Foundation “Declining childhood” report cited Philadelphia, New York City, Mississippi and California as places reporting declines in childhood obesity rates.  (Massachusetts appears to have dropped off the list of success stories. The study Secretary Sebelius referred to was a census in a multi-center pediatric practice.)

California’s reported decline was based on a Robert Wood Johnson Foundation-funded study. I critiqued it at the time for the wide variation in reports of increases and decreases by county in the state. See Is California’s Childhood Obesity Picture Really Improving? I noted that the number of overweight/obese students had actually gone up even though the prevalence rate had gone down 1.1%, due to an increase in enrollment.

Mississippi’s prominence in the RWJF report may surprise many since CDC rates it as one of the states with the highest rates of obesity, 34%. Regardless, the RWJF report referred us to another RWJF funded project, the Center for Mississippi Health Policy. The “Declining Childhood” report states, “In 2006, the Mississippi State Board of Education set nutritional standards for food and beverages sold in school vending machines. The Healthy Students Act of 2007 required the state’s public schools to provide more physical activity time, offer healthier foods and beverages, and develop health education programs…Starting  in 2008, Mississippi’s Childcare Licensure Division helped facilitate the Color Me Healthy program and training classes to create a healthier environment in childcare centers. Mississippi’s Fruits and Veggies-More Matters program reached more than 15,000 residents in 2009 through worksite wellness programs, health fairs, and school events…Mississippi  reported a significant drop in overweight and obesity only among White students. However, rates for Black students appear to be leveling off, which is a major shift after years of steady increases.”

Actually, it’s a bit more complicated than that.  The report from the Center for Mississippi Health Policy states, “In 2011, the combined prevalence of overweight and obesity for all public school students was 40.9%…Statistically significant declines in overweight and obesity were found among white students and elementary students from 2005 to 2011…In 2011, the prevalence of overweight and obesity was significantly lower among white students than black students and significantly lower among white female students than black female students in all three grade categories.”

But, rates for black males and females are actually increasing from their low point in 2007. So they are ‘leveling off’ to the extent that they are back to earlier, higher levels.




Philadelphia was cited in the “Declining Childhood” report for its efforts to help corner stores offer fresh foods, connect schools with local farms, bring supermarkets to underserved areas and ensure that farmers’ markets accept food stamps, as well as improving the nutritional quality of foods and beverages in the schools. Data from  Philadelphia is strong. A report showed that between 2006-2007 and 2009-2010, the prevalence of obesity in Philadelphia schools decreased from 21.5% to 20.5%. Decreases were generally smaller in groups with the highest prevalence, including high school students, Hispanic males, and African American females. But the report noted, “The inconsistency of findings between subgroups and the small increases in obesity, severe obesity or both in some groups in the most recent year of data indicate that it is not yet certain that the epidemic increases in child obesity are over.”

New York City has by far the best combination of enacting comprehensive approaches to childhood with pretty solid data showing improvements. A CDC study showed the prevalence of obesity declined in grades K-8 in public schools from 2006-7 to 2010-11 by 5.5%. Obesity declined significantly in all age groups and in all socioeconomic and racial/ethnic populations. However, the decrease was smaller among black and Hispanic children than among Asian/Pacific Islanders and white children. By age, the largest decrease was seen among children age 5-6 years and, within this age group, the largest decline was among white children. Among children age 5-6, large differences were observed in obesity reduction by neighborhoods with high-income white neighborhoods having greater decreases than in poorer black neighborhoods. The editorial note suggested that the large changes in ages 5-6 indicated that the home environment or pre-school was particularly important.

So, what are the questions?

First, are national trends in childhood obesity reversing? We do not have good long term data yet.  New York and Philadelphia are showing some results but even though these are big cities they are still a small part of the country. Even in those cities, there is a great diversity in patterns among subgroups.

Second, are rates of childhood obesity at least leveling off? Well, this is tougher to assess. There is some positive indication as in the JAMA study in January 2012. In addition, Rokholm and colleagues reported on leveling of the epidemic in children and adolescent in Australia, Europe, and Japan with some decreases along with increases.  Two additional considerations. Most studies use the Body Mass Index which is a crude instrument for determining body weight. Its use for children and adolescents in the United States is of very recent vintage.  Because height is twice the value of weight in the BMI equation, and as children grow in height so rapidly, sudden changes in height can skew the picture. In addition, BMI cannot measure excess visceral adipose tissue in normal BMI individuals and so it may miss an important part of the population.

One’s time frame is also important. Some of the comparison periods in the studies above are very short, five years or so. Others may be 10 or more. So what is your frame of reference? If you look at the long-term trends in the United States, the prospect of leveling much less reversing this trend would be unprecedented in our history.


Of course, one can go back some 300 years to observe powerful trends in ever greater human height and weight, but not without periods of regression. See The Changing Body.

Third, but at least we have some models of what works, correct? Not exactly. The Robert Wood Johnson Foundation report and the First Lady’s Let’s Move campaign each is taking some credit for the changes we are seeing. But when you add in the diverse activities of New York, Philadelphia, Mississippi, and California the picture gets more cloudy of what works and what doesn’t. More focused examinations including one by Jeffrey Mechanick, another which  I co-authored and as well as other in-depth Cochrane Review on interventions for obesity in children found limited evidence of the effectiveness of any specific policies. It should be noted that many communities have undertaken programs like those reported in California, Mississippi, New York City and Philadelphia, but we do not have reports from them.

Finally, in obesity discussions, cause and effect are often mixed up. And well-intentioned participants may omit some factors out of either ignorance or lack of complete understanding of how an external factor may affect a conclusion. Two such externalities come to mind here. The first is that almost all these studies of a leveling effect span, at least in part, the recent recession, starting around 2007. The obesity literature has not assessed what impact this might have had. On the one hand, economic insecurity may have caused individuals or families to reduce food expenditures, such as meals away from home, which might cause a reduction in weight. On the other hand, an increase in stress due to economic uncertainty might have driven up the consumption of  comfort foods. By the same token, individuals looking for employment may be more sensitive to their appearance. Perhaps closer to home, during this period, the Federal Trade Commission in a December 2012 report indicates a reduction in food marketing to children and adolescents during the same timeframe. If food marketing to children is as influential as many advocates believe, this may be a significant, if overlooked contributor to the putative leveling.

Bottom Line: It’s complicated. The First Lady should keep the champagne on ice.


CNBC Reports “Wellness” will increase costs to employees

February 22nd, 2013

CNBC reports Obama’s Wellness regulations will raise healthcare costs on employees. See report


Obesity and Essential Health Benefits: The Final Rule

February 21st, 2013

The Department of Health and Human Services issued final regulations defining “Essential Health Benefits” which will have to be included in insurance programs listed on state exchanges and all non-grandfathered health insurance plans in the group and individual markets. The EHB covers 10 categories covering hospitalization, prescription drugs, etc. See Fact Sheet.

The regulation is generally close to the proposed regulation with the exception of expansion of mental health, habilitative care and pediatric dental and vision services.

Last July, interim final regulations were issued which require these plans to include under prevention and wellness, the US Preventive Services Task Force recommendations, which include Intensive Behavioral Counseling for Adult Obesity.

Unfortunately, it appears that HHS has no problem with allowing most state exchanges to use “benchmark” plans which exclude bariatric surgery, according to a report by the Obesity Care Continuum. Coverage of prescription medicines for obesity is murky. The EHB regulations state that plans must provide at least one drug in each category or class of the US Pharmacopeia. But it uses version 5.0 for Medicare. Under the Medicare statute, Part D, drugs to treat obesity are excluded so they don’t appear to be covered. However, this might be challenged under the EHB rules that the benefits must be designed in a manner which does discriminate based on age, disability, or expected length of life and must take in the needs of a diverse population.

The regulations limit deductibles to $2,000 for individual coverage and $4,000 for family coverage.

The STOP Obesity Alliance and my own comments, had argued for more clarity in the inclusion of obesity treatments.


Improvements Seen in Children’s, Teen’s Diets

February 21st, 2013

Looking for good news? Well, you may need a magnifying glass but it appears caloric intake in American children and adolescents is coming down. In a new report from the CDC, among children and adolescents aged 2–19, caloric intakes decreased for most age groups between 1999–2000 and 2009–2010. According to the report, “Trends in the protein, carbohydrate, and fat intakes were inconsistent. Protein intakes, expressed as a percentage of total kilocalories, increased for all boys and for all girls, and carbohydrate intakes, expressed on the same basis, decreased for all boys and for all girls. However, the observed trends for protein and carbohydrate intakes were not found for all racial and ethnic groups. The percentage of kilocalories from protein increased for all sex and racial and ethnic groups except for non-Hispanic black girls. The percentage of kilocalories from carbohydrate decreased for non-Hispanic white boys and girls and for non-Hispanic black boys, but there was no trend for the other sex and racial and ethnic groups. The only trend in fat intakes was a decrease in saturated fat intakes of Mexican-American boys and girls.

The percentage of calories from protein, carbohydrate, and fat were within the ranges recommended for these macronutrients for this age group, but the percentage of calories from saturated fat was above the 10% recommended in the Dietary Guidelines for Americans, 2010. In 2009–2010, on average, U.S. children and adolescents consumed between 11% and 12% of kilocalories from saturated fat.”