Archive for January, 2015

Gallup Survey Shows Increasing Rates of Obesity

January 30th, 2015

The Gallup Organization and Healthways have tracked adult obesity in the United States over seven years. In their most recent report, they found that rates have continued to tick up, rising more than 2% points since 2008 reaching 27.7%. The rate for overweight and normal weight have decrease to 35.2% from 36.7% and to 35.1% from 36.1%, respectively. These results are based on self-reported results unlike the NHANES data which use clinical measurements. Significantly, rates of morbid or severe obesity  (a BMI of 40.0 or more) have reached 4%, the highest in the history of the survey. Obesity rates among seniors showed the sharpest uptick, a 4% point increase since 2008. The survey showed a relationship between obesity and lower incomes and long-term unemployment. Gallup research indicates that overall well-being predicts future obesity more than obesity predicting future well-being. Gallup suggests that weight management programs should address financial and social wellbeing.


Bases for obesity public policies basically worthless

January 30th, 2015

Policy-makers, employer wellness programs, many physicians, the First Lady and most of the public health establishment espouse lifestyle changes, especially increased physical activity as the way (with or without caloric restriction) to prevent and reduce obesity and its related cardiovascular diseases. Millions of dollars have been spent to get Americans to increase their physical activity levels. For such programs to succeed they must have accurate information on levels of physical activity in the general population.

Virtually all of the studies on which these leaders rely come from self-reported answers to questionnaires, especially the National Health and Nutrition Examination  Survey (NHANES). Richard S. Cooper and colleagues who have compared NHANES results to objective data from accelerometers in 3,370 adults. The results are pretty shocking. They found:

“The estimates of both vigorous and moderate activity were extremely low, and contrast dramatically with those obtained by self-report. Vigorous activity lasting even 1 minute was only observed in 2% of any of  gender-race/ethnic groups and a 10 minute episode of moderate activity- the intensity obtained by walking up stairs was recorded in only one-third of the participants on any day of monitoring. ..

The major finding from these analyses is the demonstration that the population that population estimates of activity levels from surveys by questionnaire are markedly at variance with those obtained by objective managements. As the only source available from past surveys, questionnaires have been used in analytic research and have informed public policy for the last 50 years. If the data presented here are correct, a re-evaluation of the conclusions from much of this literature would be required. For example, based on national survey data it was assumed in Healthy People 2010 that 23 percent of adults engaged in vigorous activity of more than 20 minutes per episode at least 3 times a week at the beginning of this decade. However, in the NHANES data presented here, <1% of the population achieved this level of expenditure. Likewise, current guidelines recommend 150 minutes of moderate or 75 minutes of vigorous activity per week for adults. Only 0.3%, or 10 of the 3,370 individuals in this sample achieved that level.

Despite the widely held perception that low levels of energy expenditure in activity is an important risk factor for obesity, prospective data do not support this view. Randomized trials, where activity levels are rigorously measured and no attempt is made to restrict calories, likewise show that even substantial increases in energy expenditure in exercise do not result in weight loss because of compensatory increases in intake. We conclude, therefore, that the associations observed in the NHANES data presented here between activity and relative weight are spurious – i.e. the direction of the causality is most likely from obesity to lower activity.”

Things are not any better on the energy-intake side. Self-reported energy intake values are far inferior to objectively measured double-labelled water method, rendering energy intake information virtually useless according to a letter from 15 distinguished obesity researchers in 2013. A similar group of distinguished made the observation that “this extreme lack of validation of self-reported energy intake can be credibly drawn about energy intake derived from self-reported energy intake measures.”

So, the ground of almost all obesity pubic policies regarding energy intake and expenditure is at least questionable and maybe misleading. A similar group of research leaders has concluded that, ” We argue here that it is time to move from the common view that self-reports of (energy intake) EI and  physical activity energy expenditure (PAEE) are imperfect, but nevertheless deserving of use to a view commensurate with the evidence that self-reports of EI and PAEE are so poor that they are wholly unacceptable for scientific research on EI and PAEE…it is unacceptable to use decidedly inaccurate instruments which may misguide health-care policies, future research and clinical judgment…Researchers and sponsors should develop objective measures of energy balance.”

The Obama Administration and the First Lady have shown their commitment to addressing obesity. Now is their time to get serious and direct the National Institutes of Health, the Food and Drug Administration and the Centers for Disease Prevention to combine efforts to develop more accurate and reliable measures.

EEOC Under Pressure for Employer Wellness Guidance

January 30th, 2015

The Senate Health, Education, Labor and Pensions Committee (HELP) held a hearing on Jan. 29, 2016 on employer wellness programs. (See video here.) The purpose of the hearing appeared to be to put pressure on the Equal Employment Opportunity Commission (EEOC) which has recently sued several companies alleging that their wellness programs violated the Americans with Disability Act.

Ranking Democrat Patty Murray indicated that the EEOC would be issuing a proposed guidance in the near future, as reported earlier.

While billed as a debate over employer wellness programs, most of the witnesses were representatives of business groups, with the exception of one representative of the Consortium for Citizens with Disabilities, Jennifer Mathis, who gave the most detailed statement. The business representatives gave the usual pep rally cries of “these programs work” line, citing a couple of positive anecdotes and avoiding the volume of studies showing incentives and penalties do not work.


World Health Organization’s Credibility Problem

January 29th, 2015

The World Health Organization (WHO) plays a vital role in fighting everything from ebola to avian flu and a hundred other communicable and non-communicable diseases. In recent years, non-communicable diseases (NCDs) have assumed greater importance as major communicable diseases have declined and the impact of NCDs has increased.

So, it was of some interest when the WHO recently issued its 2014 Global Status Report on NCDs. WHO’s Global Target #7 is “Halt the Rise in Diabetes and Obesity.”  (Ok, it isn’t exactly “Remember the Alamo!” but it is their target.)

The report, directed to senior health ministers around the world, states in its Executive Summary:

Obesity increases the likelihood of diabetes, hypertension, coronary heart disease, stroke and certain types of cancer. Worldwide, the prevalence of obesity has nearly doubled since 1980. In 2014, 11% of men and 15% of women aged 18 years and older were obese. More than 42 million children under the age of 5 years were overweight in 2013. The global prevalence of diabetes in 2014 was estimated to be 9%. Obesity and diabetes can be prevented through multisectoral action that simultaneously addresses different sectors that contribute to the production, distribution and marketing of food, while concurrently shaping an environment that facilitates and promotes adequate levels of physical activity. Diabetes risk can be reduced by moderate weight loss and moderate daily physical activity in persons at high risk. This intervention has been scaled up to the whole population in a small number of high-income countries. However, it is difficult to implement this intervention at scale in low- and middle-income countries, partly because current methods for identifying people at high risk are cumbersome and rather costly. Further research is urgently needed to evaluate the effectiveness of interventions to prevent obesity and diabetes.

The main body of the report asks, “What are the cost-effective policies and interventions for reducing the prevalence of obesity and diabetes?” Good Question. Unfortunately, WHO offers a bad answer:

Although evidence on what works as a package of interventions for obesity prevention is limited, much is known about the promotion of healthy diets and physical activity, which are key to attaining the obesity and diabetes targets. Evidence of population-wide policies and settings-based and individual-based interventions that have worked are described below.

Population-wide policies

Evidence suggests that changes in agricultural subsidies to encourage fruit and vegetable production could be beneficial in increasing the consumption of fruits and vegetables and improving dietary patterns. (Ed: citation is discussed below.) Evidence strongly supports (Ed: same citation) the use of such subsidies and related policies to facilitate sustained long-term production, transportation and marketing of healthier foods.

Let’s look at what the WHO considers to be “evidence”. One paper is cited for “evidence”. Written by David Wallinga, director of the Food and Health Program, Institute for Agriculture and Trade Policy in Minneapolis, MN, titled, “Agricultural Policy and Childhood Obesity: A Food Systems and Public Health Commentary” (Health Affairs, 2010;29(3):405-10), it is an expansive, creative foray in possible changes in agricultural policy in the United States in anticipation of the reauthorization of the Farm Bill.

Let me draw your attention to the word “Commentary” in the title because that is exactly what it is. The paper, which is quite good and worth reading reviewing the history of US agricultural policy which has evolved to favor “cheap calories”. The author reflects that perhaps it is time to shift to an agricultural policy which favors the production of fruits and vegetables. He makes a very nuanced observation that, “Diets rich in fruits and vegetables can help manage weight and can lower risks for cancer and other chronic diseases, especially when they replace calorie-dense, nutrient poor foods.” In addition to using the qualifying verb “can”, Wallinga offers no citations for this assertion but that is not the point. Maybe it is my legal education but I think “evidence” means something more than philosophical on what might be the effects of future policy changes at all levels of government and affecting many vital economic sectors. I doubt Mr. Wallinga would consider his paper to be “evidence” of anything. For WHO to call it “evidence” to the intended audience of health ministers is simply misleading. Worse, it assumes that the only intervention they might make are enormous changes in their countries agricultural programs. Since agriculture is a major economic sector in most countries, such an approach is likely to be, well, fruitless.

Statin Use on the Rise

January 6th, 2015

CDC reports statin usage for the control of cholesterol has increased  by one-third over the past decade. In 2012, 28% of people over age 40 reported using a cholesterol-lowering medication, up from 2003 rate of 20%. Most of the increase was in statins. 71% of adults with cardiovascular disease and 54% of adults with high cholesterol reported medication usage to control their cholesterol, according to an article in the Washington Post by Tanya Lewis.

The high use of statins has several implications for persons with obesity. Obviously, this trend improves the health of many persons with obesity and  are at greater risk of cardiovascular disease. However, it can also be a confounding factor in research studies. Looking for changes in cardiovascular disease through weight loss (by any method) can be more difficult to find because of the effectiveness of statins. High use of statins was referenced as one of the reasons by the Look Ahead trial was terminated early.


Opportunity to Expand Coverage of Bariatric Surgery and Anti-obesity Drugs

January 6th, 2015

Kaiser Health News reports today on the poor coverage of drugs for obesity by Medicare and private insurance plans. Health plans which are part of the health exchanges established by the Affordable Care Act also have poor coverage. However, there is a strategy to deal with the health exchange ( or marketplace) plans.

As reported here in a paper (see p.8)  Christopher Still and I wrote on the Affordable Care Act’s impact on persons with obesity, the law has a unique provision allowing for review of plans for ‘discriminatory benefit design.’ Robert Pear of the New York Times reports that the Center for Medicare and Medicaid Services is looking at plans to see if their benefit are structured to discriminate against persons with H.I.V./AIDs, autism, diabetes, bipolar, schizophrenia and other diseases. The article reports that the Obama Administration has said it would challenge restrictions on benefits if they were “not based on clinically indicated, reasonable medical management practices.”

This is a huge opportunity for the obesity community to persuade CMS to look at the lack of coverage of anti-obesity drugs and bariatric surgery in plans on the health marketplaces. It is also an opportunity to have CMS look at whether health plans are adequately including behavioral counseling for adult obesity as they are required to do.


Causes of Obesity: It isn’t Physical Activity

January 5th, 2015

So, our popular culture, as well as many physicians, believe that increased physical activity can either prevent obesity or bring about weight loss. The Today Show is an example of this popular, if wrong, view.

Lost in all this panting-cries for more steps are the actual research results. So it was interesting to find this interview at the University of Delaware annual Foltyn Family Health Sciences Seminar with Dr. Amy Luke of Loyola University Chicago. Dr.Luke has a distinguished career and a host of peer-reviewed publications.

Dr. Luke has been at the epicenter of the debate over whether it is energy intake or energy expenditure (i.e. physical activity) that is the cause of the obesity epidemic. Her research has taken her to rural Ghana, the Seychelles, urban South Africa, Jamaica, and the U.S.  Using objectively measured criteria (stable isotope techniques and accelerometers in five cohorts) Luke found that in developing countries, residents were not expending significantly more energy than those in developed nations like the U.S.

She told the U.Delaware audience, “Physical activity is important for a whole host of health benefits, but it may not be as important as we thought in the prevention of obesity. This points to the need for strong objective measures of the factors on which we are basing public policy.” (Michelle Obama: are you listening?) Dr. Luke has concluded that it is diet, not physical activity, which is responsible for the obesity epidemic


ADA Urges Lower BMI Cutoff for Asian-Americans

January 5th, 2015

The American Diabetes Association (ADA) is lowering the Body Mass Index (BMI) cutpoint for screening Asian-Americans for type 2 diabetes to a BMI of >23kg/m2. In the new article, the evidence for a lower BMI cutpoint is discussed.  The authors note the presence of Asian-Americans and the projections for their increasing population, especially in 10 states, including California, New York, Texas, New Jersey, Hawaii, Illinois, Washington, Florida, West Virginia, and Pennsylvania.  The authors also note the limitations of current measurement techniques, observing that  BMI does not into account the relative proportions of fat and lean tissue and cannot distinguish the location of fat distribution. There is a propensity for Asians to develop visceral versus peripheral adiposity which is more closely associated with insulin resistance and type 2 diabetes. The new standard is not a measure of increased mortality or morbidity but a guide how to use BMI to screen for the presence of type 2 diabetes, with a focus on reacting to BMI cut-offs for eligibility of weight-reduction services or treatment reimbursable by payers.

There a couple of points. First, it is unfortunate that the ADA is not taking on the use of BMI for criteria for products (such as anti-obesity drugs) or services. Changing the BMI cut-offs to accommodate a poor public policy only adds to the distortion of our understanding of excess adipose tissue. The paper understates the fact that the BMI is such a poor standard for use in clinical settings. Third, aside from the literature about cut-offs, the problem is “Who is an Asian-American?” In addition to covering a number of various ethnic groups, determining whether one is “Asian-American” has a host of problems, including the issue of inter-marriage. Demographers are having a hard time determining just what “Asian-American” means. The problem originates with the Census Bureau criteria, as well as the problem of inter-marriage and self-identification as Asian-American versus White. Historically, the Census Bureau has combined Asians, Native Hawaiians and other Pacific Islanders, even though there are significant differences in physiology and body composition between Asians and the other two groups. Listen to this interesting discussion on the Diane Rehm Show on NPR on January 5, 2015 on this very topic.